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ProgrammeTopic highlightsPulmonary tumours: what are the indications?

Pulmonary tumours: what are the indications?

We spoke to Prof. Andrea Veltri to learn more about his presentation at CIRSE 2022.

Watch his lecture in the session, “Pulmonary tumours: where do we stand.”

With regards to interventional oncology, a fundamental course on lung tumour ablation covering the question “Where do we stand?” is on one hand necessary. This information can be shared with a less experienced practice with respect to imaging-guided ablative therapies (IGTA) of liver and kidney tumours; but on the other hand, this topic seems repetitive because the steps forward are still slow and difficult.

 

It is well known that local treatment of SCLC is anecdotal and in terms of NSCLC the pretherapeutic clinical and radiological assessment is configured as the management of the pulmonary node, when it is incidental or found during a cancer screening. In both cases there are consolidated guidelines [1-3]. These guidelines begin with the stratification of the risk of the incidental nodules in the patient or from the positive test (LDCT) in the cancer screening, pass from CT without and with contrast (CECT). Following the initial guidelines, dimensional and/or volumetric monitoring of the smaller nodes is done and metabolic imaging (FDG-PET) is used. Later, biopsy typing (TTNB) of the larger ones or in case of growth should be done. The final radiological diagnosis should be discussed together with the multidisciplinary board (MTB) where the best therapeutic option will be decided.

 

The MTB meeting is also the ideal place to discuss the treatment decisions in case of oligometastatic disease (OMD) involving the lung, where IGTA can be one of the options. In this case, the pre-therapeutic radiological assessment is often limited to imaging for staging or restaging a known tumour, demonstrating OMD of colorectal cancer (CRC) or oligoprogression of treated NSCLC. The pre-treatment assessment, in most cases, consists of a chest CECT scan associated with the abdominal study. Sometimes PET-CT completes the pre-treatment assessment where the presence of other extra-thoracic or abdominal metastases can be relevant. It can also better demonstrate viable tissue in metastases already treated with systemic or local therapy (e.g. previous SBRT).

 

To date, the guidelines of the leading oncological scientific societies (ESMO, NCCN) relegate IGTA for NSCLC Stage IA (peripheral T1abc, N0) as an option for inoperable patients not receiving SBRT or definitive RT, but this indication is questionable. Few prospective trials and many retrospective studies demonstrate the non-inferiority of IGTA compared to SBRT [5, e.g.], but the number of treated patients included in studies is very unbalanced in favor of SBRT, so much so that oncologists will believe that the results of RT are more evident than those of IGTA. The logical consequence is that larger and randomised prospective trials are needed to insert the IGTA closest to RT in the algorithm for stage IA medically inoperable NSCLC, as requested from the NCCN by the SIO as early as 2019.

 

In case of OMD, IGTA are considered one of the therapies in the “toolbox “of the instruments for local ablative treatment. In the treatment of OMD, the MTB discusses possible patient choices (including surgery, IGTA, SBRT and embolisation techniques) based on clinical condition, resectability, molecular profile, etc. [6-7]. International guidelines are available especially for CRC and NSCLC, but in clinical practice they are often translated to other neoplasms, especially gastrointestinal. For lung metastases there is also a growing body of literature, mainly based on observational studies, but prospective, randomised trials are still needed to directly compare therapeutic options and better define the indications of percutaneous IGTA of pulmonary tumours [8].

 

Contraindications to lung IGTA for both primary and metastatic tumours are well summarised in the CIRSE Standards of Practice on Thermal Ablation of Primary and Secondary Lung Tumours [4]. This includes: the presence of nodal and distant metastases (except for oligometastatic disease); untreatable coagulopathies; an ECOG performance status >2; a life expectancy of less than one year; an end-stage lung disease and/or respiratory failure; lesions located <1 cm from hilum, large vessel, main bronchi, trachea or esophagus (if adjunctive techniques to space them out are not applicable).

 

Indications and contraindications to pulmonary IGTA depend on the evidence, which in the literature is not yet robust enough to lead to strong recommendations in the guidelines of the main oncological scientific societies.

 

Andrea Veltri

 

University of Turin, Orbassano/IT

 

Prof. Andrea Veltri is head of the Diagnostic and Interventional Radiology Unit at the San Luigi Gonzaga University Hospital-Oncology Department in Orbassano (TO), Italy.

 

He completed his residency in Torino (IT) in 1991, received the European Diploma of Clinical Ultrasonography in 1993 and attended a brief fellowship at the Radiology Department of the University of Pittsburgh Medical Center (Pennsylvania, USA) in 1994. Since 2006 he is a professor of radiology at University of Turin Medical School and Radiology Residency Program.

