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One of the first lessons learned in life is not to play with fire. Sticking your finger in a flame or on a hot stove can do a number on your finger. Burnt flesh hurts and takes a while to heal. Based on our early experiences, heat wouldn't seem to contain many healing powers. True, heat can destroy but its therapeutic potential is elusive. Heat is difficult to control.
Or, maybe it is better said, was difficult to control. Recognizing the destructive potential of heat, engineers and researchers have been successful in finding ways to harness and apply heat in a controlled fashion so as to limit the resultant destruction to a desired volume of tissue and thus was born thermal ablation.
Thermal ablation therapy is a hot topic in more ways than one. No question—it's definitely hot. And thermal ablation is on the cutting edge of interventional techniques, as evidenced by the increasing number of enthusiastic reports on thermal ablation appearing in the literature over the last 2 years.
The reports have been coming so hot and heavy that you might be a bit confused by it all. No wonder, what with the great variety of available ablation techniques proposed for use at various sites and under various conditions. This is particularly true for those of us who don't perform, or have not yet performed, such a procedure and may lack knowledge of the underlying physical principles at play with these techniques. It is not easy to sort it all out.
Take heart. In this issue, Goldberg et al. [1] provide a perspective, an informative backgrounder, on this subject suitably entitled, "Thermal Ablation Therapy for Focal Malignancy: A Unified Approach to Underlying Principles, Techniques, and Diagnostic Imaging Guidance." The article is just as advertised. These authors review the various techniques, explain the physical principles involved, describe essential differences of the various techniques, detail the sources of potential problems, and outline steps that should be taken to avoid them; it's just what you need to know to bring yourself up-to-date on this hot subject.
No doubt, "toasting tumors" has appeal.
"Thermal ablation." The phrase carries a note of finality and gives the immediate impression of triumph. Thermal ablation is likely to be an easy sell to patients. It sounds simple and worth the effort. The prospect of ridding yourself of tumors without the tribulations of surgery is attractive.
However, lest we get carried away, we must remind ourselves of the fact that being able to do something is not sufficient reason to do it. The ability to perform is not an indication to do so. The ability to perform should not, in and of itself, be construed as an indication to proceed. It's one thing to be able to do something. It's another to prove doing so is worthwhile.
Now that researchers have demonstrated that thermal ablation can be safely performed, it must be determined for what specific tumors and under what specific circumstances it should be used. There are many questions to be answered. Which sites are amenable? What tumors are responsive? Are some more responsive than others? What is the maximum size of tumor that can be treated? How does one best treat tumors with irregular geometry? How many foci of metastases can be treated at one sitting?
How effective is this form of treatment? How long does the therapeutic effect last? What is the recurrence rate? What is the impact on patient survival? What is the impact on the quality of life? Are the conditions of patients in some way, either objectively or subjectively, improved by treatment of multiple metastases? Is the survival of such patients significantly prolonged?
Where does thermal ablation fit with other forms of treatment? Can it be combined with chemotherapy or surgery to any advantage?
Much remains to be determined.
The organ sparing or organ preservation potential of thermal ablation of small tumors of the kidney, pancreas, lung, and even osteoid osteomas of the bony skeleton, is certainly intriguing. The potential to treat multifocal metastases or multicentric foci of primary hepatocellular carcinoma in the liver and elsewhere is encouraging. And it is reasonable to anticipate improvements. Future modifications of present techniques will certainly enhance the ease and effectiveness and further expand the role of thermal ablation.
In short, thermal ablation appears safe and has shown great promise, but its ultimate role remains to be determined. We look forward to reporting the refinements and progress on all this "hot stuff" right here in the pages of the AJR. Stay tuned.
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