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3.7.4 Advanced Techniques
Several techniques can be used to increase the dis-
tance of the applicator from vital structures to
minimize collateral tissue damage. Fixating the
probe with ice within or immediately adjacent to
targeted tissue during cryoablation allows enough
security to torque the probe, mobilizing the abla-
tion zone away from adjacent structures. This
technique is particularly useful to move the zone
of ablation away from nerves (e.g., phrenic) and
critical structures (e.g., esophagus). A second tech-
nique is the induction of an iatrogenic pneumo-
thorax or pneumoperitoneum in order to air-
insulate the targeted tumor and injury-prone
structures (▶ Fig. 3.11). Finally, when using cryo-
ablation in the chest wall, a sterile glove filled with
warm water placed on the skin or an infusion of
a mixture of sterile water and lidocaine into the
subcutaneous tissues may present frostbite of the
overlying skin.
23
3.8 Complications
The most frequent complications—pneumothorax,
pleural effusion, and hemothorax—are shared in
all three types of lung ablation to varying degrees
(▶ Table 3.2). Although pneumothorax remains
the most common complication, occurring in
approximately 15 to 40% of percutaneous lung
ablations, depending on the thermal energy used,
only approximately 10 to 15% of pneumothoraces
require manual aspiration or chest tube placement
(▶ Fig. 3.12).
23,24,25,26,27,28
A gradual pleural
Fig. 3.4 Microwave ablation requiring repositioning due to heat sink effect. (a) Axial images in lung windows
demonstrate a colorectal metastasis in the right lower lobe. (b) Ablation images with the patient in the prone position
demonstrate the antenna appropriately positioned within the nodule. Axial images during 5 minutes (c) and 10 minutes
(d) at 90 W demonstrate surrounding ground glass, which spares the medial aspect of the nodule (arrowhead). (e) Given
the inadequate ablation margin medially, the antenna is repositioned to the medial aspect of the nodule. (f) An
additional 5 minutes at 90 W demonstrates an adequate ablation margin medially (arrowhead). Postablation images
demonstrate ablation zone hemorrhage and inflammation (g) at 1 month with subsequent cavitation (h) at 2 months.
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
45
effusion is a relatively common sequela of percuta-
neous ablation, occurring in approximately 15 to
20% of patients. Few (4%) require intervention for
symptom relief. A rapidly accumulating pleural
effusion detected by CT or radiography during the
immediate postprocedural period should warrant
expedited clinical evaluation to exclude a poten-
tially lethal hemothorax and to prompt immediate
intervention, such as embolization or ligation of
the bleeding vessel, if required.
Unique to RFA and less commonly MWA, is post-
ablation syndrome (PAS), likely related to the
release of inflammator y cytokines at the site of ab-
lation into the systemic circulation. This occurs in
roughly 40% of patients undergoing RFA and an
infrequent 2% of MWA patients.
23,26,28
The symp-
toms include low-grade fever, chills, malaise, myal-
gia, anorexia, and nausea, and they typically ensue
within the first 24 to 48 hours and last up to 7 to
14 days. Treatment is largely symptomatic and
involves antipyretics, pain control, and antitus-
sives, as needed.
29
Less common complications include infection,
bronchopleural fistula, pulmonary hemorrhage,
Fig. 3.5 Percutaneous cryotherapy (PCT) of a paratracheal mesothelioma recurrence. (a) An axial fused positron
emission tomography computed tomographic image demonstrates a hypermetabolic focus (arrowhead) in the right
paratracheal region, representing recurrent mesothelioma. (b) With the patient in a prone position, a single cryoprobe
was positioned within the ill-defined soft tissue fullness (arrowhead) of the right paratracheal region. (c) An ice ball
(arrowheads) following PCT encompasses the soft tissue mass but preserves integrity of adjacent trachea, partly due to
the cold sink effect.
Fig. 3.6 Tangential approach for a juxtapleural osteosarcoma metastasis using radiofrequency ablation (RFA). (a) Axial
computed tomographic image in lung windows demonstrates an irregular nodule (arrow) abutting the pleura in the left
upper lobe. (b) Ablation image demonstrates RFA probe placement adjacent to the nodule (arrowhead, probe tip; arrow,
nodule), tangential to the pleura to ensure adequate ablation of the juxtapleural component of metastasis.
(c) Postablation images demonstrate adequate coverage of the nodule with ground glass.
