A Need for Multidisciplinary Understanding of Ablation in Oncology

Our colleagues in surgical, medical, and radiation oncology still need to be made aware of the efficacy and application of ablation.

Consider a 65-year-old female patient presenting to the local thoracic multidisciplinary conference with a small (<1 cm) colorectal metastasis in the periphery of the right lung and a similar lesion in the left lung. Both lesions were sited in positions easily accessible to a percutaneous treatment. These lesions have been slowly growing and appear to be oligometastases. This is a common presentation with metastases that have bypassed the liver. Everyone in the room recognised that these metastases would not be the last this patient would have.

In a unit where microwave ablation of lung metastases is available and has been very successful it beggars imagination when the thoracic surgeon suggested one lesion be resected and the other one watched and the response from the remainder of the conference (except the interventional radiologists) was not ablation but bilateral thoracotomy two weeks apart. One can only imagine what the response will be when the next lung metastasis appears in this patient.

The thoracic surgeon looked stunned when ablation was suggested as if it had never been done before and unfortunately the medical oncologists and radiation oncologists did not comment. Considering evidential medicine and cost-containment, let alone the best interests of the patient, this conference decision is a travesty. Sadly it is all too prevalent and one of the reasons that interventional oncology is not making the difference it should.

We need a similar document to the Barcelona-Clınic Liver Cancer Group for lung metastases. In a recent study of 27 patients with lung metastases after liver resection, the median disease-free survival was 13 months after lung resection with curative intent and the 5-year survival was 39% (Gonzalez M, Robert JH, Halkic N, Mentha G, Roth A, Perneger T, Ris HB, Gervaz P. Surg. Survival after lung metastasectomy in colorectal cancer patients with previously resected liver metastases. World J Surg. 2012;36:386-391). Ablation of small lung lesions is as effective as surgery, provided the tumor is completely ablated. Dead is dead. Many ablations are only offered as a last resort after every other treatment modality has been tried and has failed. That any ablations succeed at all in that environment is remarkable.

Repeated thoracotomy and segmental resection has obvious limits even to surgeons. Medical oncologists continue to administer multiple drug therapies until disease progression or toxicity occurs even when all hope of cure has passed. Surely lung ablation, repeated if necessary, is a reasonable alternative to present to the patient with oligometastases. Unfortunately in most cases the patient is the last to know what the true options for their disease are. Should the patient be able to access the deliberations of a multidisciplinary conference, they will find that only the final decision is recorded, not the options that were available to them.