RPS 609a - Lung and mediastinal interventions

Purpose:

To determine whether an autologous blood clot seal (ABCS) after lung and mediastinal biopsy can prevent and minimise the risk of pneumothorax.

Methods and materials:

A prospective study enrolling 20 patients was conducted from August 2018-July 2019. Patients undergoing CT-guided biopsy of lung and mediastinal masses were candidates. A biopsy path of at least 2 cm aerated lung was selected so that an effective blood clot seal might be applied and any blebs, fissures, and blood vessels in the pathway were avoided. The biopsy was performed with CT guidance using a 20-gauge coaxial system. The patient’s clotted blood, which ranged from 1 ml to 5 ml, was injected into the needle track while the guiding needle was withdrawn, filling the entire needle track to the visceral pleura. Immediately after withdrawing the needle, the puncture site was put in a dependent position.

Results:

ABCS after a biopsy was performed in 20 deep-seated and risky lung and mediastinal masses ranging from 10 mm-25 mm in the age group of 35-68 years. Only one patient developed a very small pneumothorax, which was revealed only in post-procedure CT and was not seen in a chest skiagram taken one hour after the procedure.

Conclusion:

The use of autologous blood clot seal after biopsy of deep lung and mediastinal lesions significantly prevents and minimizes the risk of pneumothorax. It appears to be more beneficial when a 20 gauge coaxial needle and immediate dependant positioning of the puncture site is used.

Limitations:

An ongoing study with a limited number of patients within a one year period. Long-term study with more number of patients is needed.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate the predictive value of the apparent diffusion coefficient (ADC) for the treatment response in unresectable primary and secondary lung neoplasms using transpulmonary chemoembolisation (TPCE) and transarterial chemoperfusion (TACP).

Methods and materials:

42 primary (n=13) and secondary (n=29) unresectable lung lesions of 31 patients undergoing TPCE and TACP were included. Lesion diameter, volume, and ADC values were measured on an MRI series including a diffusion-weighted imaging (DWI) sequence at the beginning and end of each treatment cycle. Treatment response was evaluated on a per-lesion basis. Partial response (PR) was defined as a size decrease of ≥30%, progressive disease (PD) as an increase of≥20%, and stable disease (SD) was the remaining lesions. A statistical analysis of ADC values was performed using t-tests, an analysis of variance, and receiver-operating characteristic curves.

Results:

9 lesions recorded PR: the mean pre-treatment ADC was 1.164x10^-3 mm²/s and the mean ADC increase was 32.9%. 19 lesions recorded SD: the mean pre-treatment ADC was 1.449x10^-3 mm²/s and the mean ADC increase was 6.9%. 14 lesions recorded PD: the mean pre-treatment ADC was 1.418x10^-3 mm²/s and the increase in the mean ADC was 5.0%. The difference in ADC changes between response groups was significant (p≤0.02). Pre-treatment ADC recorded an area under the curve (AUC) of 0.774 for response prediction. A threshold ADC increase of 20.7% showed 88% sensitivity and 78% specificity for response prediction (AUC 0.838).

Conclusion:

The study showed significant differences in mean ADC changes comparing PR to SD (p=0.02) and PR to PD (p<0.01) groups with a correlation between lesion volume reduction and an early increase in ADC in patients undergoing TPCE and TACP.

Limitations:

A retrospective study design with a small number of patients.

Ethics committee approval

Approval by the Institutional Review Board.

Funding:

No funding was received for this work.

Purpose:

To evaluate the efficacy and accuracy of CT-guided fine-needle aspiration citology (FNAC) in lung cancer typing.

Methods and materials:

From January 2013-December 2017, 640 FNAC specimens were collected from 640 patients and examined with rapid on-site evaluation (ROSE), and subsequently underwent immunological tests (TTF-1, p40, CK 5/6, CK 7, and Napsin). Afterwards, cytological findings were compared with final histologic diagnoses. Overall adequacy and accuracy rates were determined by comparison with the final diagnosis.

