“Refusing an interventional oncology procedure if it is not clinically or technically indicated, or if it is exceedingly risky, should not be perceived as a professional failure. Indeed, it is often as useful to patients as a well performed ablation,” Luigi Solbiati, professor of Techniques and Methods of Diagnostic Imaging, School of Radiology, University of Milan, Italy, and one of the pioneers of interventional oncology, told Interventional News.
What drew you to radiology and interventional oncology?
My father was a medical doctor and he chose to become a radiologist because he loved technology (photography, movies, etc). I probably “inherited” this passion for technology from him and, accordingly, when I decided to become a doctor, radiology was an “unavoidable” choice. He was a “conventional” radiologist and when I told him that I was starting to use needles, catheters and electrodes, he was surprised and worried, and told me that I was not a surgeon!
Who were your mentors in interventional radiology and what do you still remember from their wisdom?
Four people were of crucial importance in my career. Initially, the chairman of the Department of Radiology of the General Hospital of the town (Busto Arsizio, in the Milan area) where I was born and where I still work, Giuseppe Montali, who taught to me rigorous methodology, full-time dedication to work and passion for scientific activity, even in a non-teaching hospital. Thanks to him, I spent a very fruitful period of staging at the Royal Marsden Hospital in Sutton, UK, where I met one of the greatest pioneers in ultrasound, David Cosgrove. When I got back to Busto, I started my collaboration with another important mentor in my career, Carlo Ravetto, chairman of the Department of Pathology, one of the European pioneers in fine-needle aspiration cytology and author of the first Italian book on this modality. In those years, at the very beginning of the 80s, he could perform only biopsies of palpable targets, so when I started using real-time sonography, he pushed me to guide his needles into non-palpable targets. Accordingly, in a short time, we developed one of the largest experiences in the world on US-guided fine-needle aspiration of abdominal pathologies. Together with him, in 1982, I performed (probably) the very first treatment of a solid tumour (parathyroid adenoma) through direct percutaneous injection of ethanol, even before ethanol was used for the ablation of hepatocellular carcinoma (HCC). My third mentor, colleague and friend was Tito Livraghi, the “father” of ethanol ablation of HCC.
Even if we have always worked in two different hospitals, 50km distant from each other, we spent a long time together, testing new devices (the very first world clinical tests with cool-tip radiofrequency electrodes were performed by us, in our respective hospitals, on two consecutive days), participating in meetings all around the world and organising in Milan (from 1994 to 2002), the first-ever meetings dedicated only to the modern interventional oncology (named, at that time, “Image-guided therapies of neoplastic diseases”). A person of essential importance in my career (in addition to her importance in my life) is my wife, Tiziana Ierace, who since the beginning of my activity in interventional oncology, has been my main co-worker. She has great technical ability with interventional devices and her devotion to the clinical and also human problems of our neoplastic patients is inspiring. We have together performed the most technically and clinically challenging treatments with a negligible percentage of side-effects and a very high rate of success.
Could you describe a moment in your career in interventional oncology when you were amazed by what the specialty could achieve?
The first case which comes to my mind is also the very first and an absolutely rare case in my “interventional” life. It was 1982, and the day after performing a “normal” ultrasound-guided aspiration biopsy of a cervical mass that turned out to be a parathyroid adenoma, the chief nephrologist of my hospital called me to ask what kind of procedure I had done because the patient, affected by primary hyperparathyroidism, had suddenly become normocalcaemic.
This was due to a small intralesional haematoma which had compressed the hyperfunctioning parenchyma, thus reducing its hormonal activity. A few days later, this led us to think that the injection of a chemical agent able to achieve sclerosis of small blood vessels (like ethanol) into such lesions could have had an ablative effect on the tumour. This simple intuition really opened the way to subsequent developments of interventional oncology.
Can you describe a memorable case and how interventional oncology came to the rescue?
