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CASE REPORT
Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 811-813

Computed tomography-guided percutaneous microwave ablation for pulmonary multiple ground-glass opacities


Department of Oncology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China

Date of Submission31-Mar-2021
Date of Acceptance12-May-2021
Date of Web Publication9-Jul-2021

Correspondence Address:
Xin Ye
Department of Oncology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, 16766 Jingshi Road, Jinan, 250021, Shandong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.jcrt_531_21

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 > Abstract 


With the wide application of low-dose computed tomography (CT) and high-resolution CT, the increasing cases of pulmonary nodules are identified through routine thoracic imaging examination, many of which are presented as multiple ground-glass opacities (GGOs). The multiple GGOs could be divided into four pathological types and usually got different combined mutation patterns, suggesting that each GGO is an independent event and should be treated separately. However, there is no established guideline to the treatment of multiple GGOs so far. Here, we report a multiple GGOs case with a different mutation pattern treated by CT-guided percutaneous microwave ablation.

Keywords: Ground-glass opacity, microwave ablation, pulmonary nodule


How to cite this article:
Xue G, Li Z, Wang G, Wei Z, Ye X. Computed tomography-guided percutaneous microwave ablation for pulmonary multiple ground-glass opacities. J Can Res Ther 2021;17:811-3

How to cite this URL:
Xue G, Li Z, Wang G, Wei Z, Ye X. Computed tomography-guided percutaneous microwave ablation for pulmonary multiple ground-glass opacities. J Can Res Ther [serial online] 2021 [cited 2021 Jul 29];17:811-3. Available from: https://www.cancerjournal.net/text.asp?2021/17/3/811/321033




 > Introduction Top


The rapid medical imaging development and broad application of high-resolution computed tomography (CT) increase pulmonary nodules identification through thoracic imaging examination. These nodules are multiple ground-glass opacities (GGOs)[1] classified as pure GGOs (pGGOs), without solid components inside, and mixed GGOs (mGGOs) with pure GGO and consolidated regions. Two or more GGOs synchronously found in the same lobe, lung, or bilateral lungs, with multifocal origins rather than intrapulmonary metastasis, are multiple GGOs. They are divided into atypical adenomatous hyperplasia, adenocarcinoma in situ, microinvasive lung adenocarcinoma, and invasive adenocarcinoma. GGOs have different mutation patterns combined, suggesting separated treatments.[2] No established guideline on multiple GGOs therapies exists. We report a multiple GGOs case with different mutation patterns treated by CT-guided percutaneous microwave ablation (MWA).


