Factors Associated with Hospital Length of Stay and Adverse Events following Percutaneous Ablation of Lung Tumors.

PURPOSE: To explore the association between risk factors established in the surgical literature and hospital length of stay (HLOS), adverse events, and hospital readmission within 30 days after percutaneous image-guided thermal ablation of lung tumors. MATERIALS AND METHODS: This bi-institutional retrospective cohort study included 131 consecutive adult patients (67 men [51%]; median age, 65 years) with 180 primary or metastatic lung tumors treated in 131 sessions (74 cryoablation and 57 microwave ablation) from 2006 to 2019. Age-adjusted Charlson Comorbidity Index, sex, performance status, smoking status, chronic obstructive pulmonary disease (COPD), primary lung cancer versus pulmonary metastases, number of tumors treated per session, maximum axial tumor diameter, ablation modality, number of pleural punctures, anesthesia type, pulmonary artery-to-aorta ratio, lung densitometry, sarcopenia, and adipopenia were evaluated. Associations between risk factors and outcomes were assessed using univariable and multivariable generalized linear models. RESULTS: In univariable analysis, HLOS was associated with current smoking (incidence rate ratio [IRR], 4.54 [1.23-16.8]; P = .02), COPD (IRR, 3.56 [1.40-9.04]; P = .01), cryoablations with ≥3 pleural punctures (IRR, 3.13 [1.07-9.14]; P = .04), general anesthesia (IRR, 10.8 [4.18-27.8]; P < .001), and sarcopenia (IRR, 2.66 [1.10-6.44]; P = .03). After multivariable adjustment, COPD (IRR, 3.56 [1.57-8.11]; P = .003) and general anesthesia (IRR, 12.1 [4.39-33.5]; P < .001) were the only risk factors associated with longer HLOS. No associations were observed between risk factors and adverse events in multivariable analysis. Tumors treated per session were associated with risk of hospital readmission (P = .03). CONCLUSIONS: Identified preprocedural risk factors from the surgical literature may aid in risk stratification for HLOS after percutaneous ablation of lung tumors, but were not associated with adverse events.

Comparison of expected imaging findings following percutaneous microwave and cryoablation of pulmonary tumors: ablation zones and thoracic lymph nodes.

OBJECTIVE: To compare temporal changes of ablation zones and lymph nodes following lung microwave ablation (MWA) and cryoablation. METHODS: This retrospective cohort study compared lung ablation zones and thoracic lymph nodes following MWA and cryoablation performed 2006-2020. In the ablation zone cohort, ablation zone volumes were measured on serial CT for 12 months. In the lymph node cohort, the sum of bidimensional products of lymph node diameters was measured before (baseline) and up to 6 months following ablation. Cumulative incidence curves estimated the time to 75% ablation zone reduction and linear mixed-effects regression models compared the temporal distribution of ablation zones and lymph node sizes between modalities. RESULTS: Ablation zones of 59 tumors treated in 45 sessions (16 MWA, 29 cryoablation) in 36 patients were evaluated. Differences in the time to 75% volume reduction between modalities were not detected. Following MWA, half of the ablation zones required an estimated time of 340 days to achieve a 75% volume reduction compared to 214 days following cryoablation (p = .30). Thoracic lymph node sizes after 33 sessions (13 MWA, 20 cryoablation) differed between modalities (baseline-32 days, p = .01; 32-123 days, p = .001). Following MWA, lymph nodes increased on average by 38 mm2 (95%CI, 5.0-70.7; p = .02) from baseline to 32 days, followed by an estimated decrease of 50 mm2 (32-123 days; p = .001). Following cryoablation, changes in lymph nodes were not detected (baseline-32 days, p = .33). CONCLUSION: The rate of ablation zone volume reduction did not differ between MWA and cryoablation. Thoracic lymph nodes enlarged transiently after MWA but not after cryoablation. KEY POINTS: • Contrary to current belief, the rate of lung ablation zone volume reduction did not differ between microwave and cryoablation. • Transient enlargement of thoracic lymph nodes after microwave ablation was not associated with regional tumor spread and decreased within six months following ablation. • No significant thoracic lymph node enlargement was observed following cryoablation.

Comparison of Percutaneous Image-Guided Microwave Ablation and Cryoablation for Sarcoma Lung Metastases: A 10-Year Experience.

