Cryo-immunology: a review of the literature and proposed mechanisms for stimulatory versus suppressive immune responses

Applications of cryotherapy in premalignant and malignant esophageal disease: Preventing, treating, palliating disease and enhancing immunogenicity?

Cryotherapy is a treatment modality that uses extreme cold to destroy unwanted tissue through both immediate and delayed cellular injury. This therapy is increasingly being adopted across various medical specialties due to its minimally invasive nature and technological advancements that have been made. In the esophagus, cryotherapy is particularly utilized for the management of Barrett esophagus. It has been demonstrated to be effective and safe with potential benefits, such as a reduction in pain, over radiofrequency ablation. Additionally, it might offer a valuable alternative for patients unresponsive to radiofrequency ablation. Cryotherapy is applied for other conditions as well, including esophageal squamous cell neoplasia and malignant dysphagia. More research is needed to gain understanding of the utility in these conditions. Interestingly, cryotherapy has shown the ability to enhance the host’s immune response in reaction to antigens left in situ after treatment. While preclinical data have demonstrated promising results, the immune response is often insufficient to induce tumor regression in the clinical setting. Therefore, there is growing interest in the combination of cryotherapy and immunotherapy where ablation creates an antigen depot, and the immune system is subsequently stimulated. This combination holds promise for the future and potentially opens new doors for a breakthrough in cancer treatment.

Immunogenic cell death as interplay between physical anticancer modalities and immunotherapy

Current cancer treatment strategies in practice nowadays often face limitations in effectiveness due to factors such as resistance, recurrence, or suboptimal outcomes. Traditional approaches like chemotherapy often come with severe systemic side effects due to their non-specific action, prompting the development of more targeted therapies. Among these, physical ablation techniques such as radiotherapy (RT) and focused ultrasound (FUS) have gained attention for their ability to precisely target malignant tissues, reduce physical and mental stress for the patients, and minimize recovery time. These therapies also aim to stimulate the immune system through a process referred to as immunogenic cell death (ICD), enhancing the body's ability to fight cancer, explaining abscopal effects. RT has been the most established of the abovementioned techniques for decades, and will not be included in the review. While initially focused on complete tumor ablation, these techniques are now shifting towards milder, more controlled applications that induce ICD without extensive tissue damage. This review explores how physical ablation therapies can harness ICD to boost anticancer immunity, emphasizing their potential to complement immunotherapies and improve outcomes for cancer patients.

Thermal Protection Techniques for Image-guided Musculoskeletal Ablation

Percutaneous image-guided thermal ablation has gained wide acceptance among physicians for the treatment of benign and malignant tumors of the musculoskeletal system. Increasing evidence to support the efficacy of thermal ablation techniques in primary and adjuvant treatment of soft-tissue sarcomas, treatment of oligometastatic disease to bone and soft tissue, and metastatic pain palliation has positioned interventional oncology alongside surgery, systemic therapies, and radiation therapy as the fourth pillar of modern comprehensive cancer care. Despite the expanding indications and increasing use in clinical practice, thermal ablation carries a significant risk of injury to the adjacent vulnerable structures, predominantly the skin, bowel, and neural structures. Knowledge of the mechanism of action of each thermal ablation modality informs the physician of the attendant risks associated with a particular modality. Thermal ablation mechanisms can be divided into hypothermic (cryoablation) and hyperthermic (radiofrequency ablation, microwave ablation, high-intensity focused US, or laser). Active thermal protection techniques include hydrodissection, pneumodissection, direct skin thermal protection, and physical displacement techniques. Passive thermal protection techniques include temperature monitoring, biofeedback, and neurophysiologic monitoring. The authors provide an overview of the mechanism of action of the most commonly used thermal ablation modalities, review the thermal injury risks associated with these modalities, and introduce the active and passive thermal protective techniques critical to safe and effective musculoskeletal ablative therapy. ©RSNA, 2025 See the invited commentary by Tomasian and Jennings in this issue.

Rapid thawing enhances tissue destruction in a mouse model of cutaneous cryoablation: Insights into oxidative stress and neutrophil activation

BACKGROUND

Cryoablation is an integral therapeutic approach in dermatology for eliminating viral warts and benign tumors by damaging tissue through freeze-thaw cycles. Rapid thawing of the frozen area by warming it with fingertips during cryoablation is a common technique in Japan; however, its efficacy has not been elucidated.

OBJECTIVE

This study aimed to evaluate the effect of rapid thawing on cryoablation-treated skin and clarify the underlying mechanisms using cryoablation model mice.

METHODS

Cryoablation was performed on the dorsal skin of mice using a liquid nitrogen-soaked cotton swab, followed by rapid thawing by warming with fingertips or natural thawing without treatment. The effects on skin ulcers, immune cell infiltration, and oxidative stress were assessed.

RESULTS

Rapid thawing enlarged cryoablation-induced skin ulcers. The numbers of cryoablation-induced CD3+ T cells, neutrophils, neutrophil extracellular traps (NETs), and TUNEL+ cells increased with rapid thawing. Visualization of oxidative stress in OKD48 transgenic mice showed that oxidative stress signals in the cryoablation-treated area were enhanced with rapid thawing. Real-time PCR analysis of mouse skin demonstrated that cryoblation-induced levels of NOX2 and HO-1 were significantly elevated with rapid thawing. In mouse melanoma tumors treated with cryoablation, rapid thawing significantly inhibited tumor growth and increased the infiltration of neutrophils, NETs, and TUNEL+ cells compared to the group without rapid thawing.

CONCLUSION

Rapid thawing during cryoablation enhances neutrophil and lymphocyte infiltration, increases oxidative stress, and induces cell death, leading to greater tissue destruction in mice. Dermatologists should consider employing rapid thawing techniques during cryoablation when higher therapeutic intensities are required.

Cryoablation in breast tumours

Cryoablation is a percutaneous thermal ablation technique developed to destroy focal groups of cells using extreme cold. It is an outpatient and image-guided procedure, performed under local anaesthesia, with typically short recovery times and good outcomes. Percutaneous cryoablation has good success rates for treating breast fibroadenomas. It is used in cases of malignant tumours mainly when a patient refuses surgery or is not considered to be a suitable candidate. Some studies indicate that cryoablation could be as effective and safe as lumpectomy in cases of low-risk early-stage breast cancer. Moreover, some studies have reported a regression of metastatic foci after ablation of a primary tumour thanks to an anti-tumour immune response stimulated by cryoablation. This article describes the technique and its indications with regards to breast tumours according to the existing literature.

Focal therapy in prostate cancer: Development, application and outcomes in the United Kingdom

Prostate cancer is a significant health issue in the United Kingdom, with rising incidence rates prompting the exploration of innovative treatment options. Focal therapy has emerged as a targeted approach that aims to treat localised prostate cancer while minimising damage to surrounding healthy tissue and subsequent adverse side effects. Focal therapy is National Institute for Health and Care Excellence (NICE)-approved treatment modality for patients with intermediate-risk localised prostate cancer. This is an evolving field, reflecting the rapidly improved understanding of both the trajectory patients face following a diagnosis of prostate cancer, and how best to apply ablative techniques. In this narrative review, we evaluate the historical development, current practices, clinical outcome reported in UK-based studies, and future directions of focal therapy for prostate cancer in the United Kingdom, highlighting its evolution as a viable treatment option.