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
46
Fig. 3.7 Tangential approach for microwave ablation (MWA) of a biopsy-proven NSCLC in the juxtapleural left lower
lobe. (a) Axial computed tomographic image in lung windows with the patient in the prone position demonstrates a
juxtapleural spiculated nodule in the left lower lobe. (b, c) Consecutive axial images demonstrate placement of the
antenna adjacent to the tumor (arrow), but with the tumor intervening between the probe and the pleura to prevent
ablation injury to the pleura. Note is made of a trace pneumothorax related to probe placement. (d, e) Consecutive axial
images demonstrate adequate ablation margins (arrowheads) with ground glass and airspace consolidation
encompassing the tumor (arrow) with associated volume loss of the adjacent lung. (f) A coronal image confirms the
ablation margin, consisting of airspace consolidation (arrow) and surrounding ground glass, encompassing the tumor.
Fig. 3.8 Pleural anesthesia prior to percutaneous thermal ablation. (a) Axial computed tomography (CT) demonstrates a
19-gauge coaxial needle (arrowhead) with the tip terminating in extrapleural soft tissues. (b) Postanesthesia, a 19-gauge
coaxial needle (arrowhead) has been advanced into the extrapleural space with a convex collection of 10 mL of 1%
lidocaine in the extrapleural space. The targeted lung lesion (arrow) is along the path of the needle. (c) Intraprocedural
CT images demonstrate subsequent microwave ablation antenna placement (arrow) within the pulmonary tumor.
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
47
neural injury, tumor seeding, and air embolism.
Bronchopleural fistula is of particular concern with
aggressive ablation, especially MWA, of peripheral
pulmonary, pleural, and chest wall lesions, result-
ing in a communication between the peripheral
airway or lung and the pleural space.
30
It requires
prolonged catheter drainage and, possibly, escalat-
ing adjunctive treatments, including autologous
pleural blood patch or sealant placement or surgi-
cal wedge resection
31,32,33
(▶ Fig. 3.13).
3.9 Postprocedural
Management and Follow-up
Evaluation
3.9.1 Postprocedural
Management
Following the ablation procedure, patients recover
in the posttreatment care unit with the punctured
lung dependent. With an anterior lung puncture,
Fig. 3.9 Imaging end point with radiofrequency ablation (RFA). (a) Preablation computed tomographic (CT) image in
lung window demonstrates a right lower lobe pericentimeter biopsy-proven non–small cell lung cancer (arrow). (b) With
the patient in a prone position, a single radiofrequency electrode (arrowhead) was inserted into the nodule (arrow). (c)
Ablation images demonstrate adequate coverage of the tumor with ground glass (arrowheads). (d) In an axial CT image
1 week later the zone of ablation shows interval cavitation (arrow) with surrounding consolidation (arrowhead).
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
48
the patient is placed in ipsilateral decubitus posi-
tion to decrease the risk of delayed pneumothorax
and to reduce bleeding into the central airway,
while vital signs and oxygenation are frequently
monitored. For lung ablations, chest radiographs
are generally obtained at 2 and 4 hours postproce-
dure to check for complications, such as pneumo-
thorax; however, they may be acquired less
frequently, if at all, in certain situations in which
the lung parenchyma was not traversed, such as in
chest wall ablations. On occasion, if the patient is
symptomatic, follow-up chest radiographs at 24
and/or 48 hours following the ablation can assess
for interval pleural effusion, airspace consolida-
tions, or delayed or progressive pneumothorax.
3.9.2 Follow-up Evaluation
Following discharge, periodic imaging is required
to identify any complications, confirm expected
postablation appearances, exclude local tumor
progression, and screen for disease progression at
other intra- and extrathoracic sites. Although there
is no proven standardized imaging modality or
protocol within the literature, many feel that CT
with interval positron emission tomographic
(PET)-CT can be helpful in determining the efficacy
of the ablation
34,35
(▶ Fig. 3.14).
Given that the common pathological end point
of ablation, regardless of thermal energy used, is
coagulation necrosis, many of the imaging findings
are strikingly similar across the modalities.
Although the descriptions of the timing of radio-
graphic findings are beyond the scope of this chap-
ter, in general, the size of the zone of ablation may
be larger compared to the preablation tumor for
the first 3 to 6 months (2 months in PCT), but
should generally be smaller after 6 months
(▶ Fig. 3.15 and ▶ Fig. 3.16).
34,36,37
3.10 Outcomes
Much of the data on percutaneous thermal abla-
tion in the lung has been generated for RFA.
Fig. 3.10 Percutaneous cryotherapy
(PCT) of two colorectal metastases in
the left upper lobe using two cryop-
robes for each lesion. (a) Preprocedure
computed tomographic (CT) image
demonstrates two juxtapleural nod-
ules (arrows) in the left upper lobe, an
ideal case for using PCT. (b) Axial
images demonstrate two probes (black
arrowheads) adjacent to or within each
nodule (white arrows). (c) Sagittal and
(d) coronal images confirm two probes
(white arrowheads) adjacent to or
slightly within each nodule (arrow).
