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on Coagulation Necrosis in a Canine Tumor Model Radiology 230: 761-767, 2004 26. Steinke K, King J, Glenn D et al Percutaneous Radiofrequency Ablation of Lung Tumors with Expandable Needle Electrodes: Tips from Preliminary experience AJR 183: 605-611, 2004 27. Lee JM, Jin GY, Goldberg SN et al Percutaneous Radiofrequency Ablation for Inoperable Non-Small Cell Lung Cancer and Metastases: Preliminary Report Radiology 230: 125-134, 2004 28. Akeboshi M, Yamakado K, Nakatsuka A et al Percutaneous Radiofrequency Ablation of Lung Neoplasms : Initial Therapeutic Response J Vasc Interv Radiol 15 : 463-470, 2004 29. Kotaro Y, Susumu K, Yoshifumi S et al Thoracic Tumors Treated with CT-guided Radiofrequency Ablation: Initial Experience Radiology 231: 850-857, 2004 30. Cosmo G, Vittorio M, Giuseppe C et al Radiofrequency Ablation of 40 Lung Neoplasms: Preliminary Results AJR 183: 361-368, 2004 31. Vaughn C, Mychaskiw G 2nd, Sewell P et al Massive hemorrhage during radiofrequency ablation of a pulmonary neoplasm Anesth Anal 94(5):1149-51, 2002 32. Rose S C. Fotoohi M, Levin D et al Cerebral Microembolization during Radiofrequency Ablation of Lung Malignancies. Journal of Vascular & Interventiona I Radiology. 13(0):1051-1054, 2002 33. Jin GY, Lee JM, Lee YC, Han YM .Acute cerebral infarction after radiofrequency ablation of an atypical carcinoid pulmonary tumor. AJR Am J Roentgenol. 182(4):990-992, 2004 34. Martini N, Bains MS, Burt ME et al . Incidence of local recurrence and second primaries in resected stage I lung cancer. J Thorac Cardiovasc Surg 109: 120-129, 1995 35. Naruke T, Goya T, Tsuchiya R et al. Prognosis and survival in resected lung carcinoma based on the new international staging system J Thorac Cardiovasc Surg 96: 440-447, 1988 36. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1NO non-small cell lung cancer. Lung cancer study group. Ann Thorac Surg 60: 615-623, 1995 37. Herrera LJ, Fernando HC, Peny Y Radiofrequency ablation of pulmonary malignant tumors in nonsurgical candidates. J Thorac Cardiovasc Surg. 125(4): 929-37, 2003. 38. Kodama K, Doi 0, Higashiymama M, et al .Intentional limited resection for selcetd patients with T1 NO non small- cell lung cancer: a single institute study. J Thorac Cardiovasc Surg 114: 347-353, 1997

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39. Okada M, Yoshikawa K, Hatta T, et al . Is segmentectomy with lymph node assessment an alternative to lobectomoy for non small -cell lung cancer of 2 cm or smaller I Ann Thorac Surg 71:956-960, 2001 40. Jain S, Dupuy DE, Cardarelli et al . Percutaneous Radiofrequency Ablation of Pulmonary Malignancies: Combined treatment with Brachytherapy AJR 181: 711-715, 2003 41. Kvale RA, Simoff M, Prakash UBS . Palliative care. Chest 123: 284S-311S, 2003 42. SUPPORT principal investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA 274: 1591-1598, 1995 43. Langendijk JA, Ten Velde GPM, Aaronson NK, et al. Quality of life after palliative radiotherapy in nonsmall cell lung cancer: a prospective study. Int J Radiat Oncol BioI Phys 47: 149-155, 2000 44. Callstrom M ,Charboneau W , Goetz MP, et aI, Painful Metastases InvolVing Bone: Feasibility of Percutaneous CT- and US-guided Radio-frequency Ablation Radiology 224: 87-97, 2002 45. Posteraro AF, Dupuy DE, Mayo-Smith W.Radiofrequency ablation of bony metastasic disease. Clin Radiol 59:803-811, 2004 46. Bojarski J. Dupuy DE, Mayo-Smith W. CT Imaging findings of pulmonary neoplasms after Treatment with Radiofrequency Ablation: results in 32 tumors. AJR [in pressJ. 47. Swenson 5J, Viggiano RW, Midthun DE, et al. Lung nodule enhancement on CT : a multicentric study. Radiology 314: 73-80, 2000 48. Berber E , Foroutani A, Garland AM, et al. Use of CT hounsefield unit denSity to identify ablated tumor after laproscopic radiofrequency ablation of ablated tumors. Surg Endosc 14:799-804, 2000 49. Patz EF Jr, Connolly J, Herndon J. Prognostic value of thoracic FDG PET imaging after treatment for non-small cell lung cancer. AJR Am J Roentgenol. 174(3):769-74, 2000 50. Akhurst T, Downey RJ, Ginsberg MS et al. An initial experience with FDG- PET in the imaging of residual disease after induction chemotherapy for lung cancer. Ann Thorac Surg 73:259-264, 2002

