DOI:10.2214/AJR.04.0235
AJR 2005; 185:894-898
© American Roentgen Ray Society
Pulmonary Radiofrequency Ablation Complicated by Subcutaneous Emphysema and Pneumomediastinum Treated with Fibrin Sealant Injection
Martin G. Radvany1,2,
Patrick F. Allan3,
William C. Frey3,
Kevin P. Banks1 and
David Malave4
1 Department of Radiology, Brooke Army Medical Center, MCHE-DR, 3851 Roger
Brooke Dr., Fort Sam Houston, TX 78234.
2 Uniformed Services University of the Health Sciences, Bethesda, MD.
3 Department of Pulmonary Medicine, Brooke Army Medical Center, Fort Sam
Houston, TX 78234.
4 Department of Cardiothoracic Surgery, Brooke Army Medical Center, Fort Sam
Houston, TX 78234.
Received February 13, 2004;
accepted after revision October 15, 2004.
Address correspondence to M. G. Radvany.
Introduction
Radiofrequency ablation of non-small cell lung carcinoma involves inserting
a needle through the chest wall into the lesion and administering
electromagnetic radiation that is absorbed by the tissue as heat and results
in tissue necrosis. In the lung, the insulating effect of the neighboring
alveolar air limits the spread of tissue damage
[1]. Radiofrequency ablation is
an alternative to radiation for palliative cancer therapy and has had minimal
procedure-related complications
[2,
3]. We present a patient
treated with radiofrequency ablation for palliation of severe pain secondary
to metastatic lung cancer. The patient's delayed complication from
radiofrequency ablation is the first reported case of subcutaneous emphysema
with pneumomediastinum, to our knowledge. The complication was treated with
transthoracic instillation of a fibrin-based sealant into the tumor cavity
produced by the tissue necrosis.
Case Report
The patient is an 82-year-old woman with a medical history significant only
for adenocarcinoma of the lung. The patient initially developed right-sided
back pain in 1995, and evaluation revealed an osteolytic lesion of the
posterior fourth rib. Needle biopsy diagnosed adenocarcinoma, but extensive
workup failed to yield a primary cancer. The patient received therapeutic
doses (6,000 cGy) of external beam radiation therapy with resolution of the
pain. The patient was followed with serial chest radiographs, and in 1998 a
left upper lobe lesion was discovered. Left upper lobectomy revealed primary
adenocarcinoma of the lung. The patient did well until 2001 when her cancer
metastasized to the abdomen. Multiple chemotherapeutic regimens improved the
patient's abdominal disease, and she was stable until January 2003.
In January, she returned with excruciating back pain. CT of the chest
revealed a posterior right upper lobe lesion invading the chest wall
(Fig. 1A). PET showed uptake
(standard uptake value [SUV], 6.9) consistent with malignant disease
(Fig. 1B). The patient was
evaluated for repeat external beam radiation therapy. Because of the
previously administered therapy to the same area and her poor functional
status, however, she was not a good candidate for repeat external beam
radiation therapy; therefore, she was referred to interventional radiology for
further evaluation.
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Fig. 1A —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Axial CT image obtained before ablation through lung apices
shows spiculated mass in right upper lobe coinciding with patient's prior
abnormality detected on chest radiography.
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Fig. 1B —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. PET image corresponding to A obtained before ablation
shows avid FDG uptake in lesion (standard uptake value, 6.9) consistent with
malignancy.
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Radiofrequency ablation was deemed a viable treatment option and was
subsequently performed with the patient under general anesthesia in the
interventional radiology suite. The ideal approach was determined using
preprocedure CT scans and real-time fluoroscopy. The planned course aligned
the electrode shaft parallel to the longitudinal axis of the lesion.
With the use of standardized sterile technique, local anesthesia was
injected from the skin down to the parietal pleura. Based on the size of the
target tumor, a 10-cm-long, 3- to 5-cm adjustable-diameter array needle
electrode (Starburst XL, RITA Medical Systems) was used in conjunction with
the RITA 1500X radiofrequency generator. The needle electrode was advanced
percutaneously into the tumor under fluoroscopic guidance, and the tines were
deployed to 2 cm. Radiofrequency ablation electrode placement was verified in
the anteroposterior and lateral orthogonal planes, and it was noted that the
inferomedial portion of the mass would not be adequately treated and that a
second overlapping treatment would be needed
(Fig. 1C).
