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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 18
| Issue : 2 | Page : 405-410 |
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Safety and efficacy of microwave ablation to treat pulmonary nodules under conscious analgosedation with sufentanil: A single-center clinical experience
Pikun Cao1, Wenjun Meng2, Guoliang Xue1, Nan Wang1, Zhichao Li1, Yongmei Kong3, Zhigang Wei1, Xin Ye1
1 Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, China
2 Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
3 Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
| Date of Submission | 02-Aug-2021 |
| Date of Acceptance | 24-Dec-2021 |
| Date of Web Publication | 04-May-2022 |
Correspondence Address:
Xin Ye
Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, 250014
China
Zhigang Wei
Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Lung Cancer Institute, Jinan, Shandong Province, 250014
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrt.jcrt_1286_21
Purpose: The present study was designed to evaluate the safety and efficacy of computed tomography-guided percutaneous microwave ablation (MWA) to treat pulmonary nodules under conscious analgosedation with sufentanil.
Materials and Methods: February to May 2021, 124 patients with 151 pulmonary nodules were enrolled in this study. The patients underwent 124 sessions of MWA. Sufentanil (0.25 μg/kg) was injected intravenously before MWA.
Results: The technical success was 100% and no procedure-related deaths. The dosage of sufentanil was 16.6 ± 3.0 μg. The mean tumor diameter in the enrolled patients was 1.3 ± 0.8 cm. The intraoperative mean numerical rating scale (NRS) was 2.2 ± 1.7. Among the patients with NRS >3, seven patients had nodules adjacent to the pleura, while in ten patients, they were not adjacent. The mean systolic, diastolic blood pressure, and heart rate of patients were 139.1 ± 23.5 mmHg, 77.8 ± 12.3, and 76.1 ± 13.4 times/min, respectively, before sufentanil injection. The mean lowest systolic, lowest diastolic blood pressure, and lowest heart rate intraoperative were 132.9 ± 22.0 mmHg, 76.1 ± 12.1, and 74.0 ± 13.5 times/min. Twenty-six patients had mild adverse events including nausea (6.45%, 8/124), dizziness (2.42%, 3/124), vomiting(4.03%, 5/124), nausea and dizziness (2.42%, 3/124), nausea with vomiting and dizziness (2.42%, 3/124), urinary retention (1.61%, 2/124) and respiratory depression (0.81%, 1/124).
Conclusion: Sufentanil is a feasible, safe, and effective analgesic for MWA in patients with pulmonary nodules. It can be used for clinical promotion.
Keywords: Microwave ablation, pulmonary nodules, sufentanil, adverse events, lung cancer
How to cite this article:
Cao P, Meng W, Xue G, Wang N, Li Z, Kong Y, Wei Z, Ye X. Safety and efficacy of microwave ablation to treat pulmonary nodules under conscious analgosedation with sufentanil: A single-center clinical experience. J Can Res Ther 2022;18:405-10 |
How to cite this URL:
Cao P, Meng W, Xue G, Wang N, Li Z, Kong Y, Wei Z, Ye X. Safety and efficacy of microwave ablation to treat pulmonary nodules under conscious analgosedation with sufentanil: A single-center clinical experience. J Can Res Ther [serial online] 2022 [cited 2022 Oct 1];18:405-10. Available from: https://www.cancerjournal.net/text.asp?2022/18/2/405/344707 |
Pikun Cao and Wenjun Meng contributed equally to this article. They are co-first authors.
Xin Ye and Zhigang Wei are co-corresponding author.
| > Introduction | |  |
Lung cancer incidence is on the increase globally, and primary lung cancer is the leading cause of cancer-related mortality being the most frequently diagnosed cancer worldwide.[1],[2] To complicate matters, the lungs are also the second most metastatic site for malignant tumors.[3] With the widespread use of high-resolution computed tomography (CT) for routine chest imaging and examination, pulmonary nodules can be distinguished with increased frequency including early lung cancer, precancerous, metastasis, or benign nodules.[4],[5] Although the best treatment option for early-stage lung cancer is surgical resection, more than 20% of early-stage lung cancer patients cannot be handled by operations.[6],[7] Therefore, for patients with unresectable malignant pulmonary nodules, several alternative therapies are available, including stereotactic radiotherapy, chemotherapy, and thermal ablation.
