What is the role of radiofrequency ablation in stage I inoperable NSCLC?
Radiofrequency ablation (RFA) is a minimally invasive technique which uses a percutaneous probe to thermally ablate tumours of the liver and lung. It is a treatment option for patients who are unsuitable for lobectomy, which is the standard of care for stage I NSCLC.
Sublobar resection versus RFA
One non-randomised single institution study compared outcomes following sublobar resection (n = 25), cryoablation therapy (n = 27) and RFA (n = 12) in 64 patients with stage I NSCLC judged unsuitable for lobectomy. Survival at three years was in the range of 77 – 87% with no statistically significant differences between groups. Cancer free survival at three years was 61% for the sublobar resection group vs 50% for the RFA and 46% for the cryoablation groups (P > 0.05). There was a non-significant increase in incidence of pneumothorax and haemoptysis in the patients having non-surgical treatments. A second non-randomised single institution study compared sublobar resection (n = 45), 3D conformal radiotherapy (n = 39) and RFA (n = 12) in patients not fit for lobectomy, but no survival estimates were provided for the RFA group. There were three cases of pneumothorax requiring therapy in patients having RFA, but none in the other groups. A third non-randomised study, with only 22 patients, reported longer survival in matched patients treated with surgery compared with RFA (P = 0.054). In a larger single institution cohort study, survival (not adjusted for risk factors) was superior in high risk patients having wedge resection (n = 59) compared with RFA (n = 62), P = 0.044, but when the analysis was restricted to patients with T1 tumours, the difference was no longer significant (P = 0.499). Finally, in a single institution retrospective comparison of primary tumour control and survival in patients with stage I NSCLC who were treated with sublobar resection, RFA or radiotherapy (both conventional fractionation and SABR), primary tumour control was superior in patients having sublobar resection compared with the other modalities, but there were no differences in overall survival.
In a non-randomised single institution study, the survival and cost of treating elderly patients unsuitable for lobar resection were compared for sublobar resection (n = 28) and RFA (n = 56). In addition to the primary therapies, there were differences in the use of adjuvant chemotherapy and radiotherapy between the groups. Although the survival of the surgical group was significantly longer, the cost per month of life lived was less for the RFA group.
Evidence summary and recommendations
Further studies are required to define the efficacy and toxicities of radiofrequency ablation in the treatment of stage I NSCLC before its routine use can be recommended.
There are several techniques available for thermal ablation of tumours of which RFA is one. The others are microwave and cryo-ablation.
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