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Fig. 1C —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Fluoroscopic image obtained during radiofrequency ablation
shows intralesional placement of radiofrequency ablation probe.
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During the first application of energy, the power was initiated at the
lowest setting and increased in 5- to 10-W increments until 35-50 W, when the
system impedance rose to more than 400 
and the target temperature of
90°C was achieved. Ablation was performed for 10 min, and the tines were
then withdrawn and the radiofrequency ablation needle was repositioned to
treat the inferomedial portion of the mass. The tines were again deployed to 2
cm, and the energy application was repeated using an identical protocol. A
conventional chest radiograph obtained 6 hr after the procedure did not show
pleural or mediastinal air. A thin sliver of subcutaneous air was noted in the
right axilla and was thought to be consistent with expected postprocedural
changes (Fig. 1D). Two days
after the procedure, the patient reported complete remission of her upper back
pain attributed to her tumor.
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Fig. 1D —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Frontal radiographic view of chest obtained 6 hr after
ablation shows thin radiolucency in subcutaneous tissues adjacent to right
upper lobe. This was thought to be normal postoperative finding. No
pneumothorax is present.
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Seven days after the intervention, the patient began to note a progressive
"puffiness" on her right upper back spreading to her right
anterior chest and shoulder. These skin changes eventually involved the entire
circumference of her neck and bilateral cheeks. Physical examination showed
"crackling" in the areas of "puffiness," and chest
radiography confirmed the subcutaneous emphysema
(Fig. 1E). A chest CT scan
showed cavitation of the treated tumor, significant right-sided subcutaneous
emphysema, and pneumomediastinum without pneumothorax
(Fig. 1F).
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Fig. 1E —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Follow-up chest radiograph obtained 11 days after ablation due
to patient's complaint of right shoulder pain shows massive subcutaneous
emphysema centered around upper right thorax. No pneumothorax is present.
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Fig. 1F —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Axial CT image obtained 12 days after ablation through level
of lesion verifies presence of massive subcutaneous emphysema. Tumor bed in
right lung apex shows fibrosis and cavitary changes consistent with recent
radiofrequency ablation.
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Because of the progressive subcutaneous emphysema and poor surgical
candidacy, CT-guided transthoracic sealing of the cavity was attempted. The
patient was placed in the prone position, and conscious sedation was
administered. The patient was anesthetized again from the skin to the parietal
pleura using sterile technique. Sealant (Tisseel fibrin, Baxter-Immuno) was
prepared for injection. An 18-gauge Turner needle (Cook) was advanced through
the chest wall and into the tumor cavity. Placement of the needle within the
cavity was verified on CT (Fig.
1G). Six milliliters of heated Tisseel fibrin sealant was injected
into the cavity, and an additional 2 mL of sealant was injected into the
needle track as it was withdrawn. Repeat CT through the cavity showed near
complete filling of the lesion (Fig.
1H). The patient was hospitalized overnight with mild improvement
in the subcutaneous emphysema by clinical examination.
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Fig. 1G —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Axial CT image obtained during injection of fibrin sealant
through level of tumor bed shows tip of procedure needle placed within
superior aspect of radiofrequency ablation cavity using CT guidance.
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Fig. 1H —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Axial CT image obtained immediately after application of 8 mL
of sealant shows partial filling of radiofrequency ablation cavity.
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Four weeks after the sealant procedure, minimal residual subcutaneous
emphysema was present (Fig. 1I)
and the patient continued to be pain-free. Subsequent chest radiographs (not
shown) obtained 16 weeks after the sealant procedure was performed for
alternative indications showed complete resolution of subcutaneous emphysema
and no other complications. The patient continues to do well and has no
evidence of active disease 1 year after her ablation.
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Fig. 1I —82-year-old woman with medical history significant only for
adenocarcinoma of lung. Patient initially developed right-sided back pain in
1995, and evaluation revealed osteolytic lesion of posterior fourth rib.
