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ORIGINAL ARTICLE
Year : 2019  |  Volume : 15  |  Issue : 4  |  Page : 760-765

The application of computed tomography-guided percutaneous coaxial biopsy combined with microwave ablation for pulmonary tumors


Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Date of Web Publication14-Aug-2019

Correspondence Address:
Xiaoyi Ding
Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin 2nd Road, Huangpu District, Shanghai 200025
China
Zhongmin Wang
Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin 2nd Road, Huangpu District, Shanghai 200025
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_778_18

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 > Abstract 


Background: The aim of the study is to evaluate the technique, safety, efficacy, and clinical value of computed tomography (CT)-guided percutaneous coaxial biopsy combined with microwave ablation (MWA) therapy for pulmonary tumors.
Materials and Methods: CT-guided percutaneous coaxial biopsy combined with MWA was performed on 27 tumors in 23 patients who received treatment at our hospital from August 2014 to November 2017. The patients were followed up from 2 to 42 months. The outcomes were evaluated with plain and contrast spiral CT scans.
Results: After treatment, lower density and lower CT values than baseline values were observed in the ablated area. The positive rate of biopsy was 81.48%. Seventeen patients had complete remission, four had partial remission, and two had progressive disease, with an effective rate of 91.3%. Until February 2018, 14 patients survived. Seven patients with metastatic lung cancer died of primary tumor progression. Two patients with primary lung cancer also died; one died of a lung infection and the other of cerebral hemorrhage. The 1-year local control rate was 88.9%, and the median progression-free survival was 33 months. The 1-, 2-, and 3-year survival rates were 91.3%, 69.6%, and 60.9%, respectively.
Conclusion: CT-guided percutaneous coaxial biopsy combined with MWA can improve the quality of life of patients, prolong survival, and improve the survival rate. It is currently one of the most promising interventional treatments.

Keywords: Coaxial biopsy, computed tomography-guided, microwave ablation, pulmonary tumor


How to cite this article:
Liu J, Huang W, Wu Z, Wang Z, Ding X. The application of computed tomography-guided percutaneous coaxial biopsy combined with microwave ablation for pulmonary tumors. J Can Res Ther 2019;15:760-5

How to cite this URL:
Liu J, Huang W, Wu Z, Wang Z, Ding X. The application of computed tomography-guided percutaneous coaxial biopsy combined with microwave ablation for pulmonary tumors. J Can Res Ther [serial online] 2019 [cited 2019 Aug 17];15:760-5. Available from: http://www.cancerjournal.net/text.asp?2019/15/4/760/264302




 > Introduction Top


Lung cancer is one of the most common malignancies, with the highest morbidity and mortality worldwide. Although surgery is the best treatment for it, currently, only 20% of patients meet the indications for surgery.[1] For patients with advanced-stage disease unable to tolerate or unwilling to undergo surgery, microwave ablation (MWA) has become an important treatment.[2],[3],[4] However, there is relatively little relevant research data regarding computed tomography (CT)-guided percutaneous coaxial biopsy combined with MWA. In this study, this method of treatment was performed in patients with lung cancer at our hospital during the past 3 years. We found CTguided percutaneous coaxial biopsy combined with MWA can improve the quality of life of patients, prolong survival, and improve the survival rate. We herein report the results concretely.


 > Materials and Methods Top


Patients

A total of 23 patients who were hospitalized in the Department of Interventional Radiology of our hospital from August 2014 to November 2017 were included. These patients had single- or multiple-lung lesions, as seen on CT. There were 17 men and six women, ranging in age from 41 to 77 years, with the median age being 63 years. According to the patient history and imaging, nine patients had primary lung cancer (seven were in Stage I and two were in Stage IV with bone metastases) and 14 had metastatic lung cancer (primary tumors were confirmed by pathological analysis; the metastases were only in the lungs). These patients were generally in a good condition, with stable tumor control.