 

Since the 1990s, he has been dealing with image-guided ablative therapies of tumours, first of the liver, then later the other organs addressed by the newborn discipline of interventional oncology.

 

He is active member of the Italian Society of Diagnostic and Interventional Radiology (SIRM), European Society of Radiology (ESR) and Cardiovascular and Interventional Radiology Society of Europe (CIRSE, member and fellow). For many years he has been in the faculty of the annual congress of CIRSE, ECIO, and the Mediterranean Interventional Oncology-Live, which has been held in Rome since 2015.

 

References

  1. MacMahon H, Naidich DP, Goo JM, Lee KS, Leung ANC, Mayo JR, Mehta AC, Ohno Y, Powell CA, Prokop M, Rubin GD, Schaefer-Prokop CM, Travis WD, Van Schil PE, Bankier AA. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. 2017 Jul;284(1):228-243. doi: 10.1148/radiol.2017161659.
  2. Callister ME, Baldwin DR, Akram AR, Barnard S, Cane P, Draffan J, Franks K, Gleeson F, Graham R, Malhotra P, Prokop M, Rodger K, Subesinghe M, Waller D, Woolhouse I; British Thoracic Society Pulmonary Nodule Guideline Development Group; British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax. 2015 Aug;70 Suppl 2:ii1-ii54. doi: 10.1136/thoraxjnl-2015-207168.
  3. American College of Radiology Committee on Lung-RADS®. Lung-RADS Assessment Categories version1.1. Available at https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/LungRADSAssessmentCategoriesv1-1.pdf . Accessed on January 1, 2020
  4. Venturini M, Cariati M, Marra P, Masala S, Pereira PL, Carrafiello G. CIRSE Standards of Practice on Thermal Ablation of Primary and Secondary Lung Tumours. Cardiovasc Intervent Radiol. 2020 May;43(5):667-683. doi: 10.1007/s00270-020-02432-6.
  5. Uhlig J, Ludwig JM, Goldberg SB, Chiang A, Blasberg JD, Kim HS. Survival Rates after Thermal Ablation versus Stereotactic Radiation Therapy for Stage 1 Non-Small Cell Lung Cancer: A National Cancer Database Study. Radiology. 2018 Dec;289(3):862-870. doi: 10.1148/radiol.2018180979.
  6. Van Cutsem E, Cervantes A, Adam R, Sobrero A, Van Krieken JH, Aderka D, Aranda Aguilar E, Bardelli A, Benson A, Bodoky G, Ciardiello F, D’Hoore A, Diaz-Rubio E, Douillard JY, Ducreux M, Falcone A, Grothey A, Gruenberger T, Haustermans K, Heinemann V, Hoff P, Köhne CH, Labianca R, Laurent-Puig P, Ma B, Maughan T, Muro K, Normanno N, Österlund P, Oyen WJ, Papamichael D, Pentheroudakis G, Pfeiffer P, Price TJ, Punt C, Ricke J, Roth A, Salazar R, Scheithauer W, Schmoll HJ, Tabernero J, Taïeb J, Tejpar S, Wasan H, Yoshino T, Zaanan A, Arnold D. ESMO consensus guidelines for the management of patients with metastatic colorectal cancer. Ann Oncol. 2016 Aug;27(8):1386-422. doi: 10.1093/annonc/mdw235.
  7. Yoshino T, Arnold D, Taniguchi H, Pentheroudakis G, Yamazaki K, Xu RH, Kim TW, Ismail F, Tan IB, Yeh KH, Grothey A, Zhang S, Ahn JB, Mastura MY, Chong D, Chen LT, Kopetz S, Eguchi-Nakajima T, Ebi H, Ohtsu A, Cervantes A, Muro K, Tabernero J, Minami H, Ciardiello F, Douillard JY. Pan-Asian adapted ESMO consensus guidelines for the management of patients with metastatic colorectal cancer: a JSMO-ESMO initiative endorsed by CSCO, KACO, MOS, SSO and TOS. Ann Oncol. 2018 Jan 1;29(1):44-70. doi: 10.1093/annonc/mdx738.
  8. Prud’homme C, Deschamps F, Moulin B, Hakime A, Al-Ahmar M, Moalla S, Roux C, Teriitehau C, de Baere T, Tselikas L. Image-guided lung metastasis ablation: a literature review. Int J Hyperthermia. 2019 Oct;36(2):37-45. doi: 10.1080/02656736.2019.1647358.