Published online before print July 1, 2005, 10.1148/radiol.2362040992
(Radiology 2005;236:666-670.)
© RSNA, 2005
Artificially Induced Pneumothorax for Percutaneous Transthoracic Radiofrequency Ablation of Tumors in the Hepatic Dome: Initial Experience1
Thierry de Baère, MD,
Clarisse Dromain, MD,
Mathieu Lapeyre, MD,
Patriccio Briggs, MD,
Jean Sébastien Duret, MD,
Antoine Hakime, MD,
Valérie Boige, MD and
Michel Ducreux, MD, PhD
1 From the Departments of Medical Imaging (T.d.B., C.D., M.L., P.B., J.S.D., A.H.) and Medicine (V.B., M.D.), Institut Gustave Roussy, 94805 Villejuif, France. Received June 9, 2004; revision requested August 19; revision received September 14; accepted October 20.
Address correspondence to T.d.B. (e-mail: debaere{at}igr.fr).
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ABSTRACT
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After institutional review board approval, informed consent was obtained from six patients (four men and two women, aged 47–74 years) with a total of six tumors of the liver dome. These patients were treated by means of radiofrequency (RF) ablation with computed tomographic (CT) guidance and a transthoracic approach. With use of general anesthesia, a right pneumothorax was induced by means of manual injection of air until the route allowing access to the tumor was cleared of all lung parenchyma. Then RF ablation was performed with transthoracic extrapulmonary transdiaphragmatic access. After retrieval of the RF electrode, the pneumothorax was fully aspirated. All procedures were successfully performed without complications. Artificially induced pneumothorax appears useful and safe for CT-guided RF ablation of liver dome tumors, although this experience was minimal, with only six patients treated.
© RSNA, 2005
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INTRODUCTION
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Percutaneous access to liver tumors for local ablative therapies is obtained with image guidance. Ultrasonography (US) is most often preferred to computed tomography (CT) because angulation is possible in any direction, visualization is in real time, and US is widely available. However, some tumors remain challenging or even impossible to reach with a needle by means of US guidance either because of their location or because tumor visibility is poor. Tumors located in the dome of the liver, especially those more anteriorly positioned, are among the most difficult tumors to target with US guidance. When CT is used to target such high-seated tumors, a transthoracic approach is needed because most of the punctures are performed in the scanning plane. This approach usually traverses lung parenchyma, and there is a risk of complications associated with lung puncture (1–3). The purpose of our study was to evaluate a technique allowing CT-guided percutaneous transthoracic-transdiaphragmatic access to liver tumors for radiofrequency (RF) ablation without traversing lung parenchyma.
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Materials and Methods
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Patients
Between February 2002 and March 2003, among 103 patients referred for RF ablation of liver tumors, six patients (four men, two women; age range, 47–74 years) bearing a total of six solitary liver tumors were treated by means of a transthoracic approach with CT guidance after institutional review board approval and informed consent had been obtained. CT guidance was chosen because three tumors were not visible at US and the other three tumors, although depicted at US, were not considered amenable to US-guided puncture because of their location in the hepatic dome. The tumors included four hepatocellular carcinomas and two metastases and measured 1.8–3.7 cm (mean, 2.3 cm) in largest diameter. All tumors were visualized at CT without injection of contrast medium. One tumor was hyperattenuating and five were hypoattenuating compared with the surrounding liver parenchyma.
Procedures
Patients underwent chest CT before the RF ablation procedure so the interventional radiologist (T.d.B.) could rule out diffuse lung disease, pleural effusion, or metastatic disease. Chest CT scans were obtained without contrast medium injection by using a single–detector row spiral scanner (HiSpeed; GE Medical Systems, Milwaukee, Wis) and 5-mm collimation. The patients were administered general anesthetic, and oxygen saturation of the blood was monitored during the entire procedure. After general anesthesia was induced, the liver was scanned by using 5-mm collimation, without injection of contrast medium. The entry site of the RF electrode was chosen in the CT scanning plane containing the tumor. This entry site was cleansed with povidone iodine and sterilely draped. In addition, the anterior axillary line was cleaned at the same level. All procedures were performed by a single author (T.d.B.) with 15 years of experience in imaging-guided interventional procedures and 8 years of experience in RF ablation.
