Microwave Ablation with Tumor Permittivity Microwave Ablation with - - PowerPoint PPT Presentation

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Microwave Ablation with Tumor Permittivity Microwave Ablation with Tumor Permittivity Feedback Control: an Feedback Control: an Ablate & Ablate & Resect bl bl & & Resect Study in 10 Patients with S Study in 10 Patients

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SLIDE 1

Microwave Ablation with Tumor Permittivity Microwave Ablation with Tumor Permittivity Feedback Control: an Feedback Control: an bl & bl & S d i i i h S d i i i h Ablate & Ablate & Resect Resect Study in 10 Patients with Study in 10 Patients with Pulmonary Malignancies Pulmonary Malignancies

Farrah J. Wolf, MD, Farrah J. Wolf, MD, Bassam Bassam Aswad Aswad, MD, , MD, Thomas Ng, MD, & Damian E. Thomas Ng, MD, & Damian E. Dupuy Dupuy, MD, FACR , MD, FACR

Departments of Diagnostic Imaging, Pathology, Thoracic Surgery, Departments of Diagnostic Imaging, Pathology, Thoracic Surgery, & Office of Research Administration & Office of Research Administration Rhode Island Hospital Rhode Island Hospital Rhode Island Hospital Rhode Island Hospital

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SLIDE 2

Disclosures Disclosures Disclosures Disclosures

Damian E. Damian E. Dupuy Dupuy, MD , MD

MedWaves MedWaves

–

Grant Support Grant Support

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SLIDE 3

Background Background Background Background

Pulmonary Tumor Ablation Pulmonary Tumor Ablation

  • 20

20-

  • 25% patients with NSCLC present

25% patients with NSCLC present p p p p with localized disease with localized disease

  • Stage I, II and

Stage I, II and IIIa IIIa  surgical resection surgical resection

  • RFA is a safe and valuable

RFA is a safe and valuable tx tx option

  • ption
  • Most widely used ablative modality

Most widely used ablative modality y y y y

  • Surgically

Surgically unresectable unresectable

  • Medically inoperable

Medically inoperable

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SLIDE 4

Background Background Background Background

  • Advantages of microwave ablation

Advantages of microwave ablation

  • Hotter

Hotter

  • Faster

Faster

  • ↓

↓ Heat sink

Heat sink

  • No grounding pads

No grounding pads

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SLIDE 5

Background Background Background Background Heat Heat

↑ Kinetic

Kinetic Energy Energy Energy Energy

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SLIDE 6

Background Background Background Background

Dielectric Dielectric A li d A li d Properties of Properties of Tissues Tissues Applied Applied Conditions Conditions

Permittivity Permittivity

Physical Elements Physical Elements Physical Elements Physical Elements

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SLIDE 7

Background Background Background Background

Tumor Permittivity Feedback Control Tumor Permittivity Feedback Control

“Temperature Control” “Temperature Control” Temperature Control Temperature Control Mode Mode

Power 10 Power 10-

  • 32 Watts

32 Watts Frequency 902 Frequency 902-

  • 928 MHz

928 MHz

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SLIDE 8

Background Background Background Background

Maximize energy deposition within tumor Maximize energy deposition within tumor + Minimize the reflectivity/reverse power Minimize the reflectivity/reverse power + Hotter Hotter intra intra-

  • tumoral

tumoral temperatures temperatures with penetration with penetration into surrounding aerated lung tissue into surrounding aerated lung tissue g g g g

Oncologic resection margin (1cm) Oncologic resection margin (1cm)

