Emergency Surgery for Massive Lung Necrosis Following Microwave Ablation

This video presents the case of a rare complication of microwave ablation (MWA) in a thirty-three-year-old woman with lung metastases from colon cancer. The patient has a medical history of metastatic colon cancer, smoking, and alcohol use. Previous surgeries include segmental colon and liver resections. Massive pulmonary necrosis and tension pneumothorax developed after ablation and were managed by surgery.

The Surgery

In this case, the complications were addressed through surgical intervention. A thoracotomy was conducted with the patient in the left lateral decubitus position through a 3 cm incision at the right sixth intercostal space to access the thoracic cavity. Upon visual examination, seroma pockets containing hematoma were identified in both anterior and posterior locations. These pockets were opened, and hematoma and fibrin debris were meticulously cleared. Following pneumolysis, the upper lobe and the sixth segment remained intact, while the lateral segments of the lower lobe and the middle lobe formed a cavity covered in yellow fibrin with visible bronchial openings. The damaged parenchyma was brought together with Vicryl sutures and a wedge resection was performed using three staples to partially close the defect in the lateral basal segment of the lower lobe. As complete closure of the defect was not possible, the incision was enlarged for primary repair using 3-0 Vicryl in the defective areas of the middle and lower lobes. Subsequently, successful control of air leakage was achieved, and after managing bleeding, a 24 Fr chest tube was inserted. The layers were appropriately closed, leading to a successful recovery, and the patient was discharged two days after the surgery.

Surgical Management of Lung Metastases

The personalized management of lung metastases through surgery is tailored to the patient based on the cancer's characteristics, encompassing its extensions and stage. This approach is recommended for patients with controlled primary disease and resectable lung metastases. Various prognostic factors, such as the disease-free interval, completeness of resection, and the presence of lymph node metastases are carefully taken into account to enhance the selection of patients for optimal results (1).

Alternative Therapies: MWA and RFA

Microwave ablation and radiofrequency ablation (RFA) are alternative therapies in cases of patient refusal of surgery or unresectebale tumors. Microwave ablation is an increasingly popular procedure used to manage various types of cancer by delivering microwave energy to the tumor tissue, causing necrosis and destroying the cancer cells.

Studies showed that MWA could be a substitute therapy for RFA in terms of effectiveness and safety for treating pulmonary tumors. Higher intratumoral temperatures, less severe heat sink effects, shorter ablation times, and a larger ablation zone are several advantages of MVA over RFA (2).

Complications of MWA

Pneumothorax stands out as the most prevalent complication associated with microwave ablation (MWA) in lung tumors, with occurrence rates ranging from 8.5 percent to 63 percent (3). Approximately 0.8 percent to 15 percent of cases necessitate the placement of a chest tube (3). Additional complications encompass pleural effusion, pulmonary hemorrhage, chest wall injury, pulmonary abscess, thermal injury to adjacent structures, tumor recurrence, and the potential for seeding along the needle tract (4).

Risk Assessment and Caution

A study assessing the safety of MWA procedures adjacent to the interlobar fissure reported increased risk of complications and suggested that puncturing the antenna through the interlobar fissure could potentially increase the risk of complications (5). The results from this study, coupled with the case presented here, underscore the crucial significance of conducting meticulous and individualized risk assessments when managing lesions in close proximity to the interlobar fissure and visceral pleura. The authors believe that ablating lesions in these locations should be carefully assessed and rethought.

References

1. Patrini D, Panagiotopoulos N, Lawrence D, Scarci M. Surgical management of lung metastases. British Journal of Hospital Medicine. 2017;78(4):192-198. doi:10.12968/hmed.2017.78.4.192
2. Shi F, Li G, Zhou Z, et al. Microwave ablation versus radiofrequency ablation for the treatment of pulmonary tumors. Oncotarget. 2017;8(65):109791-109798. doi:10.18632/oncotarget.22308
3. Vogl T, Nour-Eldin NE, Albrecht M, et al. Thermal Ablation of Lung Tumors: Focus on Microwave Ablation. RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren. 2017;189(09):828-843. doi:10.1055/s-0043-109010
4. Smith SL, Jennings PE. Lung radiofrequency and microwave ablation: a review of indications, techniques and post-procedural imaging appearances. The British Journal of Radiology. 2015;88(1046):20140598. doi:10.1259/bjr.20140598
5. Wang N, Xu J, Wang G, et al. Safety and efficacy of microwave ablation for lung cancer adjacent to the interlobar fissure. Thoracic Cancer. 2022;13(18):2557-2565. doi:10.1111/1759-7714.14589

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