BACKGROUND. To our knowledge, outcomes between percutaneous microwave ablation (MWA) and cryoablation of sarcoma lung metastases have not been compared. OBJECTIVE. The purpose of this study was to compare technical success, complications, local tumor control, and overall survival (OS) after MWA versus cryoablation of sarcoma lung metastases. METHODS. This retrospective cohort study included 27 patients (16 women, 11 men; median age, 64 years; Eastern Cooperative Oncology Group performance score, 0-2) who, from 2009 to 2021, underwent 39 percutaneous CT-guided ablation sessions (21 MWA and 18 cryoablation sessions; one to four sessions per patient) to treat 65 sarcoma lung metastases (median number of tumors per patient, one [range, one to 12]; median tumor diameter, 11.0 mm [range, 5-33 mm]; 25% of tumors were nonperipheral). We compared complications according to ablation modality by use of generalized estimating equations. We evaluated ablation modality, tumor size, and location (peripheral vs nonperipheral) in relation to local tumor progression by use of proportional Cox hazard models, with death as the competing risk. We estimated OS using the Kaplan-Meier method. RESULTS. Primary technical success was 97% for both modalities. Median follow-up was 23 months (range, one to 102 months; interquartile range, 12-44 months). A total of seven of 61 tumors (11%) showed local progression. Estimated 1-year and 2-year local control rates were, for tumors 1 cm or smaller, 97% and 95% after MWA versus 99% and 98% after cryoablation, and for tumors larger than 1 cm, 74% and 62% after MWA versus 86% and 79% after cryoablation. Tumor size of 1 cm or smaller was associated with a decreased cumulative incidence of local progression (p = .048); ablation modality and tumor location were not associated with progression (p = .86 and p = .54, respectively). Complications (Common Terminology Criteria for Adverse Events [CTCAE] grade, ≤ 3) occurred in 17 of 39 sessions (44%), prompting chest tube placement in nine (23%). There were no CTCAE grade 4 or 5 complications. OS at 1, 2, and 3 years was 100%, 89%, and 82%, respectively. CONCLUSION. High primary technical success, local control, and OS support the use of MWA and cryoablation for treating sarcoma lung metastases. Ablation modality and tumor location did not affect local progression. The rate of local tumor progression was low, especially for small tumors. No life-threatening complications occurred. CLINICAL IMPACT. Percutaneous MWA and cryoablation are both suited for the treatment of sarcoma lung metastases, especially for tumors 1 cm or smaller, whether peripheral or nonperipheral. Complications, if they occur, are not life-threatening.

Outcomes Following Percutaneous Microwave and Cryoablation of Lung Metastases from Adenoid Cystic Carcinoma of the Head and Neck: A Bi-Institutional Retrospective Cohort Study.

OBECTIVE: The aim of this study was to report outcomes following percutaneous microwave and cryoablation of lung metastases from adenoid cystic carcinoma (ACC) of the head and neck. MATERIAL AND METHODS: This bi-institutional retrospective cohort study included 10 patients (6 females, median age 59 years [range 28-81]) who underwent 32 percutaneous ablation sessions (21 cryoablation, 11 microwave) of 60 lung metastases (median 3.5 tumors per patient [range 1-16]) from 2007 to 2019. Median tumor diameter was 16 mm [range 7-40], significantly larger for cryoablation (22 mm, p = 0.002). A median of two tumors were treated per session [range 1-7]. Technical success, local control, complications, and overall survival were assessed. RESULTS: Primary technical success was achieved for 55/60 tumors (91.7%). Median follow-up was 40.6 months (clinical) and 32.5 months (imaging, per tumor). Local control at 1, 2, and 3 years was 94.7%, 80.8%, and 76.4%, respectively, and did not differ between ablation modalities. Five of fifteen recurrent tumors underwent repeat ablation, and secondary technical success was achieved in four (80%). Assisted local tumor control at 1, 2, and 3 years was 96.2%, 89.8%, and 84.9%, respectively. Complications occurred following 24/32 sessions (75.0%) and 57.2% Common Terminology Criteria for Adverse Events (CTCAE) lower than grade 3. Of 13 pneumothoraces, 7 required chest tube placements. Hemoptysis occurred after 7/21 cryoablation sessions, and bronchopleural fistula developed more frequently with microwave (p = 0.037). Median length of hospital stay was 1 day [range 0-10], and median overall survival was 81.5 months (IQR 40.4-93.1). CONCLUSION: Percutaneous computed tomography-guided microwave and cryoablation can treat lung metastases from ACC of the head and neck. Complications are common but manageable, with full recovery expected.

