Interventional Oncology Pioneer Luigi Solbiati, MD, Discusses Therapy Trends

Luigi Alessandro Solbiati, MD, is professor of radiology at the Humanitas University and Research Center in Rozzano, Italy. Interventional Oncology 360 spoke with Dr. Solbiati at the 2015 Synergy interventional oncology meeting. He shared some thoughts on the growth of the interventional oncology specialty and the evolution of specific therapies like microwave ablation and radiofrequency ablation. 

IO360: How have you seen interventional oncology evolve over the years?

Solbiati: I am very impressed by the development of interventional oncology throughout the world. The first ablation I did was in 1982, 32 years ago. That’s why I am considered one of the pioneers of interventional oncology. I did not expect to see such an impressive growth of interventional oncology in the world. But there are several reasons this happened. First, technology is improving every day, so we can now reach tumors in different parts of the body and different areas safely and quickly with low costs. Second, we are always improving the quality of our treatments in terms of the amount of energy delivered in radiofrequency and microwave procedures, for example. Also, intra-arterial treatments are improving. 

In the early days of interventional oncology, we had maybe one or two options and decided quickly on a course of treatment. Today, we have a multidisciplinary team that discusses every case, especially every complex case. Patient by patient and lesion by lesion, we decide what is the best treatment option. This leads to the problem of trying to offer all options in a single center. In Italy, for example, the diffusion radiofrequency ablation was impressive in the first 10 or 15 years of interventional oncology therapy. We saw the development of many small centers performing only radiofrequency operations. These centers now are outdated because this is not currently the way to manage most of our oncologic patients. This is the era of multidisciplinarity, so patients have to be concentrated in centers that can offer all the possible alternatives: surgery, interventional oncology, transcutaneous therapies, and intra-arterial therapies such as chemoembolization, radioembolization, and so on. These increase in complexity but also dramatically improve our results. We have changed the history of cancer in conjunction with surgery and in conjunction with clinical oncology and radiotherapy. These four pillars of oncology are increasingly improving results in our patients. 

We are now beginning to face the problem of when to say no. We will see patients in their 90s with oncologic problems, and they are aware that you can possibly offer noninvasive or minimally invasive treatments, so they ask for that. Again, you have to be very careful and discuss treatment on a case-by-case basis, because you may have complications not directly related to your treatment but to the age of the patient, cardiac situation, pulmonary situation, brain conditions. This is creating a different scenario. The question is now sometimes when to say, no, I cannot treat you, because the risks related to your general condition, not your oncologic situation, may be too high. This is the current situation in Italy. 

The discussion we had just a few minutes ago in the panel we just finished was regarding colorectal metastases. Now we see, treat, and even cure patients who were operated on 10, 12, 15 years ago for colon cancer. If you go back to when I started my career – I am old, but not so old – the scenario was completely different, so this is a clear advantage for our patients. 

IO360: Are there therapies you believe will become more widely used?

Solbiati: There are two parts to this answer. First, existing therapies are continually being modified and improved. Almost all of them have room to grow. A few years may go by, and then a new technique replaces the previous one. The second part is the introduction of new treatments. A typical example in my opinion is radiofrequency versus microwaves. In China, they started using microwave ablation with their own machines many years ago because they could not afford to buy the traditional, expensive radiofrequency machines. The results of microwaves in China with those machines were not so convincing, for sure worse than what we had with radiofrequency in the Western world. So radiofrequency was diffused everywhere and became the most important radio modality. 

At the moment, there is no more scientific investment or economic investment being made in radiofrequency, and people are moving to microwaves. This is because now we have technology for microwaves that is completely different, much better performing. Recently, I moved to a private Milan university, the largest private university in Italy, where we have all the different kinds of therapies and I almost completely replaced radiofrequency, used for 20 years, with microwaves. I don’t know if in the near future, radiofrequency will dramatically improve in order to overcome microwaves, but this is the current status. 

Irreversible electroporation is also getting traction, and it was totally nonexistent until about 5 years ago. We are now defining what types of situations, probably limited situations, in which IRE is better than microwave or radiofrequency ablation. 

Ten or 15 years ago, cryoablation was very difficult to use percutaneously because of the large size of the cryoprobes that you introduce through the skin. Now they have very thin cryoprobes, and in bone treatments and some particular cases of kidney tumors, cryoablation is probably better than all the others. 

Cancer centers with interventional oncology cannot afford to have just one technology. You must have different technologies. In my previous hospital, 3 or 4 years ago, a throat specialist came to me and said we have a patient with malignant lymph nodes in the neck. The patient had surgery for papillary thyroid cancer. Usually they are very young patients. This is not such an aggressive disease, but it tends to regrow in the neck area in the lymph nodes, and it becomes increasingly difficult to operate repeatedly. Complications with the nerves and vessels increase. We asked, why not use an ablation technology to destroy these continuously growing lymph nodes in a minimally invasive way? In the beginning I was doubtful because no one had done it, but we decided to try it. We chose laser. Laser was thought to be almost useless for this ablation, but laser can be driven into a small target percutaneously without any damage to surrounding structures because it uses a very thin needle. So we started and it’s now becoming a treatment of choice in some situations. These patients are extremely satisfied because they come to the hospital in the early morning, the procedure takes 20 to 40 minutes, they stay for just 1 or 2 hours of observation, and they can go home the same day and start working the day after. It’s amazing. 

Another therapy that is well known in Europe but not so well known in the United States is ablation for goiter. Goiter is extremely common in Europe, and traditional therapy is thyroidectomy. Patients with goiter are often young female patients with a normally functioning thyroid gland, so removing the entire gland just because of a slowly growing benign mass is really a problem sometimes. 

Now, with ablation, we can treat using radiofrequency, applying the therapy for 20 to 45 minutes depending on the size of the tumor using only local anesthesia. The patients feel nothing; they can talk to us during the procedure. After 2 hours of observation, patients go home, and in a few months, we have a reduction in size of up to 70% of the initial volume, and that’s good. It’s enough because it’s not a malignant disease. You don’t need to destroy the entire mass. If you destroy 70% of the mass, it’s excellent because the reduction in volume allows the patient to have a normal life without any local problem. Day by day, we introduce new applications. It’s great progress. 

Suggested citation: Ford J. Interventional oncology pioneer Luigi Solbiati, MD, discusses therapy trends. Intervent Oncol 360. 2016;4(1):E18-E20.