Seven years ago, a 43-year-old lady with a long history of colorectal carcinoma and metachronous hepatic metastases treated with chemotherapy and two surgical resections came to our department asking for thermal ablation as her new liver metastases were unresponsive to chemotherapy and non-resectable. The situation of her liver was really challenging and initially we refused ablation, as being too risky and likely destined to be unsuccessful. But when the lady, being completely aware of her fate, told us that she only wished to be able to see her two young daughters grow a few more years, we thought we should take up the challenge. Since then, we have performed eight radiofrequency ablation sessions of new liver metastases in seven years. When a few months ago, we had to surrender when faced with an explosion of new lesions, the lady calmly understood and in front of her daughters, now both adults, thanked us with all her heart because we had helped her to reach her goal.
What are the three things you focus on as a teacher of interventional oncology?
The first thing I like to focus on when I teach is absolute human respect for our oncology patients and their relatives. Committment to excellence and technical skill must always go hand in hand with awareness of the human situation, both clinical and psychological. The second is that gently refusing an interventional procedure (if it is not clinically or technically indicated, or if it is exceedingly risky) should not be perceived as a professional failure—indeed it is often as useful to patients as a well performed ablation. The third is that even when you have personal problems, you should always work happily and smile in front of patients and colleagues and encourage your trainees with enthusiasm and passion.
What have the three most interesting findings from your research so far been?
Recently, we have been developing a brand new technique with diode laser fibres for the percutaneous ablation of metachronous malignant cervical adenopathies from thyroid papillary carcinomas which do not take up 131 I (and are thus not treatable with radioiodine), but FDG-avid on CT-FDG PET, in patients who have already undergone thyroidectomy and lymphadenectomy. In these patients, repeat surgery, although challenging and with high rate of side effects, would be again the only possible therapy. Even though our experience is preliminary, laser ablation under simple local anaesthesia in outpatients is allowing us to achieve excellent results on follow-up without side effects. Accordingly, we are now starting to use the same treatment for parathyroid adenomas in primary hyperparathyroidism, in patients with contraindications to surgery or during acute hypercalcaemic crisis. The third research field we have been studying for the last 10 years is that of real-time fusion of sonography and CT (or MRI or FDG-PET) for the guidance of ablations of challenging targets (in liver, kidney, etc) poorly visible with sonography alone or visualised only in the short phase of arterial enhancement. The most recent advancement we are working on is the development of a microwave antenna with an internal canal in which a magnetic microsensor applied on tip of a stylet can be inserted. This would allow us to achieve an extremely precise localisation of the antenna position during the whole procedure, in spite of the formation of gas and/or patient movements.
What are the three most interesting papers you read in 2011 in the field of interventional oncology?
In the field of interventional oncology more and more interesting papers are being published monthly. It is very challenging to select the most interesting. Of course, everyone will indicate the papers that are most relevant for his own specific fields of interest within the world of interventional oncology. Following this way, among the papers published between the end of 2011 and the beginning of 2012, I indicate three articles dealing with HCC. The first was published in The Lancet by Forner et al, which analysed the most recent data in the literature and the existing BCLC classification of HCC. The authors review the therapeutic flow-chart of HCC, replacing (for the first time) resection with ablation as the treatment of choice for very early stage HCC in patients who are not candidates to liver transplantation.
This fundamental recognition of the role of ablation in this pathology is confirmed also by the paper published in Radiology by Peng et al who retrospectively compare the outcomes of HCCs smaller than 2cm treated with either ablation or resection. Efficacy and safety of radiofrequency ablation are better than those of resection, particularly for centrally located HCCs. The third paper was published by Shiina et al in American Journal of Gastroenterology on 10-year outcome and prognostic factors of HCC treated with radiofrequency ablation. The cumulative five- and 10-year survival rates of 60.2% and 27.3% with a 2.2% major complication rate conclusively demonstrates the role of ablation in this disease.
Can ablation replace resection for curative liver treatment?