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SLIDE 9

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

Study Design Study Design

  • Prospective study

Prospective study

  • Prospective study

Prospective study

  • Ablate and

Ablate and Resect Resect Protocol Protocol

IRB approved IRB approved

  • IRB approved

IRB approved

  • HIPPA compliant

HIPPA compliant

  • 10 consecutive patients at our institution

10 consecutive patients at our institution

  • Inclusion Criteria

Inclusion Criteria

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SLIDE 10

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

Patients Patients

  • Surgical resection of a biopsy

Surgical resection of a biopsy-proven proven Su g ca esect o

  • a b opsy

Su g ca esect o

  • a b opsy p o e

p o e pulmonary malignancy pulmonary malignancy

  • Pre

Pre-operative staging CT and PET

  • perative staging CT and PET-CT

CT

  • Pre

Pre operative staging CT and PET

  • perative staging CT and PET CT

CT

  • Informed consent obtained prior to

Informed consent obtained prior to enrollment enrollment enrollment enrollment

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SLIDE 11

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

Patients Patients

  • March 2009

March 2009 – January 2010 January 2010

  • March 2009

March 2009 January 2010 January 2010

  • 10 patients (6 male, 4 female)

10 patients (6 male, 4 female) M 71 ( 52 M 71 ( 52 82) 82)

  • Mean age 71 years (range, 52

Mean age 71 years (range, 52-82) 82)

  • Underwent intra

Underwent intra-

  • operative MWA of a
  • perative MWA of a

resectable resectable pulmonary malignancy pulmonary malignancy

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SLIDE 12

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

Endometrial Endometrial 5 pts 5 pts AdenoCa AdenoCa Mets Mets Colorectal Colorectal

Primary Disease Primary Disease

3 pts 3 pts 3 pts 3 pts SCC SCC

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SLIDE 13

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

Tumors Tumors

  • Mean maximum tumor diameter 2 4cm

Mean maximum tumor diameter 2 4cm

  • Mean maximum tumor diameter 2.4cm

Mean maximum tumor diameter 2.4cm

  • range, 0.9

range, 0.9-

  • 5.0cm

5.0cm

Mean tumor volume 8 6cm Mean tumor volume 8 6cm3

  • Mean tumor volume 8.6cm

Mean tumor volume 8.6cm3

  • range, 0.4

range, 0.4-

  • 53cm

53cm3

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SLIDE 14

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

Ablate & Ablate & Resect Resect Protocol Protocol

  • Initial consultation

Initial consultation

  • Intra

Intra-

  • Op

Op

GETA GETA

  • GETA

GETA

  • Thoracotomy

Thoracotomy with tumor exposure with tumor exposure Aeration of lung tissue via double Aeration of lung tissue via double lumen ET lumen ET

  • Aeration of lung tissue via double

Aeration of lung tissue via double-lumen ET lumen ET

  • MWA and Air

MWA and Air-

  • leak testing

leak testing Standard Resection (wedge or Standard Resection (wedge or lobectomy lobectomy)

  • Standard Resection (wedge or

Standard Resection (wedge or lobectomy lobectomy)

  • Pathologic analysis

Pathologic analysis

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SLIDE 15

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

MWA Technique MWA Technique

  • Straight 14 Gauge 4cm active tip MW

Straight 14 Gauge 4cm active tip MW

  • Straight, 14 Gauge, 4cm active tip MW

Straight, 14 Gauge, 4cm active tip MW antenna antenna

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SLIDE 16

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

MWA Antenna MWA Antenna

Cutting Tip Cutting Tip Reflectivity and Temp Sensor Reflectivity and Temp Sensor Antenna Antenna Cutting Tip Cutting Tip

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SLIDE 17

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

MWA Technique MWA Technique

Tumor Permittivity Feedback Control Tumor Permittivity Feedback Control Tumor Permittivity Feedback Control Tumor Permittivity Feedback Control

  • “Temperature Control Mode”

“Temperature Control Mode”

  • Power 10

Power 10-

  • 32 Watts

32 Watts

  • Energy efficient design

Energy efficient design

F 902 F 902 928 MH 928 MH

  • Frequency 902

Frequency 902-928 MHz 928 MHz

  • Target Temp 110

Target Temp 110-

  • 120

120 ・C C

  • Single 10 minute ablation

Single 10 minute ablation

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SLIDE 18

Materials & Methods Materials & Methods Materials & Methods Materials & Methods

Pathologic Analysis of Pathologic Analysis of Resected Resected Specimens Specimens

