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Radio Frequency Ablation [RFA], Cryosurgery, VATS
compiled by doctordee
Search LMS site
RFA of Tumors in Lung, Liver, Bone, Adrenal or Kidney
[and Heart, Prostate, Breast, Brain, Lymph Nodes, Nerve Ganglia]

An extensive site from the NIH

Cancer J Sci Am. 1999 Nov-Dec;5(6):356-61.
Radiofrequency ablation: a minimally invasive technique with multiple applications.
Fetch PMID: 10606477

Search Pubmed for RFA and Lung

Search Pubmed for RFA and Bone

Search Pubmed for RFA and Liver

Search Pubmed for RFA and Liver and Sarcoma

Search Pubmed for RFA and Kidneys

Search Pubmed for RFA and Adrenal

Search Pubmed for RFA and Pancreas

Search ASCO

RFA How Does it Work?

Spend some time here - see the series - UCSF

University of Mississippi

MDA

Search for other locations where RFA is done Google


Letter from Neil:
Our decision to for Radio Frequency Ablation (RFA) of Bev's two ~5 cm lung tumors was based on our conclusion that there was very little downside risk and that avoiding a thoracotomy was highly desirable. Our rationale was as follows:

1) If the RFA fails surgery can still be done. Doing RFA closes the door to absolutely no other procedure.

2) The RFA procedure is 'trivial' in comparison to the major insult of a thoracotomy; the percutaneous puncture incision for RFA is only 3 mm (1/8").

3) Surgery is done under general anesthesia with its inherent risks of morbidity and mortality; recovery time is typically 3-4 months. RFA is most often done as an outpatient procedure under conscious sedation; you're up on your feet and out and around in a day or two and full recovery time is a week or so.

4) RFA can be done as many times as is necessary - it is not self-limiting in terms of scar tissue, etc. If part of the tumor is missed the first time (unlikely) it's no big deal to go in again for the remainder. If new nodules pop up in the same lung or in the other lung, it's easy to do them as they appear; that's not the case with surgery.

5) In my wife's case a thoracotomy and surgical wedge resection would have taken about 30% of her lung capacity; RFA took about 5%.

6) The journal-published results of RFA on liver/kidney tumors seems quite good - although there is no comparable long-term experience with lung tumors.

7) The new RadioTherapeutics Co-Access Electrode System seems to solve many problems. It provides a cannula with a removable trochar for percutaneous insertion into the tumor. The RFA electrode is then inserted though the same cannula for the RFA procedure.

Cordially, Neil December 2001
Do not limit your interest to RFA. Think in broader terms so as to include cryoablation, photodynamic therapy, laser ablation, VATS, etc. All of these minimally invasive procedures have the potential to accomplish some of the things that previously could only be done with the "gold standard" of open surgery.

Doctordee would also add, as with many procedures, the results will vary with location and size of the tumor/s, as well as with the skill of the pracitioner. AS ALWAYS she recommends expertise in the person you choose. For RFA, that would be an Interventional Radiologist. You can send your scans on CD to more than one Interventional Radiologist, and if they wish to see you because they think they can ablate the tumors, ask them about the results they have so far on recurrence from their RFA ablation, as well as the complication rate, for the site you are considering for RFA. Get people experienced with the technique. Surgery remains the gold standard, but RFA can destroy lung tumors and conserve lung tissue.


What is Radio Frequency Ablation?
Written by Beth C, November 2001
Updated by doctordee November 2003

Radio Frequency Ablation (RFA) is a procedure used to destroy undesirable tissue. This procedure is being used to destroy tumors in the liver, lungs, bone, kidney, pancreas, and adrenal gland, as well as heart, prostate, breast, brain, lymph nodes, and nerve ganglia.

RFA starts by passing radio frequency energy through the lesion. Heat is generated at the site of the lesion through agitation caused by this energy. This heat produces coagulation and cellular destruction --necrosis -- resulting in destruction of the lesion or tissue. The electrode is heated on the way out, sterilizing the track, to prevent local recurrences due to implantation seeding of tumor cells.