Results:

Of the 640 cases, concordance between “adequate” interpretation by ROSE and unequivocal malignant or benign diagnoses on final interpretation was 100%. In 80% of the specimens, it was possible to perform immunohistological analysis. The complication rate was 7%; no bleeding occurred but we did observe pneumothorax, which was distinguished in “early”, when it was diagnosed during or at the end of the procedure and treated percutaneously, or “delayed”, when it occurred in the first 24 hours and was surgically treated.

Conclusion:

Lung cancer typing according to cytological criteria is feasible, accurate, and comparable with results of a histological analysis on small specimens. In addition, the possibility of immunological testing combined with the minimally invasive specimen harvesting can come up to the oncologists’ increasing demands of a specific target for the new therapeutic frontiers (chemoimmunotherapy, radiotherapy, or surgery).

Limitations:

A retrospective study and a single-centre experience.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To identify the causes of failure and/or relapse of the endovascular treatment of haemoptysis.

Methods and materials:

We conducted a retrospective study from a prospective database of all patients who underwent endovascular treatment for haemoptysis from September 2015-March 2019. We collected clinical data such as age, gender, volume, the tolerability of haemoptysis, and the cause of haemoptysis. We reviewed CT-angiography and digital angiography. We defined failure (failure of catheterism or persistence of haemoptysis), short-term relapse (<1 month), and long-term relapse (>1 month).

Results:

148 patients (114 men and 34 women, median age: 57 y) were included in the study. Cancer (51 cases), tuberculosis (22 cases), bronchiectasis (20 cases), aspergillosis (15 cases), and cryptogenic haemoptysis (14 cases) accounted for more than 80% of causes. Failures and relapses were observed in 38 patients (26%). Failure, short-term relapse, and long-term relapse were respectively observed in 6 (4%), 23 (16%), and 9 (6%) patients.
Among the 29 patients who experienced a failure of treatment or a short-term relapse, the two most common causes of failure and relapse were an incomplete embolisation (17 patients/29; 59%) and an error concerning the involved circulation (4 patients/29; 14 %).
A re-embolisation enabled the control of haemoptysis in 22 of 29 patients (76%), for a total of 141/148 patients in the whole study (95%).

Conclusion:

Incomplete embolisation and an error concerning involved circulation are the most frequent causes (21 patients/29) of failure/relapse in patients who experienced a failure of treatment and short-term relapse.
Re-embolisation enables the control of haemoptysis in 22 of these 29 patients (76%).

Limitations:

A retrospective monocentric analysis of a patient series with haemoptysis.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To determine the value of conventional MRI with contrast, apparent diffusion coefficient (ADC) value calculation, and CT with contrast in the assessment of early- and long-term treatment response after ablation of inoperable lung tumours with microwave ablation (MWA) and radiofrequency (RFA).

Methods and materials:

58 patients with 86 lung lesions were treated with MWA and RFA according to the guidelines and evaluated by MRI with contrast including T1.T2 WI, T1 post-contrast, and diffusion-weighted imaging (DWI) using b-values (50, 400, and 800 mm2/s) and ADC value measurement before and 24 hours after ablation. Follow-up by chest CT and/or MRI after 24 hours, three, six, nine months, one year, and every 6 months onwards to determine response to ablation was conducted. ADC value changes after ablation were compared to NRT response.

Results:

56 lesions (65.1%) showed complete response and 30 lesions (34.9%) showed a local progression (residual activity). There was a statistical significant difference in T2 WI signal intensity after ablation in both groups (P=0.047) but no significant difference in T1 WI at all over the follow-up period (P=0.914). There was a statistical significant difference in contrast enhancement between local progression lesions and responsive lesions during the follow-up period (P=0.001).

The ADC value measured 24 hours after ablation in the responding groups (1.71 ± 0.3× 10⁻³ mm²/s) was statistically significantly higher than in the non-responding groups (1.42 ± 0.3×10̵³mm²/s) (P=0.001).

A cut-off ADC value (1.42) has been suggested as a reference point to predict the response (66.69% sensitivity, 84.23% specificity, 66.8% PPV, and 84.3% NPV).