Percutaneous CT-guided microwave ablation (MWA) is a local thermal ablation technique commonly used to treat primary or metastatic tumors.[8] Their efficacy and safety have been confirmed in those tumors. Recently, this precise and minimally invasive technique has been increasingly applied.[9],[10],[11],[12],[13],[14] MWA uses electromagnetic energy to cause water molecules to rotate rapidly, transferring kinetic energy and heat to nearby tissues, promoting protein coagulation, and ultimately causing irreversible damage to cancer cells.[15] However, due to local high-temperature stimulation, patients may feel pains, which tend to move during surgery, resulting in the displacement of the microwave probe and unnecessary danger.[16] Therefore, pain control is an essential component during MWA sessions.
There is no uniform standard for intraoperative analgesia in MWA for pulmonary nodules. Based on our experience, the application of conscious analgosedation with sufentanil during MWA has achieved good results. We have conducted this single-center, retrospective clinical study. Sufentanil is a highly lipophilic synthetic piperidine opioid derivative with a high affinity for μ-opioid receptors.[17] Sufentanil has a fast onset of action and relatively few side effects. It is popular globally and suitable for intraoperative pain control.[18] In this retrospective study, the feasibility, safety, and preliminary results of the treatment of pulmonary nodules with MWA were studied.
| > Materials and Methods | | |
Patients
The institutional review board of the investigating institution approved this study. One hundred and twenty-four patients who underwent MWA for pulmonary nodules in our hospital from February 2021 to May 2021 were enrolled in this study. The inclusion criteria were (1) pulmonary nodules confirmed by chest CT, suspected to be malignant; (2) American Society of Anesthesiologists Grade I-II; (3) Eastern Cooperative Oncology Group physical status 0–2; (4) 18 years and older patients and nonpregnant women; and (5) unsuitable for surgery due to advanced age, poor cardiopulmonary functions or other comorbidities, or due to high anxiety or fear refusal of surgery. The exclusion criteria were (1) enhanced CT, positron emission tomography-CT, enhanced magnetic resonance confirmed the presence of regional lymph node metastasis or distant metastasis; (2) poor-controlled infection; (3) severe coagulation disorder which cannot be corrected; (4) platelet is less than or equal to 50 × 109/L; (5) patients with serious disease in heart, lung, brain, and other organs; and (6) renal or hepatic failure.
Instruments and microwave ablation procedure
The MWA was guided by CT (Lightspeed 64 V, United Imaging Healthcare, Shanghai, China) and its system was ECO-100A1 (ECO Medical Instrument Co., Ltd., Nanjing, Jiangsu, China), MTC-3C (Vison-China Medical Devices R and D Center, Nanjing, Jiangsu, China), or KY-2450B (Canyon Medical Inc., Nanjing, Jiangsu, China), with the frequency being 2450 ± 50 MHz, and the continuous wave output power, 0-100W, is adjustable. The effective length of the microwave antenna is 100–180 mm, the outer diameter is 14–20 G, and it has a 1.5 cm radiation tip (tapered end). The surface temperature of the antenna is cooled by a water circulating cooling system.
According to the size and location of the tumor, an ablation plan was designed through real-time CT to determine the appropriate body posture, surface puncture point, optimal puncture trajectory, number of antennas, and the ablation power. Sufentanil (Yichang Humanwell Pharmaceutical Co., Ltd. Yichang, Hunan, China) was injected intravenously into the patient at a dose of 0.25 μg/kg body weight before MWA. Sufentanil (100 μg) was added to 50 mL of 0.9% sodium chloride injection, and it was administered statically at a rate of 10 mL/min. The antenna gradually penetrates the target lesion and then starts to work with a predetermined power and duration. Furthermore, the ablation needle is adjusted appropriately to reach the boundary of 5–10 mm beyond the target lesion. Finally, the punctured wound is bandaged after disinfection. At the end of the operation, CT scans of the whole lung were repeated to assess technical success and immediate complications. When the tumor was treated as planned and the ablation area completely covers the target, the procedure was considered successful. The blood pressure, heart rate before anesthesia, and lowest blood pressure along with lowest heart rate during anesthesia were recorded. Adverse effects included nausea, vomiting, dizziness, nausea with vomiting and dizziness, urinary retention, and respiratory depression. The highest NRS was also recorded. The chest CT scans were repeated on the second day after ablation to reassess whether there are complications and the outcome of ablation.