  • Gross inspection and sectioning

Gross inspection and sectioning Gross inspection and sectioning Gross inspection and sectioning

  • Maximum diameters

Maximum diameters

  • Prolate

Prolate ellipse volumetric estimations ellipse volumetric estimations

  • Prolate

Prolate ellipse volumetric estimations ellipse volumetric estimations

  • H & E staining

H & E staining C ll l d th fi d ith NADH C ll l d th fi d ith NADH

  • Cellular death confirmed with NADH

Cellular death confirmed with NADH assays assays

  • + staining = mitochondrial enzymatic

+ staining = mitochondrial enzymatic activity, cellular viability activity, cellular viability

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SLIDE 19

Results: Gross Analysis Results: Gross Analysis Results: Gross Analysis Results: Gross Analysis

Ablation Zone Characteristics: Ablation Zone Characteristics:

  • Ablation zone measurements

Ablation zone measurements

  • Ablation zone measurements

Ablation zone measurements

  • Grossly measurable in 5

Grossly measurable in 5 resected resected specimens specimens Mean maximum diameter 4 8cm Mean maximum diameter 4 8cm

  • Mean maximum diameter 4.8cm

Mean maximum diameter 4.8cm

  • (range, 3.0

(range, 3.0-

  • 6.5)

6.5)

Mean volume 15 1cm Mean volume 15 1cm3

  • Mean volume 15.1cm

Mean volume 15.1cm

  • (range, 7.3

(range, 7.3-

  • 25.1)

25.1)

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SLIDE 20

Results: Gross Analysis Results: Gross Analysis Results: Gross Analysis Results: Gross Analysis

Ablation Zone Characteristics Ablation Zone Characteristics

  • Pleural retraction

Pleural retraction

  • Pleural retraction

Pleural retraction

5.0cm, SCC 5.0cm, SCC

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SLIDE 21

Results: Gross Analysis Results: Gross Analysis Results: Gross Analysis Results: Gross Analysis

Ablation Zone Characteristics Ablation Zone Characteristics

  • Hyperemic ellipsoid zone of coagulation

Hyperemic ellipsoid zone of coagulation

  • Hyperemic ellipsoid zone of coagulation

Hyperemic ellipsoid zone of coagulation necrosis necrosis

2.5cm, 2.5cm, AdenoCa AdenoCa

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SLIDE 22

Results: H & E Analysis Results: H & E Analysis Results: H & E Analysis Results: H & E Analysis

Ablation Zone Characteristics Ablation Zone Characteristics

  • H & E staining of all specimens

H & E staining of all specimens H & E staining of all specimens H & E staining of all specimens

  • Coagulation necrosis:

Coagulation necrosis:

Loss of cellular architecture Loss of cellular architecture

  • Loss of cellular architecture

Loss of cellular architecture

  • No discernable membrane

No discernable membrane Amorphous cytoplasm Amorphous cytoplasm

  • Amorphous cytoplasm

Amorphous cytoplasm

  • Nuclear changes

Nuclear changes

2.5cm, 2.5cm, AdenoCa AdenoCa

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SLIDE 23

Results: H & E Analysis Results: H & E Analysis Results: H & E Analysis Results: H & E Analysis

Ablation Zone Characteristics Ablation Zone Characteristics

  • Coagulation necrosis:

Coagulation necrosis: Coagulation necrosis: Coagulation necrosis:

2.6cm, CRC Met 2.6cm, CRC Met

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SLIDE 24

Results: H & E Analysis Results: H & E Analysis Results: H & E Analysis Results: H & E Analysis

Ablation Zone Characteristics Ablation Zone Characteristics

  • Cytotoxic

Cytotoxic heating of heating of peri peri-tumoral tumoral aerated aerated Cytotoxic Cytotoxic heating of heating of peri peri tumoral tumoral aerated aerated pulmonary parenchyma pulmonary parenchyma