Smaller lesions can be difficult to
skewer when using the large-caliber
cryoprobes and in this case required
two cryoprobes each for adequate
ablation margins. The respective
crossing cryoprobes (black arrowheads)
are noted in each image. (e) Immedi-
ate postablation images demonstrate
extensive perilesional hemorrhage
(white arrowheads) encompassing the
margins of the targeted nodule (black
arrows). (f) Follow-up CT approxi-
mately 3 weeks later demonstrates
hemorrhage resolution with an abla-
tion zone showing central cavitation
(arrowhead).
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
49
Compounding the limited outcome data for ther-
mal ablation in the lung is the heterogeneity of the
patient population, lesions treated, and criteria for
treatment.
3.10.1 Radiofrequency Ablation
Survival following thermal ablation is dependent
on many factors. For patients with NSCLC, survival
is strongly correlated with clinical tumor stage,
such that potential cure can be achieved in stage
1A and 1B NSCLC. Better survival is associated with
smaller baseline tumor size, which theoretically
allows for achieving complete necrosis. Simon and
colleagues reported that the median survival for
medically inoperable stage 1 NSCLC was 29
months with 1-, 2-, 3-, 4-, and 5-year survival rates
of 78%, 57%, 36%, 27%, and 27%, respectively.
25
Reemphasizing the importance of tumor size was
the fact that local tumor progression rates over
time were significantly lower in patients with
smaller index lesions ( ≤ 3 vs. > 3 cm, p < 0.002)
with median time to progression of ≤ 3 cm being
45 months and > 3 cm being 12 months. Similar
survival rates were found by Lencioni and col-
leagues in a prospective, intention-to-treat, multi-
center clinical trial for inoperable NSCLC with
RFA.
38
The 1- and 2-year survival rates for inoper-
able NSCLC were 70% and 48%, respectively, and
the 2-year survival for stage I NSCLC was 75%. In a
retrospective review in 50 patients undergoing
RFA for inoperable stage I NSCLC, Hiraki and col-
leagues found the 1-, 2-, 3-, 4-, and 5-year overall
survivals to be 94%, 86%, 74%, 67%, and 61%,
Fig. 3.11 Malignant thymoma recurrence along the left paraspinal space requiring intentional pneumoretroperitoneum
prior to percutaneous cryotherapy. (a) Axial computed tomographic (CT) image in soft tissue windows with the patient
in a prone position demonstrates a soft tissue mass (arrowhead) along the left paraspinal region, representing malignant
thymoma recurrence. The relatively decompressed stomach (arrow) abuts the soft tissue mass. (b) A 19-gauge coaxial
needle (arrowhead) was introduced into the retroperitoneum with subsequent injection of room air to cause a large
retropneumoperitoneum (arrow). (c) A preablation CT image demonstrates one of three cryoprobes (black arrow) is
positioned within the mass (white arrowhead). The stomach has been displaced from the expected ablation margin. (d)
The three cryoprobe positions in relation to the mass (arrowheads) are confirmed on a sagittal reformatted CT. (e) A
postablation CT demonstrates the hypodense ice ball (arrowheads) encompassing the previously seen mass with
extension of the ice ball into the left neural foramen. (f) Follow-up CT performed 3 months later demonstrates interval
decrease in size and increased hypodensity of the left paraspinal tumor (arrowhead), likely representing scar tissue.
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
50
resepctively.
39
Interestingly, tumor size had no
prognostic significance. Additionally, there was no
significant survival difference (p = 0.057) between
overall sur vival of stage Ia and stage Ib patients.
Given the poor outcomes of surgical resection,
chemotherapy and radiation therapy in unresect-
able recurrent NSCLC, a retrospective review on
the outcomes of RFA in 44 patients and 51 tumor
targets was performed by Kodoma and col-
leagues.
40
The 1-, 3-, and 5-year overall survival
rates were 97.7%, 72.9%, and 55.7%, respectively.
There were 5 of 41 patients with recurrences over
the 5 years, 3 of which were successfully retreated
with RFA. The 1-, 3-, and 5-year secondary local
tumor progression rates were 5.4%.
RFA as an adjunctive role with chemotherapy in
stage III and IV NSCLC performed super iorly to
chemotherapy alone with overall survival of 42
months versus 29 months, respectively (p = 0.03).
