DOI: 10.1148/radiol.2461070629
(Radiology 2008;246:334-335.)
© RSNA, 2008
CT-guided Pulmonary Radiofrequency Ablation
Cornelis J. A. Haasbeek, MD *,
Suresh Senan, MRCP, FRCR, PhD *,
Egbert F. Smit, MD, PhD 
and
Frank J. Lagerwaard, MD, PhD *
* Departments of Radiation Oncology, VU University Medical Center, De Boelelaan 1117, Amsterdam 1081, the Netherlands
e-mail: cja.haasbeek{at}vumc.nl
Department of Pulmonology, VU University Medical Center, De Boelelaan 1117, Amsterdam 1081, the Netherlands
Editor:
We read with interest the article by Dr Simon and colleagues (1), in the April 2007 issue of Radiology, on the results of computed tomographically (CT)-guided radiofrequency (RF) ablation in 153 patients, which included 116 cases of primary lung cancer that was medically inoperable or for which the patient refused surgery. The local control and complications associated with this procedure were well documented by these experienced investigators. However, their discussion cites only outcomes following older conventional radiation therapy delivery and failed to cite recent data obtained by using stereotactic radiation therapy (SRT) from groups in Japan, North America, and Europe.
The reported 3-year local control rates after RF ablation were 57% and 25% for T1 and T2 tumors, respectively, which are no better than the results of high-dose conventional radiation therapy (reviewed in Qiao et al [2]; see table 4 of that article). However, far superior local control rates on the order of 90% have been obtained in stage I non–small cell lung cancer (NSCLC) with SRT, which allows the delivery of biologically equivalent doses in excess of 100 Gy in one to five fractions on an outpatient basis (3). The noninvasive SRT technique results in a less than 3% incidence of toxicity exceeding grade 2 and has no adverse effect on overall quality of life and no treatment-related mortality (4–8). In contrast, RF treatment was complicated by a pneumothorax in 28% of patients and required chest tube insertion in 10% of patients and had a procedure-specific 30-day-mortality rate of 2.6%. Similar morbidity data were reported in other reports of RF ablation (9–11), with toxicity requiring hospitalization in approximately 10% of patients owing to pneumo- or hematothorax, massive hemoptysis, bronchopleural fistulas, or abscesses.
Discussions on nonsurgical treatment options in stage I NSCLC must consider high-precision SRT, particularly as the available data suggests that RF ablation appears to be associated with significantly more mortality and morbidity. A randomized trial in patients with inoperable disease comparing these two options is eagerly awaited.
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References
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- Simon CJ, Dupuy DE, Dipetrillo TA, et al. Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients. Radiology 2007;243:268–275.[Abstract/Free Full Text]
- Qiao X, Tullgren O, Lax I, Sirzen F, Lewensohn R. The role of radiotherapy in treatment of stage I non-small cell lung cancer. Lung Cancer 2003;41:1–11.[Medline]
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- Lagerwaard FJ, van der Geld Y, Slotman BJ, Senan S. Quality of life after stereotactic radiotherapy for medically inoperable stage I lung cancer [abstr]. Int J Radiat Oncol Biol Phys 2006;66(suppl):S133–S134.
- de Baere T, Palussiere J, Auperin A, et al. Midterm local efficacy and survival after radiofrequency ablation of lung tumors with minimum follow-up of 1 year: prospective evaluation. Radiology 2006;240:587–596.
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Response
Damian E. Dupuy, MD *,
Caroline J. Simon, MD *,
Thomas A. DiPetrillo, MD 
,
Thomas Ng, MD 
, and
William W. Mayo-Smith, MD *
* Department of Diagnostic Imaging, Brown Medical School/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
e-mail: ddupuy{at}lifespan.org
Department of Radiation Oncology, Brown Medical School/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
Department of Thoracic Surgery, Brown Medical School/Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
We appreciate the comments from Dr Hasbeek and colleagues. SRT will likely provide better results than standard techniques, but its widespread implementation has not occurred in the United States. Many centers still use conventional techniques. McGarry et al (1) reported a local failure rate of 21%, which was less common with total doses greater than 16 Gy. Pulmonary toxicity was found to be much greater in central lesions with SRT. In a retrospective study, Japanese study patients who received a biological effective dose of 100 Gy or greater had a local recurrence rate of 8% (2). The pulmonary toxicity is reported to be lower with SRT. However, in a report at the 47th Annual Meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO) by Timmerman et al (3), of 70 patients undergoing SRT the grade 3 and 4 toxicity rate was 11%. In addition, Timmerman et al reported a death rate of 8.5% with three 20-Gy fractions. These preliminary results from a U.S. population similar to the patients in our cohort differ from the toxicity quoted by Dr Hasbeek and colleagues. On the basis of the U.S. experience, the Radiation Therapy Oncology Group (study 0236) began a prospective study with modified dosing and treatment of peripheral lesions only. The results of this trial are pending. Furthermore, in response to the invasiveness of RF ablation, many patients who undergo SRT need CT-guided biopsy or fiducial placement prior to SRT. Since most of these early lung cancers are not accessible bronchoscopically, we do not see a solution to preventing a needle being placed into these patients for diagnosis. The pneumothorax rate for biopsy and RF ablation is comparable. Many of our frail patients with lung cancer may undergo RF ablation and biopsy at the same sitting. We are excited to have the opportunity to use and study both techniques in patients with lung cancer who are not candidates or refuse surgery. It is very important for the radiation oncology community to keep an open mind until all the results of these two techniques have been appropriately studied.
D.E.D is a consultant for Celsion (Columbia, Md), Civco Medical Instruments (Kalona, Iowa), and Microsulis (Waltham, Mass) and is supported by Valleylab (Boulder, Colo) and Endocare (Irvine, Calif). W.W.M. is supported by GE Healthcare (Fairfield, Conn).
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References
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- McGarry RC, Papiez L, Williams M, Whitford T, Timmerman RD. Stereotactic body radiation therapy of early-stage non-small-cell lung carcinoma: phase I study. Int J Radiat Oncol Biol Phys 2005;63:1010–1015.[CrossRef][Medline]
- Onishi H, Araki T, Shirato H, et al. Stereotactic hypofractionated high-dose irradiation for stage I non-small cell lung carcinoma: clinical outcomes in 245 subjects in a Japanese multi-institutional study. Cancer 2004;101:1623–1631.[CrossRef][Medline]
- Timmerman R, Mcgarry R, Yiannoutsos C, et al. Excessive toxicity when treating central tumors in a phase II study of stereotactic body radiation therapy for medically inoperable early-stage lung cancer. J Clin Oncol 2006;24:4833–4839.[Abstract/Free Full Text]
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