Radiofrequency Ablation of Thoracic Lesions: Part 2, Initial Clinical Experience—Technical and Multidisciplinary Considerations in 30 Patients
Eric vanSonnenberg1,2,
Sridhar Shankar1,2,3,
Paul R. Morrison1,
Rashmi T. Nair1,2,
Stuart G. Silverman1,2,
Michael T. Jaklitsch4,5,
Franklin Liu1,2,6,
Lawrence Cheung1,2,
Kemal Tuncali1,2,
Arthur T. Skarin7 and
David J. Sugarbaker4,5
1 Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115.
2 Department of Radiology, Dana Farber Cancer Institute, Harvard Medical School,
44 Binney St., Boston, MA 02115.
3 Present address: Department of Radiology, University of Massachusetts Medical
Center, Worcester, MA.
4 Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115.
5 Department of Surgery, Dana Farber Cancer Institute, Harvard Medical School,
Boston, MA 02115.
6 Present address: University of Washington Medical Center, Seattle, WA.
7 Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical
School, Boston, MA 02115.
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Fig. 1A. —Combined radiofrequency ablation for lung and rib malignancy
in 52-year-old man, supplemented by paravertebral nerve blocks to avoid or
ameliorate pain. Radiofrequency probe (arrows) has been inserted into
malignant soft tissue for ablation.
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Fig. 1B. —Combined radiofrequency ablation for lung and rib malignancy
in 52-year-old man, supplemented by paravertebral nerve blocks to avoid or
ameliorate pain. Active portion of probe (arrows) has been pulled
back into eroded portion of rib that was causing patient's pain. Within
several days, pain abated completely.
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Fig. 1C. —Combined radiofrequency ablation for lung and rib malignancy
in 52-year-old man, supplemented by paravertebral nerve blocks to avoid or
ameliorate pain. At conclusion of radiofrequency ablation of lung and rib
lesions, paravertebral nerve block (arrows) was performed.
Bupivacaine was used as long-acting local anesthetic to prevent acute
postprocedural pain from ablation.
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Fig. 2A. —Multiplanar reformatting of axial CT data confirms accurate
intraprocedural probe positioning for radiofrequency ablation in 65-year-old
man with colon carcinoma metastatic to lung. Sagittal reconstruction shows
probe entering from posterior into this colon carcinoma metastasis in right
lung. H = heart.
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Fig. 2B. —Multiplanar reformatting of axial CT data confirms accurate
intraprocedural probe positioning for radiofrequency ablation in 65-year-old
man with colon carcinoma metastatic to lung. Coronal reconstruction shows
central shaft of probe with umbrellalike circumferential tines
(arrows).
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Fig. 3A. —Two protective maneuvers for radiofrequency ablation of
thoracic lesions are creation of posterior hydroma in 73-year-old-man with
severe emphysema and primary lung carcinoma to avoid lung parenchyma, and
instillation of cool saline into endotracheal tube cuff to protect trachea
from heat of radiofrequency ablation. Preprocedure prone CT scan shows tumor
adjacent to mediastinum. Note overlying emphysematous lung. T = tumor.
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Fig. 3B. —Two protective maneuvers for radiofrequency ablation of
thoracic lesions are creation of posterior hydroma in 73-year-old-man with
severe emphysema and primary lung carcinoma to avoid lung parenchyma, and
instillation of cool saline into endotracheal tube cuff to protect trachea
from heat of radiofrequency ablation. Two 22-gauge needles have been inserted
into extrapleural tissues for instillation of 75 mL of distilled sterile
water. Extrapleural tissues have been widened (arrows). Note scar in
left lung adjacent to major fissure.
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Fig. 3C. —Two protective maneuvers for radiofrequency ablation of
thoracic lesions are creation of posterior hydroma in 73-year-old-man with
severe emphysema and primary lung carcinoma to avoid lung parenchyma, and
instillation of cool saline into endotracheal tube cuff to protect trachea
from heat of radiofrequency ablation. Widened tissues allow insertion of
radiofrequency probe (long arrow) into tumor without traversing lung.
No pneumothorax developed during procedure. Endotracheal tube in trachea
during general anesthesia has cool distilled water and air–fluid level
within cuff (short arrows) for protection against heat of
radiofrequency procedure. Arrowhead points to endotracheal tube.
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Fig. 4A. —Solution to problem of access to posterior right lung tumor
in 60-year-old woman with metastatic cystosarcoma shielded by overlying rib.
Prone CT scan displays tumor adjacent to thoracic vertebra and mediastinum.
Note overlying rib and transverse process (arrows) of thoracic
vertebra. Lateral approach was not used to reduce likelihood of pneumothorax
in this patient with emphysema. T = tumor.