Thermal Ablation, Embolization, and Selective Internal Radiation Therapy Combined with Checkpoint Inhibitor Cancer Immunotherapy: Safety Analysis.

PURPOSE: To describe interventional oncology therapies combined with immune checkpoint inhibitor (ICI) therapy targeting the programmed death 1 pathway in patients with different neoplasms. MATERIALS AND METHODS: This was a retrospective cohort study of patients who underwent tumor-directed thermal ablation, embolization, or selective internal radiation therapy (SIRT) between January 1, 2011, and May 1, 2019, and received anti-programmed death 1/PD-L1 agents ≤ 90 days before or ≤ 30 days after the interventional procedure. Immune-related adverse events (irAEs) and procedural complications ≤ 90 days after the procedure were graded according to the Common Terminology Criteria for Adverse Events version 5.0. The study included 65 eligible patients (49% female; age 63 years ± 11.1). The most common tumors were metastatic melanoma (n = 28) and non-small cell lung cancer (NSCLC) (n = 12). Patients underwent 78 procedures (12 patients underwent > 1 procedure), most frequently SIRT (35.9%) and cryoablation (28.2%). The most common target organs were liver (46.2%), bone (24.4%), and lung (9.0%). Most patients received ICI monotherapy with pembrolizumab (n = 30), nivolumab (n = 22), and atezolizumab (n = 6); 7 patients received ipilimumab and nivolumab. RESULTS: Seven (10.8%) patients experienced an irAE (71.4% grade 1-2), mostly affecting the skin. Median time to irAE was 33 days (interquartile range, 19-38 days). Five irAEs occurred in patients with melanoma, and no irAEs occurred in patients with NSCLC. Management required corticosteroids (n = 3) and immunotherapy discontinuation (n = 1); all irAEs resolved to grade ≤ 1. There were 4 intraprocedural and 32 postprocedural complications (77.8% grade < 3). No grade 5 irAEs and/or procedural complications occurred. CONCLUSIONS: No unmanageable or unanticipated toxicities occurred within 90 days after interventional oncology therapies combined with ICIs.

Active Versus Passive Thaw After Percutaneous Cryoablation of Pulmonary Tumors: Effect on Incidence, Grade, and Onset of Hemoptysis.

BACKGROUND. Hemoptysis is common after percutaneous image-guided cryoablation of pulmonary tumors. OBJECTIVE. The purpose of our study was to evaluate the effect of a final active thaw on the incidence, grade, and onset of hemoptysis after percutaneous cryoablation of pulmonary tumors. METHODS. This retrospective cohort study included 60 consecutive CT-guided cryoablation sessions targeting 95 pulmonary tumors in 47 patients from March 2017 to September 2020. The final thaw of a triple-freeze protocol was active (electrical, helium-free) in 27 of 60 sessions (45%, active group) and passive in 33 of 60 sessions (55%, passive group). The incidence, onset, and management of hemoptysis were recorded using prospectively collected data. Hemoptysis, pneumothorax, and hemothorax within 30 days after ablation were graded according to Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The volume of immediate posttreatment changes on CT was quantified using semiautomated segmentation. Outcomes were compared between groups using generalized estimating equation models. A parsimonious multivariable model for hemoptysis incidence was developed using purposeful selection of predefined covariates followed by bootstrap resampling. Local tumor control was compared between groups using the Kaplan-Meier method and log-rank testing. RESULTS. Hemoptysis occurred after 26 of 60 (43%) sessions and was self-limited (CTCAE grade 1) in 22 of 26 (85%) sessions. The incidence of hemoptysis was lower in the active group than in the passive group (19% vs 64%, respectively; p = .002). The odds of hemoptysis adjusted for immediate posttreatment changes were 92% lower in the active group (odds ratio [OR], 0.08 [95% CI, 0.02-0.37]; p = .004). The odds of hemoptysis greater than grade 1 were 79% lower in the active group (OR, 0.21 [95% CI, 0.07-0.64]; p = .006). In the active group, the onset of hemoptysis was significantly delayed (OR, 0.75 [95% CI, 0.61-0.91]; p = .005). Pneumothorax (p = .60), hemothorax (p = .84), and local tumor control (p = .77) did not differ between groups. CONCLUSION. Active thaw after the final freeze reduces the incidence and grade of hemoptysis and delays the onset of hemoptysis after percutaneous cryoablation of pulmonary tumors without adversely affecting other procedural complications and local tumor control. CLINICAL IMPACT. Active thaw after the final freeze improves the safety profile of triple-freeze cryoablation of pulmonary tumors by reducing the incidence and grade of hemoptysis and by delaying the onset of hemoptysis beyond the immediate recovery period.

