Gianpaolo Carrafiello, follow up after thermoablation therapy, jfim ifupi milan 2018

Follow-up
after thermoablation therapy
Full Professor of Radiology University of Milan
Chief of Diagnostic and Interventional Radiology of San Paolo Hospital, Milan, Italy
G. Carrafiello
Abdominal and Urinary multiparametric

DisadvantagesAdvantages
- Margins difficult to see
- Risk of injury to adjacent organs
- Less Invasive
- Repeatability
- Shorter hospitalization
PERCUTANEOUS IMAGING GUIDED THERMAL ABLATION
Direct application of chemical (nonenergy) or
energy-based (thermal and nonthermal) therapies
to eradicate or substantially destroy focal tumors
performed percutaneously under imaging guidance

Imaging Follow-up after thermoablation therapy
Planning
Targeting Monitoring
Intraprocedural
Modification
FOLLOW-UP
IMAGING
&
ABLATION

§  Post Treatment Evaluation
§  Imaging-Follow-up

§  Post Treatment Evaluation: assessment of immediate treatment response
•  Technical success, or was the tumor treated according to
protocol?
•  Complication or were critical structures and complications
avoided?
•  Technique efficacy, or was the tumor effectively ablated?

Technical success, or was the tumor treated according to protocol?

whether the tumor was treated according to protocol
and was covered completely by the ablation zone.
Tumor coverage can be assessed either during or immediately following the
procedure, most often with contrast-enhanced CT or contrast-enhanced US.

General characteristics
-Refers to the area of coagulative necrosis induced by ablation
-Should encompass the treated tumor with a circumferential
margin of 5-10 mm around the tumor
-Periablation hyperemia due to inflammatory reaction and
granulation tissue formation induced from thermal injury.
-Peri-ablation changes should progressively decrease 4-9
months after ablation.
Technical success : ABLATION ZONE

-Immediate post-op: The ablation zone appears hypoattenuating or
heterogeneously hyperattenuating because of coagulative necrosis

- The shape can be irregular due to heat sink effect.
- NECT: a sharply marginated, hypoattenuating rim
- CECT: an ill-defined, thin rim of enhancement on arterial phase and
sometimes persists on portal venous phase.
CT findings

-Initial follow-up: the ablation appears hyperintense on T1, hypointense on T2 due to
coagulative necrosis and blood products.
- No enhancement
- T2: a subtle hyperintense rim suggestive of periablation edema
- Post contrast MR: an ill-defined, thin rim of enhancement on arterial phase and
sometimes persists on portal venous phase

MR findings

RM pre
W/o mdc w mdc
RM post

Technical success : ABLATION ZONE & CEUS

PLANNING
TARGETING
INTRAPROCEDURAL
MODIFICATION
MONITORING
IMMEDIATE
ASSESSMENT
of TREATMENT
New Technology: C-arm CBCT

6 mo FU 3 mo FU
Predictability

COMBINED THERAPIES IN LARGE HCC

CBCT HA (after ablation) CBCT HA (PRE ablation)

CBCT HA (after ablation)
CBCT HA (PRE ablation)
DSA (after ablation pre TACE) DSA (end of combined treatment)
CBCT HA (after ablation) Lipiodol CBCT (at the end of procedure)

Complication or were critical structures and complications avoided?
Complications should be reported using the most recent version of
the SIR Classification standard table so that they can be categorized
consistently according to severity.

Complication: Minor Complications

41mm
Complication: Minor Complications

Complication: Major Complications

Complication: MajorComplications

Technique efficacy, or was the tumor effectively ablated?
•  primary efficacy rate is defined as the percentage of target
tumors successfully eradicated following the initial procedure or a
defined course of treatment.
•  Secondary or assisted efficacy rate is defined as including tumors
that have undergone successful repeat ablation following
identification of local tumor progression.

- Caused by incomplete coverage of tumor because of large tumor size,
inaccurate targeting or heat sink effect.
- MR offers a higher sensitivity than CT in detecting residual disease.

CT findings
- CECT: residual disease appears as an eccentric, irregular, peripheral
enhancing nodule with early arterial enhancement and washout on
delayed phase.
Technique efficacy: RESIDUAL DISEASE

- Caused by incomplete coverage of tumor because of large tumor size,
inaccurate targeting or heat sink effect.
- MR offers a higher sensitivity than CT in detecting residual disease.