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Fig. 4B. —Solution to problem of access to posterior right lung tumor
in 60-year-old woman with metastatic cystosarcoma shielded by overlying rib.
Prone CT scan shows 14-gauge Bonopty needle (Radi Medical Systems) that has
been inserted through rib just posterior to lesion.
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Fig. 4C. —Solution to problem of access to posterior right lung tumor
in 60-year-old woman with metastatic cystosarcoma shielded by overlying rib.
Bonopty needle (arrow) has been advanced through inner cortex of rib.
Needle-type radiofrequency probe has been placed coaxially through Bonopty
needle and into lesion (arrowhead) for ablation.
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Fig. 5. —Radiofrequency ablation near heart. This 79-year-old man had
solitary prostate metastasis near heart. Supine contrast-enhanced CT scan
immediately after ablation shows radiofrequency probe (arrows) in
tumor approximately 1 cm from heart. Patient suffered no adverse effects and
had complete necrosis of tumor.
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Fig. 6. —Radiofrequency ablation for pain control. This 88-year-old
woman with 15-cm primary bronchogenic carcinoma was having intense chest wall
pain from growth of tumor into soft tissues. On prone CT scan, radiofrequency
probe (arrows) is in peripheral portion of tumor where there has been
direct extension into chest wall. Four radiofrequency applications were
performed in this session. Note gas (arrowhead) in tumor, indicating
necrosis. Patient's pain went from 10 to 3 (on a scale of 10) within 1
week.
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Fig. 7A. —Complications from radiofrequency ablation of thoracic
lesions and their management. Intraprocedural management of pneumothorax with
5-French sheath (arrows) in 79-year-old man. Evacuation of
pneumothorax allowed procedure to continue.
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Fig. 7B. —Complications from radiofrequency ablation of thoracic
lesions and their management. This 67-year-old woman with primary bronchogenic
carcinoma had peritumoral blood on this prone CT scan during radiofrequency
ablation procedure and coughed 4 oz (112 g) of hemoptysis 2 days later.
Bronchoscopy showed no lesion, and bleeding ceased spontaneously.
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Fig. 7C. —Complications from radiofrequency ablation of thoracic
lesions and their management. Photograph of sitting 64-year-old man who
suffered immediate posterior skin burn (arrow) on his left mid back
at site of entrance of radiofrequency probe and initial localizing 22-gauge
needle. Needle was left in place during radiofrequency ablation in this
patient, early in our experience. This presumably resulted in retrograde burn
that injured skin. Patient needed surgical débridement that eventually
led to healing.
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Fig. 7D. —Complications from radiofrequency ablation of thoracic
lesions and their management. This 78-year-old man with primary bronchogenic
carcinoma adjacent to arch of aorta had three radiofrequency burns performed
into tumor (T). One day after procedure patient became hoarse and had
paralysis of left vocal cord. This was thought to be due to injury from
ablation that affected recurrent laryngeal nerve. Hoarseness improved 6 weeks
later, aided by Gelfoam (gelatin sponge, Upjohn) injection into vocal
cord.
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Fig. 8A. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors in four cases. Preprocedural contrast-enhanced supine CT
scan of primary bronchogenic carcinoma in right lower lobe in 59-year-old
woman shows inhomogeneous enhancement of lesion (arrow).
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Fig. 8B. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors in four cases. Contrast-enhanced prone CT scan immediately
after radiofrequency ablation shows no enhancement in lesion (arrow)
in this 59-year-old woman.
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Fig. 8C. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors in four cases. Preprocedural contrast-enhanced supine
T1-weighted MR image shows enhancement of lung tumor (arrow) in right
mid lung zone in a 36-year-old woman.
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Fig. 8D. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors in four cases. Postprocedural contrast-enhanced MR image at
24 hr shows that tumor no longer enhances. Surrounding high-intensity blood
and reactive effect are visualized.
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Fig. 8E. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors in four cases. Preprocedural FDG PET scan shows uptake in
paraaortic left upper lung metastasis (arrow) from colon in a
65-year-old man.
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Fig. 8F. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors in four cases. Follow-up PET scan 1 month after initial
ablation shows two persistent nodules of uptake in previously ablated lesion.
This indicated need for supplemental ablation session, which was performed 6
weeks later.
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Fig. 8G. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors. Chest radiograph 6 days after ablation shows that ablated
area of metastatic adenoid cystic carcinoma in 36-year-old woman has cavitated
(arrow) and has a focus of internal soft-tissue density
(arrowhead).
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Fig. 8H. —Various imaging modalities to assess radiofrequency ablation
of thoracic tumors. Chest radiograph 1 month after ablation shows near
complete resolution of both tumor and effects of ablation
(arrow).
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Copyright © 2005 by the American Roentgen Ray Society.
