Chapter 77

Thoracic surgeons and oncologists currently have a new tool in their oncologic armamentarium against focal lung cancer that is provided by the interventional radiologist—image-guided percutaneous radiofrequency ablation (RFA). The procedure is still relatively new and is yet to find its clear niche. Although the literature is sparse, the experience with RFA for tumors in other organs (e.g., liver, kidney, and bone) combined with early results of RFA for lung tumors heralds optimism, particularly for patients who are not surgical candidates.

This chapter describes the types of patients who may benefit from RFA, along with early results, risks, and complications. An overview of RFA techniques, mechanisms, and equipment is given. Finally, the varied expertise and respective roles of the multidisciplinary team are highlighted.

Currently, RFA is not a first-line form of therapy for either primary or secondary pulmonary tumors. RFA should be considered only if thoracic surgeons and oncologists, as well as radiation therapists, have exhausted more conventional options or determined that these traditional methods are not suitable.1–10 For example, patients who have undergone prior operations such that reoperation is not feasible, patients who have had maximal radiation or chemotherapy, and patients with severe respiratory compromise that preclude surgery are candidates for RFA.1,2 Patients with an inoperable tumor and refractory pain may have that pain ameliorated by RFA. Associated painful erosion of ribs or growth into portions of the mediastinum may be treated by RFA as well.1,2 As with hepatic tumors, a combined approach with surgical excision, segmentectomy, or lobectomy for one or more tumors, combined with RFA for other tumors in different lobes, may be performed; in the latter situation, intraoperative RFA can be an option.

Ablation may have either cure or cytoreductive palliation as the goal, each of which must be conveyed to patients, families, and referring physicians prior to RFA. Both primary bronchogenic carcinoma and metastatic7 tumors can be treated. Various primary non-small cell carcinomas (NSCLC) and metastatic cell types have been treated. Smaller tumors are more likely to be cured. Since small cell lung carcinoma is a systemic disease, it usually is not an indication for local RFA, although rarely focal therapy may be used. Mesothelioma has been treated as well.2

Typically, once the clinical team of the thoracic surgeon, the oncologist, and the radiation therapist has opined that the patient may be a candidate for RFA, the patient is referred to the tumor ablation interventional radiology team. The radiologists will review the patient's relevant radiologic images (i.e., chest x-ray, CT scan, MRI, and CT/PET scan) to ascertain the size and extent of disease, extrathoracic lesions, number of tumors to potentially be treated, proximity of vital structures, and nonpulmonary tumors (rib, etc.) that also might benefit from RFA. If the ablation team concurs that the patient is an appropriate candidate, the patient and family have a consultation with the team. Discussion ensues about ...

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