Radio Frequency Ablation is a specialized technique, and should be carried out in a specialized treatment center. When using RFA for liver tumors, celiotomy (abdominal incision) or laparoscopic approaches are preferred because they allow IOUS (intra-operative ultrasound), which may demonstrate hidden additional metastases. Operative RFA also allows concomitant resection and/or cryosurgical ablation.

For liver metastases, the procedure can be used to treat the small residual tumor load in the contralateral lobe following liver resection in those considered unresectable at the first presentation. This new therapeutic strategy increases surgical resectability in patients previously judged unresectable. RFA can also be combined with cryosurgical ablation.

How does it work?
Using conventional imaging methods -- ultrasound, CT scan, or MRI -- an electrode is positioned strategically within the lesion. The electrode is then connected to a radiofrequency generator and the energy is delivered into the tissue. As the cells are heated, they are destroyed. The mechanism of RFA is similar to that of a microwave oven, heating from the inside out. The tissue reabsorbs the destroyed cells over a period of time.

RFA can be carried out percutaneously --puncturing through the skin-- meaning without a classical surgical incision. Percutaneous RFA should be reserved for patients at high risk for anesthesia, those with recurrent or progressive lesions, and those with smaller lesions sufficiently isolated from adjacent organs. Radio frequency ablation when combined with cryosurgical ablation reduces the morbidity of multiple freezes. RFA is safer than cryosurgical ablation and can be performed via different approaches (percutaneously, laparoscopically, or at celiotomy).

The duration of the procedure depends on a number of factors, including the number of applications and the location of the lesions. RFA may be performed through an open incision or via laparoscopy -- through multiple, small skin incisions. RFA can also be done percutaneously -- through small skin punctures.

Generally, patients will have IV access through which they will be given medication. The need for general anesthesia, sedation, or pain medication will be determined by the clinical intervention approach. Every effort is made to ensure that patients do not feel pain during the procedure. The length of hospitalization depends on how the procedure is performed, however, patients may only be in the hospital overnight.

Complications
Complications of RFA can include bleeding into the chest or abdominal cavities or other structures, burns of vascular structures or skin or diaphragm, persistent pain, pleural effusions, cholecystitis, abcesses, trauma to the liver, and liver failure. Some of the RFA complications can be fatal. Another complication is increased temperature caused by tumor lysis syndrome. This condition results when the destroyed tumor releases enzymes that the body treats as a foreign substance. The body fights these enzymes like it would an infection, causing fever, and less often, mild fatigue. However, within a couple of days the patient's temperature should return to normal.

RFA is a safe and effective alternative for the attempted ablation of unresectable malignancies and when used adjunctively can reduce the morbidity of cryosurgery. Percutaneous and laparoscopic RFA can be performed effectively with less than 24 hours of hospitalization. Radio frequency ablation alone or combined with surgical resection or cryosurgical ablation resulted in reduced blood loss and shorter hospital stay.

Recurrence / Retreatment
Some lesions, especially larger lesions, may require more than one treatment session to destroy the entire tumor. In some patients additional lesions will arise at a later date and these can also be retreated. As long as the lesions are visible via CT Scan or ultrasound, they can be treated using RFA, as many times as necessary.
Tumors near a major blood vessel often recur locally since the blood vessel itself draws heat away from the area during the treatment in what is known as the "heat sink phenomenon." As a result, the tumor cells next to the blood vessel cannot get hot enough to achieve cellular death. Tumors too close to vital structures or nerves, can result in the heat damaging closely positioned structures. For RFA, size and location of the tumors to be ablated are very important.
RFA of Lung Tumors
Lung RFA and Insurance Hassles

Dear Madam Brimstone,
My insurance company is giving me hassles about paying for lung RFA. Do you have any corroboratory material I can use to convince them?
About To Be Burned Twice
...
Dear Twice,
Here are some citations for the insurance company

1. Search Pubmed for RFA and Lung
As of November 2003, there are 28 articles listed in this search.

2. Effect of Radio Frequency Ablation on Lung Cancer.
ASCO [ 1342 - 2001]

3.Percutaneous imaging-guided radio frequency ablation (RFA) of metastatic colorectal cancer (CRC) in lung
ASCO [2216 - 2002]

4. Percutaneous Imaging-Guided Radio Frequency Ablation (RFA) of Secondary Colorectal Cancers (CRC) in Lung.
ASCO [2203 - 2001]