Statistical analysis
Continuous variables were reported as the mean ± standard deviation. Paired Student's t-test was used to analyze the blood pressure and heart rate before and after the conscious analgosedation with sufentanil. Categorical variables were analyzed using the χ2 or Fisher exact test. P < 0.05 was defined as statistically significant. All statistical analyses were performed using SPSS 24.0 (SPSS Inc., Chicago, IL).
| > Results | | |
Patient characteristics
Between February 2021 and May 2021, a total of 124 patients (68 females and 56 males with a mean age of 60.9 ± 12.0 years, and a range of 28–84 years) with 151 pulmonary nodules who underwent percutaneous CT-guided MWA were assessed in the present study. Ninety-five patients with pulmonary nodules were considered as primary lung tumors that have not been confirmed by pathology. Most of the patients underwent MWA after a synchronized needle biopsy. A small number of patients refused to undergo needle biopsy and only received MWA therapy. Fourteen patients have been pathologically confirmed to be lung cancer before MWA treatment. The remaining 15 patients had lung metastases, and the primary tumors were gastrointestinal cancer (n = 8), liver cancer (n = 2), kidney cancer (n = 2), oral cancer (n = 1), ovarian cancer (n = 1), and breast cancer (n = 1). Detailed patient characteristics are listed in [Table 1].
Local effect
The success rate of MWA surgery was 100%, and all patients could tolerate it. No patient died due to MWA. The mean tumor diameter in the enrolled patients was 1.3 ± 0.8 cm, ranging from 0.3 to 4.0 cm. Among them, 32 patients had tumors sized 2.0 cm or larger, 70 patients had tumors sized 1 cm or smaller, and 49 patients had tumors sized between 1 cm and 2 cm. One hundred and two patients ablated one lesion, 17 patients ablated two lesions, and five patients ablated three lesions. We found that 74 patients' nodules were adjacent to the pleura. Pulmonary nodules under the costal pleura (n = 40) accounted for most of the subpleural tumors, while nodules under the mediastinal (n = 12), interlobar (n = 12), cervical (n = 6), and diaphragmatic (n = 4) pleurae were relatively less common. Pulmonary nodules under the costal pleura (n = 40) accounted for the majority of subpleural tumors, while the mediastinum (n = 12), interlobular (n = 12), cervix (n = 6), and diaphragm (n = 4) were relatively rare. Forty-nine patients were treated with two antennas. Thirteen (10.5%), 106 (85.5%), and five (4.0%) patients were treated with a power of 30, 40, and 50 W, respectively. The mean ablation times were 7.8 ± 4.8 min, with a range of 3.0–24.5 min. The mean time of the procedure was 41.1 ± 14.7 min, with a range of 15–85 min [Table 2]. | Table 2: Characteristics of pulmonary nodules, parameters of microwave ablation and the course of treatment in 151 sessions
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Anesthesia outcomes
The mean body weight is 67.3 ± 11.1 kg (40–95 kg) and the dosage of sufentanil was 16.6 ± 3.0 μg (10–24 μg). The mean systolic blood pressure, diastolic blood pressure, and heart rate of patients were 139.1 ± 23.5 (87–202) mmHg, 77.8 ± 12.3 (47–108), and 76.1 ± 13.4 (40–119) times/min, respectively, before sufentanil injection. The mean lowest systolic blood pressure, lowest diastolic blood pressure, and lowest heart rate intraoperative were 132.9 ± 22.0 (87–196) mmHg, 76.1 ± 12.1 (50–106), and 74.0 ± 13.5 (40–125) times/min, respectively. The difference between these three indicators before and during anesthesia is statistically significant (P < 0.001, P = 0.032, and P = 0.006, respectively). Twenty-six patients had mild adverse events including nausea (6.45%, 8/124), dizziness (2.42%, 3/124), vomiting(4.03%, 5/124), nausea and dizziness (2.42%, 3/124), nausea with vomiting and dizziness (2.42%, 3/124), urinary retention (1.61%, 2/124) and respiratory depression (0.81%, 1/124). No serious adverse events occurred including apnea, skeletal muscle rigidity (pectoral muscle rigidity), myoclonus, hypotension, tachycardia, miotic, allergic reactions, and cardiac arrest. The mean NRS scores intraoperative were 2.2 ± 1.7 (0–9). There were 25 (20.2%) patients with an NRS score of 0, 82 (66.1%) patients with an NRS score of 1–3, 13 (10.5%) patients with an NRS score of 4–6, and 4 (3.2%) patients with an NRS score of 7–9 [Table 3]. The details of the anesthesia outcomes are recorded in [Table 3]. Finally, we found no statistically significant difference in pain scores between the two groups (P = 0.094). The details NRS score for the two groups were listed in [Figure 1]. | Table 3: Anesthesia outcomes of microwave ablation to treat pulmonary nodules under conscious analgo-sedation with sufentanil
