Interventional Oncology: Adding Options to the Care of Patients with Cancer
Authors: Daniel B. Brown
Journal: Journal of the National Comprehensive Cancer Network (2015)

Last spring, the husband of a patient I treated in 2004 unexpectedly contacted me. I initially met with him and his wife to discuss salvage treatment options for her metastatic colorectal cancer (CRC). After a right hepatectomy to treat metachronous metastases from her colon cancer, she had developed a new 3-cm focus deep in segment 4. The tumor had progressed on oxaliplatin and irinotecan. The hepatobiliary surgeon was hesitant about repeat surgery, out of concern that her short disease-free interval might portend rapid development of widespread metastatic disease. Her medical oncologist and surgeon inquired whether any percutaneous options were available for the new metastasis. During the clinic visit, the anxiety felt by the patient and her husband was palpable. Young and previously healthy, she had exhausted standard therapeutic options. Fortunately, my group was able to successfully perform radiofrequency ablation on the metastasis. We followed up with her in our clinic, and a year later she developed a new retroperitoneal focus that we also ablated. Over time, I moved to a new institution and was no longer directly involved in her care. The most recent communication was a heartfelt thank you from her husband for helping to provide her with a cancer-free decade because she remained not only alive but also disease-free 10 years after treatment. Anecdotal outcomes surpassing expectations are one of the strongest positive reinforcements clinicians receive, but this patient’s clinical course also provides relevant insights into the current status of interventional oncology, particularly as it relates to treatment options for liver metastases from CRC. Minimally invasive imageguided treatments, such as chemoembolization, radioembolization with yttrium-90 (90Y) microspheres, and thermal ablation, are increasingly being used in the United States. Current indications for these treatments are part of several NCCN Guidelines. Ablation is the preferred treatment modality in renal cell carcinoma for surgical candidates with suboptimal health, and outcomes appear similar to those of partial nephrectomy for patients with T1a tumors. Transarterial therapies are recommended for progressive liver metastases in many patients with neuroendocrine tumors. Transarterial therapies and ablation are also the preferred treatments for patients with unresectable hepatocellular carcinoma. Complete resection of hepatic metastases from CRC that has spread to the liver can be curative; this option is the gold standard and will remain so. However, given that only 10% to 20% of patients are candidates for resection, the overwhelming majority of patients with liver-dominant metastatic disease survive only as allowed by systemic or biologic agents. This bleak prognosis has led to more aggressive measures for patients with unresectable disease, including maximal operative debulking supplemented by ablation of remaining disease. Given the expansion of potential surgical strategies for cure, it is worth reevaluating palliative options, including whether 90Y provides benefit within the first 2 lines of systemic therapy. Enthusiasm in the oncology community regarding the benefit of 90Y for CRC metastases remains mixed at best. These reservations are understandable, because much of the literature contains anecdotal reports, and, similar to my patient, are from single-center retrospective experiences with limited sample size. The issue of prospective data is being addressed: multiple large-scale prospective randomized trials comparing firstand secondline therapy with and without 90Y are in progress. An additional randomized prospective trial is evaluating 90Y plus chemotherapy as part of maintenance therapy after first-line FOLFOX/bevacizumab versus maintenance therapy alone. Daniel B. Brown, MD