5. Radio Frequency Ablation (Rfa) of Metastatic Lesions in Adrenocortical Cancer (Acc)
ASCO [609N - 2000]

6. Chest
Radiofrequency thermal ablation of a metastatic lung nodule
..."This case illustrates the use of RF ablation in a patient in whom surgical resection was no longer possible and where chemotherapy was unlikely to produce benefit. This technique may offer a viable method of cytoreduction when other treatments have not succeeded."
Abstract

7. European Radiology Issue: Volume 12, Supplement 3 December 2002 Pages: S166 - S170
Radiofrequency thermal ablation of a metastatic lung nodule
Abstract

Checking the FDA site for approvals on devices. Devices seem to be approved by what they are used for. The one for several of the RFA models says:
"...for the ablation and coagulation of soft tissue, including the partial or complete ablation of non-resectable liver lesions."
I think that mets in the lung would probably meet the approved category of "soft tissue."


Subject: lung RFA and FDA approval
From: Been Burned
To: About to be Burned 2ce
Dear Burned:
Mme Brimstone is right when she indicates that the FDA approval for RFA is via its approval for the equipment. Dr. Sewell of U of Mississippi was very explicit about that when I asked him about the status of FDA approval for his treatment of lung tumors by RFA. He said that there will not be any additional approval for this specific procedure, that the FDA has approved the equipment for the treatment of cancer and that's it. He will write papers for professional meetings and publications, but acceptance of the procedure will come as it is done and the results become known. So, use the abstracts and texts that show that RFA kills cancer cells, there should be no doubt about that, and keep escalating, take to the State Insurance Commissioner if you need to.
Sincerely,
Been Burned and Ready to Be Burned Again if I Need to.
Current Open RFA Clinical Trials

There are currently seven clinical trials being run on RFA. [as of November 2003]
[Including one by Dr Suh at UCLA on lung metastases.]

Search PDQ Clinical Trials
Cryoablation [Cryosurgery]

Cryoablation of Tumors [Often liver.]

Cryoablation [sometimes called cryosurgery] is done with a machine which uses pressurized argon and helium gases to regulate freezing and thawing processes. There is scanning during placement of the probe. Once the probe is activated, freezing and thawing cycles are monitored with MRI. Multiple cycles are performed to obliterate as much of the tumor as possible.

Freezing tumor cells interrupts critical cell functions and results in cell death. Cells that remain within the body are absorbed along with scar tissue. The effectiveness of cryotherapy has been well documented as it is utilized in the treatment of numerous lesions throughout the body. Freezing and thawing cycles have been well studied; they are not experimental in nature.

The procedure is performed under general anesthesia. After freezing, the probe is removed and the incision is closed with two or three sutures. Recovery time ranges from two to eight days, depending on the location of the lesion and depth of treatment. You will need pain medication.

Risks of the procedures include freezing of non-target tissues, internal bleeding, infection and damage to normal structures in the vicinity of the target tumor. [From FAQs of next section]

"The technological advances which have caused renewed interest in cryosurgery are the development of intraoperative ultrasound to monitor the therapeutic process and the development of new cryosurgical equipment designed to use supercooled liquid nitrogen. The thin, highly efficient probes, available in several sizes, can be placed in diseased sites via endoscopy or percutaneously in minimally invasive procedures. The manner of use is to place the probe in the desired location in the diseased tissue with ultrasound guidance. If required by the size or location of the tumor, as many as five probes can be inserted and cooled to -195 degrees C simultaneously. The process of freezing is monitored by ultrasound which displays a hypoechoic (dark) image when the tissue if frozen. Rapid freezing, slow thawing, and repetition of the freeze/thaw cycle are standard features of technique." [1]
"The cases selected for cryosurgery are generally those for which no conventional treatment is possible. ... Diverse tumors [in sites] such as the brain, bronchus, bone, pancreas, kidney, and uterus, have ... been treated in small numbers by cryosurgery. Judging from this experience, further expansion in the use of cryosurgical techniques seems certain." [1]

1. Cryobiology 1997 Jun;34(4):373-84
Minimally invasive cryosurgery--technological advances.
Baust J, Gage AA, Ma H, Zhang CM.
Center for Cryobiological Research State University of New York, Binghamton 13902, USA.
Fetch PMID: 9200822

Search Pubmed for cryoablation and sarcoma treatment

Search Pubmed for cryoablation and cancer clinical trials results

RFA and Cryosurgery FAQs
RFA & Cryoablation of Tumors

This is Dr Sewell's FAQs Sheet.