Current Perspectives of Immunotherapy for Hepatocellular Carcinoma

Hepatocellular carcinoma is the sixth most common tumor and the third leading cause of cancer death worldwide. It ranks fourth in the spectrum of malignant tumor incidence and second in the order of death from major malignant tumors in China. Hepatocellular carcinoma is a complex ecosystem containing non-tumor cells (mainly immune-related cells), and its immunotherapy can stimulate the recognition of specific tumor antigens, inhibit the proliferation of cancer cells, and produce over-memory lymphocytes, which can prevent recurrence. So, immunotherapy of hepatocellular carcinoma is increasingly becoming a research hotspot in liver cancer treatment. With the intensive research in recent years, great progress has been made in immunotherapy for hepatocellular carcinoma, including immune checkpoint inhibitors, pericyte therapy, vaccination, and antiviral therapy. In addition, the study found that the therapeutic effect of combination therapy was enhanced compared to monotherapy. This review summarizes the most prominent immunotherapies currently available for the clinical treatment of patients with HCC and the main opportunities and challenges facing HCC research.

Cutaneous Immune Responses to Ablative Fractional Laser, Heat- and Cold-Based Dermatological Procedures

OBJECTIVE

Physical treatment modalities, such as ablative fractional laser (AFL), electrocautery, and cryotherapy, are extensively used in the field of dermatology. This study aimed to characterize the short-term innate and adaptive immune responses induced by AFL compared with heat- and cold-based procedures.

MATERIALS AND METHODS

Innate (CD11b+Ly6G+ neutrophils) and adaptive (CD8+CD3+ T cells) immune cell infiltration and histopathological changes were examined in murine skin on Days 1 and 7, following AFL, monopolar-electrocautery (RF), thermocautery, and cryotherapy. Interventions were standardized to reach the reticular dermis. Clinical skin reactions were photo-documented daily. As a comparator, the adaptive immune response was examined in murine basal cell carcinomas (BCC) on Day 7 after AFL exposure.

RESULTS

Baseline histopathology confirmed immediate deep dermal tissue impact by all procedures. Immune cell dynamics varied across treatments throughout the progression of clinical and histopathological responses. On Day 1, AFL and heat-based procedures triggered an innate immune response, characterized by CD11b+Ly6G+ neutrophil cell infiltration that correlated with histopathological findings and immediate onset of clinical skin reactions. In addition, heat-based procedures led to an increase in overall dermal CD45+ cells (Day 1), which continued to rise for AFL and RF-electrocautery at Day 7 posttreatment. On the contrary, cryotherapy did not induce immediate (Day 1) innate immune responses, but instead a delayed increase in neutrophil and CD45+ cell infiltration (Day 7), which coincided with the late onset of clinical reaction. CD3+ T cells and CD8+CD3+ T cells demonstrated a similar pattern, with an increase observed for heat-based procedures on Day 1 and a delayed increase for cryotherapy on Day 7. Distinctive for AFL-treated skin, the level of dermal CD3+ T cells increased over time, significant by Day 7, and AFL-treated mouse BCCs responded with increased CD8+ T cell infiltration at Day 7 posttreatment.

CONCLUSION

Heat- and cold-based procedures developed distinct cutaneous immune responses, with cryotherapy resulting in a delayed response compared to immediate immune responses from heat-based procedures. The substantial T cell response induced by AFL in the skin and BCC tumors indicates a potential for AFL as an adjuvant in immunotherapeutic treatments of keratinocyte cancers.

Evaluating the Impact of Adjunctive Partial Cryoablation on Dual Checkpoint Inhibitor Immunotherapy Response in a Murine Model

Purpose To evaluate the impact of adjunctive partial cryoablation on checkpoint inhibitor (CPI) immunotherapy response. Materials and Methods One hundred fifty-six mice (equal number of male and female animals) with dual-implanted tumor models were treated with dual CPI or a vehicle and randomized to treatment of a single tumor with partial cryoablation. Tumors were followed for 60 days following cryoablation for response assessment. In additional groups, the tumor microenvironment was characterized via flow cytometry, cytokine analysis, and immunohistochemistry. Statistical comparison was made between the different treatment groups regarding T-cell infiltration and activation characteristics within the noncryoablated tumor and cytokine levels within the partially ablated tumor. Additionally, qualitative assessment of T-cell activation within the cryoablated and noncryoablated tumors at immunofluorescence was carried out. Results At 60 days following treatment, CPI and adjunctive cryoablation-treated MC-38 mice had a significantly increased survival rate (79%) compared with mice treated with CPI alone (61%; P < .001). CT-26 mice also had an increased survival rate (57% vs 35%, respectively; P = .04). Following cryoablation, increases in inflammatory cytokines and chemokines within the treated tumors were observed. Flow cytometry of noncryoablated tumor showed increased CD8 T-cell activation. Immunofluorescence and histologic evaluation following cryoablation further demonstrated a robust CD8 T-cell and myeloid infiltrate. Conclusion Adjunctive cryoablation significantly increased the response to dual CPI in multiple cancer models at both partially ablated and distant (nonablated) tumor sites. Immune analysis suggests cryoablation promotes a vigorous immune response within the partially cryoablated tumor that increases activation of the adaptive immune system within distant tumor sites. Keywords: Cancer, Cryoablation, Checkpoint Inhibitor Immunotherapy, Tumor Response Supplemental material is available for this article. © RSNA, 2024.

Cryotherapy in the Treatment of Early-Stage Breast Cancer

Breast cancer is one of the most common malignancies, affecting millions of people worldwide annually. The treatment paradigm for early-stage breast cancer is in flux. The focus is now on opportunities to de-escalation treatment to minimize morbidity and maximize patients' quality of life. Recently, percutaneous minimally invasive ablative techniques have been explored. Early trials in small population of patients demonstrated cryoablation to be effective, safe, and well-tolerated in an outpatient setting. Subsequent surgical resection was performed and the ablation success rate was the highest if the tumor was less than 1.5 cm and with < 25% ductal carcinoma in situ component. ACOSOG Alliance Z1072, a phase II trial with curative intent, demonstrated 100% ablation in all tumors smaller than 1 cm and 92% success in lesions without multifocal disease and less than 2 cm in size. There are ongoing prospective clinical trials to investigate the efficacy of cryoablation without surgical excision for treatment of early-stage breast cancer. FROST (Freezing Instead of Removal Of Small Tumors) started in 2016 is ongoing, ICE3 (Cryoablation of Low Risk Small Breast Cancer) started in 2014 just released 5 years results, and COOL-IT: Cryoablation vs Lumpectomy in T1 Breast Cancers is also ongoing. These prospective trials will expand our knowledge on the safety and value of cryoablation. It is crucial to understand the indications, technical nuances, and distinctive imaging findings for cryoablation as it has potential to revolutionize standard surgical practice.

Progress in the Application of Bronchoscopic Cryotherapy in Pediatric Pulmonary Diseases

Cryotherapy in interventional bronchoscopy is a new treatment modality which has recently been made available for the pediatric airway. Lack of experience and safety concerns have led to hesitant adaptation. The aim of this work was to elaborate on the application progress of cryotherapy in pediatric pulmonary diseases and also to assess indications, success rates, and complications of airway cryotherapy in children. In summary, cryotherapy via flexible bronchoscopy is a safe and feasible method. The application scope in pediatrics is similar to that in adults, and it is mainly used in airway obstructive diseases. However, it is primarily caused by benign conditions, and the interventional treatment mainly seeks to provide long-lasting symptomatic alleviation. Thus, prevention, treatment, and prognosis of long-term complications are issues that should be carefully considered in pediatric applications.

Prospects of Synergy: Local Interventions and CAR T Cell Therapy in Solid Tumors

Chimeric antigen receptor T cell therapy has been established in the treatment of various B cell malignancies. However, translating this therapeutic effect to treat solid tumors has been challenging because of their inter-tumoral as well as intratumoral heterogeneity and immunosuppressive microenvironment. Local interventions, such as surgery, radiotherapy, local ablation, and locoregional drug delivery, can enhance chimeric antigen receptor T cell therapy in solid tumors by improving tumor infiltration and reducing systemic toxicities. Additionally, ablation and radiotherapy have proven to (re-)activate systemic immune responses via abscopal effects and reprogram the tumor microenvironment on a physical, cellular, and chemical level. This review highlights the potential synergy of the combined approaches to overcome barriers of chimeric antigen receptor T cell therapy and summarizes recent studies that may pave the way for new treatment regimens.