Fourteen patients with metastatic lung cancer were selected according to the following criteria: those who were unable to tolerate or unwilling to undergo surgery; the number of lesions in the lung was <5; the maximum diameter of the lesions was <3 cm; the distance between lung metastases and cardiac large blood vessels was ≥0.5 cm; and a life expectancy of ≥3 months. The exclusion criteria included extrapulmonary metastasis, uncontrolled primary malignancy, and serious failure of important organs (heart, lung, liver, or kidney).

Among a total of 27 lesions, the ablation was performed in 20 single lesions, and in three patients, the ablation was performed for 2–3 lesions. The tumor diameter range was 0.50–2.40 cm, with the average diameter being 1.33 cm. The general patient and tumor characteristics are summarized in [Table 1]. All the patients were stable before treatment and had no bleeding tendencies or abnormal coagulation function. Among them, patients with clinical Stage IV (primary or metastatic) disease had not undergone postoperative adjuvant chemotherapy. All procedure performed in our study involving human participants were in accordance with the ethical standards. Moreover, informed consents were obtained from all individual participants included in the study.
Table 1: General patient characteristics

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Methods

An MTC-3C MWA system (Vison-China Medical Devices R and D Center, Nanjing, China) was used, with the main frequency being 2450 MHz, and the output power being 5–120 W (continually adjustable). The microwave antenna had an effective length of 100–180 mm and an outside diameter of 18 G. In addition, the MWA system had a water circulation cooling system to reduce the surface temperature. A GE LightSpeed 16 spiral CT system (GE Healthcare, Atlanta, GA, USA) was used for imaging guidance and monitoring. A 17-G trocar and an 18-G biopsy gun (Meichuang Medical Devices Co., Ltd., Shanghai, China) were used to obtain tissue specimens for pathological analysis.

Enhanced CT scans were performed to assess the location, number, and size of the tumors. Before treatment, routine blood tests including assessments of disseminated intravascular coagulation, liver and kidney function, and electrolyte levels, as well as electrocardiography were performed. We administered local anesthetic agents and preemptive analgesic agents. All patients fasted for 6 h before the procedure. As preemptive analgesia, 50 mg of pethidine and 10 mg of diazepam were administered 30 min before the treatment and a 2.5 mg fentanyl patch was placed on the patient's chest 12 h before the treatment.

All processes were performed under spiral CT guidance. The patient's oxygen saturation, blood pressure, and heart rate were monitored during the whole procedure. The patient's position in the examination bed was determined by the location of the lesion in the lung (supine or prone position). We began the CT scan with 5 mm contiguous slices and defined the exact skin entry site from the CT images, and then marked this area on the skin. 2% lidocaine was injected at the puncture site for local anesthesia. A percutaneous entry route was chosen on the basis of the lesion size, morphology, location, adjacent structures, and access route. After confirming that the needle was located in the lesion, the biopsy gun was inserted coaxially. The depth of the biopsy gun setting for tissue sampling depended on the size of the lesion. In general, the depth was 1–2 cm, and a sample was taken only once. All the samples were fixed in formalin and sent for cytology, histopathology, and immunohistochemistry examinations.

The antenna probe was placed in the lesion with a guiding trocar, and then the MWA and water circulation cooling instrument were connected. Skin protection was accomplished using a continuous cold saline gauze (4°C–8°C) around the needle entrance to prevent high-temperature skin injury. The ablation power (60–80 W) and time (3–10 min) were set according to the size of the lesion, and the microwave frequency was 2450 MHz. The ablation range was set from 0.5 cm to 1.0 cm beyond the edges of the lesion. At the end of the treatment, the ablation needle was slowly withdrawn in parallel with the ablation needle tract to achieve hemostasis and prevent tumor spread along the needle tract. After completing MWA of the targeted lesion, an immediate CT scan was performed to determine the efficacy and whether any WMA-related complications such as pneumothorax, pulmonary hemorrhage, or any other soft tissue injury, had occurred.

