FOR THOSE RUNNING OUT OF ALTERNATIVES-- high frequency focused ultrasound

[Lani]

have no idea how available it might be in US or elsewhere, but nice to see new modalities being investigated

Radiol Med. 2011 Feb 1. [Epub ahead of print]
High-intensity focused ultrasound (HIFU) in patients with solid malignancies: evaluation of feasibility, local tumour response and clinical results.
Orgera G, Monfardini L, Della Vigna P, Zhang L, Bonomo G, Arnone P, Padrenostro M, Orsi F.

Interventional Radiology Unit of European Institute of Oncology, 435 Via Ripamonti, 20141, Milan, Italy, gianluigi.orgera@ieo.it.
Abstract
PURPOSE: The purpose of this study was to evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for ablation of solid tumours without damaging the surrounding structures.

MATERIALS AND METHODS: A specific written informed consent was obtained from every patient before treatment. From September 2008 to April 2009, 22 patients with 29 lesions were treated: nine patients with liver and/or soft-tissue metastases from colorectal carcinoma (CRC), six with pancreatic solid lesions, three with liver and/or bone metastases from breast cancer, one with osteosarcoma, one with muscle metastasis from lung cancer, one with iliac metastasis from multiple myeloma and one with abdominal liposarcoma. The mean diameter of tumours was 4.2 cm. All patients were evaluated 1 day, 1 month and 3 months after HIFU treatment by multidetector computed tomography (MDCT), positron-emission tomography (PET)-CT and clinical evaluation. The treatment time and adverse events were recorded.

RESULTS: All patients had one treatment. Average treatment and sonication times were, respectively, 162.7 and 37.4 min. PET-CT or/and MDCT showed complete response in 11/13 liver metastases; all bone, soft-tissue and pancreatic lesions were palliated in symptoms, with complete response to PET-CT, MDCT or magnetic resonance imaging (MRI); the liposarcoma was almost completely ablated at MRI. Local oedema was observed in three patients. No other side effects were observed. All patients were discharged 1-3 days after treatment.

CONCLUSIONS: According to our preliminary experience in a small number of patients, we conclude that HIFU ablation is a safe and feasible technique for locoregional treatment and is effective in pain control.

PMID: 21293939

[Ellie F]

Really interesting. Wonder if any of the results were due to an immune response being triggered?
Pancreatic tumours are known to be especially difficult, hope this will encourage the research in a lot of different cancers.
Thanks Lani

[Rich66]

The mean diameter of tumours was 4.2 cm.

PET-CT or/and MDCT showed complete response in 11/13 liver metastases; all bone, soft-tissue and pancreatic lesions were palliated in symptoms, with complete response to PET-CT, MDCT or magnetic resonance imaging (MRI); the liposarcoma was almost completely ablated at MRI. Local oedema was observed in three patients. No other side effects were observed. All patients were discharged 1-3 days after treatment.

Wow! Sounds like tremendous response for larger tumors. I know my heart sank when mom was told by an interventional radiologist that success with cryo or RF ablation goes down significantly at 3cm. Too bad oncs don't seem to be aware of this....
As with most things in mets land, earlier the better.
The question will be whether anyone will do this level of HIFU outsode trials..especially in the US.
The immune response issue is a good question. It seems like ablation can trigger good and not so good immune reactions.

[Lani]

the problem is oncs do meds, surgeons do surgery, rads do radiation therapy and interventional rads do what they do and the patients if they are lucky only get to see them altogether prior to treatment for a tumor board.

I hope the internet/videoconferencing could be used to get all the brains together to add what they could do to help a particular patient and so everyone could see the end result of the other doctors' interventions so all would become aware of what was available and what seems to be working.

Until then one can only be vigilant about getting information and trying to spread it around.

[michka]

Lani, what you describe is exactly what I am going through. I am trying to get all the information myself and get the onc, the interventional radiologist and the surgeon to communicate and not only through me. The consensus seems to be for me a liver resection. They said "it's worth trying to go for a "curative" tentative. But this takes days and days!

Rich, the RFA guy is terrific.It's Joan who found him for me! He said "I can do it but I would go for surgery in your case even if it will be more difficult for you. But if you choose RFA, I have a 90% success rate in your case but don't wait because your mets are 20mm. The smaller they are, the better for success.".

