March 2021 | Issue 81
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IR Services IRs call on WHO
Profile Parag Patel
Insights from the SIR president-elect page 24
Ablation 2.0: Improved precision as interventionalists approach A0 Ablation is entering a new era of increased precision and quantification, the interventional radiology (IR) community argues, with outcomes that match or surpass those of surgery. Whilst reaching equipoise with their surgical counterparts has been a goal for interventional radiologists since the advent of ablative treatments for cancer, some expert interventionalists claim that the increased precision of modern thermal ablation techniques, coupled with improvements in radiology mean physicians are often treating smaller volume tumours. This now positions the procedure as the “definitive” treatment for select patients in some cancers. Several clinical trials—including the ACCLAIM, COLLISION, and COVER-ALL trials—are currently underway, and aim to bolster the evidence-base demonstrating favourable patient outcomes from thermal ablation.
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e are now talking about Varian, a radiotherapy company, which ablation 2.0,” past in 2019 itself acquired Endocare, a Society of Interventional company specialising in cryoablation Oncology (SIO) president Stephen and microwave ablation, and Alicon, Solomon (Memorial Sloan Kettering a provider of embolic therapy for liver Cancer Center, New York, USA) says. cancer treatment. “Ablation 1.0”, in his eyes, is the basic Cascination is another company concept underpinning the minimally offering an over-arching solution invasive procedure: put a needle in, for ablation, with products designed use image guidance, burn or freeze for imaging, planning, navigation, the cancerous tissue to destroy it. “But validation, treatment, and treatment ablation 2.0,” he explains, “means that verification. Breen believes this we are focusing more on precision, on is the direction industry is taking, margins, and specifically the road to A0 and represents a shift away from a [where all tumour cells are eradicated].” more modular approach where one When discussing soft and organisation may only offer products for hardware advances in ablation, part of this pathway. David Breen (University Hospital of Southampton, Southampton, UK) Developing improved adopts the framework of “planning, planning software execution, confirmation”. Planning Several different groups around the uses preprocedural scans to map out world are working on developing probe positions and angles, along with planning software for ablation estimation of the ablation zone—all treatments with the goal of obtaining the steps taken ahead of performing the a predictable technical outcome. “In ablation. Execution is the act of probe order to do this effectively,” current SIO Intra-ablation feedback: software positioning, sometimes using guidance president Matthew Callstrom (Mayo using biomechanical deformable tools. The final stage, confirmation, Clinic, Rochester, USA) explains, “it is registration volumetric imaging involves determining the adequacy of necessary to have accurate registration treatment margins in order to verify complete ablation.. software for all phases of the ablation, including planning, “Of these three stages, confirmation and perhaps intraprocedural evaluation of device placement, and planning are the two that are beginning to enter a higher postprocedural measurement of the margins of the level of engineering maturity and reliability,” Breen ablation. This approach will transition thermal ablation explains. Guidance tools, as they currently stand, must still from a subjective technical endpoint to an objective be used with careful operator insight”. technical endpoint. I think the exciting aspect of this is that The upcoming European Conference on Interventional many efforts are underway and will become more widely Oncology (ECIO; 10–13 April, online) is hosting a session available to proceduralists.” entitled “Different ways of killing cancer and why we need From the department of Interventional Radiology at all of them”, which explores advances in ablation. The University of Texas MD Anderson Cancer Center In a further sign of the times, several large companies (Houston, USA), Bruno Odisio tells Interventional are positioning themselves to buy smaller businesses News that he and imaging physicist Kristy K Brock have operating in this space. In 2020, for example, imaging received a National Institute of Health (NIH) grant for behemoth Siemens Healthineers acquired all shares of Continued on page 2
COVID-19 Rising to the challenges ahead page 34
IO solutions for patients with brain tumours: Intraarterial delivery of chemotherapy improves survival The use of intra-arterial (IA) delivery for the treatment of malignant brain tumours is safe and provides clinical benefits in terms of survival when used with the appropriate therapeutic agents, according to a small, phase II study presented at the virtual European Conference on Interventional Oncology (ECIO; 24 February, online). Delivering these results, Gérald Gahide (Sherbrooke University Hospital, Sherbrooke, Quebec, Canada) told delegates that while the study demonstrated the technical feasibility and safety of this application, “there is a dire need for designing multicentre, prospective, phase III studies to properly compare IA and intravenous [IV] treatments”. GLIOBLASTOMAS AND LYMPHOMAS, both types of primary malignant cerebral nervous system tumours, are quite rare, with an incidence of 8.85 out of 100,000 and seven out of 1,000,000, respectively, of the adult population in the USA. Standard treatment for the former tumour is cytoreductive surgery, where the interventionalist takes a debulking strategy of removing as much of the tumour as possible. When used in conjunction with complementary external beam radiation and chemotherapy, the median survival time is 14.6 months. Gahide told delegates: “Unfortunately, it is impossible to remove all of the tumour because it is a very infiltrated disease and relapse is the norm, and five-year survival is less than 10%”. Commenting on the treatment of cerebral nervous system lymphoma, he said: “The only point that people agree on is that there should be high IV [intravenous] dose of methotrexate (3g/m2) during the induction, but, as of today, there is no consensus regarding what other drugs to use for induction or consolidation.”
Survival improved with intraarterial delivery
In their prospective, phase II study, Gahide and colleagues treated 51 patients at first (n=39) Continued on page 4