 > Case Report Top


A nonsmoker 44-year-old male, with no family cancer records and ~15 years of contact with graphite powder and pulverized lime, was admitted to the hospital with short breath and anhelation for a week, with no headache, cough, or fever. Blood examination and tumor markers were negative. CT scan showed both lungs with multiple nodules and lesions on the inferior lobar portion. A 25 mm × 23 mm irregular mGGO with lobulation and spiculation signs was observed in the right inferior lobar [Figure 1]a with air bronchogram and pleural indentation. Two nodules were in the left inferior lobar: The 7 mm one was an mGGO at interlobar fissure [Figure 1]c, and the 3 mm one was a pGGO in the lateral posterior segment [Figure 1]e.
Figure 1: (a) 25 mm × 23 mm mGGO lesion (arrow) in RLL on the axial HRCT before MWA. (b) PET-CT scan of mGGO lesion (arrow) with increased 18F-FDG metabolism (SUVmax: 4.6) in RLL before MWA. (c) mGGO lesion (arrow) of 7 mm maximum diameter in LLL on the axial HRCT before MWA. (d) PET-CT scan of mGGO lesion (arrow) with slightly increased 18F-FDG metabolism (SUVmax: 2.5) in LLL before MWA. (e) pGGO lesion (arrow) of 3 mm maximum diameter in LLL observed on the axial HRCT before MWA. (f) PET-CT scan of pGGO lesion (arrow) without 18F-FDG metabolism in LLL before MWA. (g) Ablation-synchronous biopsy of mGGO lesion in RLL with an ablation power/time of 40W/6 min. (h) Histopathology of invasive adenocarcinoma mGGO in RLL with S768I mutations in exon 20 of the EGFR. (i) Ablation-synchronous biopsy on mGGO lesion in LLL with an ablation power/time of 40W/5 min. (j) Histopathology of invasive adenocarcinoma mGGO in LLL with deletion in exon 19 of the EGFR. (k) MWA on pGGO lesion in LLL with an ablation power/time of 40W/3 min (no biopsy was taken because of the small-sized lesion). (l) Fried-egg sign in mGGO lesion in RLL 3 months after MWA. (m and n) Reactive fibrous scars in mGGO and pGGO lesion in LLL 3-months after MWA. (o) Further involution of fried-egg sign in mGGO lesion in RLL 6-months after MWA. (p and q) Further involution of reactive fibrous scars in mGGO and pGGO lesion in LLL 6 months after MWA. (r) Fried-egg sign replaced by fibrous scars 12 months after MWA. (s and t) Further involution of reactive fibrous scars in mGGO and pGGO lesion in LLL 12-months after MWA. HRCT = High-resolution computed tomography, mGGO = Mixed ground-glass opacities, RLL = Right lower lung, LLL = Left lower lung, PET-CT = Positron emission tomography-computed tomography, MWA = Microwave ablation, pGGO = Pure ground-glass opacities, 18F-FDG = 18-F fluorodeoxyglucose, SUVmax = maximum standardized uptake value, EGFR = Epidermal growth factor receptor

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The patient was diagnosed with (1) lung space-occupying lesion of the right lower lung (RLL), lung cancer to be excluded; (2) primary or secondary left lower lung (LLL) cancer to be confirmed; (3) and LLL ground-glass nodule. Positron emission tomography-CT scan reported the clinical stage of the lesion [Figure 1]b, [Figure 1]d and [Figure 1]f. (1) mGGO in RLL with increased 18-F fluorodeoxyglucose (18F-FDG) metabolism (maximum standardized uptake value [SUVmax]: 4.6). mGGO in LLL with slightly increased 18F-FDG metabolism (SUVmax: 2.5) following lung cancer imaging findings: multiple primary minimally invasive adenocarcinoma (IA) or IA lung cancer (MPLC). (2) pGGO in LLL without 18F-FDG metabolism. (3) Bilateral hilar and mediastinal lymph nodes without increased 18F-FDG metabolism. We revised the diagnosis as (1) MPLC and (2) pGGO in LLL.

Following National Comprehensive Cancer Network (NCCN) guidelines for MPLC,[3] we organized a multidisciplinary discussion with thoracic surgery, oncology, and medical imaging departments, which suggested the following diagnosis and treatment options: (1) Pulmonary lobectomy, wedge, or segmental resection and (2) image-guided thermal ablation. Patient refused surgery and received CT-guided MWA-synchronous biopsy of mGGOs in RLL and LLL on February 20, 2020, and March 19, 2020. The MWA of pGGO in LLL was also done on the latter day [Figure 1]g, [Figure 1]i and [Figure 1]k. Pathological diagnosis revealed invasive adenocarcinoma (lepidic predominant) on both nodules [Figure 1]h and [Figure 1]j. A next-generation sequencing detection clarified the MPLC or the two nodules intrapulmonary metastasis, revealing S768I mutations in exon 20 of the epidermal growth factor receptor (EGFR) (mGGO in RLL) and deletion in exon 19 of the EGFR (mGGO in LLL). The patient was diagnosed with adenocarcinomas in (1) RLL (cT1cN0M0 IA3) and (2) LLL (cT1aN0M0 IA1). After ablation, the follow-ups were conducted in 3, 6, 12 month respectively. The previous mGGO and pGGO lesion sites gradually disappeared and were replaced by the reactive fibrous scars[Figure 1]l, [Figure 1]m, [Figure 1]n, [Figure 1]o, [Figure 1]p, [Figure 1]q, [Figure 1]r, [Figure 1]s, [Figure 1]t.