2.6cm, Endometrial Met 2.6cm, Endometrial Met

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SLIDE 25

Results: NADH Analysis Results: NADH Analysis Results: NADH Analysis Results: NADH Analysis

Ablation Zone Characteristics Ablation Zone Characteristics

  • NADH Staining Assays

NADH Staining Assays

  • NADH Staining Assays

NADH Staining Assays

  • 6 specimens

6 specimens Confirming complete lack of viability Confirming complete lack of viability

  • Confirming complete lack of viability

Confirming complete lack of viability

  • ablation zones

ablation zones

  • aerated pulmonary parenchyma

aerated pulmonary parenchyma

  • aerated pulmonary parenchyma

aerated pulmonary parenchyma

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SLIDE 26

Results: NADH Analysis Results: NADH Analysis Results: NADH Analysis Results: NADH Analysis

1.0cm, 1.0cm, AdenoCa AdenoCa

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SLIDE 27

Results: NADH Analysis Results: NADH Analysis Results: NADH Analysis Results: NADH Analysis

Ablation Zone Characteristics Ablation Zone Characteristics

  • NADH Staining

NADH Staining

  • NADH Staining

NADH Staining

  • Non

Non-

  • viable cells extending up to and

viable cells extending up to and including vessel walls including vessel walls including vessel walls including vessel walls

  • no evidence of thrombosis

no evidence of thrombosis

0.2cm 0.2cm

2.3cm, 2.3cm, AdenoCa AdenoCa

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SLIDE 28

Results Results Results Results

Safety Safety

  • Intra

Intra-operative post

  • perative post-ablation air leak

ablation air leak

  • Intra

Intra operative, post

  • perative, post ablation air leak

ablation air leak

  • 1 Patient

1 Patient

Post Post operative mortality rate 1% (1/10)

  • perative mortality rate 1% (1/10)
  • Post

Post-operative mortality rate, 1% (1/10)

  • perative mortality rate, 1% (1/10)
  • POD # 5 s/p

POD # 5 s/p lobectomy lobectomy P i i f il P i i f il

  • Progressive respiratory system failure

Progressive respiratory system failure

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SLIDE 29

Results Results Results Results

Study Limitations Study Limitations

  • Underestimation of ablation zone size

Underestimation of ablation zone size Underestimation of ablation zone size Underestimation of ablation zone size

  • MWA

MWA  significant tissue contraction significant tissue contraction

  • Up to 52% in center of ablation zone

Up to 52% in center of ablation zone 1 p

  • Measure contracted tissue

Measure contracted tissue

  • Falsely smaller ablation zone volumes

Falsely smaller ablation zone volumes Falsely smaller ablation zone volumes Falsely smaller ablation zone volumes

  • Tissue

Tissue friablilty friablilty  limited gross analysis limited gross analysis Small cohort size Small cohort size

  • Small cohort size

Small cohort size

1 Brace CL, Diaz TA, Hinshaw JL, Lee FT Jr. Tissue contraction caused by radiofrequency and microwave ablation: a laboratory study in liver and lung. JVIR 2010; 21:1280-6.

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SLIDE 30

Conclusions Conclusions Conclusions Conclusions

  • Maximize the delivered MW energy

Maximize the delivered MW energy

  • Minimize the reflectivity/reverse power

Minimize the reflectivity/reverse power

  • Minimize the reflectivity/reverse power

Minimize the reflectivity/reverse power

  • MWA

MWA Tumor Tumor Permitivitty Permitivitty Feedback Control Feedback Control resulted in : resulted in : resulted in : resulted in :

  • Cytotoxic

Cytotoxic intra intra-

  • tumoral

tumoral temperatures temperatures E t i f th bl ti i t t d E t i f th bl ti i t t d

  • Extension of the ablation zone into aerated,

Extension of the ablation zone into aerated, peri peri-

  • tumoral

tumoral pulmonary tissue pulmonary tissue Oncologic resection margin Oncologic resection margin

  • Oncologic resection margin

Oncologic resection margin

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SLIDE 31

Thank You Thank You

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SLIDE 32