Assessment

In this study, enhanced CT scans were performed every 2–3 months as a reference to evaluate the efficacy until the end of follow-up. The Modified Response Evaluation Criteria in Solid Tumors (RECIST) incorporating CT scan findings were used to evaluate the initial response to treatment.[5] The RECIST consists of four levels, including complete remission (CR), partial remission (PR), stable disease, and progressive disease (PD). Local tumor progression was mainly indicated by variations in the enhancement pattern and size of the tumor. In case of progression, lesions tended to gradually become larger and showed uneven, scattered, nodular, or eccentric enhancement on follow-up enhanced CT compared with the previous imaging examination. Conversely, the tumor was considered completely treated if the entire ablation lesion was not significantly enhanced and decreased in size. Symptoms that occurred within 1 month after treatment were considered treatment-related complications. Follow-up was performed until February 2018, and the follow-up time ranged from 2 to 42 months. The median follow-up time was 31 months, and the follow-up rate was 100%. Progression-free survival (PFS) was calculated from the time of diagnosis until progression or death. Overall survival was calculated from diagnosis to death or the date of the last follow-up.

Statistics analysis

The data were analyzed with SPSS for Windows version 17.0 (IBM, Chicago, IL, USA). Survival curves were constructed with the Kaplan–Meier method and compared with the log-rank test. P < 0.05 was considered statistically significant.


 > Results Top


Efficacy

In this study, CT-guided percutaneous coaxial biopsy combined with MWA was performed on 27 tumors in 23 patients. Combining patient history and imaging data, nine patients had primary lung cancer (four cases of carcinoma in situ, one case of lung squamous cell carcinoma, three cases of lung adenocarcinoma, and one case of lung sarcomatoid carcinoma), and 14 patients had metastatic lung cancer (lung metastasis from intestinal adenocarcinoma in seven cases, lung metastasis from esophageal cancer in three cases, lung metastasis from kidney cancer in one case, lung metastasis from pheochromocytoma in one case, lung metastasis from malignant schwannoma in one case, and lung metastasis from liver cancer in one case), as confirmed by biopsy results. The overall positive rate of primary and secondary lung malignancies was 81.48%.

Twenty-three patients with 27 lesions were successfully treated with MWA under CT guidance. The ablation time ranged from 1 min to 10 min, with the mean ablation time being 4.4 min. CT scans were performed immediately after treatment. All lesions showed increased shadowing, most of them were blurred, and some showed honeycomb-like changes or empty areas. After 1 month, the ground-glass opacity around the lesions was absorbed predominantly, and the lesions appeared enlarged compared with preoperative measurements. Enhanced CT scan showed no central enhancement, while the edges of the lesions were enhanced and blurred. In our study, 19 lesions showed no enhancement, eight showed only partial peripheral enhancement, and most lesions showed empty areas. Within 3–6 months after treatment, the lesions gradually reduced in size and showed no enhancement on enhanced CT scan, and some of the lesions were surrounded by fibrous bundles [Figure 1]. There were 17 patients with CR, four with PR, and two with PD. The effective rate was 91.3%.
Figure 1: A 72-year-old female with lung metastasis from colorectal carcinoma in the right upper lobe with an axial diameter of 2.3 cm (a). Ablation was performed after accurate insertion of a microwave ablation probe into the focus of the tumor (b). An immediate postoperative computed tomography scan showed that the lesion had enlarged slightly and had ill-defined and irregular margins (c). The lesion gradually decreased in size and was replaced by fibrous tissue during 1 (d), 3 (e), and 6 (f) months of follow-up

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Patients were followed up until February 2018; 14 patients survived. The 1 year local control rate was 88.9%. The median PFS was 33 months. The 1-, 2-, and 3-year survival rates were 91.3%, 69.6%, and 60.9%, respectively [Figure 2]. Seven patients with metastatic lung cancer died of primary tumor progression. Two patients with primary lung cancer also died; one died of a lung infection and the other died of cerebral hemorrhage. For patients who did not experience CR, we performed therapeutic intervention based on their imaging data. Four patients with PR underwent a second MWA procedure. Patients with PD were treated with implantation of 125 I radioactive particles.
Figure 2: Kaplan–Meier curves for progression-free survival in 23 patients after computed tomography-guided percutaneous coaxial biopsy combined with microwave ablation (a). Kaplan–Meier curves for overall survival in 23 patients after computed tomography-guided percutaneous coaxial core biopsy combined with microwave ablation (b)