 > Discussion Top


Multiple GGOs have different imaging characteristics, pathological types, and controversial treatments,[4] and age and performance status of the patient limit their surgical intervention. No standard algorithms were established to select which lesions (if any) to be treated or for the follow-up of untreated residual nodules.[5] Other nonsurgical options (i.e. stereotactic body radiation therapy [SBRT] and image-guided thermal ablation) exist, with few reports of treatments using SBRT for multiple GGOs. CT-guided percutaneous MWA is a successful and safe alternative without complications to treat multiple GGOs, with fewer complications, minimal invasion, good tolerability, higher repeatability, and quicker recovery in treating multiple GGOs.[6],[7]

A synchronous ablation biopsy was conducted, causing minor bleeding and more sample capacity. The lack of interference on the subsequent pathological diagnosis and molecular detection was critical.[8] Synchronous core-needle biopsy and an MWA through a coaxial cannula are technically safe and feasible in managing suspicious pulmonary nodules,[9] having fewer complications and similar effects to sequential procedures.[9],[10] Here, two nodules proceed by MWA had the same historical type in different lungs, without lymphatics invasion, no extrapulmonary metastases, and different molecular types. The diagnosis of MPLC is precise, and a follow-up of MPLC patients containing a helical chest, a CT scan, history taking, and physical examination is recommended every 6–12 months,[3] according to NCCN guidelines. Although EGFR driver mutation exists, we chose follow-up as insufficient evidence for the early application of tyrosine kinase inhibitors.

The MWA constitutes an alternative for treating multiple GGOs. A prospective multicenter study of MWA would be necessary to clarify the effectiveness and safety of this treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Liu B, Ye X. Management of pulmonary multifocal ground-glass nodules: How many options do we have? J Cancer Res Ther 2020;16:199-202.  Back to cited text no. 1
    
2.
Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger K, Yatabe Y, et al. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society: International multidisciplinary classification of lung adenocarcinoma: Executive summary. Proc Am Thorac Soc 2011;8:381-5.  Back to cited text no. 2
    
3.
Kozower BD, Larner JM, Detterbeck FC, Jones DR. Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:S369-99.  Back to cited text no. 3
    
4.
Hertzanu Y, Ye X. Computed tomography-guided percutaneous microwave ablation: A new weapon to treat ground-glass opacity-lung adenocarcinoma. J Cancer Res Ther 2019;15:265-6.  Back to cited text no. 4
    
5.
Sihoe AD, Petersen RH, Cardillo G. Multiple pulmonary ground glass opacities: Is it time for new guidelines? J Thorac Dis 2018;10:5970-3.  Back to cited text no. 5
    
6.
Huang G, Yang X, Li W, Wang J, Han X, Wei Z, et al. A feasibility and safety study of computed tomography-guided percutaneous microwave ablation: A novel therapy for multiple synchronous ground-glass opacities of the lung. Int J Hyperthermia 2020;37:414-22.  Back to cited text no. 6
    
7.
Yang X, Ye X, Lin Z, Jin Y, Zhang K, Dong Y, et al. Computed tomography-guided percutaneous microwave ablation for treatment of peripheral ground-glass opacity-Lung adenocarcinoma: A pilot study. J Cancer Res Ther 2018;14:764-71.  Back to cited text no. 7
    
8.
Ni Y, Xu H, Ye X. Image-guided percutaneous microwave ablation of early-stage non-small cell lung cancer. Asia Pac J Clin Oncol 2020;16:320-5.  Back to cited text no. 8
    
9.
Wang D, Li B, Bie Z, Li Y, Li X. Synchronous core-needle biopsy and microwave ablation for highly suspicious malignant pulmonary nodule via a coaxial cannula. J Cancer Res Ther 2019;15:1484-9.  Back to cited text no. 9
    
10.
Li X, Ye X. Computed tomography-guided percutaneous core-needle biopsy after thermal ablation for lung ground-glass opacities: Is the method sound? J Cancer Res Ther 2019;15:1427-9.  Back to cited text no. 10
    


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