Cryoablation and post-progression immune checkpoint inhibition in metastatic melanoma: a phase II trial

Image-guided percutaneous cryoablation is an established minimally invasive oncologic treatment. We hypothesized that cryoablation may modify the immune microenvironment through direct modulation of the tumor, thereby generating an anti-tumor response in tumors refractory to immune checkpoint inhibition (ICI). In this non-randomized phase II single-center study (NCT03290677), subjects with unresectable melanoma progressing on ICI underwent cryoablation of an enlarging metastasis, and ICI was continued for a minimum of two additional cycles. The primary endpoints were safety, feasibility and tumor response in non-ablated lesions. From May 2018 through July 2020, 17 patients were treated on study. The study met its primary endpoints with the combination strategy found to be safe and feasible with an objective response rate of 23.5% and disease control rate of 41% (4 partial response, 3 stable disease). Our data support further study of this synergistic therapeutic approach.

Image-guided Ablative Procedures

Various image-guided ablative procedures include chemical and thermal ablation techniques and irreversible electroporation. These have been used for curative intent for small tumours and palliative intent for debulking, immunogenicity and pain control. Understanding these techniques is critical to avoiding complications and achieving superior clinical outcomes. Additionally, combination with immunotherapy and chemotherapies is rapidly evolving. There are numerous opportunities in interventional radiology to advance ablation techniques and seamlessly integrate into current treatment regimens for both benign and malignant tumours.

Recent advances of ultrasound-responsive nanosystems in tumor immunotherapy

Immunotherapy has revolutionized cancer treatment by boosting the immune system and preventing disease escape mechanisms. Despite its potential, challenges like limited response rates and adverse immune effects impede its widespread clinical adoption. Ultrasound (US), known for its safety and effectiveness in tumor diagnosis and therapy, has been shown to significantly enhance immunotherapy when used with nanosystems. High-intensity focused ultrasound (HIFU) can obliterate tumor cells and elicit immune reactions through the creation of immunogenic debris. Low-intensity focused ultrasound (LIFU) bolsters tumor immunosuppression and mitigates metastasis risk by concentrating dendritic cells. Ultrasonic cavitation (UC) produces microbubbles that can transport immune enhancers directly, thus strengthening the immune response and therapeutic impact. Sonodynamic therapy (SDT) merges nanotechnology with immunotherapy, using specialized sonosensitizers to kill cancer cells and stimulate immune responses, increasing treatment success. This review discusses the integration of ultrasound-responsive nanosystems in tumor immunotherapy, exploring future opportunities and current hurdles.

Ultrasound-augmented cancer immunotherapy

Cancer is a growing worldwide health problem with the most broadly studied treatments, in which immunotherapy has made notable advancements in recent years. However, innumerable patients have presented a poor response to immunotherapy and simultaneously experienced immune-related adverse events, with failed therapeutic results and increased mortality rates. Consequently, it is crucial to develop alternate tactics to boost therapeutic effects without producing negative side effects. Ultrasound is considered to possess significant therapeutic potential in the antitumor field because of its inherent characteristics, including cavitation, pyrolysis, and sonoporation. Herein, this timely review presents the comprehensive and systematic research progress of ultrasound-enhanced cancer immunotherapy, focusing on the various ultrasound-related mechanisms and strategies. Moreover, this review summarizes the design and application of current sonosensitizers based on sonodynamic therapy, with an attempt to provide guidance on new directions for future cancer therapy.

Modern cancer therapy: cryoablation meets immune checkpoint blockade

Cryoablation, as a minimally invasive technology for the treatment of tumors, destroys target tumors with lethal low temperatures. It simultaneously releases a large number of tumor-specific antigens, pro-inflammatory cytokines, and nucleoproteins, known as "danger signals", activating the body's innate and adaptive immune responses. However, tumor cells can promote the inactivation of immune effector cells by reprogramming immune checkpoints, leading to the insufficiency of these antigens to induce an immune response capable of eradicating the tumor. Immune checkpoint blockers rejuvenate exhausted T cells by blocking immune checkpoints that induce programmed death of T cells, and are therefore considered a promising therapeutic strategy to enhance the immune effects of cryoablation. In this review, we provide a detailed explanation of the immunological mechanisms of cryoablation and articulate the theoretical basis and research progress of the treatment of cancer with cryoablation combined with immune checkpoint blockers. Preliminary data indicates that this combined treatment strategy exhibits good synergy and has been proven to be safe and effective.

Endoscopic spray cryotherapy for dysphagia palliation in esophageal cancer: Systematic review and meta-analysis

Background and study aims Endoscopically delivered liquid nitrogen spray cryotherapy is reported to be a safe and possibly more effective strategy for dysphagia palliation in patients with advanced esophageal cancer. This systematic review and meta-analysis aimed to pool all available data to evaluate the impact of this treatment modality. Methods Electronic databases (PubMed, Embase, and Cochrane Library) from January 2005 through June 2023 were searched for studies evaluating endoscopically delivered liquid nitrogen spray cryotherapy for dysphagia palliation in patients with advanced esophageal cancer. Pooled proportions were calculated using random-effects (DerSimonian-Laird) model. Results From an initial 895 studies, data were extracted and analyzed from five studies comprising a total of 230 patients that met inclusion criteria. In this pooled analysis, dysphagia improved or did not deteriorate in 81.40% of patients (95% confidence interval [CI] 73.75-87.99). Significant improvement in dysphagia was reported by 55.19% of patients (95% CI 29.62-79.37). An alternate method of dysphagia palliation despite spray cryotherapy was required in 18.78% of patients (95% CI 8.09-32.63) with 10.56% (95% CI 2.53-23.18) requiring esophageal stents. The weighted mean number of spray cryotherapy sessions per patient was 3.37 (95% CI 2.55-4.18). The pooled major adverse event rate was 3.26% (95% CI 0.15-10.14). Conclusions Endoscopic liquid nitrogen spray cryotherapy can effectively and safely treat dysphagia in esophageal cancer. It can be considered an option for dysphagia palliation in centers with expertise and equipment.

Present and future of metal nanoparticles in tumor ablation therapy

Cancer is an important factor affecting the quality of human life as well as causing death. Tumor ablation therapy is a minimally invasive local treatment modality with unique advantages in treating tumors that are difficult to remove surgically. However, due to its physical and chemical characteristics and the limitation of equipment technology, ablation therapy cannot completely kill all tumor tissues and cells at one time; moreover, it inevitably damages some normal tissues in the surrounding area during the ablation process. Therefore, this technology cannot be the first-line treatment for tumors at present. Metal nanoparticles themselves have good thermal and electrical conductivity and unique optical and magnetic properties. The combination of metal nanoparticles with tumor ablation technology, on the one hand, can enhance the killing and inhibiting effect of ablation technology on tumors by expanding the ablation range; on the other hand, the ablation technology changes the physicochemical microenvironment such as temperature, electric field, optics, oxygen content and pH in tumor tissues. It helps to stimulate the degree of local drug release of nanoparticles and increase the local content of anti-tumor drugs, thus forming a synergistic therapeutic effect with tumor ablation. Recent studies have found that some specific ablation methods will stimulate the body's immune response while physically killing tumor tissues, generating a large number of immune cells to cause secondary killing of tumor tissues and cells, and with the assistance of metal nanoparticles loaded with immune drugs, the effect of this anti-tumor immunotherapy can be further enhanced. Therefore, the combination of metal nanoparticles and ablative therapy has broad research potential. This review covers common metallic nanoparticles used for ablative therapy and discusses in detail their characteristics, mechanisms of action, potential challenges, and prospects in the field of ablation.

