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  Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 6  |  Page : 80-83
 

Artificial pneumothorax for pain relief during microwave ablation of subpleural lung tumors


1 Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
2 Department of Oncology, Tengzhou Central People's Hospital Affiliated to Jining Medical College, Tengzhou, Shandong Province, China

Date of Web Publication24-Dec-2015

Correspondence Address:
X Ye
Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.172519

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 » Abstract 

Background: When microwave ablation (MWA) is used for subpleural lesions, severe pain was the common side effect under the local anesthesia conditions during the procedure and postprocedure. To study the pain relief effect of artificial pneumothorax in the treatment of subpleural lung tumors with MWA. Materials and Methods: From February 2012 to October 2014, 37 patients with 40 subpleural lung tumors underwent MWA, including 17 patients of 19 sessions given artificial pneumothorax prior to MWA (group-I), and 20 patients of 21 sessions without artificial pneumothorax (group-II). Patient's pain assessment scores (10-point visual analog scale [VAS]) at during-procedure, 6, 12, 24, and 48 h after the MWA procedure and mean 24 h morphine dose were compared between the two groups. Complications of the artificial pneumothorax were also summarized. Results: Pain VAS were 0.53, 0.65, 1.00, 0.24, and 0.18 at during-procedure, 6, 12, 24, and 48 h for group-I and 5.53, 2.32, 2.82, 1.21, and 0.21 for group-II, respectively. Pain VAS in group I was significantly decreased at during-procedure, 6, 12, and 24 h after the MWA (P < 0.001). No statistical pain VAS difference was observed at 48 h after the MWA between the two groups (P > 0.05). The mean 24 h morphine dose was 5.00 mg in group-I and 12.63 mg in group-II (P = 0.000). “Artificial pneumothorax” related complications occurred in two patients from group-I, including one pleural effusion and one minor hemoptysis. No patient in group-I and group-II died during the procedure or in 30 days after MWA. Conclusion: Artificial pneumothorax is a safe and effective method for pain relief during MWA of subpleural lung tumors.


Keywords: Artificial pneumothorax, lung tumor, microwave ablation


How to cite this article:
Yang X, Zhang K, Ye X, Zheng A, Huang G, Li W, Wei Z, Wang J, Han X, Ni X, Meng M, Ni Y, Yuan Q, Xing C. Artificial pneumothorax for pain relief during microwave ablation of subpleural lung tumors. Indian J Cancer 2015;52, Suppl S2:80-3

How to cite this URL:
Yang X, Zhang K, Ye X, Zheng A, Huang G, Li W, Wei Z, Wang J, Han X, Ni X, Meng M, Ni Y, Yuan Q, Xing C. Artificial pneumothorax for pain relief during microwave ablation of subpleural lung tumors. Indian J Cancer [serial online] 2015 [cited 2019 Aug 23];52, Suppl S2:80-3. Available from: http://www.indianjcancer.com/text.asp?2015/52/6/80/172519

FNx01Yang X and Zhang K contributed equally to this work



 » Introduction Top


Lung cancer is the leading cause of death among all types of cancers around the world. More than 1,800,000 people died worldwide every year.[1] In the last decade, many new local treatment methods, including thermal ablation and the stereotactic radiotherapy, have been developed to treat lung tumor patients who have limited benefit from traditional chemotherapy or radiotherapy.[2],[3] Microwave ablation (MWA) has been proved to be safe and effective in the treatment of primary and metastatic lung tumor.[4],[5],[6],[7],[8],[9] When MWA was used for subpleural lesions, severe pain was the common side effect under the local anesthesia conditions during the procedure and postprocedure.[6],[8],[9] This prospective study was to evaluate the effect of artificial pneumothorax for pain relief during MWA of subpleural lung tumors.


 » Materials and Methods Top


From February 2012 to October 2014, 17 patients (9 men and 8 women, age: 63 ± 10 years) with 19 subpleural lung tumors were treated by MWA with artificial pneumothorax (group-I) and 19 patients (10 men and 9 women, age: 68 ± 9 years) with 21 subpleural lung tumors were treated with MWA without artificial pneumothorax (group-II). All patients were evaluated by an interdisciplinary group consisting of pain physician, surgeon, and medical oncologist. Ethics approval was obtained from the institutional review board of Shandong Provincial Hospital Affiliated to Shandong University Hospital and Teng Zhou Central People's Hospital Affiliated to Jining Medical College. All patients provided written informed consent before the procedure. Baseline characteristics were listed in details in [Table 1].
Table 1: Baseline characteristics of 37 patients with subpleural lung tumors