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Safety

During the MWA procedure, 21 patients experienced tolerable pain and thermal sensation and did not experience discomfort after treatment. One patient developed hemopneumothorax and underwent thoracic surgery for closed thoracic drainage. After 1 month, all the laboratory indexes returned to normal. A postoperative CT scan revealed that the hemopneumothorax had resolved. One patient who had acute exudative pleuritis with moderate pleural effusion was immediately sent to the respiratory department for thoracocentesis and drainage. After treatment with antibiotics for 2 weeks, he recovered. After 1 month, a CT scan showed that the inflammation had resolved. Two patients developed small pneumothoraces immediately after ablation. After 1 month, CT scans showed that the pneumothorax had resolved. Two patients had fever from 2 to 7 days after the treatment. The temperatures of these patients ranged from 37.8°C to 38.4°C for 3–5 days. They all recovered after symptomatic treatment. No needle track implantation or death was observed during the procedure or within 30 days after ablation.


 > Discussion Top


In the past, a pathological diagnosis was mainly obtained through surgery.[6] However, surgery has many disadvantages, such as considerable trauma and high cost. CT-guided percutaneous lung biopsy has advantages for the diagnosis of peripheral pulmonary disease.[7] The main complications associated with it are pneumothorax and local pulmonary hemorrhage.[8],[9],[10] The incidences of pneumothorax and pulmonary hemorrhage have been reported to be as high as 43% and 33%, respectively, for conventional biopsy;[11] these rates were significantly higher than those in our study. It has also been reported that the success rate of CT-guided coaxial biopsy was significantly higher than that of ultrasound-guided biopsy or fine-needle aspiration biopsy.[12],[13]

Lu et al.[14] performed noncoaxial MWA in 69 patients with lung cancer. The results showed that the 1-and 2-year survival rates were 66.7% and 44.9%, respectively. Similarly, in another study,[15] radiofrequency ablation (RFA) was performed in 329 patients with lung cancer. The 1- and 2-year survival rates were 68.2% and 35.3%, respectively. Both results were significantly lower than our findings. Compared to RFA, MWA is a less studied but promising option, because it offers larger ablation zones, reduced procedural times, and decreased heat-sink effects.[16],[17] Thus, MWA has already become an effective means of nonsurgical treatment for lung cancer. Furthermore, it is safe and feasible, with relatively low complications and few requirements for short-term readmission.[18]

CT-guided percutaneous coaxial biopsy combined with MWA is more suitable for the diagnosis and treatment of pulmonary lesions than MWA alone. According to reports,[19] the positive rate of multislice spiral CT-guided coaxial biopsy was 94.9%, and the specificity was 100% for lung lesions. The guiding needle used for this method is lighter and more convenient to operate than those used for other techniques. The deviation of the needle tip is reduced by the weight of the equipment and can improve diagnostic accuracy. Through the coaxial positioning of the guide needle, the angle of the biopsy punch can be adjusted within a small range several times in a single puncture. Thus, the number of pleural ruptures and the probability of damage to the small pulmonary blood vessels and bronchial branches around the lesion are reduced, thus greatly reducing complications associated with biopsy. For some deeper lesions, if a noncoaxial needle is used, the aponeuroses of back muscles can significantly reduce the speed of cutting and affect the amount of tissue sampled.[20] However, due to the protection of the guiding needle in the coaxial puncture method, this obstacle of tough tissue is eliminated, improving the quality of the tissue sampled, and increasing the positive rate of biopsy. In our study, the overall positive rate of primary and secondary lung malignancies was 81.48%, which may be mainly related to the following factors: some lesions were small (minimum diameter of 0.5 cm), and some lesions were close to the large thoracic vessels. To reduce the risk of bleeding and pneumothorax, we performed only one biopsy in each patient.