3:50 p.m. Bone William Charboneau, MD Mayo Clinic Rochester, MN

4:05 p.m. HCC

Daniel B. Brown, MD Mallinckrodt Institute 0/ Radiology Saint Louis, MO

Many issues come into play when deciding how to treat an individual patient with HCC. These factors are often interrelated and the treating IR needs to consider more than one while forming a treatment plan. Items to consider include: • Tumor number/burden • Tumor size • Tumor location • Liver function • Operator experience Treatment strategies to be addressed include arterial infusion and direct ablation. Most operators in the US perform embolizationlchemoembolization as an arterial therapy and radiofrequency ablation as a direct ablative therapy. Therefore, this presentation will focus on these modalities. Tumor number/burden: If a cirrhotic patient has greater than 50% liver replacement by tumor, the IR needs to proceed with great caution. Usually, patients with a significant disease burden have too much tumor for radiofrequency ablation and they will be managed with chemoembolization alone. If the liver function tests are reasonably well maintained, embolization can be carefully performed. A reasonable strategy is to perfolm a series of sessions which can be broken down by segments rather than lobar infusions. "Stalling small" will allow the operator to assess the level of toxicity resulting from chemoembolization while minimizing the risk from extensive hepatic necrosis. As always, diagnostic alleriography through the portal venous phase is essential to ensure that the main pOllal vein is patent or that there is sufficient collateral flow to allow safe treatment. Tumor size: Ablative technologies are best suited for small tumors, specifically those less than 3 cm in diameter. In patients reqUiring treatment of a single tumor measuring up to 6 cm in diameter, radiofrequency ablation may be combined with intravascular techniques that simulate the surgical Pringle maneuver. Investigators have described pre-ablation embolizationlchemoembolization as well as temporary arterial and hepatic venous balloon occlusion to increase the diameter of the ablation sphere. Although combination therapy allows the use of radiofrequency ablation to treat larger tumors, here are no available studies demonstrating improved durable tumor destruction with combined chemoembolization/radiofrequency ablation over chemoembolization alone. Tumors larger than 6 cm are generally t.reated with chemoembolization without supplemental ablative techniques. Tumor location: Location in the liver is not usually a critical issue for safety or efficacy of chemoembolization. However, tumors in certain specific locations may tip the interventionalist to evaluate for arterial supply apart from the hepatic arteries, particularly if the tumor has been previously treated. Tumors located along the dome of the liver adjacent to the diaphragm may be supplied by the inferior phrenic artely. Tumors on the anterior margin of the liver can be supplied by the internal mammary

arteries. Peripheral tumors along the posterior and lateral margins of the liver may be supplied by the intercostal arteries. When treating arteries with potential supply to the skin, the operator should either embolize with particles alone or consider coil embolization of the feeding artelY distal to the tumor supplying branches. Tumor location can be extremely important when performing radiofrequency ablation. Tumors within 2 cm of the portal hilum are poor candidates for radiofrequency ablation. Thermal injUlY to the bile ducts with subsequent stricture formation is a potentially disastrous outcome of treatment. Investigators have described injection of chilled saline in the bile ducts to avoid this complication. Hilar tumors are also adjacent to the largest vascular structures in the liver that may limit the margin of the thermal sphere secondary to the heat sink effect. If one performs radiofrequency ablation with conscious sedation, treatment of tumors adjacent to or involVing the liver capsule is much more painful. Treatments should also be planned so that the point of access traverses normal liver before entering the tumor. Needle tract seeding is a potential complication with radiofrequency ablation and traversing normal parenchyma prior to puncturing the tumor can minimize this risk. Liver function: Upper limits of liver function that can tolerate therapy with chemoembolization or radiofrequency ablation remain undefined. Patients with the following constellation of findings are generally considered to be at risk of an adverse outcome from chemoembolization: • More than 50% replacement of hepatic parenchyma with tumor • AST > 100 IU/L • LDH > 425 mU/ml • Bilirubin> 2 mg/dl Liver decompensation can be partial and patients can reestablish a new baseline following chemoembolization. Patients with Child A disease are more likely to drop to Child B status than Child B patients are to Child C. Child C patients have poor survival following chemoembolization and treatment of these individuals should be done on a case-by-case basis. Child A patients do survive significantly longer than Child B patients with low albumin «3.3 g/dL). Chemoembolization in individuals with severe hepatic dysfunction should be done as superselectively as possible to avoid treatment of non-cancerous parenchyma. One of the main limitations of radiofrequency ablation, the size of the thermal sphere that is created, may actually be a benefit in a patient where the operator wants to minimize treatment of non-cancerous liver. Ablation may prOVide a less risky alternative in patients with severe hepatic dysfunction although the operator needs to consider whether an intervention will extend a patient's life span, the primary mission of treatment. Operator experience: Individual IR's will have different levels of experience in performing chemoembolization and radiofrequency ablation based on when and

