Ann Thorac Surg 2009;87:948-950. doi:10.1016/j.athoracsur.2008.07.069
© 2009 The Society of Thoracic Surgeons
Case Reports
Percutaneous Computed Tomography–Guided Radiofrequency Ablation of Lung Tumors Complicated With Idiopathic Interstitial Pneumonia
Tomohisa Okuma, MD*,
Toshiyuki Matsuoka, MD,
Shinichi Hamamoto, MD,
Kenji Nakamura, MD,
Yuichi Inoue, MD
Department of Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
Accepted for publication July 22, 2008.
* Address correspondence to Dr Okuma, Department of Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku, Osaka, 545-8585, Japan (Email: tomohisa_o-kuma{at}nifty.com).
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Abstract
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We report 3 patients with lung cancer complicated with interstitial pneumonia who were treated by percutaneous computed tomography–guided radiofrequency ablation. Patient 1 recovered from a pneumothorax without chest drainage. Patient 2 presented with a progressive pneumothorax after discharge from the hospital and required readmission for air drainage. In patient 3, the pneumothorax did not improve by chest drainage and pleurodesis, and the patient died of acute exacerbation of interstitial pneumonia. Radiofrequency ablation of intractable lung cancer with complicating interstitial pneumonia requires careful consideration because a progressive pneumothorax may require surgical intervention or result in acute exacerbation of interstitial pneumonia.
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Introduction
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In the treatment of lung cancer accompanied by interstitial pneumonia, there is no general agreement on the therapeutic approach or treatment options, because surgical intervention, radiotherapy, or chemotherapy could result in an acute, life-threatening exacerbation of the pneumonia [1–3]. The management of treatment-related acute exacerbation of interstitial pneumonia is limited; the patient generally does not respond well to any type of therapy, including high-dose steroids [3].
Radiofrequency ablation (RFA) seems a promising therapy because it provides effective local control of lung tumors that are either unresectable or unsuitable for chemotherapy or radiotherapy due to impaired pulmonary function or previous surgical intervention [4, 5]. A few reports have been published of high-risk lung cancer cases with complicating interstitial pneumonia that were treated with RFA [5, 6]. Here, we describe 3 patients with lung cancer complicated with interstitial pneumonia and who were treated with RFA.
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Case Reports
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Computed tomography (CT)–guided RFA was approved by the Osaka City University Graduate School of Medicine Institutional Review Board (IRB) as an alternative treatment for lung tumors. In our hospital lung tumors that are inoperable or untreatable by other therapeutic options are treated by RFA after obtaining informed consent from the patients and their family. The diagnosis of idiopathic pulmonary fibrosis is determined by radiographic and clinical findings, including characteristic chest radiographic or high-resolution CT abnormalities and abnormal results from pulmonary function tests, after the exclusion of other known causes including use of drugs, environmental exposure, and collagen vascular disease.
Patient 1
A 79-year-old man had been diagnosed with pulmonary fibrosis 5 years before presentation and was treated with oral prednisolone at 2.5 mg/day. Follow-up CT scans had shown nodules in the S1+2 segment of the left lung, which was confirmed as pulmonary adenosquamous carcinoma by a bronchoscope biopsy specimen. Under local anesthesia of the subcutaneous tissue using 1% procaine and 5 mg of diazepam given orally before the procedure for premedication, an 18-gauge LeVeen electrode (3-cm array diameter) was introduced through a skin incision and advanced to the 32-mm lesion in the left S1+2 segment. Minor pneumothorax and subcutaneous emphysema were observed at electrode puncture. The patient did not require oxygen supplementation. A chest CT scan taken 4 days after ablation showed no deterioration of pneumothorax, and the patient was discharged the next day.
Patient 2
This 82-year-old man had interstitial pneumonia. Two years earlier he had undergone surgical resection of the left lower lobe of the lung and adjacent diaphragm for pulmonary squamous cell carcinoma at another hospital. A follow-up CT scan 6 months before presentation showed an intrapulmonary metastasis in the right S6 segment. RFA was performed for the 18-mm metastatic lesion in the right S6 segment. A small pneumothorax was observed at the time of electrode insertion. The patient was not dyspneic and was discharged from the hospital 5 days after ablation. However, dyspnea developed after discharge, and 2 weeks later he was admitted to the referring hospital and treated with tube thoracostomy for 1 week.
Patient 3
A 66-year-old man had been diagnosed with interstitial pneumonia 4 years earlier and was treated with 100 mg of oral cyclosporine. A follow-up chest CT scan revealed a 34-mm nodule in the segment S4 of the left lung (Fig 1A), which was subsequently diagnosed as squamous cell carcinoma by bronchoscope biopsy specimen. Home oxygen therapy at 1.5 L/min was initiated 1 month before RFA, and oral prednisolone was administered at a dose of 10 mg/d.