41
Combination therapy of mostly RFA with external-
beam radiation therapy and brachytherapy in
medically inoperable stage I and II NSCLC in 41
patients by Grieco et al found overall survival rates
of 86.8% at 1 year, 70.4% at 2 years, and 57.1% at 3
years, which was felt to represent improved
survival compared to either treatment modality
alone.
42
A number of factors have been found to influ-
ence survival and local control in patients under-
going RFA in the setting of pulmonary metastatic
disease, including tumor size ≤ 3 cm, absence of
extrapulmonary metastases at the time of abla-
tion,
43
single metastasis, normal carcinoembryonic
antigen (CEA) prior to therapy in colorectal meta-
stases, prolonged disease-free interval between
primary therapy and development of first meta-
stases, and initial complete response to ablation.
44,
45
Local control is affected by smaller tumor size
(≤ 1.5–3.5 cm) and lack of a subtending bronchus >
2 mm.
46,47
█
Pearls
●
Thermal ablation is an effective treatment
alternative in select patients with primary or
secondary lung or chest wall malignancies.
●
The choice of RFA, MWA, or PCT depends on
operator comfort as well as patient and tumor
characteristics, including, but not limited to,
tumor size and location.
●
Thermal ablation in the lung and chest wall can
be safely performed as an outpatient proce-
dure with up to 4 hours of postprocedural
observation.
●
Complications are relatively similar across the
various thermal energies, although pneumo-
thorax tends to be the most common, which
occasionally requires chest tube insertion.
●
The survival outcomes of thermal ablation in
the lung across the various energy modalities
approach those of surgical resection and radia-
tion therapy.
●
PCT is the preferred modality of treatment for
chest wall and pleural lesions because it is less
painful than RFA and MWA.
●
The data regarding chest wall and pleural ma-
lignancies are limited, but in our experience
has a significant role in local control and pallia-
tion for recurrent mesothelioma, thymoma,
and metastatic disease.
In inoperable patients with colorectal pulmonary
metastatic disease, Chua and colleagues found that
the median progression-free survival was 11
months (95% confidence interval 9–14), and the
median overall survival was 51 months. The 3-
and 5-year survival rates were 60% and 45%,
respectively,
43
which compares well with the
Table 3.2 Complication percentages associated with ra-
diofrequency ablation (RFA), microwave ablation (MWA),
and percutaneous cr yotherapy (PCT)
Summary pulmonary RFA
54
MWA
26
PCT
23
Complications %
Pneumothorax 42.7 39 12
Minor 28.3 27 11
Chest tube 14.4 12 1.4
Pleural effusions 14.8 21 14
Pain 14.1 2
Pyrexia 4.4 2 42
Hemoptysis 4.3 6 62
Pneumonia 1.5
Abscesses 0.4 3
Bronchopleural fistula 0.4
Subcutaneous emphysema 0.2 5
Burn/skin injury 3 5
Acute respiratory distress/
hospital admission
2/15
Procedure-related death 0.2 1
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
51
surgical metastasectomy rate. Nakamura and col-
leagues reported that complete tumor ablation of
sarcoma pulmonary metastases was a significant
factor for prognosis, with the 1- and 3-year surviv-
al rates of 88.9% and 59.2% with complete ablation
versus 29.6% and 0% with incomplete tumor abla-
tion.
48
Furthermore, Simon and colleagues
reported 1-, 2-, 3-, 4-, and 5-year survival rates for
colorectal metastases as 87%, 78%, 57%, 57%, and
57%, respectively.
25
As with NSCLC, there is likely an adjunctive role
of RFA with chemotherapy in the setting of pulmo-
nary metastatic disease. Inoue and colleagues
demonstrated a significant difference in survival
between those patients with colorectal metastases
receiving chemotherapy and RFA and in those
receiving chemotherapy alone at 88% and 33%,
respectively, at 3 years.
44
Chua and colleagues
found that the use of adjunct systemic chemother-
apy was an independent predictor for overall sur-
vival in patients undergoing RFA for unresectable
colorectal pulmonary metastases.
47
3.10.2 Microwave Ablation
Unlike RFA, outcome data are limited regarding
MWA therapy for lung cancer or pulmonary meta-
static disease, although results would be expected
Fig. 3.12 Postablation pneumothorax complicating microwave ablation of a biopsy-proven non–small cell lung cancer.