Patient Information Concerning Radio Frequency Tumor Ablation and Cryoablation of Tumors

Interventional radiologists at the University of Mississippi Medical Center are developing minimally invasive, image-guided methods of destroying primary and secondary tumors. Current therapies entail the use of thermal energy and are known formally as Percutaneous Magnetic Resonance (MR) - Guided Cryogenic Tumor Ablation or Percutaneous Computer Tomography (CT)- Guided Radio Frequency Tumor Ablation. Procedures are carried out with a radio frequency ablation probe or a cryoablation probe. Either instrument can be inserted through a small incision. Then the tip of the probe is secured in the target tumor under image guidance, such as CT or MRI, which assists the physician in his effort to destroy carcinomas by exposing the tumor to extreme fluctuations in temperature. Advantages of either technique include minimally invasive access to the defect without significant post-operative pain or discomfort related to the procedure as well as reduction of cost and recovery time in the hospital. Moreover, patients who do not qualify for conventional therapies because of unrelated but notable health problems may be suitable candidates for these innovative procedures.

Cryoablation [sometimes called cryosurgery] is a theoretically sound therapeutic technique. It is performed with a machine that was developed in Tel Aviv, Israel, which uses pressurized argon and helium gases to regulate freezing and thawing processes. Visualization of the probe as it passes through the body allows for the introduction of the probe through a clear pathway and precise positioning of the probe. Once the probe is activated, freezing and thawing cycles are monitored with MRI. Multiple cycles are performed to obliterate as much of the tumor as possible. The procedure is performed under general anesthesia. After freezing, the probe is removed and the incision is closed with two or three sutures. Patients are awakened in the recovery room and transported to the general oncology ward for further observation. The oncology service as well as the interventional radiology service cares for the patient on the ward for the remainder of the patient's hospital stay. Recovery time ranges from two to eight days, depending on the location of the lesion and depth of treatment. Risks of the procedures include freezing of non-target tissues, internal bleeding, infection and damage to normal structures in the vicinity of the target tumor.

Freezing tumor cells interrupts critical cell functions and results in cell death. Cells that remain within the body are absorbed along with scar tissue. The effectiveness of cryotherapy has been well documented as it is utilized in the treatment of numerous lesions throughout the body. Freezing and thawing cycles have been well studied; they are not experimental in nature. Accessing the tumor through a small incision under image guidance comprises the innovative aspect of this operation.

Hospital stay after radio frequency tumor ablation is generally shorter than after cryoablation, in part because of the smaller probe that is used in the former procedure. Some lesions that could not be treated with conventional methods can be addressed and eliminated through modern technological advances. Patients with other significant health problems who are not candidates for conventional treatments might be eligible for these novel techniques. It is not uncommon for cryogenic or radio frequency treatments to be the only ones available to the patient who has additional health problems. Radio frequency ablation is less painful and takes less time than cryotherapy.

Frequently Asked Questions

Am I a candidate for these procedures? What do I do to receive this treatment?

Answer: Each procedure has benefits and risks unique to itself. The location of the tumor, the size of the tumor, the type of tumor as well as any previous chemotherapy or radiation all have bearing on which procedure would benefit you most. After obtaining pertinent clinical information and reviewing CAT scans and MRI's, I will be able to recommend which treatment would be your best option. The initial step in evaluation is to forward your most recent MRI and CAT scan images and reports, a medical history, a biopsy report, and a pathology slide to the University of Mississippi Medical Center for my review. Additionally, a phone consultation with your oncologist is usually very beneficial to me in obtaining more pertinent information.