CT-guided percutaneous coaxial biopsy combined with MWA can also lead to some major complications. Therefore, it is important to strictly evaluate the indications and contraindications. In our study, most major complications were easily managed. Only one patient developed hemopneumothorax and one patient developed acute exudative pleurisy. Both recovered after conservative treatment. When performing a biopsy, the large thoracic blood vessels should be avoided as much as possible to reduce bleeding and injury, and the biopsy needle should be inserted under CT guidance.

Studies have shown that lesions <3 cm in diameter can be ablated completely. Within a certain range of time, the longer the ablation procedure is, the greater is the diameter of ablation.[21] In addition, multiple needle insertions can be used until the entire lesion is ablated. The most common complications of MWA are pain and fever. In general, the pain is mild to moderate. Some lesions that are close to the pleura may be associated with worse pain than other lesions, and general anesthesia may be needed. After treatment, mild-to-moderate fever may occur, which may be caused by the heat of absorption due to aseptic necrosis of the tumor. Usually, we use levofloxacin as a prophylactic antibiotic for 3 days after treatment. In our study, only one patient developed hemopneumothorax, and one patient developed acute exudative pleurisy. Both recovered after timely chest drainage and symptomatic treatment. Thus, CT scans should be performed immediately after surgery, and changes in patients' vital signs should be monitored closely.

CT-guided percutaneous coaxial biopsy combined with MWA is a safe, accurate, effective, and minimally invasive treatment method for pulmonary tumors. This technique is one of the best choices for lung cancer patients who cannot tolerate or are unwilling to undergo surgical treatment. However, in our study, the sample size of patients was small, and the follow-up time was short. Studies with a larger sample size and long-term follow-up are still needed to verify the efficacy of this technique.

In this study, CT-guided percutaneous coaxial biopsy combined with MWA was performed in patients with lung cancer (both primary and metastatic). The use of coaxial puncture for biopsy, to reduce complications, played an important role in the clinic. Moreover, it had high sensitivity and specificity for pulmonary tumors. This technique not only reduced the complications of biopsy but also improved the quality of life of the patients, prolonged survival, and improved survival rates. It is currently one of the most promising interventional treatments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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Stattaus J, Kalkmann J, Kuehl H, Metz KA, Nowrousian MR, Forsting M, et al. Diagnostic yield of computed tomography-guided coaxial core biopsy of undetermined masses in the free retroperitoneal space: Single-center experience. Cardiovasc Intervent Radiol 2008;31:919-25.  Back to cited text no. 12
    
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Schulze R, Seebacher G, Enderes B, Kugler G, Fischer JR, Graeter TP, et al. Complications in CT-guided, semi-automatic coaxial core biopsy of potentially malignant pulmonary lesions. Rofo 2015;187:697-702.  Back to cited text no. 13
    
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Lu Q, Cao W, Huang L, Wan Y, Liu T, Cheng Q, et al. CT-guided percutaneous microwave ablation of pulmonary malignancies: Results in 69 cases. World J Surg Oncol 2012;10:80.  Back to cited text no. 14
    
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Lu Q, Li X, Han Y, Zhang Z, Yan X, Huang L, et al. Radiofrequency ablation for the treatment of lung neoplasms: A retrospective study of 329 cases. Zhongguo Fei Ai Za Zhi 2011;14:865-9.  Back to cited text no. 15
    
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Lee H, Jin GY, Han YM, Chung GH, Lee YC, Kwon KS, et al. Comparison of survival rate in primary non-small-cell lung cancer among elderly patients treated with radiofrequency ablation, surgery, or chemotherapy. Cardiovasc Intervent Radiol 2012;35:343-50.  Back to cited text no. 16
    
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