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Fig 1. Patient 3 was 66-year-old man who had been treated 4 years earlier for interstitial pneumonia. (A) The computed tomography (CT) scan before radiofrequency ablation (RFA) showed a 34-mm tumor in the S4 of the left upper lobe. (B) The CT scan taken 9 days after RFA showed diffuse infiltrative opacities in both lungs, suggesting acute exacerbation of interstitial pneumonia.
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A minor pneumothorax was observed at the time of electrode insertion. After the procedure, the general condition of the patient was favorable without fever, hemosputum, or signs of dyspnea, and with oxygen saturation measured by pulse oximetry of 92% while receiving oxygen at 2 L/min. However, the patient complained of respiratory distress 2 days after RFA, which was confirmed radiologically to be due to aggravation of the pneumothorax, and required chest tube insertion. A repeat roentgenogram showed no signs of improvement of the pneumothorax at 7 days after chest tube drainage.
In the afternoon of the eighth day after RFA, pleurodesis was performed with OK-342 (picibanil, 500 U). The next morning (9 days after ablation), however, the patient became dyspneic, and the condition did not improve by oxygen inhalation with a 10 L/min reservoir mask. Arterial blood gases were partial pressure of arterial oxygen, 31 Torr; partial pressure of carbon dioxide, 61.3 Torr, pH 7.36; and bicarbonate ion (HCO3
–), 25 mEq. A chest roentgenogram and CT scan revealed bilateral diffuse infiltrative opacities in the lung (Fig 1B), suggesting acute exacerbation of interstitial pneumonia. The patient was intubated and mechanically ventilated with 100% oxygen and also treated with 1 g methylprednisolone. The patient did not respond to the treatment and died in the evening of the same day. Consent for autopsy could not be obtained from the family.
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Comment
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The most common complication of lung RFA is pneumothorax caused by needle puncture, accounting for around 30% in some reports [4, 5, 7]. Most of the reported cases were mild and did not need air drainage, although a sizeable percentage required tube insertion. Pneumothorax associated with interstitial pneumonia may cause severe impairment of pulmonary function. In the present series, pneumothorax was observed in all three patients after electrode insertion. The first patient showed mild pneumothorax with favorable recovery after the procedure, although the second patient required chest tube insertion for pneumothorax after discharge from our hospital. In the third patient, the puncture-associated pneumothorax was intractable, and he died from acute exacerbation of interstitial pneumonia 9 days after the procedure. Possible causes of acute exacerbation are: (1) puncture-associated pneumothorax; (2) chest tube placement for air evacuation; (3) the inflammatory response induced by chemical pleurodesis, and (4) inflammation associated with lung tissue ablation.
There are many reports on the feasibility of RFA of lung tumors as one of the options for minimally invasive treatment for local control of inoperable lung tumors [4–8]. Lung RFA is generally a safe procedure, and preliminary survival data are encouraging; however, its role for the treatment of lung cancer has not yet been determined. Hiraki and colleagues [8] reported RFA of non-small cell lung cancer should be considered only for nonsurgical candidates. RFA of lung cancer with complicating interstitial pneumonia especially requires careful consideration because pneumothorax during electrode insertion may require chest tube drainage or acute exacerbation of pneumonia may develop. Further studies are needed to define the indications for lung RFA in terms of preoperative respiratory capacity.
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References
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- Fujimoto T, Okazaki T, Matsukura T, et al. Operation for lung cancer in patients with idiopathic pulmonary fibrosis: surgical contraindication? Ann Thorac Surg 2003;76:1674-1679.[Abstract/Free Full Text]
- Yuksel M, Ozyurtkan MO, Bostanci K, Ahiskali R, Kodalli N. Acute exacerbation of interstitial fibrosis after pulmonary resection Ann Thorac Surg 2006;82:336-338.[Abstract/Free Full Text]
- Hyzy R, Huang S, Myers J, Flaherty K, Martinez F. Acute exacerbation of idiopathic pulmonary fibrosis Chest 2007;132:1652-1658.[Abstract/Free Full Text]
- Fernando HC. Radiofrequency ablation to treat non-small cell lung cancer and pulmonary metastases Ann Thorac Surg 2008;85:S780-S784.[Abstract/Free Full Text]
- Simon CJ, Dupuy DE, Dipetrillo TA, et al. Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients Radiology 2007;243:268-275.[Abstract/Free Full Text]
- Takao M, Shimamoto A, Shimpo H, et al. Recurrent lung cancer with interstitial pneumonia treated with percutaneous radiofrequency ablation[in Japanese] Kyobu Geka 2005;58:53-57.[Medline]
- Okuma T, Matsuoka T, Yamamoto A, et al. Frequency and risk factor of various complications after computed tomography-guided radiofrequency ablation of lung cancers Cardiovasc Intervent Radiol 2008;31:122-130.[Medline]
- Hiraki T, Gobara H, Iishi T, et al. Percutaneous radiofrequency ablation for clinical stage 1 non-small cell lung cancer: results in 20 nonsurgical candidates J Thorac Cardiovasc Surg 2007;134:1306-1312.[Abstract/Free Full Text]
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Abstract
Introduction