Ablation is a local therapy and therefore local control (preventing tumoural growth) is the primary goal of ablation, while “cure” means complete recovery from disease. For HCC, the only curative therapy (although not in 100% of cases) is liver transplantation. For liver metastases, ablation can be curative only if combined with effective systemic chemotherapy.
However, according to the recent BCLC staging and treatment strategy (Forner A, et al, The Lancet, 2012), ablation is the first-line treatment for very early stage HCC in patients who are not candidates for liver transplantation and for early stage HCC in patients with associated diseases. For liver metastases from colorectal carcinoma, in our experience (Radiology 2012, in press) local control can be achieved in almost 93% of nodules within 2cm in size and accordingly ablation may be considered the first-line treatment for metastases of this size, replacing surgery.
If you had a wish-list what would you improve in interventional oncology practice?
From the clinical side, given the long dedication of my group to the ablation of hepatic metastases, my first wish would be the official recognition of ablation as first-line treatment of hepatic metastases within the size range of 2cm. From the organisational side, my first wish would be for a much stronger support of healthcare leadership to departments of interventional oncology in terms of equipment, staff and space, taking into increasing account the cost-effectiveness of interventional procedures compared to that of surgery. My third wish is for a new organisational model of the departments of interventional oncology which may include also beds for day procedures and a few beds for the 24–48 hours hospitalisation following major ablative interventions.
What are the three honours you have received that you are proud of?
The acknowledgments and thanks coming from patients successfully treated have always been the most valuable recognition for my professional activity. Among the honours officially received, I remember the invitation to give teaching lectures at the famous Mayo Clinic in Rochester on ultrasound-guided aspiration biopsies and ethanol injection of parathyroid tumours and HCC when I was still very young, in 1989. More recently, the invitations to give the Andreas Gruentzig lecture at the CIRSE Annual Meeting, and the memorial lecture for the 150th anniversary of the death of Christian Doppler at the historic Billrothhaus in Vienna (where I was asked to put my signature just below those of Virchow, Billroth, Rokitansky, Freud, etc!) are the most prestigious honours that I have received.
What are your interests outside of medicine?
Even if family and work take up most of my time, I have some interests that I began cultivating when I was young and hope to be able to improve even more after my retirement (which is not very far-off): travelling as a tourist throughout the world, landscape and technical photography, computer technology, watching various films and listening to music, mostly pop-rock, but also classical.
1977 Degree in Medicine at the University of Milan, Italy
1981 Board Certification in Radiology, University School of Milan
Postgraduate education completed through residencies at:
Department of Ultrasound (Prof D O Cosgrove), Royal Marsden Hospital in Sutton, UK (1981)
Department of Medical Physics (Prof J Woodcock), Bristol Hospital, UK (1982)
Department of Radiology (Prof E van Sonnenberg), University of San Diego (USA) (1988)
Academic and professional appointments
1980–1989 Assistant, Department of Radiology, Busto Arsizio General Hospital, Italy
1989–1999 Vice-chairman, Department of Radiology, General Hospital of Busto Arsizio
1999–2002 Chairman, Ultrasound Division, Department of Radiology, General Hospital of Busto Arsizio
2002 to date Chairman, Diagnostic Imaging Department, General Hospital of Busto Arsizio
2010 to date Chairman, Department of Interventional Oncologic Radiology, General Hospital of Busto Arizio
1988 to date Contract professor of Techniques and Methods of Diagnostic Imaging, School of Radiology, University of Milan, Italy
Italian Society of Radiology (SIRM)
Radiological Society of North America (RSNA)
Society of Interventional Radiology (SIR)
Cardiovascular and Interventional Radiological Society of Europe (CIRSE)
Italian Society of Ultrasound in Medicine and Biology (SIUMB)
More than 500 presentations (keynote lectures, lessons and papers) to international and
national meetings, courses and congresses in 36 different countries