PH

where they trained as well as the referring patterns at each institution. In the process of developing an interventional oncology service, operators should choose first cases wisely. In a chemoembolization practice, initial focus should be on patients with well preserved liver function and hepatopedal portal venous flow. For RFA, treatment of small tumors will lead to the most satisfying results in a single session. If there is doubt about the ability to treat the entire lesion, one should discuss with the patient that more than one session may be needed or combine radiofrequency ablation may with chemoembolization to maximize effect. Radiofrequency ablation of tumors in challenging locations such as the dome of the liver provide specific challenges and risks such as diaphragmatic thermal injury or pneumothorax. Even with experience, it is important to discuss the potential for these complications with patients prior to the procedure. For referring physicians, informed solid post-procedural management will be an important reassurance that the IR they are sending their patients to is clinically able to treat and manage patients with complex issues. 4:20 p.m.

NET David Madofj, MD MD Andel'Son Cancer Center Houston, TX 4:35 p.m. BREAK

Taking Care of Your Patient: Symptom Management and Palliative Care Moderator: Michael C. Soulen, MD 4:50 p.m.

When Enough is Enough: The Intersection of Interventional Radiology and Palliative Care David Weissman, MD

5:50 p.m. Complications After Catheter-based Therapy Jose 1. Bilbao, MD, PhD Clinica Universitaria De Navarra Pamplona 6:10 p.m. Complications After Ablative Therapy Thierry de Baere, MD Institut Gustave Roussy Villejuif, France Radiofrequency (RF) is one of the most promising imaging-guided thermal ablation techniques used to treat liver, lung, bones, kidney and other tumors. Lessons learned from pioneers in the field of complications can lower your rate of complications by selecting appropriate patients and tumors, providing appropriate peri-ab-

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!ation cares, and recognizing the complications earlier enough to provide adequate treatment. This syllabus will be limited to liver and lung. LIVER

RF ablation of liver tumors is performed either percutaneously, or during open surgelY as an adjunct to liver resection to destroy unresectable tumors, or less frequently during laparoscopy. Todate, more than 10,000 radiofrequency procedures in the liver have been reported in publications, and the technique is considered relatively safe with a mortality rate of 0 to 0.9 % , and a major complication rate of 2 to 6% [1-4]. Complication rate is lower for percutaneous RF than for surgical procedures (1, 2, 4].

Infection Abscess is the more frequent clinically symptomatic complication after radiofrequency [2, 3, 5]. This complication raises the question of prophylactic antibiotherapy but no clear cut recommendations can be given because there is no scientific proof that prophylactic antibiotherapy is of any benefit. Consequently, further comparative trials on the value and the type of prophylactic antibiotherapy are needed. However, adequate patient selection will help in lowering the rate of such complications. Indeed, we demonstrated a highly Significant difference between the rate of abscess for patients with (3/3) and for patients without (4/223) a bilioenteric anastomosis [2]. In the same manner, Livraghi et al found 2 patients with a bilio-enteric anastomosis among the six abscesses that occurred after radiofrequency in analysis of 2,320 patients [3]. Bilioenteric anastomosis should be considered a major risk factor for septic complications after radiofrequency ablation, as we earlier demonstrated it was after transarterial chemoembolization or percutaneous ethanol injection [6]. Consequently, if radiofrequency ablation is mandatory in patients within a bilioentric anastomosis, a regimen of antibiotic prophylaxis should be tailored for them. Geschwind et al recently reported uneventful transarterial chemoembolization in patients bearing bilioenteric anastomosis using prophylaxis with intravenous tazobactam sodium/piperacillin sodium 10 g a day maintained for 3 days associated with bowel preparation with 45 ml of oral fleet phospho-soda, 1 g neomycin and 3 g a day of oral erythtromycin the day before the procedure [7]. Patients bearing biliary stents, namely crossing the ampulla, and patients who undelwent a sphincterotomy probably have a high risk of post ablation septiC complications. Furthermore, abscesses usually occurred a few weeks after RF 03 days to two months in our experience), thus indicating that there should probably be an interval between radiofrequency treatment and the administration of any subsequent immunodepressive treatment such as chemotherapy, even if it is difficult to give precise recommendations concerning the duration of this interval.