Radiotherapy, photodynamic therapy, and cryoablation-induced abscopal effect: Challenges and future prospects

Local therapy modalities such as radiation therapy, photodynamic therapy, photothermal therapy, and cryoablation have been used to treat localized tumors for decades. The discovery of the abscopal effect causes a paradigm shift where local therapy also causes systemic effects and leads to the remission of nonirradiated tumors. The abscopal effect of radiation therapy, alone or in combination with other treatments, has been extensively studied over the last six decades. However, the results are unsatisfactory in producing robust, reproducible, and long-lasting systemic effects. Although immunotherapy and radiation therapy are promising in producing the abscopal effect, the abscopal effect's mechanism is still unclear, owing to various factors such as irradiation type and dose and cancer type. This article reviews the research progress, clinical and preclinical evidence of the abscopal effect by various local therapies alone and in combination with chemotherapy and immunotherapy, case reports, and the current challenges in producing the abscopal effect by various local therapies, focusing on radiotherapy, photodynamic therapy, cryoablation, and the prospects for obtaining a robust, reproducible, and long-lasting abscopal effect.

Local Therapeutics for the Treatment of Oligo Metastatic Prostate Cancer

PURPOSE OF REVIEW

Metastatic prostate cancer remains universally lethal. Although de-novo metastatic prostate cancer was historically managed with systemic therapy alone, local therapies are increasingly utilized in the early treatment of the disease, particularly in patients with oligometastatic prostate cancer (OMPC). OMPC represents an intermediate stage between clinically localized and widespread metastatic disease. Diseases classified within this stage present an opportunity for localized targeting of the disease prior to progression to widespread metastases. The purpose of this review is to discuss the contemporary and emerging local therapies for the treatment of OMPC.

RECENT FINDINGS

To date, there are three utilized forms of local therapy for OMPC: cryoablation, radiation therapy, and cytoreductive prostatectomy. Cryoablation can be utilized for the total ablation of the prostate and has shown promising results in patients with OMPC either in combination with ADT or with ADT and systemic chemotherapy. Radiation therapy along with ADT has demonstrated improvement in progression-free survival. The STAMPEDE Arm G, PEACE-1, and the HORRAD clinical trials have investigated radiation therapy for mPCa compared to standard of care versus systemic therapy with varying results. Cytoreductive radical prostatectomy (CRP) in conjunction with ADT has also been proposed in the management of OPMC with promising results from case-control and retrospective studies. Currently there are larger controlled trials investigating CRP for OPMC including the SIMCAP, LoMP, TRoMbone, SWOG 1802, IP2-ATLANTA, g-RAMPP, and FUSCC-OMPCa trials. Given the novel nature of local treatments for OPMC, treatment selection is still controversial and requires long-term follow-up and randomized clinical trials to aid patient and clinician decision making.

Preliminary Results of Preoperative Planning Using 3D Printing and Augmented Reality in Cryotherapy Treatment of Giant Cell Tumor of Bone-CRIO2AR Project

Giant Cell Tumor of Bone is a benign tumor with high local aggressive expansion, which, in rare cases, spreads metastasis. Surgical treatment, which often consists of wide curettage to reduce recurrence risk, can lower the quality of life for those affected. Along with aggressive surgery, adjuvant intraoperative techniques have been implemented such as PMMA and cryotherapy. One of the most widely used cryotherapy techniques involves the use of probes to generate ice balls, which have been scientifically shown to have various impacts on the tumor. Although this has been acknowledged, no one has yet tested a way to accurately plan the positioning of cryotherapy probes before surgery, according to the research conducted by the authors. CRIO2AR is a randomized clinical prospective ongoing study by which it will be experimented via preoperative planning of ice probes placement using AR and 3D printing technologies. By studying a single clinical case with these technologies, the surgeon gains better awareness of patient's anatomy and tumor localization. Preliminary results are shown in the article. The first results are confirming that these technologies are applicable in clinical practice. Secondly, preoperative planning is proving to be reliable, easily replicable, and useful for the surgeon.

Cryoablation and immunity in non-small cell lung cancer: a new era of cryo-immunotherapy

Despite remarkable advances in tumor response and patient survival in the past decade, systemic immunotherapies for lung cancer result in an objective response in only around half of patients treated. On the basis of this limitation, combination strategies are being investigated to improve response rates. Cryoablation has been proposed as one such technique to induce immunogenic cell death and synergize with systemic immunotherapies, including immune checkpoint inhibitors. Cryoablation has been traditionally delivered percutaneously with imaging guidance although recent technological advances allow for bronchoscopic delivery. Herein, we review the pre-clinical and clinical evidence for the use of cryoablation in non-small cell lung cancer and potential induction of anti-tumor immunity. We highlight ongoing studies involving this approach and propose areas of future investigation.

Effects of Inflammatory Cell Death Caused by Catheter Ablation on Atrial Fibrillation

Atrial fibrillation (AF) poses a serious healthcare burden on society due to its high morbidity and the resulting serious complications such as thrombosis and heart failure. The principle of catheter ablation is to achieve electrical isolation by linear destruction of cardiac tissue, which makes AF a curable disease. Currently, catheter ablation does not have a high long-term success rate. The current academic consensus is that inflammation and fibrosis are central mechanisms in the progression of AF. However, artificially caused inflammatory cell death by catheter ablation may have a significant impact on structural and electrical remodeling, which may affect the long-term prognosis. This review first focused on the inflammatory response induced by apoptosis, necrosis, necroptosis, pyroptosis, ferroptosis and their interaction with arrhythmia. Then, we compared the differences in cell death induced by radiofrequency ablation, cryoballoon ablation and pulsed-field ablation. Finally, we discussed the structural and electrical remodeling caused by inflammation and the association between inflammation and the recurrence of AF after catheter ablation. Collectively, pulsed-field ablation will be a revolutionary innovation with faster, safer, better tissue selectivity and less inflammatory response induced by apoptosis-dominated cell death.

Treatment of Hepatocellular Carcinoma by Multimodal In Situ Vaccination Using Cryoablation and a Plant Virus Immunostimulant

PURPOSE

To test the hypothesis that cryoablation combined with intratumoral immunomodulating nanoparticles from cowpea mosaic virus (CPMV) as an in situ vaccination approach induces systemic antitumoral immunity in a murine model of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Mice with bilateral, subcutaneous RIL-175 cell-derived HCCs were randomized to 4 groups: (a) phosphate-buffered saline (control), (b) cryoablation only (Cryo), (c) CPMV-treated only (CPMV), and (d) cryoablation plus CPMV-treated (Cryo + CPMV) (N = 11-14 per group). Intratumoral CPMV was administered every 3 days for 4 doses, with cryoablation performed on the third day. Contralateral tumors were monitored. Tumor growth and systemic chemokine/cytokine levels were measured. A subset of tumors and spleens were harvested for immunohistochemistry (IHC) and flow cytometry. One- or 2-way analysis of variance was performed for statistical comparisons. A P value of <.05 was used as the threshold for statistical significance.

RESULTS

At 2 weeks after treatment, the Cryo and CPMV groups, alone or combined, outperformed the control group in the treated tumor; however, the Cryo + CPMV group showed the strongest reduction and lowest variance (1.6-fold ± 0.9 vs 6.3-fold ± 0.5, P < .0001). For the untreated tumor, only Cryo + CPMV significantly reduced tumor growth compared with control (9.2-fold ± 0.9 vs 17.8-fold ± 2.1, P = .01). The Cryo + CPMV group exhibited a transient increase in interleukin-10 and persistently decreased CXCL1. Flow cytometry revealed natural killer cell enrichment in the untreated tumor and increased PD-1 expression in the spleen. Tumor-infiltrating lymphocytes increased in Cryo + CPMV-treated tumors by IHC.