Pneumothorax induction.—An 18-gauge epidural needle obtained from an epidural kit (Epidural Minipack; Portex, Keene, NH) was inserted in the scanning plane on the anterior axillary line. Moderate positive pressure was manually maintained on the piston of the dedicated syringe provided in the epidural kit as the needle tip was progressed through the chest wall. When the piston was advanced, as less resistance was encountered, 2–3 mL of air was injected and the location of the needle tip was verified with CT. If the needle had not reached the pleural space on the CT image, it was pushed forward again with positive pressure on the piston until the tip reached the pleural space. Once the needle had reached the pleural space, 50 mL of air, obtained through a microporous filter contained in the epidural kit, was injected. A 0.035-inch guidewire was then threaded through the needle in the pleural cavity to exchange the needle for a straight 5-F side-hole catheter (Cook, Bjaeverskov, Denmark), which was connected to a 50-mL syringe and a microporous filter through a three-way stopcock. Air obtained through the filter was then injected into the pleural space through the catheter until all lung parenchyma was cleared from the route leading to the liver tumor. CT scans were obtained after injection of 200, 400, 600, and 800 mL of air to check clearance of the lung parenchyma.
RF ablation.—RF ablation procedures were performed according to the standardization of terms reported by Goldberg et al (4).
With CT monitoring, the RF electrode was inserted through the chest wall and then through the empty pleural space and the diaphragm to the liver and finally reached the targeted tumor. RF ablation was performed by using an expandable electrode (CoAccess LeVeen; Radiotherapeutics, Sunnyvale, Calif) in five patients and an internally cooled cluster probe consisting of three electrodes (Radionics, Burlington, Mass) in one patient. After completion of the RF ablation session, the RF electrode was removed and the intrahepatic needle tract was coagulated.
Pneumothorax removal.—After RF ablation, intrapleural air was aspirated through the catheter into the syringe and expelled through the stopcock. This maneuver was repeated until no more air could be aspirated. A chest CT examination covering the entire chest was performed to evaluate any residual pneumothorax. All patients spent one night in the hospital and underwent chest radiography on the day after RF ablation; radiographs were interpreted by a senior physician from the diagnostic radiology department to rule out a pneumothorax. Patients then underwent follow-up CT every 2 months for the first 6 months and, thereafter, every 3 months up to 1 year.
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Results
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No diffuse lung disease, pleural effusion, or lung metastasis was found at preprocedural chest CT.
Pneumothorax Induction
All pneumothoraces were induced without puncturing the lung parenchyma. To confirm that the needle tip was correctly positioned in the pleural space, one CT assessment was needed in three patients, two CT assessments were needed in one patient, and three CT assessments were needed in two patients. Less than 5 mL of air was injected subcutaneously in the last three patients (Figs 1, 2). The time required for adequate placement of the 18-gauge needle in the pleural cavity was less than 8 minutes in all patients. In all six patients, we were able to clear the lung parenchyma from the route used to reach the tumor with the RF electrode. Injection of 200–800 mL (mean, 566 mL) of air was required. Oxygen saturation did not decrease in any patient, and, consequently, no changes were made in the ventilation parameters during the procedure.
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Figure 1a. Transverse CT scans in a 60-year-old man. (a) Scan shows newly appeared hypoattenuating, unenhanced, 2-cm oval colon cancer metastases in liver segment VII. (b) An 18-gauge epidural needle is inserted on the anterior axillary line, and its tip has reached the pleural space, where 50 mL of air is injected, inducing a mild pneumothorax (arrow) in the anterior part of the pleural cavity. (c) Needle is exchanged for a 5-F side-hole catheter, seen entering the pleural cavity. Note the three-way stopcock (arrow) and filter (arrowhead) attached to the hub of the catheter. (d) RF electrode enters the diaphragm and traverses an air-filled pleural cavity without puncturing visceral pleura or lung parenchyma. (e) RF electrode has been deployed in the targeted area in the liver. (f) Scan obtained 6 months after ablation shows a nonenhancing area of ablation covering the initial tumor location.
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Figure 1b. Transverse CT scans in a 60-year-old man. (a) Scan shows newly appeared hypoattenuating, unenhanced, 2-cm oval colon cancer metastases in liver segment VII. (b) An 18-gauge epidural needle is inserted on the anterior axillary line, and its tip has reached the pleural space, where 50 mL of air is injected, inducing a mild pneumothorax (arrow) in the anterior part of the pleural cavity. (c) Needle is exchanged for a 5-F side-hole catheter, seen entering the pleural cavity. Note the three-way stopcock (arrow) and filter (arrowhead) attached to the hub of the catheter. (d) RF electrode enters the diaphragm and traverses an air-filled pleural cavity without puncturing visceral pleura or lung parenchyma. (e) RF electrode has been deployed in the targeted area in the liver. (f) Scan obtained 6 months after ablation shows a nonenhancing area of ablation covering the initial tumor location.
