Ultrasound-guided intra-tumoral administration of directly-injected therapies: a review of the technical and logistical considerations

Directly-injected therapies (DIT) include a broad range of agents within a developing research field in cancer immunotherapy, with encouraging clinical trial results in various tumour subtypes. Currently, the majority of such therapies are only available within clinical trials; however, more recently, talimogene laherparepvec (T-VEC, Imlygic) has been approved as the first oncolytic virus therapy in the USA and Europe. Our institution contributes to multiple different trials exploring the efficacy of DIT, the majority of which are performed by oncologists in clinic. However, specific, challenging cases - mainly neck tumours - require image-guided administration. This review article addresses the technical and logistical factors relevant to the incorporation of image-guided DIT into an established ultrasound service. Image-guidance (usually with ultrasound) is frequently needed for certain targets that cannot be palpated or are in high-risk locations, e.g. adjacent to blood vessels. A multi-disciplinary approach is essential to facilitate a safe and efficient service, including careful case-selection. Certain protocols and guidance need to be followed when incorporating such a service into an established ultrasound practice to enhance efficiency and optimise safety. Key learning points are drawn from the literature and from our early experience at a tertiary cancer centre following image guided DIT for an initial cohort of 22 patients (including 11 with a neck mass), addressing trial protocols, pre-procedure work-up, organisation, planning, consent, technical aspects, procedure tolerability, technical success, and post-procedure considerations. With appropriate planning and coordination, and application of the learning points discussed herein, image-guided administration of DIT can be safely and efficiently incorporated into an established procedural ultrasound list. This has relevance to cancer centres, radiology departments, individual radiologists, and other team members with a future role in meeting the emerging need for these procedures. This paper provides advice on developing such an imaging service, and offers certain insights into the evolving remit of radiologists within cancer care in the near future.