CONCLUSIONS

Cryoablation and intratumoral CPMV, alone or combined, demonstrated potent efficacy against treated HCC tumors; however, only cryoablation combined with CPMV slowed the growth of untreated tumors, consistent with an abscopal effect.

Cryoablation and Immunotherapy: An Enthralling Synergy for Cancer Treatment

As less invasive options for surgical tumor removal, minimally invasive ablative techniques have gained popularity. Several solid tumors are being treated with cryoablation, a non-heat-based ablation technique. Cryoablation data in comparison over time demonstrates better tumor response and faster recovery. Combining cryosurgery with other cancer therapies has been explored to improve the cancer-killing process. Cryoablation with the combination of immunotherapy, results in a robust and efficient attack on the cancer cells. This article focuses on investigating the ability of cryosurgery to create a strong antitumor response when combined with immunologic agents resulting in a synergetic effect. To achieve this objective, we combined cryosurgery with immunotherapy using Nivolumab and lpilimumab. Five clinical cases of lymph node, lung cancer, bone, and lung metastasis were followed and analyzed. In this series of patients, percutaneous cryoablation and addressing immunity agents were technically feasible. In the follow-ups, there appeared to be no radiological evidence of new tumor development.

Combining energy-based focal ablation and immune checkpoint inhibitors: preclinical research and clinical trials

Energy-based focal therapy (FT) uses targeted, minimally invasive procedures to destroy tumors while preserving normal tissue and function. There is strong emerging interest in understanding how systemic immunity against the tumor can occur with cancer immunotherapy, most notably immune checkpoint inhibitors (ICI). The motivation for combining FT and ICI in cancer management relies on the synergy between the two different therapies: FT complements ICI by reducing tumor burden, increasing objective response rate, and reducing side effects of ICI; ICI supplements FT by reducing local recurrence, controlling distal metastases, and providing long-term protection. This combinatorial strategy has shown promising results in preclinical study (since 2004) and the clinical trials (since 2011). Understanding the synergy calls for understanding the physics and biology behind the two different therapies with distinctive mechanisms of action. In this review, we introduce different types of energy-based FT by covering the biophysics of tissue-energy interaction and present the immunomodulatory properties of FT. We discuss the basis of cancer immunotherapy with the emphasis on ICI. We examine the approaches researchers have been using and the results from both preclinical models and clinical trials from our exhaustive literature research. Finally, the challenges of the combinatory strategy and opportunities of future research is discussed extensively.

Immunomodulatory effect of locoregional therapy in the tumor microenvironment

Cancer immunotherapy appears to be a promising treatment option; however, only a subset of patients with cancer responds favorably to treatment. Locoregional therapy initiates a local antitumor immune response by disrupting immunosuppressive components, releasing immunostimulatory damage-associated molecular patterns, recruiting immune effectors, and remodeling the tumor microenvironment. Many studies have shown that locoregional therapy can produce specific antitumor immunity alone; nevertheless, the effect is relatively weak and transient. Furthermore, increasing research efforts have explored the potential synergy between locoregional therapy and immunotherapy to enhance the long-term systemic antitumor immune effect and improve survival. Therefore, further research is needed into the immunomodulatory effects of locoregional therapy and immunotherapy to augment antitumor effects. This review article summarizes the key components of the tumor microenvironment, discusses the immunomodulatory role of locoregional therapy in the tumor microenvironment, and emphasizes the therapeutic potential of locoregional therapy in combination with immune checkpoint inhibitors.

In-situ tumor vaccination by percutaneous ablative therapy and its synergy with immunotherapeutics: An update on combination therapy

Percutaneous tumor ablation is now a widely accepted minimally invasive local treatment option offered by interventional radiology and applied to various organs and tumor histology types. It utilizes extreme temperatures to achieve irreversible cellular injury, where ablated tumor interacts with surrounding tissue and host via tissue remodeling and inflammation, clinically manifesting as post-ablation syndrome. During this process, in-situ tumor vaccination occurs, in which tumor neoantigens are released from ablated tissue and can prime one’s immune system which would favorably affect both local and remote site disease control. Although successful in priming the immune system, this rarely turns into clinical benefits for local and systemic tumor control due to intrinsic negative immune modulation of the tumor microenvironment. A combination of ablation and immunotherapy has been employed to overcome these and has shown promising preliminary results of synergistic effect without significantly increased risk profiles. The aim of this article is to review the evidence on post-ablation immune response and its synergy with systemic immunotherapies.

The analysis of immunogenic cell death induced by ablation at different temperatures in hepatocellular carcinoma cells

Introduction: Ablation therapy is a commonly used tool in the management of hepatocellular carcinoma (HCC). After ablation, dying cancer cells release a variety of substances that trigger subsequent immune responses. Immunogenic cell death (ICD) has been a trending topic in recent years and has been discussed many times along with oncologic chemotherapy. However, the subject of ablative therapy and ICDs has been little discussed. The purpose of this study was to investigate whether ablation treatment induces ICD in HCC cells and whether different types of ICDs arise because of different ablation temperatures. Methods: Four different HCC cell lines (H22, Hepa-16, HepG2 and SMMC7221) were cultured and treated under different temperatures (-80°C, -40°C, 0°C, 37°C, and 60°C). Cell Counting Kit-8 assay was performed to analyze the viability of different cell lines. Apoptosis was detected by flow cytometry assay, and a few ICD-related cytokines (calreticulin, ATP, high mobility group box 1, and CXCL10) were detected by immunofluorescence or enzyme-linked immunosorbent assay. Results: The apoptosis rate of all kinds of cells increased significantly in -80°C group (p < 0.01) and 60°C group (p < 0.01). The expression levels of ICD-related cytokines were mostly significantly different between the different groups. For calreticulin, Hepa1-6 cells and SMMC7221 cells showed significantly higher protein expression levels in 60°C group (p < 0.01) and significantly lower protein expression levels -80°C group (p < 0.01). The ATP, high mobility group box 1 and CXCL10 expression levels were significantly higher in 60°C, -80°C and -40°C group of all four cell lines (p < 0.01). Conclusion: Different ablative treatments could induce different types of ICDs in HCC cells, providing a promising track for the development of individualized cancer therapies.

Progress in the cryoablation and cryoimmunotherapy for tumor

With the rapid advancement of imaging equipment and minimally invasive technology, cryoablation technology is being used more frequently in minimally invasive treatment of tumors, primarily for patients with early tumors who voluntarily consent to ablation as well as those with advanced tumors that cannot be surgically removed or cannot be tolerated. Cryoablation is more effective and secure for target lesions than other thermal ablation methods like microwave and radiofrequency ablation (RFA). The study also discovered that cryoablation, in addition to causing tumor tissue necrosis and apoptosis, can facilitate the release of tumor-derived autoantigens into the bloodstream and activate the host immune system to elicit beneficial anti-tumor immunological responses against primary. This may result in regression of the primary tumor and distant metastasis. The additional effect called " Accompanying effects ". It is the basis of combined ablation and immunotherapy for tumor. At present, there is a lot of research on the mechanism of immune response induced by cryoablation. Trying to solve the question: how positively induce immune response. In this review, we focus on: 1. the immune effects induced by cryoablation. 2. the effect and mechanism of tumor immunotherapy combined with cryoablation. 3.The clinical research of this combination therapy in the treatment of tumors.