I thank you Lani for all this information you give us. I am so grateful you do this for our group. I am now trying to process your posts saying that the liver is like a tomato, that liver resection is good for ER+ and that operations can generate bad immune system reactions.
If only new curative less invasive procedures could come out!
Michka

[Trish]

It's great indeed to see other modalities involved and I too am struggling with the coordination required to get the best decision with regard to medication, surgery and radiation. Thanks for posting.
Trish

[Lani]

Mischa, I said the consistency of the liver is said to be most simiilar to tomato aspic (I don't know if they serve/make tomato aspic in France, but it is like a congealed fruit gelee--don't know how to do an accent ague with my keybord) thickened with corn starch and refrigerated over night) The contents of a tin of tomato aspic will stand on their own once the tin is removed (like a tower of jello) but if you tried to sew one "tower of jello" to another "tower of jello" or put a stitch in it to try to tie off a blood vessel, it could be difficult not to get it to come apart (and bleed)

Sorry for my culinary analogies, especially in a country that cares so much for its food!

[Joan M]

Sloan-Kettering has high-frequency focused ultrasound equipment (see third graph under Facilities subheading):

http://www.mskcc.org/mskcc/html/59769.cfm

And I would agree with Michka an Lani about doctor collaboration. I think there are a lot of turf wars.

Joan

[Rich66]

Been reading about this and so far seems like there might be limited utility in areas of the body that move due to breathing (lungs etc)..sigh.

[Lani]

Rich I saw an interesting poster (out of Germany if I remember) at a meeting within the past 2 years, where they gave "air" with increased oxygen content to patients to breathe prior to breast radiation therapy. It allowed the patients to "breath-hold" longer so as not to move (lungs.chestwall,etc) during treatment.

If available couldn't see why it wouldn't work w HIFU as well

[Rich66]

Maybe related? Wait...on second read..seems to suggest collapsing the treatment lung gives better ablaation.

Ann Thorac Surg. 2010 Oct;90(4):1116-9.
Microwave ablation of lung tissue: impact of single-lung ventilation on ablation size.

Santos RS, Gan J, Ohara CJ, Daly B, Ebright MI, Desimone M, Fernando HC.

LINK

Source

Department of Cardiothoracic Surgery, Boston University School of Medicine, Boston, Massachusetts, USA.

Abstract

BACKGROUND:

Thermal ablation is increasingly used to treat pulmonary tumors in medically inoperable patients. Most procedures are performed with sedation in the radiology suite. Ideally, the ablation should encompass the entire tumor volume with a surrounding margin of necrosis; however, ablation may not be as effective in the normal aerated lung surrounding a denser tumor. Inducing atelectasis of the lung may potentially increase ablation volumes and increase local cancer control. This study examines the effect of single-lung ventilation on ablation size using a microwave system.
METHODS:

Twenty microwave ablation procedures were performed in the lungs of 10 swine. Bilateral thoracotomy using a clamshell approach was used. In one lung, ablation was performed with continuous ventilation. In the contralateral lung, single-lung ventilation was achieved by clamping the bronchus before ablation. The ablated lobes were resected and sent for pathologic analysis. Routine and supravital staining was performed.
RESULTS:

The ablation zone was clearly demarcated on gross examination, and in all cases 100% ablation occurred, without skip areas of viability. The ablation zones were elliptical with the long axis parallel to the axis of the ablation probes (active tip, 3.7 cm). Ablation diameters and volume were compared between the ventilated and nonventilated lungs. Ablation volume was superior in nonventilated lungs (10.74 cm(3) versus 7.35 cm(3); p = 0.039) primarily because of differences in the short axis of the ablation zone.
CONCLUSIONS:

Microwave energy can effectively ablate normal pulmonary parenchyma without skip areas of viable tissue within the gross ablation field. The volume of necrosis is increased in nonventilated lungs, suggesting that ablation results can be improved in patients by using general anesthesia with single-lung ventilation. Future studies will be required to confirm this hypothesis.
Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

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• Ann Thorac Surg. 2010 Oct;90(4):1120.