Needle biopsy diagnosed adenocarcinoma, but extensive workup failed to yield a
primary cancer. Follow-up chest radiograph obtained 3 weeks after percutaneous
application of sealant shows marked interval improvement of subcutaneous
emphysema and resolution of pneumomediastinum.
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Discussion
Radiofrequency ablation of primary and metastatic lung tumors results in
the reduction in lesion viability with relatively minimal procedure-related
complications [2].
Complications previously reported in case series include pneumothorax, pleural
effusion, and subcutaneous emphysema.
Sewell and Vance [4]
reported radiofrequency ablation in 10 patients who refused surgery or who had
unresectable non-small cell lung cancer. PET scans obtained after treatment
showed a lack of tumor viability within the boundary of the treatment area.
All the patients tolerated the procedure well. Complications included one case
of pain during the procedure and one instance of oversedation; four patients
developed pneumothorax that was treated with aspiration of the air before
completion of the procedure.
Nishida et al. [5] reported
successful radiofrequency ablation of primary lung lesions in six patients
without evidence of local recurrence at a mean of 303 days of follow-up. Four
patients developed mild pneumothoraces.
In the largest series reported to date (n = 29), Sewell et al.
[6] applied radiofrequency
ablation to patients with stages IA-IIIB non-small cell lung carcinoma.
Three-month follow-up revealed a 79% survival with no evidence of active
cancer in the treatment area. Of the six patients who had died, three died
from untreated extrapulmonary non-small cell lung carcinoma and one each from
pneumonia, cardiac disease, and chronic obstructive pulmonary disease.
Immediate postprocedure complication rates included a 32% incidence of
pneumothorax (15% requiring chest tube thoracostomy), 15% incidence of pleural
effusion, and 10% incidence of other complications.
An additional severe complication of radiofrequency ablation was acute
pulmonary hemorrhage that resulted in death in two patients. Both patients had
preexisting risk factors for dysfunctional hemostasis: One had
thrombocytopenia and the other was taking clopidogrel
[2,
7]. Dupuy et al.
[2] reported another severe
complication of fistula formation with treatment of tumors contiguous with
large bronchi.
Our patient's complication of subcutaneous emphysema and pneumomediastinum
without pneumothorax is unique. This complication could have resulted from a
single source or a combination of two potential pathologic processes. Tumor
destruction from the heat energy could have allowed air to track through the
damaged interstitium, dissect through the connective tissue planes of the
bronchovascular bundle to the ipsilateral hilum, and involve both the
mediastinum and subcutaneous tissue. Alternatively, tissue necrosis could have
created a fistula between the cavitary mass to the subcutaneous tissue and
mediastinum with subsequent dissection of air. The prior external beam
radiation also may have contributed to the complication.
From our multidiscipline consultation of interventional radiology,
pulmonary medicine, and cardiothoracic surgery, we determined that sealant
instillation into the necrotic cavity could treat the potential causes for the
complication. Bronchoscopic instillation of fibrin sealant has been described
in the literature mainly for therapy of bronchopleural fistulas
[8]. Instillation of sealant
via bronchoscopy requires visual placement of an infusion catheter to the
desired lesion or bronchus. Proximal lesions, typically surgical dehiscence,
have the best results. Distal lesions in the lung parenchyma can be treated as
well but have a lower success rate. Bronchoscopic catheter placement into the
right upper lobe can be challenging secondary to the stiffness of the
catheter. Our patient's lesion was a distal lesion in the right upper lobe;
therefore, the transthoracic approach was offered to the patient.
Only two cases of successful obliteration of bronchopleural fistulas via
nonsurgical transthoracic application of a fibrin-based sealant have been
reported in the literature. One case used continuous CT fluoroscopy to guide
placement of fibrin sealant via chest tube thoracostomy
[9]. A second case described
CT-guided fibrin deposition via needle thoracostomy
[10]. There is literature
advocating the instillation of fibrin sealant after transthoracic needle
biopsies as a means of reducing the incidence of pneumothorax and chest tube
thoracostomy [11].
References
- Goldberg SN, Gazelle GS, Compton CC, McLoud TC. Radiofrequency
tissue ablation in the rabbit lung: efficacy and complications.
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- Dupuy DE, Mayo-Smith WW, Abbott GF, DiPetrillo T. Clinical
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Introduction
Case Report