Tumor-Specific Immunoenhancing Effects after Local Cryoablation for Metastatic Bone Tumor in a Mouse Model

We investigated the abscopal effect after cryoablation (CA) on bone metastasis using a mouse model. Breast cancer cells were implanted in the bilateral tibiae of mice. The left tumor was treated locally with CA, and the right abscopal tumor (AT) was left untreated. The mice were divided into four groups based on the combination of CA and intraperitoneal administration of anti-PD-1 antibody (PD) as treatment interventions (Control, CA, PD, and CA + PD). The reduction ratio of the size of AT, the quantitative immune effects at enzyme-linked immunospot (ELISPOT) assay, and the intensity of infiltration of immune-related cells to AT were compared among the groups. CA alone showed a significant immunoenhancing effect on the volume change ratio of AT from day 0 to day 14 (Control-CA: p < 0.05), ELISPOT assay (Control-CA: p < 0.01), and CD4+ cell count in immunostaining (Control-CA: p < 0.05). CA alone showed no significant immunoenhancing effect on CD8+ and Foxp3+ cell counts in immunostaining, but the combination of CA and PD showed a significant immunoenhancing effect (Control-CA + PD: p < 0.01 [CD8, Foxp3]). The results suggested that the abscopal effect associated with the local cryotherapy of metastatic bone tumors was activated by CA and enhanced by its combination with PD.

A Technical Guide to Palliative Ablation of Recurrent Cancers in the Deep Spaces of the Suprahyoid Neck

Treatment options for patients with recurrent head and neck cancer, whether locoregional recurrence of previously treated head and neck cancer or secondary primary malignancy, are limited. Percutaneous ablation is a minimally invasive procedure that can be used with palliative intent in the head and neck to achieve symptomatic relief and local tumor control, potentially fulfilling treatment gaps of current standard of care options. Image guidance is key when navigating the deep spaces of the neck with special attention paid to critical structures within the carotid sheath. This review article provides an overview and highlights the important nuances of performing percutaneous ablations in the head and neck. It covers general principles, ablative modalities, image guidance, procedural technique, expected outcomes, and possible complications.

Preclinical cerebral cryoablation in non-tumor bearing pigs

Patients with brain metastases, the most common intracranial tumor, have an average survival ranging from a few months to 40 months, and new treatment initiatives are needed. Cryoablation is a minimally invasive, well-tolerated, and effective procedure commonly applied for treatment of renal tumors and certain other malignancies. We aimed to examine the clinical usefulness of this procedure in a step-by-step program starting with cerebral cryoablation in healthy pigs. In four terminal and four non-terminal non-tumor bearing pigs, we studied immediate and delayed effects of cerebral cryoablation. Safety was assessed by computed tomography (CT), and clinical observation of behavior, neurological deficits, and wellbeing. Effects were assessed by histological and immuno-histochemical analyses addressing structural and metabolic changes supported by additional magnetic resonance imaging (MRI) and positron emission tomography (PET) in the non-terminal animals. Using CT-guidance, cryoablation probes were successfully inserted without complications, and ice formation could be monitored real-time with CT. No animal developed neurological deficits or signs of discomfort. Histological and immunohistochemical analyses, MRI, and PET revealed profound structural and biological damage within the lesion. MRI and PET revealed no long-term damage to healthy tissue outside the cryoablation zone. Cerebral cryoablation appears to be a feasible, safe, and controllable procedure that can be monitored successfully with CT. The net effect is a dead brain lesion without damage of either nearby or remote healthy structures. Immediate changes are local hemorrhage and edema; delayed effects are perfusion defects, immune system activation, and astrogliosis.

Combination of ultrasound-based mechanical disruption of tumor with immune checkpoint blockade modifies tumor microenvironment and augments systemic antitumor immunity

Background

Despite multimodal adjuvant management with radiotherapy, chemotherapy and hormonal therapies, most surgically resected primary breast cancers relapse or metastasize. A potential solution to late and distant recurrence is to augment systemic antitumor immunity, in part by appropriately presenting tumor antigens, but also by modulating the immunosuppressive tumor microenvironment (TME). We previously validated this concept in models of murine carcinoma treated with a novel predominately microcavitating version of high-intensity focused ultrasound (HIFU), mechanical high-intensity focused ultrasound (M-HIFU). Here we elucidated the mechanisms of enhanced antitumor immunity by M-HIFU over conventional thermal high-intensity focused ultrasound (T-HIFU) and investigated the potential of the combinatorial strategy with an immune checkpoint inhibitor, anti-PD-L1 antibody.

Methods

The antitumor efficacy of treatments was investigated in syngeneic murine breast cancer models using triple-negative (E0771) or human ErbB-2 (HER2) expressing (MM3MG-HER2) tumors in C57BL/6 or BALB/c mice, respectively. Induction of systemic antitumor immunity by the treatments was tested using bilateral tumor implantation models. Flow cytometry, immunohistochemistry, and single-cell RNA sequencing were performed to elucidate detailed effects of HIFU treatments or combination treatment on TME, including the activation status of CD8 T cells and polarization of tumor-associated macrophages (TAMs).

Results

More potent systemic antitumor immunity and tumor growth suppression were induced by M-HIFU compared with T-HIFU. Molecular characterization of the TME after M-HIFU by single-cell RNA sequencing demonstrated repolarization of TAM to the immunostimulatory M1 subtype compared with TME post-T-HIFU. Concurrent anti-PD-L1 antibody administration or depletion of CD4⁺ T cells containing a population of regulatory T cells markedly increased T cell-mediated antitumor immunity and tumor growth suppression at distant, untreated tumor sites in M-HIFU treated mice compared with M-HIFU monotherapy. CD8 T and natural killer cells played major roles as effector cells in the combination treatment.

Conclusions

Physical disruption of the TME by M-HIFU repolarizes TAM, enhances T-cell infiltration, and, when combined with anti-PD-L1 antibody, mediates superior systemic antitumor immune responses and distant tumor growth suppression. These findings suggest M-HIFU combined with anti-PD-L1 may be useful in reducing late recurrence or metastasis when applied to primary tumors.

Cryoablation reshapes the immune microenvironment in the distal tumor and enhances the anti-tumor immunity

As one of the local treatments, cryoablation plays an increasingly important role in the comprehensive treatment of malignant tumors with its advantages of less trauma, high reproducibility, and minimally invasive. Activation of anti-tumor immunity, another characteristic of cryoablation, has attracted more and more attention with the extensive application of immunotherapy. Unfortunately, the mechanism by which cryoablation enhances anti-tumor immunity is still unclear. In this study, we applied a multi-omics approach to investigate the effects of local cryoablation in the distal tumor microenvironment. The results revealed that large amounts of tumor antigens were released post-cryoablation, leading to a sterile inflammatory response in distant tumors. During this period, activated lysosome-related pathways result in over-expression of SNAP23 (Synaptosome associated protein 23) and STXBP2 (Syntaxin binding protein 2), activation of immune effector cells, suppression of the release of immunosuppressive factors, and finally enhancement of anti-tumor immunity, which shows a broad prospect in combined immunotherapy.

Circulating tumor cells in patients undergoing androgen deprivation therapy with versus without cryosurgery for metastatic prostate cancer: a retrospective analysis

BACKGROUND

The study aimed to assess the value of circulating tumor cells (CTCs) as a prognostic and treatment response marker in patients undergoing androgen deprivation therapy (ADT) plus cryosurgery vs. ADT alone for metastatic prostate cancer (mPCA).

METHODS

This retrospective analysis included 43 patients with mPCA: 23 receiving ADT alone (control) and 20 receiving additional cryosurgery (cryosurgery group). CTCs and progression-free survival (PFS) were compared between the two groups. Cox proportional hazards regression was conducted to identify variables associated with PFS.