What is the estimated time before I can receive any treatment?
Answer: In general, it usually takes at least two weeks to complete the initial evaluation where I review the clinical information and the x-ray images. An appointment in the Oncology Clinic here at the University can then be scheduled if the procedure appears technically feasible based on the preliminary information I receive. That appointment can usually be obtained in approximately two to three weeks. Overall, some patients are treated within two to three weeks of my first becoming aware of their situation, but is more routine to have a patient treated four to six weeks after the initial contact.

Is this treatment offered anywhere else?
Answer: Both of these treatments are new and thus there are very few people within the world who are experienced in these procedures. We are certainly one of the leading centers in the world with only a handful of other locations suited and capable of performing these procedures. In general, my personal experience places my rank as one of the top three people in the world performing these procedures.

Is this considered a major surgery?
Answer: Yes. Both procedures usually require general anesthesia and one to several days within the hospital. There is the risk of significant complications such as bleeding or infection and even death with both of these procedures depending on the location of the tumor.

Are these procedures experimental?
Answer: Some cryoablation procedures are investigational although cryoablation has a long history of successfully treating many malignancies. Technical advances such as utilizing the MRI for guidance are considered the experimental aspects. The radio frequency ablation is considered a very new procedure, however technically it is not experimental as the FDA has approved it here in the United States as off the shelf technology. In any event, the technology is so new that there are only a handful of people experienced with this equipment and procedure within the world.

Is this a cure for cancer?
Answer: Not at this time. This has the potential to function as a cure (a surgical cure) if the tumor is caught in its early stage where it is localized and has not metastasized. Once it has spread to different locations (metastasis), the only chance for a cure is a systemic therapy such as a cancer vaccine or perhaps some form of chemotherapy. You may think of this procedure as the equivalent of surgically removing that tumor which is frozen because once it is frozen entirely, those tumor cells are dead and will no longer grow. Tumor cells that are left alone (not frozen) for whatever reason will continue to grow unless some form of therapy is administered to them as well.

What type of tumors/cancers are normally treated by these methods?
Answer: Tumors in any organ in the abdomen or pelvis can be treated by both cryoablation and radio frequency ablation. Tumors in the lung are limited at this time to radio frequency ablation because of the breathing motion prohibiting visualization on MRI.

What happens to the tumor during the procedure?
Answer: During cryoablation, the tumor is frozen. The water within the cell freezes and expands which ruptures the cell membrane and in effect kills the tumor cell. During radio frequency ablation, heat is generated at the probe tip such that the tumor is essentially cooked. Both methods apply extreme temperature to the tumor in an effort to kill the tumor cell.

What effect will this have on my body?
Answer: The goal is to halt the growth of the tumor being treated. Potential side effects include damage to structures adjacent to the area treated. These side effects can be temporary or permanent. They potentially include infection and bleeding as well as loss of function of certain organs. The procedure is planned such that these risks are minimized. However, there is always some degree of risk with all surgical procedures.

Compared to chemotherapy and radiation, is this a better treatment?
Answer: Chemotherapy and radiation have their own merits and deficits. Which treatment is best for you and your tumor depends on a lot of individual variations which need to be addressed on a case-by-case basis. In general terms, this is a surgical treatment which can be used to augment chemotherapy or radiation and at this time is not planned as a substitute for either. When dealing with the tumor, one approach is to hit the tumor hard with all guns rather than just with one bullet.

What is the success rate?
Answer: Cases performed so far have included those patients with few options and very large or extensive tumors. Regardless, the success rate has been quite dramatic in certain cases. It is too early to determine whether survival has been significantly improved in the patients whom I have treated. However, all patients seem to be satisfied with the results at this time, and I can certainly say that I have prolonged the survival in a hand full of patients treated. The preliminary data is encouraging. One definite and clear benefit is significant pain relief from metastasis to the bone treated with cryotherapy.

How much pain will I experience?
Answer: The amount of pain the patient experiences is variable and depends on the size of the tumor treated as well as the location. Some patients have immediate pain relief whereas some patients have increased pain for the first couple of days which then returns to normal and begins to decrease.

How long will the procedure take?
Answer: Cryotherapy usually takes several hours under general anesthesia. Radio frequency ablation is usually quicker because the tumors treated with the radio frequency ablation are generally smaller. In any case, the procedure usually lasts from two to five hours.