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Artificial pneumothorax

Under computed tomography (CT)-guided, a 21 gage Chiba needle (Nagano-Ken, 389–0806, Japan) was placed adjacent to the peripherally located lesion. Following CT confirmation of the needle tip, Chiba needle was punctured into the parietal and visceral pleura. “Filtered air” was administered through the Chiba needle to enlarge the pleural cavity. 200–300 mL of air was injected into the parietal and visceral pleura, which cause 10–15 mm thick of “artificial pneumothorax” at the level of the tumors on axial CT images [Figure 1]. After the establishment of artificial pneumothorax, MWA procedure was performed. After MWA procedures, artificial pneumothorax can be drawn out or not.
Figure 1: A 62-year-old male patient with 3.2 cm × 2.5 cm left lung cancer (adenocarcinoma). (a) Tumor lesion (arrow) seen on computed tomography immediately prior to procedure. (b) Chiba needle was punctured into the parietal and visceral pleura. Two hundred milliliters of air was injected into the parietal and visceral pleura, which caused 10 mm thick of “artificial pneumothorax.” (c) The microwave antenna was punctured into lesion (arrow). (d) Ablated lesion with surrounding ground-glass opacity seen on repeat computed tomography scan immediately postmicrowave ablation. “Artificial pneumothorax” has not been withdrawn

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Microwave ablation procedures

MWA procedures were performed under CT-guidance. The detailed of MWA procedure was described in a previous publication.[6],[7] One antenna was applied for tumors ≤3.5 cm in diameter, and two for those >3.5 cm in diameter simultaneously. MWA with an output of 60–70 W/5–7 min and an ablative zone of nearly 3.5 cm × 3 cm was used, with a proposed ablative margin of 0.5 cm.

Pain assessment

A 10-point score was used for visual analog scale (VAS) evaluation.[10] VAS scores were assessed by physicians at during-procedure, 6, 12, 24, and 48 h after the MWA procedure and with the cumulative morphine dose used within 24 h from the procedure.

Complications assessment

Complications were assessed according to the standards drafted by the International Working Group on Imagine-Guided Tumor Ablation in 2005.[11] Major complications were defined as clinical symptoms during or after ablation that may be life-threatening, resulting in substantial damage and dysfunction and requiring hospitalization or prolonged hospitalization. Minor complications were defined as follows self-limiting complications without sequelae and requiring only a short hospital stay for observation or treatment. Side effects referred to pain, postablation syndrome, and asymptomatic minor bleeding or fluid accumulation on CT.

Assessment of local efficacy

Local efficacy was assessed according to the standards drafted by Ye et al.[9] Complete ablation is indicated by lesion disappearance, complete cavernous formation, fibrotic progression or scar, solid nodule involution or no change, without contrast enhanced signs on the CT scan, and/or atelectasis. Incomplete ablation is indicated by incomplete cavernous formation, with some solid or liquid components remaining and irregular peripheral or internal enhancement signs on CT scans; partial fibrosis, with solid residues in the fibrotic lesion, which presents as irregular peripheral or internal enhancement signs on CT scans; and/or solid nodules with unchanged or increased size, which also present as irregular peripheral or internal enhancement signs on CT scans.

Statistical analysis

SPSS 17.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Continuous variables were expressed as a mean ± standard deviation. Paired Student t-test was applied to evaluate the VAS score and the dose of morphine before and after the procedure. The test was two-sided, and P < 0.05 was considered of great significance.


 » Results Top


Induction of artificial pneumothorax was achieved successfully in all patients (group I). Patient VAS and the amount of morphine used are summarized in [Table 2]. In group-I, the mean VAS scores were 0.53 ± 0.62, 0.65 ± 0.49, 1.00 ± 0.61, 0.24 ± 0.44, and 0.18 ± 0.39 at during-procedure, 6, 12, 24, and 48 h, respectively. In group-II, the mean VAS scores were 5.53 ± 1.98, 2.32 ± 1.06, 2.82 ± 0.63, 1.21 ± 0.79, and 0.21 ± 0.42 at during-procedure, 6, 12, 24, and 48 h, respectively. Pain VAS was significantly different at during-procedure, 6, 12, and 24 between the two groups (P < 0.001). Pain VAS was no significantly different at 48 h between the two groups (P > 0.05) [Table 2] and [Figure 2]. The mean 24 h morphine dose was 5.00 ± 3.54 and 12.63 ± 3.86 in group-I and group-II, respectively (P = 0.000) [Table 2].
Table 2: Pain VAS score and morphine dose/24 h in group I and group II