RESULTS

Median PFS was 35 months (IQR, 33‑37) in the cryosurgery group vs. 30 months (IQR, 27‑32) in the control (p < 0.001). CTCs count was significantly lower in the cryosurgery group at both 3 months (z = 2.170, p = 0.030) and 12 months (z = 2.481; p = 0.013). In comparison to the baseline, the number of CTCs at both 3 and 12 months was lower in the cryosurgery group (p = 0.004 and p < 0.001, respectively), but not in the ADT alone group. In multivariate Cox regression, shorter PFS was associated with baseline PSA ≧100 ng/ml (HR 6.584, 95% CI, 5.309‑8.166), biopsy Gleason score ≧ 8 (HR 2.064, 95% CI, 1.608‑2.650), clinic T stage>T2b (HR 5.021, 95% CI, 3.925‑6.421), number of bone metastases>3 (HR 3.421, 95% CI, 2.786‑4.202), positive CTCs at 3 months post-treatment (HR 6.833, 95% CI, 5.176‑9.022), positive CTCs 1 year post-treatment (HR 6.051, 95% CI, 4.347‑8.424). Prostate cryosurgery was associated with longer PFS (HR 0.062, 95% CI, 0.048‑.080).

CONCLUSIONS

CTC was a prognostic and treatment response marker for mPCA. ADT plus cryosurgery could reduce CTCs and prolong PFS vs. ADT alone in mPCA patients with low metastatic volume.

Interventional magnetic-resonance-guided cryotherapy combined with microsurgery for recurrent glioblastoma: An innovative treatment?

BACKGROUND

Glioblastoma invariably recurs after primary Stupp tumor therapy and portends a poor prognosis. Cryoablation is a well-established treatment strategy for extra-cranial tumors. The safety and efficacy of interventional MR-guided cryoablation (iMRgC) has not been explored in recurrent glioblastoma.

METHODS

A retrospective analysis of data collected over a period of 24 months was performed. The inclusion criteria were: (I) recurrent glioblastoma despite Stupp protocol; (II) MRI followed by histological confirmation of recurrent glioblastoma; (III) location allowing iMRgC followed by microsurgical resection; and (IV) patient's consent. The primary objective was to assess feasibility in terms of complications. The secondary objective was to analyze progression-free survival (PFS), post-iMRgC survival and overall survival (OS).

RESULTS

The study included 6 patients, with a mean age of 67±7.6 years [range, 54-70 years]. No major complications were observed. Median PFS was 7.5 months [IQR 3.75-9.75] and 6-month PFS was 50%. Median post-iMRgC survival was 9 months [IQR 7.5-15.25] and 6-month post-iMRgC survival was 80%. Median OS was 22.5 months [IQR 21.75-30].

CONCLUSION

iMRgC for recurrent glioblastoma demonstrated a good safety profile, with no major complications. Our data suggest improved PFS and OS.

TRIAL REGISTRATION NUMBER

No. IRB00011687 retrospectively registred on July 7th 2021.

Huaier granule prevents the recurrence of early-stage hepatocellular carcinoma after thermal ablation: A cohort study

ETHNOPHARMACOLOGICAL RELEVANCE

Clinical trials have demonstrated that Trametes robinophila Murr (Huaier granule) can inhibit recurrence and metastasis after hepatocellular carcinoma (HCC) resection, but its efficacy as an adjuvant therapy after thermal ablation of early HCC is unknown.

AIM OF THE STUDY

To analyze the prognostic value and side effects of Huaier granules in HCC patients undergoing thermal ablation.

MATERIALS AND METHODS

Clinical information from 340 eligible subjects with early-stage HCC who were admitted to our department from September 1, 2008 to January 1, 2019 was extracted from the electronic medical record database. They were divided into the thermal ablation + TCM group and the thermal ablation group. Differences in their overall survival (OS), progression-free survival (PFS), extrahepatic metastatic rate (EMR), and therapeutic side effects (TSEs) between the two groups were compared. Beneficiaries of the integrated treatment and adequate treatment length were predicted.

RESULTS

The median follow-up was 32.5 months (range 2-122 months). The 1-year, 3-year and 5-year OS rates in the integrated treatment group and the control group were 93.2% vs. 92.6%, 54.5% vs. 51.4%, 23.5% vs. 19.7% (p = 0.110, HR 0.76(0.54-1.07)). The 1-year, 3-year and 5-year PFS rates were 78.8% vs. 69.4%, 50.6% vs. 40.6%, 35.3% vs. 26.5%, respectively (p = 0.020, HR 0.67(0.48-0.94)). The median OS (35 vs. 31 months) and PFS (24 vs. 12.5 months) were longer in the integrated treatment group. The EMR in the integrated treatment group was significantly lower than that in the control group (p = 0.018, HR 0.49 (0.27-0.89)). Patients with any two of the following three factors might be predicted to be beneficiaries of the integrated treatment, including younger than 65 years (p =0.039, HR 0.70 (0.50-0.98)), single tumor (p = 0.035, HR 0.70 (0.50-0.98), and tumor size ≤3 cm (p = 0.029, HR 0.69 (0.50-0.96). Patients with continuous oral administration of TCM following ablation had a lower probability of recurrence and metastasis within 2 years (p = 0.015, HR 0.67 (0.49-0.93)). Although the integrated treatment group reported a higher incidence of nausea and emesis, there were no significant differences between the two groups.

CONCLUSION

TCM following ablation may prolong PFS and suppress recurrence in patients with HCC, with continuous oral administration for more than 2 years maybe experience a greater benefit. The TSEs of the treatment are mild and can be tolerated.

Interventional Radiology Image-Guided Locoregional Therapies (LRTs) and Immunotherapy for the Treatment of HCC

Image-guided locoregional therapies (LRTs) are a crucial asset in the treatment of hepatocellular carcinoma (HCC), which has proven to be characterized by an impaired antitumor immune status. LRTs not only directly destroy tumor cells but also have an immunomodulating role, altering the tumor microenvironment with potential systemic effects. Nevertheless, the immune activation against HCC induced by LRTs is not strong enough on its own to generate a systemic significant antitumor response, and it is incapable of preventing tumor recurrence. Currently, there is great interest in the possibility of combining LRTs with immunotherapy for HCC, as this combination may result in a mutually beneficial and synergistic relationship. On the one hand, immunotherapy could amplify and prolong the antitumoral immune response of LRTs, reducing recurrence cases and improving outcome. On the other hand, LTRs counteract the typical immunosuppressive HCC microenvironment and status and could therefore enhance the efficacy of immunotherapy. Here, after reviewing the current therapeutic options for HCC, we focus on LRTs, describing for each of them the technique and data on its effect on the immune system. Then, we describe the current status of immunotherapy and finally report the recently published and ongoing clinical studies testing this combination.

Pilot study of Tremelimumab with and without cryoablation in patients with metastatic renal cell carcinoma

Cryoablation in combination with immune checkpoint therapy was previously reported to improve anti-tumor immune responses in pre-clinical studies. Here we report a pilot study of anti-CTLA-4 (tremelimumab) with (n = 15) or without (n = 14) cryoablation in patients with metastatic renal cell carcinoma (NCT02626130), 18 patients with clear cell and 11 patients with non-clear cell histologies. The primary endpoint is safety, secondary endpoints include objective response rate, progression-free survival, and immune monitoring studies. Safety data indicate ≥ grade 3 treatment-related adverse events in 16 of 29 patients (55%) including 6 diarrhea/colitis, 3 hepatitis, 1 pneumonitis, and 1 glomerulonephritis. Toxicity leading to treatment discontinuation occurs in 5 patients in each arm. 3 patients with clear cell histology experience durable responses. One patient in the tremelimumab arm experiences an objective response, the median progression-free survival for all patients is 3.3 months (95% CI: 2.0, 5.3 months). Exploratory immune monitoring analysis of baseline and post-treatment tumor tissue samples shows that treatment increases immune cell infiltration and tertiary lymphoid structures in clear cell but not in non-clear cell. In clear cell, cryoablation plus tremelimumab leads to a significant increase in immune cell infiltration. These data highlight that treatment with tremelimumab plus cryotherapy is feasible and modulates the immune microenvironment in patients with metastatic clear cell histology.