Percutaneous Cryoablation: Safety and Efficacy for Pain Palliation of Metastases to Pleura and Chest Wall.

PURPOSE: To assess safety and efficacy of percutaneous cryoablation for pain palliation of metastases to pleura and chest wall. MATERIALS AND METHODS: This retrospective single-center cohort study included 22 patients (27% female, mean age 63 y ± 11.4) who underwent 25 cryoablation procedures for pain palliation of 39 symptomatic metastases measuring 5.1 cm ± 1.9 (range, 2.0-8.0 cm) in pleura and chest wall between June 2012 and December 2017. Pain intensity was assessed using a numerical scale (0-10 points). Statistical tests t test, χ2, and Wilcoxon signed rank were performed. RESULTS: Patients were followed for a median of 4.1 months (interquartile range [IQR], 2.3-10.1; range, 0.1-36.7 mo) before death or loss to follow-up. Following cryoablation, pain intensity decreased significantly by a median of 4.5 points (IQR, 2.8-6; range, 0-10 points; P = .0002 points, Wilcoxon signed rank). Pain relief of at least 3 points was documented following 18 of 20 procedures. Pain relief occurred within a median of 1 day following cryoablation (IQR, 1-2; range, 1-4 d) and lasted for a median of 5 weeks (IQR, 3-17; range, 1-34 wk). Systemic opioid requirements decreased in 11 of 22 patients (50%) by an average of 56% ± 34. Difference in morphine milligram equivalents was not significant (P = .73, Wilcoxon signed rank). No procedure-related complications occurred despite previous radiation of 7 tumors. Of 25 procedures, 22 (88%) were performed on an outpatient basis. CONCLUSIONS: Percutaneous cryoablation for metastases to pleura and chest wall can safely provide significant pain relief within days following a single session.

Sarcopenia on preoperative chest computed tomography predicts cancer-specific and all-cause mortality following pneumonectomy for lung cancer: A multicenter analysis.

BACKGROUND: Mortality risk prediction in patients undergoing pneumonectomy for non-small cell lung cancer (NSCLC) remains imperfect. Here, we aimed to assess whether sarcopenia on routine chest computed tomography (CT) independently predicts worse cancer-specific (CSS) and overall survival (OS) following pneumonectomy for NSCLC. METHODS: We included consecutive adults undergoing standard or carinal pneumonectomy for NSCLC at Massachusetts General Hospital and Heidelberg University from 2010 to 2018. We measured muscle cross-sectional area (CSA) on CT at thoracic vertebral levels T8, T10, and T12 within 90 days prior to surgery. Sarcopenia was defined as T10 muscle CSA less than two standard deviations below the mean in healthy controls. We adjusted time-to-event analyses for age, body mass index, Charlson Comorbidity Index, forced expiratory volume in 1 second in % predicted, induction therapy, sex, smoking status, tumor stage, side of pneumonectomy, and institution. RESULTS: Three hundred and sixty-seven patients (67.4% male, median age 62 years, 16.9% early-stage) underwent predominantly standard pneumonectomy (89.6%) for stage IIIA NSCLC (45.5%) and squamous cell histology (58%). Sarcopenia was present in 104 of 367 patients (28.3%). Ninety-day all-cause mortality was 7.1% (26/367). After a median follow-up of 20.5 months (IQR, 9.2-46.9), 183 of 367 patients (49.9%) had died. One hundred and thirty-three (72.7%) of these deaths were due to lung cancer. Sarcopenia was associated with shorter CSS (HR 1.7, p = 0.008) and OS (HR 1.7, p = 0.003). CONCLUSIONS: This transatlantic multicenter study confirms that sarcopenia on preoperative chest CT is an independent risk factor for CSS and OS following pneumonectomy for NSCLC.