Conclusion:

MRI with contrast is effective in the evaluation of local tumour control after thermal ablation of inoperable lung tumours. ADC value measurement may allow early prediction of the treatment efficacy before morphological changes in conventional imaging can be detected.

Limitations:

Respiratory motion artefacts and difficulty in small lesion detection.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To retrospectively evaluate the safety, diagnostic yield, and risk factors of the diagnostic failure of CT fluoroscopy-guided core-needle biopsy (CNB) of anterior mediastinal masses performed with a large calibre single-needle technique.

Methods and materials:

We retrospectively evaluated 85 patients who underwent CT fluoroscopy-guided CNB of anterior mediastinal masses between June2017-June2019. All procedures were performed using an automated cutting needle (14 to 18G, 10 cm length), collecting at least one specimen considered adequate. The biopsy results were compared with the final diagnosis in order to evaluate the diagnostic accuracy. The procedures were divided into diagnostic success and diagnostic failure groups. Variables related to patients (age, sex, and presence of PET-CT or CE-CT/MRI prior to biopsy), lesions (size, presence of calcification, and fluid and/or fat), and procedures (patient position, approach type, size of needle, number of samples, operator’s experience, procedure time, and complications) were assessed to determine the risk factors for diagnostic failure.

Results:

Procedures were performed on 48 women and 37 men (mean age 47.7±19years). In 35 (41%) and 57 (67%) patients, PET-CT and/or CE-CT/MRI were available before performing the biopsy. The mean lesion size was 68±32.9 mm (range 9-159); 10 and 22 lesions demonstrated respectively calcification and fluid on CT images. On 85 procedures, 78 (92%) were diagnostic successes and 7 (8%) were diagnostic failures. The diagnosed masses included 42 lymphomas, 17 thymomas, 7 thymic carcinomas, 3 liposarcomas, and 10 others. The variables between the two groups were compared using Fisher’s exact test. No significant risk factor for diagnostic failure was identified.

Conclusion:

CT fluoroscopy-guided biopsy of anterior mediastinal masses performed with a large calibre (≤18G) single-needle technique is a safe and highly accurate procedure with a low complications rate (4%).

Limitations:

A retrospective study.

Ethics committee approval

n/a

Funding:

No funding was received for this work.

Purpose:

To evaluate tumour response, local tumour control, and patient survival after the palliative treatment of primary lung cancer using transpulmonary chemoembolisation (TPCE) and intra-arterial chemoperfusion (IACP).

Methods and materials:

118 patients with unresectable primary lung cancer not responding to systemic chemotherapy underwent either repetitive TPCE (n=56) or IACP (n=62) from 01/2006-04/2017 (mean number of sessions/patient: 5.3±2.2, median number of nodules: 3, bilateral lung involvement 45.8%). The chemotherapeutic agents used were mitomycin C and gemcitabine (n=14), without cisplatin (n=98), or other combinations (n=6).

Regional delivery of the chemotherapeutic agents was performed either through selective catheterisation of the tumour-supplying pulmonary arteries with subsequent embolisation or through non-selective IACP. Tumour response was assessed according to the rRECIST criteria.

Results:

Partial response was achieved in 15.3%, stable disease in 60.2%, and progressive disease in 24.6%. The estimated mean survival time (MST) and time-to-progression were 15.8±1.7 and 9.2 ±1.3 months in the TPCE group and 20±3.8 and 11.1±1.7 months in the IACP group, respectively. These differences were statistically insignificant.

Patients with advanced disease who underwent subsequent ablative therapy had a significantly longer mean survival time of 24.6±4 months versus the non-ablation group (MST=15.3±2.8; p=0-001).

Conclusion:

TPCE and IACP have the potential to improve local tumour control and prolong survival in a selected group of patients who have limited treatment options.

Limitations:

Patients were assigned to each treatment case-by-case. It might be better to do perfusion in less vascular tumours and embolisation in highly vascular ones.

The effects of critical prognostic factors were difficult to evaluate due to insufficient information in the database.

Ethics committee approval

Institutional Review Board approval was obtained. Written informed consent was not required due to the retrospective design.

Funding:

No funding was received for this work.