Current trends and perspectives in interventional radiology for gastrointestinal cancers

Gastrointestinal (GI) cancers often require a multidisciplinary approach involving surgeons, endoscopists, oncologists, and interventional radiologists to diagnose and treat primitive cancers, metastases, and related complications. In this context, interventional radiology (IR) represents a useful minimally-invasive tool allowing to reach lesions that are not easily approachable with other techniques. In the last years, through the development of new devices, IR has become increasingly relevant in the context of a more comprehensive management of the oncologic patient. Arterial embolization, ablative techniques, and gene therapy represent useful and innovative IR tools in GI cancer treatment. Moreover, IR can be useful for the management of GI cancer-related complications, such as bleeding, abscesses, GI obstructions, and neurological pain. The aim of this study is to show the principal IR techniques for the diagnosis and treatment of GI cancers and related complications, as well as to describe the future perspectives of IR in this oncologic field.

US-guided high-intensity focused ultrasound (HIFU) of abdominal tumors: outcome, early ablation-related laboratory changes and inflammatory reaction. A single-center experience from Germany

INTRODUCTION

High-intensity focused ultrasound (HIFU) is an innovative noninvasive procedure for local ablation of different benign and malignant tumors. Preliminary data of animal studies suggest an ablation-associated immune response after HIFU that is induced by cell necrosis and release of intracellular components. The aim of this study is to evaluate if a HIFU-induced early sterile inflammatory reaction is initiated after ablation of uterine fibroids (UF) and pancreatic carcinoma (PaC) which might contribute to the therapeutic effect.

MATERIAL AND METHODS

A hundred patients with PaC and 30 patients with UF underwent US-guided HIFU treatment. Serum markers of inflammation (leukocytes, CRP, IL-6) and LDH in both collectives as well as tumor markers CA 19-9, CEA and CYFRA in PaC patients were determined in sub-cohorts before and directly after HIFU (0, 2, 5 and 20 h post-ablation) as well as at 3, 6, 9 and 12 months follow-up. Peri-/post interventional imaging included contrast-enhanced MRI of both cohorts and an additional CT scan of PaC patients.

RESULTS

An early post-ablation inflammatory response was observed in both groups with a significant increase of leukocytes, CRP and LDH within the first 20 h after HIFU. Interestingly, IL-6 was increased at 20 h after HIFU in PaC patients. A significant reduction of tumor volumes was observed during one year follow-up (p < .001) for both tumor entities demonstrating effective treatment outcome.

CONCLUSION

Tumor ablation with HIFU induces an early sterile inflammation that might serve as a precondition for long-term tumor immunity and a sustainable therapeutic effect.

Distant Resolution of Actinic Keratosis following Cryosurgery: An Unusual Phenomenon

Early after the introduction of cryosurgery to clinical practice, there were reports of metastasis regressing after cryosurgery of a primary tumour, mainly prostate and breast cancer, suggesting a systemic immunological effect to a local reaction. Colleagues within dermatology have occasionally experienced similar systemic effects following cryosurgery. However, published reports of such cases are lacking. In this case, we report a photographed distant resolution of an actinic keratosis (AK) on 68-year-old woman's arm following cryosurgery of another AK on the same arm.

Synergistic enhancement of immunological responses triggered by hyperthermia sensitive Pt NPs via NIR laser to inhibit cancer relapse and metastasis

The combination of tumor ablation and immunotherapy is a promising strategy against tumor relapse and metastasis. Photothermal therapy (PTT) triggers the release of tumor-specific antigens and damage associated molecular patterns (DAMPs) in-situ. However, the immunosuppressive tumor microenvironment restrains the activity of the effector immune cells. Therefore, systematic immunomodulation is critical to stimulate the tumor microenvironment and augment the anti-tumor therapeutic effect. To this end, polyethylene glycol (PEG)-stabilized platinum (Pt) nanoparticles (Pt NPs) conjugated with a PD-L1 inhibitor (BMS-1) through a thermo-sensitive linkage were constructed. Upon near-infrared (NIR) exposure, BMS-1 was released and maleimide (Mal) was exposed on the surface of Pt NPs, which captured the antigens released from the ablated tumor cells, resulting in the enhanced antigen internalization and presentation. In addition, the Pt NPs acted as immune adjuvants by stimulating dendritic cells (DCs) maturation. Furthermore, BMS-1 relieved T cell exhaustion and induced the infiltration of effector T cells into the tumor tissues. Thus, Pt NPs can ablate tumors through PTT, and augment the anti-tumor immune response through enhanced antigen presentation and T cells infiltration, thereby preventing tumor relapse and metastasis.

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Pt NPs ablated tumor cells through PTT and served as immune adjuvants.

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Released BMS-1 and deprotected maleimide by thermo-sensitive Diels-Alder reaction.

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Pt NPs captured the antigens with exposed maleimide and stimulated dendritic cells maturation.

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Controlled release of BMS-1 in response to PTT relieved T cell exhaustion.

The efficacy of radiofrequency ablation versus cryoablation in the treatment of single hepatocellular carcinoma: A population-based study

BACKGROUND

Radiofrequency ablation (RFA) is an effective treatment for single hepatocellular carcinoma (HCC), but it is difficult to use against tumors in some locations and often leads to incomplete ablation as a result of the heat-sink effect. This study was conducted to evaluate the efficacy of cryoablation compared with that of RFA in the treatment of single HCC.

METHODS

This retrospective study was conducted based on the Surveillance, Epidemiology, and End Results (SEER) database. From 2004 to 2015, patients aged 40 to 79 diagnosed with HCC were included in the study. A propensity score matching (PSM) model was used to reduce selection biases.

RESULTS

Before PSM, the median overall survival (mOS) and median cancer-specific survival (mCSS) in the RFA group were slightly longer than those in the cryoablation group (p > 0.05). In the subgroup analysis, the mOS and mCSS of patients with tumor sizes <3, 3-5, and >5 cm who received RFA treatment were longer than those of patients given cryoablation treatment, but there was no significant difference (p > 0.05). Similar results were presented in patients at American Joint Committee on Cancer (AJCC) stages I and II. After PSM, the mOS and mCSS were slightly better in the RFA group than the cryoablation group but without significant differences. Univariate and multivariate analysis showed that cryoablation treatment was not an unfavorable factor for OS and CSS before or after PSM (p > 0.05). In the multivariable competing risk model, non-cancer-specific death was taken as a competing factor and cryoablation was also not unfavorable for the survival of patients before and after PSM (p > 0.05).

CONCLUSION

Cryoablation is non-inferior to RFA therapy for single HCC patients without lymph node invasion or distant metastasis.

Emerging photoacoustic and thermoacoustic imaging technologies for detecting primary and metastatic cancer and guiding therapy

In recent years, there has been a progressive trend towards less invasive technologies for detecting metastatic cancer and guiding therapy with the goal of lower morbidity, better outcomes, and superior cosmetic appearance than traditional methods. This mini-review examines three emerging noninvasive hybrid technologies for detecting primary cancer, metastasis and guiding thermal therapy. Real-time thermoacoustic imaging and thermometry potentially provides valuable and critical feedback for guiding focused microwave ablation therapy. Label-free photoacoustic monitoring of cancer cells is a promising clinical diagnostic and theranostic tool for detecting metastatic disease and monitoring the response to therapy. Finally, immunologically targeted gold nanoparticles combined with photoacoustic imaging is able to detect lymph node micrometastasis in mouse models of breast cancer. These emerging techniques have the potential to improve the decision to biopsy, provide more accurate prognosis, and enhance the efficacy of therapy for early and late stage cancers.