How long will I be in the hospital?
Answer: A hospital stay can be as short as twenty-four hours and as long as seven to eight days depending on the lesion treated, the location, and the size of the tumor.

How much will this cost?
Answer: The cost of the procedure is variable and depends on the method of ablation (cryotherapy versus radio frequency) as well as the location, size, and number of tumors. Each patient's case can be addressed individually, and our business manager will be happy to work with you in determining the expected cost of the procedure.
VATS [Video Assisted Thoracoscopic Surgery]

VATS is like laparascopic [or keyhole] surgery, but in the chest. It is a useful choice for lung metastases.

Search Pubmed for VATS and sarcoma treatment search

Search Pubmed for VATS and lung metastases


Below are some annotated citations of Medical Journal Article abstracts; they have been heavily edited. The full abstracts can be found on PubMed.

1. Harefuah 2001 Feb;140(2):91-4, 192
[Video-assisted thoracic surgery--experience with 586 patients]. [Article in Hebrew]
Galili R, Nesher N, Sharony R, et al. Dept. of Cardiothoracic Surgery, Carmel Medical Center and Rappaport Faculty of Medicine, Technion, Haifa.

Summary: They concluded that "thoracoscopy is a minimally invasive surgical technique with very low morbidity and high diagnostic accuracy. Postoperative recovery is brief and uneventful."
Fetch PMID: 11242935


2. J Surg Oncol 2001 Jan;76(1):47-52
Pulmonary metastasectomy: might the type of resection affect survival?
Mineo TC, Ambrogi V, Tonini G, Nofroni I. Thoracic Surgery Tor Vergata University, Rome, Italy. mineo@med.uniroma2.it

They concluded: "The type of resection did not disclose statistically significant differences on survival. Minimal surgery, especially by laser device, is recommended for less morbidity."
Fetch PMID: 11223824


3. Surgery 1999 Oct;126(4):636-41; discussion 641-2
Diagnostic and therapeutic video-assisted thoracic surgery resection of pulmonary metastases.
Lin JC, Wiechmann RJ, Szwerc MF, et al. Allegheny University Hospitals, Allegheny General, Pittsburgh, PA 15212, USA.

They concluded: "Results with VATS resection of peripheral pulmonary metastases for diagnostic and potentially curative intentions appear comparable with historical results by "open" thoracotomy. "
They added: "Conversion to thoracotomy is indicated when lesions identified preoperatively are not found or when technical problems encountered may compromise surgical margins when resecting lung metastases for potential cure."
Fetch PMID: 10520909


4. Nippon Geka Gakkai Zasshi 1998 Dec;99(12):855-60
[Surgical management of pulmonary metastases].[Article in Japanese]
Hara S, Otsuka H, Hirohata T, et al. First Department of Surgery, Kinki University School of Medicine, Osakasayama, Japan.

They found that "the size of pulmonary tumors or tumor doubling time has no significant effect on survival, while the number of metastatic foci does."
They also concluded, "VATS is not be recommended for metastatic cancer surgery, because intraoperative identification of metastatic foci is often difficult". Publication Types: Review
Fetch PMID: 10063499

this section compiled December 2001 doctordee

Comparison of RFA, VATS, and Thoracotomy for Lung Tumors
Summary of risks, benefits, and indications.


1. Thoracotomy is the surgical opening up of the thorax, the chest cavity. If done for metastases, it will allow for palpation of the entire lung, and mets that haven't shown on imaging can be removed as well. There is no size limitation to the removal. Surgeons have more mobility and access. It can be done as a bilateral procedure... eg clamshell. It is very invasive and has a long convalescence, and there can be complications. Seeding of tracks can occur, but isn't a usual occurrence.


2. VATS is Video Assisted Thoracoscopic Surgery. It is like laparoscopic or keyhole surgery. VATS is less invasive than thoracotomy, but has a limit to the size of the tissue that can be removed [tumors 3mc or under, usually]. It is possible also to seed tumor cells in the surgical tracks, but this is not a usual occurrence. You can not manually feel for other lung tumors with this. But you can get live tumor for biopsy or for chemosensitivity testing or for other purposes [eg microarray, vaccine]


3. RFA is radio frequency ablation, essentially heat ablation. RFA cooks the tumors. It is also done through the skin, also a less invasive process. The tumor must be completely ablated, with some margin, otherwise it will return. There is an optimal size tumor for this technique as well. This cannot be used near major blood vessels or vital structures because of the danger of heat injury to the surroundings. It doesn't seed its tracks as heat is applied to the exit channel. Because the tumor is ablated, it is not possibly to get tissue from it to examine. This is the technique which is most conserving of lung tissue.