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Figure 1c. Transverse CT scans in a 60-year-old man. (a) Scan shows newly appeared hypoattenuating, unenhanced, 2-cm oval colon cancer metastases in liver segment VII. (b) An 18-gauge epidural needle is inserted on the anterior axillary line, and its tip has reached the pleural space, where 50 mL of air is injected, inducing a mild pneumothorax (arrow) in the anterior part of the pleural cavity. (c) Needle is exchanged for a 5-F side-hole catheter, seen entering the pleural cavity. Note the three-way stopcock (arrow) and filter (arrowhead) attached to the hub of the catheter. (d) RF electrode enters the diaphragm and traverses an air-filled pleural cavity without puncturing visceral pleura or lung parenchyma. (e) RF electrode has been deployed in the targeted area in the liver. (f) Scan obtained 6 months after ablation shows a nonenhancing area of ablation covering the initial tumor location.
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Figure 1d. Transverse CT scans in a 60-year-old man. (a) Scan shows newly appeared hypoattenuating, unenhanced, 2-cm oval colon cancer metastases in liver segment VII. (b) An 18-gauge epidural needle is inserted on the anterior axillary line, and its tip has reached the pleural space, where 50 mL of air is injected, inducing a mild pneumothorax (arrow) in the anterior part of the pleural cavity. (c) Needle is exchanged for a 5-F side-hole catheter, seen entering the pleural cavity. Note the three-way stopcock (arrow) and filter (arrowhead) attached to the hub of the catheter. (d) RF electrode enters the diaphragm and traverses an air-filled pleural cavity without puncturing visceral pleura or lung parenchyma. (e) RF electrode has been deployed in the targeted area in the liver. (f) Scan obtained 6 months after ablation shows a nonenhancing area of ablation covering the initial tumor location.
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Figure 1e. Transverse CT scans in a 60-year-old man. (a) Scan shows newly appeared hypoattenuating, unenhanced, 2-cm oval colon cancer metastases in liver segment VII. (b) An 18-gauge epidural needle is inserted on the anterior axillary line, and its tip has reached the pleural space, where 50 mL of air is injected, inducing a mild pneumothorax (arrow) in the anterior part of the pleural cavity. (c) Needle is exchanged for a 5-F side-hole catheter, seen entering the pleural cavity. Note the three-way stopcock (arrow) and filter (arrowhead) attached to the hub of the catheter. (d) RF electrode enters the diaphragm and traverses an air-filled pleural cavity without puncturing visceral pleura or lung parenchyma. (e) RF electrode has been deployed in the targeted area in the liver. (f) Scan obtained 6 months after ablation shows a nonenhancing area of ablation covering the initial tumor location.
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Figure 1f. Transverse CT scans in a 60-year-old man. (a) Scan shows newly appeared hypoattenuating, unenhanced, 2-cm oval colon cancer metastases in liver segment VII. (b) An 18-gauge epidural needle is inserted on the anterior axillary line, and its tip has reached the pleural space, where 50 mL of air is injected, inducing a mild pneumothorax (arrow) in the anterior part of the pleural cavity. (c) Needle is exchanged for a 5-F side-hole catheter, seen entering the pleural cavity. Note the three-way stopcock (arrow) and filter (arrowhead) attached to the hub of the catheter. (d) RF electrode enters the diaphragm and traverses an air-filled pleural cavity without puncturing visceral pleura or lung parenchyma. (e) RF electrode has been deployed in the targeted area in the liver. (f) Scan obtained 6 months after ablation shows a nonenhancing area of ablation covering the initial tumor location.
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Figure 2a. Transverse CT scans in a 56-year-old woman. (a) Tumor is spontaneously hyperattenuating. (b) Tip of an 18-gauge epidural needle inserted on the anterior axillary line has reached the pleural space, and a pneumothorax (arrow) is induced after a previous inadequate injection of 3 mL of air in the subcutaneous tissue. (c) An epidural needle is exchanged for a catheter and the RF electrode is deployed in the liver tumor. (d) Scan obtained after completion of RF treatment shows no residual pneumothorax after aspiration. (e) At 1 year after ablation, a nonenhancing area of ablation is seen.
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Figure 2b. Transverse CT scans in a 56-year-old woman. (a) Tumor is spontaneously hyperattenuating. (b) Tip of an 18-gauge epidural needle inserted on the anterior axillary line has reached the pleural space, and a pneumothorax (arrow) is induced after a previous inadequate injection of 3 mL of air in the subcutaneous tissue. (c) An epidural needle is exchanged for a catheter and the RF electrode is deployed in the liver tumor. (d) Scan obtained after completion of RF treatment shows no residual pneumothorax after aspiration. (e) At 1 year after ablation, a nonenhancing area of ablation is seen.