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Figure 2: Pain visual analog scale score in Group I and Group II

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"Artificial pneumothorax” related complications occurred in two patients from group-I, including one pleural effusion and one minor hemoptysis. Pneumothorax was the most MWA-related complications. There were 8 cases (8/17, 47.1%) of pneumothorax with 2 patients (11.8%) requiring chest tube drainage in group-I, and 10 cases (10/19, 52.6%) of pneumothorax with 2 patients (10.5%) requiring chest tube drainage in group-II. The incidence of pneumothorax was no significantly different between the two groups (P > 0.05). Hemoptysis occurred in 5 cases (29.4%, group-I) and 6 cases (31.6%, group-II). The incidence of hemoptysis was no significantly different between the two groups (P > 0.05). The conventional application of hemostatic agents including snake venom thrombin, glucocorticoids, could effectively stop bleeding. In 11 cases with hemoptysis, 4 cases occurred in the process of ablation (due to the fact that ablation itself can cause blood coagulation, hemoptysis during ablation process would gradually stop with no special treatment required). There were 5 cases (5/17, 29.4%) of pleural effusion (of which 1 cases underwent chest tube insertion) in group-I, and 6 cases (6/19, 31.6%) of pleural effusion (of which 2 cases underwent chest tube insertion) in group-II. The incidence of pleural effusion was no significantly different between the two groups (P > 0.05). One patient (1/19, 5.3%) in group-II suffered from pneumonia after the procedure which could be controlled by effective antibiotics according to the sputum culture. No patient in group-I and group-II died during the procedure or in 30 days after MWA.

At 6-month follow-up, all tumors in group-I demonstrated complete ablation at CT, and one tumor in group-II showed residual viable foci (incomplete ablation) and was then ablated successfully with a second session of MWA.


 » Discussion Top


The image-guided thermoablation including radiofrequency ablation (RFA), MWA and cryoablation has been used for the treatment of various malignancies. RFA and MWA have been indicated to be effective, feasible, and minimally invasive in the treatment of lung tumors.[2], 4, [12],[13],[14],[15] MWA has several advantages over RFA including larger volumes of necrosis in shorter procedure time, less “heat sink” effect for better treatment of perivascular tissue, and maximizing the ablation zone size by positioning multiple MWA antenna into larger lesion simultaneously.[16],[17],[18],[19] Based on the substantial advantages for MWA, more patients with pulmonary malignancies were given the MWA treatment as an alternative option.

Yang et al.[6] showed that location of the lesion at 1.5 cm or less from the chest wall was significantly related to pain during MWA with local anesthesia. The parietal pleura and chest wall are sensitive to pain because abundant sensory nerve branches originate from the intercostal nerve, contrary to the case in the visceral pleura and lung parenchyma.[20] Lee et al.[21] reported a case in which an artificial pneumothorax was created to prevent pain. In this study, VAS scores of the patients in group-I at during-procedure, 6, 12, and 24 h were lower than the patients in group-II, and there is a statistically significant difference. In addition, the mean 24-h dose of morphine of the patients in group-I was also lower than the patients in group-II, and there is a statistically significant difference. The results suggest that “artificial pneumothorax” can relieve pain at during procedure and within 24 h postprocedure.

"Artificial pneumothorax” related complications occurred in two patients from group-I, including one pleural effusion and one minor hemoptysis. In other complications, the patients in group-I compared with no significant difference between the patients in group-II. No patient in group-I and group-II died during the procedure or in 30 days after MWA.


 » Conclusion Top


Creation of an artificial pneumothorax is a safe and effective method for pain relief during MWA of subpleural lung tumors.

 
 » References Top

1.
Bray F, Ferlay J, Laversanne M, Brewster DH, Gombe Mbalawa C, Kohler B, et al. Cancer Incidence in Five Continents: Inclusion criteria, highlights from Volume X and the global status of cancer registration. Int J Cancer 2015;137:2060-71.   Back to cited text no. 1
    
2.
Vogl TJ, Naguib NN, Lehnert T, Nour-Eldin NE. Radiofrequency, microwave and laser ablation of pulmonary neoplasms: Clinical studies and technical considerations – Review article. Eur J Radiol 2011;77:346-57.  Back to cited text no. 2
    