MR findings
- Focal, nodular T2 hyperintense focus adjacent to the ablation zone with
corresponding early arterial enhancement and washout on delayed phase
is suggestive of residual disease.
Technique efficacy: RESIDUAL DISEASE

§  Follow-up: Outcomes

§  Local response (imaging assessment)
§  Systemic response (pain, cancer syndromes, etc)
ü  Quality of life
ü  Time to progression (or progression-free survival)
or overall survival.

§  Follow-up: IMAGING FOLLOW-UP

§  Confirm complete ablation
§  Surrogate Biomarker of Outcomes
§  Reproducible
§  Replicable during Image Guidance
§  No Risk to Patient
§  Minimal Cost

•  there is a lack of consensus on a standard follow-up interval regimen for
imaging.
•  The most common approach include contrast-enhanced imaging within 6
weeks of the initial ablation to determine whether or not additional
ablation therapy is required and thereafter every 3–4 months, to
determine technique efficacy.
•  Imaging intervals may also vary depending on the type of underlying tumor
and the goals of treatment.

•  At most institutions, a 3 or 4-phase contrast enhanced CT is
performed immediately or within 1 month after ablation to assess the
technical success of treatment.
•  If ablation was technically successful, multiphase CT or MR may be
repeated at a 3-month intervals for evaluation of recurrence.
•  MRI is more sensitive to detect smaller residual and recurrence
tumors

Eisenhauer et al. New Response Evaluation Criteria in Solid Tumors: Revised RECIST guideline (version 1.1) – European Journal of Cancer 2009; 45: 228–247
Bajpai et al. Image-guided Treatment in the Hepatobiliary System: Role of Imaging in Treatment Planning and Posttreatment Evaluation - RadioGraphics
2015; 35:1393–1418

Eisenhauer et al. New Response Evaluation Criteria in Solid Tumors: Revised RECIST guideline (version 1.1) – European Journal of Cancer 2009; 45: 228–247
Bajpai et al. Image-guided Treatment in the Hepatobiliary System: Role of Imaging in Treatment Planning and Posttreatment Evaluation - RadioGraphics 2015; 35:1393–1418

Park et al. Spectrum of CT Findings after Radiofrequency Ablation of Hepatic Tumors - RadioGraphics 2008; 28:379–392
Minami et al. Therapeutic response assessment of RFA for HCC: Contrast-enhanced US, CT and MRI - World J Gastroenterol 2014; 20(15): 4160-4166

§  Follow-up: IMAGING FOLLOW-UP: Complete Response

3 mo. 6 mo. 12 mo. 1 mo.

1 mo FU 6 mo FU 12 mo FU
15mm

The primary technique effectiveness was 90% (9/10) because one
patient was identified as PD on CECT performed at 1 month (1 PR,
8 SD, 1 PD).

No Complete Responders were observed
§  Follow-up: IMAGING FOLLOW-UP: PANCREAS

2011 pre treatment 2011 post treatment 2012
2013 2014
§  Follow-up: IMAGING FOLLOW-UP: PANCREAS…complete or not complete this is the problem?!

-Development of tumor on follow up imaging after tumor was successfully ablated.
-Recurrence manifest as a new peripheral enhancing nodule.
-Recurrence can also appear as an irregular or asymmetric thickening along the
margin of the ablation zone or as new/progressively enlargement of the ablation
zone

§  Follow-up: IMAGING FOLLOW-UP: RECURRENCE DISEASE

CT findings
- CECT: recurrence appears as a new eccentric, irregular, peripheral
enhancing nodule with early arterial enhancement and washout on
delayed phase.


3mo. Follow up after 2°
ablation

MR findings

New focal, nodular T2 hyperintense focus adjacent to the ablation zone
with corresponding early arterial enhancement and washout on
delayed phase is suggestive of recurrence.

CT FU After surgery

•  Immediate and Long term Follow up
•  MRI > CT in detection residual and recurrence
•  CT is enough for retreatment planning in renal and liver mets
•  MRI > CT in HCC

§  CONCLUSIONS

Novel Approaches for Ablation and Embolization with ultrasound, Dual Phase CBCT and OncoSuite
LUNG ABLATION & ONCOSUITE
INTRAPROCEDURAL
MODIFICATION
MONITORING

IMMEDIATE ASSESSMENT of TREATMENT

•  7 Patients with lung tumor treated with RFA or MWA were selected and treated on the basis
of the 3D CBCT fusion imaging;
•  In all cases the volume of ablation predicted was in accordance with that obtained.

Gianpaolo Carrafiello, follow up after thermoablation therapy, jfim ifupi milan 2018

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Gianpaolo Carrafiello, follow up after thermoablation therapy, jfim ifupi milan 2018