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 | Figure 1: Distribution of the highest numerical rating scale score in patients during microwave ablation. X axis: Number of patients. Y axis: The highest numerical rating scale of patients. (a) Distribution of the highest numerical rating scale score for patients with subpleural nodules. (b) Distribution of the highest numerical rating scale score for patients with non-subpleural nodules
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| > Discussion | | |
Few reports exist on the choice of anesthesia during pulmonary nodule ablation. However, the expert consensus for thermal ablation of primary and metastatic lung tumors (2018 edition) pointed out that, according to the patient's condition, general or local anesthesia can be used for thermal ablation.[19] Pouliquen et al. reported that thoracic epidural anesthesia could offer an answer to the problem of the patients who require radiofrequency ablation (RFA) but has poor lung functions.[20] Hoffmann et al. explained that analgosedation can be used in RFA, compared with general anesthesia.[21]
How to clarify the definition of subpleural nodules is still inconclusive. Hou et al. reported nodules at a distance of <30 mm from the chest wall were defined as subpleural pulmonary nodules.[22] Okuma et al. reported that, when the distance between the tumor and the chest wall was <10 mm, patients may suffer severe pain during RFA.[23] Gillams and Lees described peripheral lung nodules <5 mm from the pleura.[24] To ensure success, the extent of the ablation zone was at least 5 mm beyond the boundary of the lesion. When the pulmonary nodule was 5 mm away from the pleura, in order to achieve complete ablation, the pleura may be destroyed by high temperature, which may cause pain or other complications in the patient. Therefore, our study defined subpleural pulmonary nodules as any distance within 5 mm of the pleura. We specifically recorded the NRS of patients with subpleural nodules compared to other types of nodules. This is of great significance for evaluating the anesthetic effect of sufentanil. In our study, there was no significant difference in NRS between the two groups. This may further explain the effectiveness of sufentanil in the treatment of pulmonary nodules by MWA.
In this study, compared to preanesthesia, the blood pressure and heart rate were lowered. We think this is related to the capacity of sufentanil to mildly lower blood pressure and heart rate.[25] The incidence of adverse reactions was 20.9% including nausea, vomiting, dizziness, urinary retention, and respiratory depression. Through analyses, the reasons may be related to the following factors. First of all, the opioid receptors in the human body mainly include μ-opioid receptors, δ-opioid, and κ-opioid. Micro-opioid receptors are widely distributed in the human gastrointestinal tract and enteric nervous system. Sufentanil is a traditional μ-opioid receptor agonist, which can cause gastrointestinal dysfunction, such as nausea and vomiting, by activating these receptors. The occurrence of dizziness is related to the inhibition of sufentanil on the central nervous system.[26],[27] Second, the cause of acute urinary retention may be because sufentanil can suppress bladder contraction.[28] In this study, two patients suffered respiratory depression, with the clinical manifestations being confusion, slowed heart rate, and unwillingness to call. The operation had to be terminated and 1 mg naloxone was immediately given intravenously immediately. Soon after, the patient's vital signs gradually leveled off, consciousness became clear, and the operation was successfully completed. The patient did not complain of discomfort after surgery and was discharged with a good recovery. Respiratory depression is a typical opioid symptom of sufentanil.[29] This crucial adverse reaction should be taken seriously, despite the low incidence. It is particularly important to find out in time, more importantly, naloxone should be routinely prepared during surgery.
It is important to note that this study has some limitations. It was a single-center, single-arm study. The purpose of this study was not to compare the results of sufentanil treatment of MWA with the results of other treatments such as local, general, or pleural epidural anesthesia. Therefore, a prospective, multicenter, randomized, controlled study is needed in the future to clarify the safety and effectiveness of sufentanil in the treatment of MWA.
| > Conclusions | | |
The results of this study showed that sufentanil is a feasible, safe, and effective analgesic for MWA in patients with pulmonary nodules. It can be used for clinical promotion.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3]
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