3.
Ahmed M, Solbiati L, Brace CL, Breen DJ, Callstrom MR, Charboneau JW, et al. Image-guided tumor ablation: Standardization of terminology and reporting criteria – A 10-year update. Radiology 2014;273:241-60.  Back to cited text no. 3
    
4.
Dupuy DE. Image-guided thermal ablation of lung malignancies. Radiology 2011;260:633-55.  Back to cited text no. 4
    
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Healey TT, Dupuy DE. Microwave ablation for lung cancer. Med Health R I 2012;95:52-3.  Back to cited text no. 5
    
6.
Yang X, Ye X, Zheng A, Huang G, Ni X, Wang J, et al. Percutaneous microwave ablation of stage I medically inoperable non-small cell lung cancer: Clinical evaluation of 47 cases. J Surg Oncol 2014;110:758-63.  Back to cited text no. 6
    
7.
Wei Z, Ye X, Yang X, Zheng A, Huang G, Li W, et al. Microwave ablation in combination with chemotherapy for the treatment of advanced non-small cell lung cancer. Cardiovasc Intervent Radiol 2015;38:135-42.  Back to cited text no. 7
    
8.
Pereira PL, Masala S; Cardiovascular and Interventional Radiological Society of Europe (CIRSE). Standards of practice: Guidelines for thermal ablation of primary and secondary lung tumors. Cardiovasc Intervent Radiol 2012;35:247-54.  Back to cited text no. 8
    
9.
Ye X, Fan W, Chen JH, Feng WJ, Gu SZ, Han Y, et al. Chinese expert consensus workshop report: Guidelines for thermal ablation of primary and metastatic lung tumors. Thorac Cancer 2015;6:112-21.  Back to cited text no. 9
    
10.
McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: A critical review. Psychol Med 1988;18:1007-19.  Back to cited text no. 10
    
11.
Goldberg SN, Grassi CJ, Cardella JF, Charboneau JW, Dodd GD 3rd, Dupuy DE, et al. Image-guided tumor ablation: Standardization of terminology and reporting criteria. Radiology 2005;235:728-39.  Back to cited text no. 11
    
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Robert Sheu Y, Hong K. Percutaneous lung tumor ablation. Tech Vasc Interv Radiol 2013;16:239-52.  Back to cited text no. 12
    
13.
Abbas G, Pennathur A, Landreneau RJ, Luketich JD. Radiofrequency and microwave ablation of lung tumors. J Surg Oncol 2009;100:645-50.  Back to cited text no. 13
    
14.
Dupuy DE, DiPetrillo T, Gandhi S, Ready N, Ng T, Donat W, et al. Radiofrequency ablation followed by conventional radiotherapy for medically inoperable stage I non-small cell lung cancer. Chest 2006;129:738-45.  Back to cited text no. 14
    
15.
Wolf FJ, Grand DJ, Machan JT, Dipetrillo TA, Mayo-Smith WW, Dupuy DE. Microwave ablation of lung malignancies: Effectiveness, CT findings, and safety in 50 patients. Radiology 2008;247:871-9.  Back to cited text no. 15
    
16.
Brace CL. Radiofrequency and microwave ablation of the liver, lung, kidney, and bone: What are the differences? Curr Probl Diagn Radiol 2009;38:135-43.  Back to cited text no. 16
    
17.
Abbas G, Schuchert MJ, Pennathur A, Gilbert S, Luketich JD. Ablative treatments for lung tumors: Radiofrequency ablation, stereotactic radiosurgery, and microwave ablation. Thorac Surg Clin 2007;17:261-71.  Back to cited text no. 17
    
18.
Wolf FJ, Aswad B, Ng T, Dupuy DE. Intraoperative microwave ablation of pulmonary malignancies with tumor permittivity feedback control: Ablation and resection study in 10 consecutive patients. Radiology 2012;262:353-60.  Back to cited text no. 18
    
19.
Sonntag PD, Hinshaw JL, Lubner MG, Brace CL, Lee FT Jr. Thermal ablation of lung tumors. Surg Oncol Clin N Am 2011;20:369-87, ix.  Back to cited text no. 19
    
20.
Dravid RM, Paul RE. Interpleural block – Part 1. Anaesthesia 2007;62:1039-49.  Back to cited text no. 20
    
21.
Lee EW, Suh RD, Zeidler MR, Tsai IS, Cameron RB, Abtin FG, et al. Radiofrequency ablation of subpleural lung malignancy: Reduced pain using an artificially created pneumothorax. Cardiovasc Intervent Radiol 2009;32:833-6.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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