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Figure 2c. Transverse CT scans in a 56-year-old woman. (a) Tumor is spontaneously hyperattenuating. (b) Tip of an 18-gauge epidural needle inserted on the anterior axillary line has reached the pleural space, and a pneumothorax (arrow) is induced after a previous inadequate injection of 3 mL of air in the subcutaneous tissue. (c) An epidural needle is exchanged for a catheter and the RF electrode is deployed in the liver tumor. (d) Scan obtained after completion of RF treatment shows no residual pneumothorax after aspiration. (e) At 1 year after ablation, a nonenhancing area of ablation is seen.
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Figure 2d. Transverse CT scans in a 56-year-old woman. (a) Tumor is spontaneously hyperattenuating. (b) Tip of an 18-gauge epidural needle inserted on the anterior axillary line has reached the pleural space, and a pneumothorax (arrow) is induced after a previous inadequate injection of 3 mL of air in the subcutaneous tissue. (c) An epidural needle is exchanged for a catheter and the RF electrode is deployed in the liver tumor. (d) Scan obtained after completion of RF treatment shows no residual pneumothorax after aspiration. (e) At 1 year after ablation, a nonenhancing area of ablation is seen.
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Figure 2e. Transverse CT scans in a 56-year-old woman. (a) Tumor is spontaneously hyperattenuating. (b) Tip of an 18-gauge epidural needle inserted on the anterior axillary line has reached the pleural space, and a pneumothorax (arrow) is induced after a previous inadequate injection of 3 mL of air in the subcutaneous tissue. (c) An epidural needle is exchanged for a catheter and the RF electrode is deployed in the liver tumor. (d) Scan obtained after completion of RF treatment shows no residual pneumothorax after aspiration. (e) At 1 year after ablation, a nonenhancing area of ablation is seen.
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RF Ablation
In each of four patients, RF treatment consisted of one RF ablation. In another patient, two RF ablations were needed for treatment because the electrode had been deployed beyond the distal end of the tumor, and the area was ablated to minimize the risk of seeding after deployment in this erroneous location. The needle was then retrieved for adequate positioning in the center of the tumor and a second ablation was performed. The patient with the largest tumor, a colorectal cancer metastasis measuring 38 mm, underwent four overlapping ablations so that the tumor and safety margins were totally encompassed.
Pneumothorax Removal
After retrieval of the RF electrode, all artificially induced pneumothoraces were fully expelled, and no air was seen in the pleural cavity on the CT scans of the thorax obtained at the end the RF session (Fig 2).
Follow-up Imaging
No pneumothorax was depicted on the chest radiographs obtained at day 1; consequently, all patients were discharged from the hospital the next morning after RF ablation. The patients did not experience thoracic or shoulder pain after the procedure. Mild abdominal pain was present in two of six patients at day 1. During the follow-up period, no abnormalities were depicted on the lung parenchyma or in the pleural space. No complications occurred during the procedures, and no complications were depicted on images obtained during follow-up. After a follow-up period of 6–21 months (mean, 10 months), five tumors were deemed fully ablated because CT scans demonstrated a nonenhancing area of coagulation necrosis where the tumor was located. The largest (38 mm) tumor was considered incompletely ablated at 6 months and was recently treated with RF ablation by means of the same transthoracic access approach.
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Discussion
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US-guided percutaneous access to tumors in the hepatic dome for biopsy or ablation can be problematic, and the use of CT guidance has been proposed to overcome these difficulties. Transpulmonary CT-guided biopsy of liver tumors has been reported to be a safe technique for sampling lesions located close to the diaphragm (5). A transthoracic-transpulmonary approach performed with CT guidance has been used to inject ethanol into liver tumors (2,3,6). In an experimental study, pulmonary hemorrhages occurred in 35% of rats by using such an approach (1).
In clinical practice, when this approach is used for percutaneous ethanol injection in hepatocellular carcinoma of the dome of the liver, lung hemorrhage, even though it rarely occurs, can be associated with severe complications such as massive hemoptysis (2) or fatal hemothorax (3). Pneumothoraces are reported to occur in up to 30% of percutaneous ethanol injection sessions in which the transthoracic-transpulmonary route is used, despite the use of a 22- to 19-gauge needle (2). This rate is much higher than that usually reported for lung biopsy. This high rate may be due to the need for two passes through the visceral pleura to reach the liver, whereas only one route is necessary for a biopsy procedure; in addition, the length of traversed lung parenchyma is usually shorter for biopsy than for accessing the liver.