(a) Preablation axial CT image in lung windows demonstrates a semisolid lesion with ill-defined borders in the right
middle lobe (white arrowheads), which is adjacent to the right major fissure (white arrow). Note is made of postbiopsy
changes lateral to the tumor (black arrowhead) related to a biopsy performed approximately 3 weeks earlier. (b) The
antenna is positioned adjacent to the lesion (arrowhead) without crossing the adjacent major fissure. The antenna
intervenes between the large pulmonary vessel (arrow), a potential cause of heat sink, and the lesion. (c) Ablation image
demonstrates coverage of the tumor margin with ground glass and airspace consolidation (arrowheads). (d) On the CT
image following antenna removal, a small pneumothorax was present, which slowly increased on a subsequent CTscan
performed 5 minutes later (image not shown), confirming an air leak. (e) A 12F chest tube (arrowhead) was placed into
the pleural space. (f) The small to moderate pneumothorax (arrowhead) was aspirated with a trace residual
pneumothorax. The chest tube side holes approximate the presumed region of air leak. The patient was discharged
home later that day with a Heimlich valve connected to the chest tube. The chest tube was removed 3 days later once
the air leak had resolved.
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
52
to be at least as good for MWA because ablation
zones trend toward being more robust, with less
thermal sink effect. Wolf et al reported their
results on mixed pulmonary tumors and found 1-,
2-, and 3-year overall survivals of 65%, 55%, and
45%, respectively. Unlike RFA, the overall survivals
were not affected by index lesions > 3 cm in size;
however, there was a statistically significant
decrease in local control for those tumors > 3 cm in
size.
26
In a group of mixed pulmonary malignancies, Lu
and colleagues found clinical efficacy and compa-
rable survival rates for NSCLC and pulmonary
metastatic disease, respectively, to prior studies
with MWA and RFA. Most notably though there
was no significant difference in local progression
between tumors < 3 cm and tumors 3 to 4 cm;
however, there was increased local progression for
those tumors > 4 cm.
49
Risk factors for local tumor progression in pri-
mary and metastatic pulmonary lesions following
MWA include the following: tumor diameter
(> 1.55 cm), tumor shape (irregular, vs. round or
oval), low applied energy (< 26.7 J/mm
3
), and pleu-
ral adhesion. Notably, adjacency to vessels>3mm
in diameter had no significant correlation with
local tumor progression.
50
3.10.3 Cryoablation
Like MWA, there are limited outcome data for PCT
in pulmonary malignancies. Compared with RFA
and sublobar resection in medically inoperable
stage I NSCLC, PCT had similar outcomes with 3-
Fig. 3.13 Novel technique for percu-
taneous treatment of percutaneous
cryotherapy (PCT)-related broncho-
mediastinal fistula. (a) Axial computed
tomographic (CT) images were ob-
tained 3 months following PCT of left
upper lobe colorectal metastases and
demonstrate extensive subcutaneous
emphysema and mediastinum without
a pneumothorax. The cavitary ablation
site (arrowhead) communicates with
the chest wall and mediastinum (not
shown). (b) A magnified view demon-
strates a bronchus (arrowhead) sup-
plying the cavitary ablation site and
the likely culprit for the persistent air
leak. (c) A 19-gauge coaxial needle
(arrowhead) was advanced into the
cavitary ablation site (arrow) and of-
fending bronchus. (d) Surgical sealant
was administered through the outer
cannula of the coaxial needle filling the
cavitary site (arrow). (e) In comparison
of portable chest X-ray prior to pro-
cedure (f) to 1 day after the proce-
dure, there is significant reduction in
the subcutaneous emphysema and
pneumomediastinum, consistent with
a successfully treated postablation
persistent air leak. Note is made of a
mediastinal drain (arrowhead) on (f)
follow-up chest X-ray that was placed
during surgical sealant administration
for immediate decompression of
pneumomediastinum.
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
53
Fig. 3.14 Follow-up imaging algorithm from our institution. Timetables for follow-up may have several different
appearances using computed tomography alone or in combination with positron emission tomography.
Fig. 3.15 Imaging changes following percutaneous cryotherapy (PCT) of a biopsy-proven non–small cell lung cancer. (a)
Preablation computed tomographic (CT) image in lung windows with the patient in the prone position demonstrates an
irregular semisolid lesion (arrow) in the right lower lobe. (b) A procedural CT scan demonstrates the cryoprobe
(arrowhead) within the lesion (arrow). (c) A postprocedure CT image with the patient in the supine position
demonstrates extensive hemorrhage and airspace consolidation (arrowheads) in the region of the previously seen tumor.
(d) An axial CT image in lung windows performed 5 weeks following the procedure demonstrates a more discrete,
consolidative appearance to the ablation site (arrowheads). (e) Follow-up CT images at approximately 5 and (f) nearly 9
months shows the expected findings of continued involution of the cryoablation zone.
Ablation of Lung Cancer, Pulmonary Metastatic Disease, and Chest Wall Malignancy
54