Since stage IV LMS has no cures, NONE of these operations would actually be considered curative, really. BUT surgical removal or ablation of lung tumors has been proven to extend survival time, and generally longer than chemotherapy treatment for lung mets. "lnk" "
See Metastasectomies" "metastasectomies.htm#010intro"

Furthermore, the lesser invasiveness of VATS and RFA lends them to managing lung mets in a frailer individual who might not be a candidate for a thoracotomy.

There are a limited number of chemotherapy agents that might work on LMS. So if there is a chance to preserve a chemo choice, or to buy some time off chemo, with a fairly noninvasive technique, it would make sense.

Even if other metastases are present, lung mets are potentially lethal and require attention. If chemo is going to be done anyway, OK, your might as well see if the lung mets shrink. BUT DO NOT lose the window of opportunity for surgery or RFA intervention of those lung tumors.

We have had 3 people with LMS lung mets treated by RFA on the LMS list. They all bought time. One of them had a recurrence from a bleed during preop embolization, requiring a thoracotomy. One of them had a recurrence of one part of a huge tumor as well as two new mets, requiring another op. One of them developed multiple small new lung mets 10 months later and went onto chemo. All of them had time off chemo with an excellent quality of life after the RFA.

One of the ladies who had VATS twice, just presented with a wraparound lung tumor invading the chest wall in the area, presumably from seeding in the area.

There is a place for VATS, RFA and thoracotomy, all of them, in the treatment of metastatic disease of the lung. All techniques have their advantages and disadvantages.

Decisions about which technique to use depend upon number and location of mets, and whether they are adjacent to blood vessels or vital organs. It depends upon whether tissue is needed for diagnosis. It may also depend upon the status of the disease in the rest of the patient's body, and how physically healthy the patient is.

The best way to decide is to seek out practitioners of all techniques and ask them about feasibility and probable outcome. Sometimes scans can be sent by courier to the doctor, alone, to cut down on traveling costs and time if the answer is NO.


Then, there is this attitude:
European Journal of Cardio-Thoracic Surgery Vol. 21, issue 6, June 2002, 1111-1114
Pulmonary Metastases: Can Accurate Radiological Evaluation Avoidthe Thoracotomic Approach?
Margarita, S., et. al.

Interesting article. The aim of the study (Italian) was to evaluate the
effectiveness of radiological assessment of lung mets and to verify if a
complete manual exploration by thoracotomy is necessary. They used
high-resolution CT and helical CT for imaging. All patients (166) underwent
axillary thoracotomy (staged if bilateral lesions were present); accurate
palpation of the lung parenchyma was always performed to identify any
radiologically undetected lesions. Non-metastatic lesions were excluded
from analysis.

"High-resolution CT (group A) correctly identified 142/188 lesions. Helical
CT (group B) identified 142/173 lesions. There was relatively poor
sensitivity of CT to identify lesions smaller than 6mm."

"Conclusions: Preoperative assessment by conventional CT is unsatisfactory
even with high-resolution approach. CT scan missed 24% of the lesions in
this study. In other studies CT missed 30-49% of mets found at thoracotomy.
This means that a significant number of smaller lesions would have been
missed with VATS approach to metastasectomy. CT sensitivity was 100% for
lesions larger than 1 cm but decreased as size of mets decreased."

These authors do not agree that VATS is a viable treatment option for
patients even with a solitary nodule. They believe a muscle-sparing
thoracotomy is mandatory in the surgical approach of pulmonary metastases.

The rebuttal to this argument is that VATS or RFA can be repeated when the undetectable lung mets grow to a size that makes them amenable to RFA or VATS. Since removal of lung mets in LMS is a palliative operation, one aimed at increasing survival, VATS or RFA. can be repeated at such time that growth of the new mets makes it warranted.

This section updated November 2003 doctordee
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