The opening plenary at the World Conference on Interventional Oncology (WCIO; 7–10 June, Boston, USA) put biopsy, which is considered a mundane procedure by some interventional radiologists, at the heart of cancer diagnosis and personalised treatment. Many experts see that doing a biopsy well could establish a fruitful collaboration with referring medical and surgical oncologists.
The session “Obtaining Tissue in the Age of Precision Medicine” highlighted biopsy as one of “the main inroads” for interventional radiologists to get into the oncology space. Biopsy is seen as a gateway procedure by interventional oncologists. Once interventional oncologists get in the door and do a good job with biopsy, they can then offer other treatments to help manage the disease that was biopsied, delegates heard.
David C Madoff, professor of Radiology, vice chair for Academic Affairs, Weill Cornell Medicine, New York, USA, and programme chair of WCIO 2018, told Interventional News: “One of the most common image-guided procedures done by interventional radiologists is biopsy. Biopsy is seen as a bread-and-butter procedure that is considered by many practitioners as a routine one. Still, it may ultimately have the most impact on anything that we do in interventional oncology. One of the reasons that it is so important is that patients’ treatments are now reliant on the tissue obtained and its typing. It used to be that obtaining tissue was simply for diagnosis, and once a diagnosis was established, patients with a particular cancer would all be treated the same way in a one-size-fits-all manner. However, we know now that tumour tissue is very heterogeneous. This can be within a tumour and there could also be heterogeneity between the primary tumour and metastases. So over the years, interventional radiologists are asked to get much larger volume samples and many more samples in order to guide personalised treatment. With biopsy, interventional oncologists play a critical role in the diagnosis and management of patients with cancer.”
Speaking at the session, Stephen Solomon, chief, Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, USA and president of the Society of Interventional Oncology, noted that in the era of precision medicine, it is essential to provide reliable tissue biopsy. He noted “in-room pathology assessment will lead to improved results. Molecular imaging can provide improved targeting as it recognises tissue heterogeneity. New technology solutions can provide in-room assessment for all hospitals,” he said.
Interventional radiologists are held responsible for the collection of the biopsy sample and it is important to set appropriate expectations on the challenging biopsy, delegates at the session heard.
Alda Tam, associate professor of Interventional Radiology, MD Anderson Cancer Center, Houston, USA, speaking of the role of biopsy in oncology clinical trials said: “[Essentially] what we are looking for is an actionable mutation or an actionable immune biomarker so that a patient’s treatment for cancer can be individualised. In order to do that, biopsy plays a critical role. In addition to this, we are being held to a molecular adequacy standard and what that means could be different for different trials.
“I think as interventional radiologists/oncologists, we need to embrace the need for interventional radiology involvement in clinical trials at the level of which trials are being developed. So you need to write the protocol and review the protocol on how you sample the tissue. At MD Anderson, protocols do not go before the Institutional Review Board unless an interventional radiology collaborator has already signed on. We need communication tools amongst ourselves to ensure that we are in compliance about the number of samples that are being requested for each protocol. Hopefully, at some level, we can move towards a standardisation of the sampling requirements, beyond just the number of cores,” she noted.
Importantly, Tam noted that it was important to weigh the risks and benefits carefully before undertaking challenging biopsies.
“Be a clinician, weigh-in on the risk of the biopsy and lesion selection,” said Tam. “At the end of the day, you want that patient to go to the trial, but if they cannot, they cannot. We ought to be realistic as we are the only ones looking at the imaging and we are the only ones who know how much tissue is going to come out of the lesion being studied. Lastly, collaborate with pathology, because feedback is essential in order to improve quality and improve results,” Tam urged.