To decrease the rate of such complications, some authors have injected saline in the pleural cavity to permit transthoracic, but extrapulmonary, access to liver dome tumors for percutaneous ethanol injection (7,8). Such saline injections have also been used for microwave (9) or RF ablation (10), where avoiding pleural and lung passes seems even more important given the larger-sized thermal ablation needles, which range between 17 and 14 gauge. One of the advantages of injecting saline in the pleural cavity is that it allows US depiction of tumors that can barely be seen without such an injection (7,11). Injecting saline in the pleura appears to be appropriate for percutaneous ethanol injection in liver tumors. When leakage occurs, and it is reported to occur in up to 41% of cases (3), it will ultimately reach the pleural cavity where the ethanol will be diluted in the large volume of saline; thus, pleural complications can be avoided.
When dealing with more recent thermal ablation techniques, such as microwave or RF ablation, injection of saline in the pleural cavity can be questionable, because saline has been demonstrated to alter tissue properties by increasing electrical conductivity and improving thermal conduction. This is true to such an extent that irregular distribution of saline can lead to an irregular area of RF ablation and can be responsible for uncontrolled RF ablation (12–14). In our opinion, injecting saline in the pleural cavity when RF ablation is performed in close proximity on the other side of the diaphragm does not appear to be as safe as injecting air, because air is an insulator of electricity and heat, whereas saline increases current conductivity. If US guidance is needed and liquid has to be injected, one should prefer dextran or 5% glucose solutions, which are nonionic.
To our knowledge, the technique reported herein, whereby an artificially induced pneumothorax is used to access a liver dome tumor for RF ablation, has never been described elsewhere. In our experience, this technique appeared to be safe and efficient, as it avoided damage to the lung parenchyma and allowed effective treatment of liver dome tumors without prolonging the hospital stay in comparison with that for our standard RF ablation practice. No pneumothorax recurred once expelled because only the parietal pleura was punctured—never the visceral pleura. This technique appears to be less aggressive than the US-guided transdiaphragmatic access that has been reported either with open surgery for RF ablation (15) or with a thoracoscopic approach for microwave coagulation (16) of liver dome tumors. In our study, all procedures were performed with general anesthesia because this is mandatory for RF ablation in our institution, particularly because these tumors were located close to the liver capsule, where ablation is most often very painful. Consequently, we have no information on clinical tolerance of RF ablation with an artificially induced pneumothorax with conscious sedation. We presume that the pain caused by a limited pneumothorax is probably mild and close to that reported after a saline injection performed with local anesthesia (9,10). We intend to evaluate this clinical tolerance because the induced pneumothorax was so useful in our experience that we would like to extend its use for biopsy of liver dome tumors.
Finally, we used a peridural needle because one was available in our interventional radiology suite, but more sophisticated tools such as a Veress needle, which is designed to induce a pneumoperitoneum before laparoscopy, can probably simplify the procedure since it can reach the pleural cavity rapidly and is even more capable of avoiding the risks of subcutaneous emphysema or lung tears and the need for CT guidance. The Veress needle is a blunt-tipped needle with a spring-loaded inner stylet and a sharply tailored outer needle for entry into the pleural cavity. The mechanism is designed so that when the needle passes through the chest wall, the blunt-tip stylet is retracted to allow the needle to penetrate the tissue. However, when the outer needle reaches the pleural space, no resistance is encountered, and the blunt stylet can thus protrude beyond the sharp tip of the needle, thereby avoiding tears in the visceral pleura and lung parenchyma. Air can be injected through this needle, but a guidewire cannot be threaded through it; therefore, a second puncture is required for catheter placement.
Artificially inducing a pneumothorax appears to be useful and safe for CT-guided RF ablation of liver dome tumors through a transthoracic but extrapulmonary route. We intend to evaluate this technique further for any transthoracic access to the liver either for RF ablation or biopsy in the near future.
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FOOTNOTES
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Abbreviations: RF = radiofrequency
Authors stated no financial relationship to disclose.
Author contributions: Guarantors of integrity of entire study, T.d.B., C.D.; study concepts and design, T.d.B., A.H.; literature research, T.d.B., P.B., J.S.D., M.L.; clinical studies, all authors; data acquisition, T.d.B., C.D., M.D., V.B.; data analysis/interpretation, A.H., T.d.B.; manuscript preparation and definition of intellectual content, T.d.B., C.D.; manuscript editing, T.d.B., C.D., M.L.; manuscript revision/review, T.d.B., M.L.; manuscript final version approval, all authors
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TOP
ABSTRACT
INTRODUCTION
