Invasive pulmonary aspergillosis: A rare complication after microwave ablation

Three cases are reported of invasive pulmonary aspergillosis (IPA) occurring after microwave ablation (MWA) for lung tumours. This is a rare complication that has not previously been described in the literature. The diagnosis of IPA was based on the following factors: host factors, clinical manifestations and mycological findings. The first case was a 63-year-old man treated for primary lung squamous carcinoma. Significant tumour regression was achieved by 18 days after MWA, medical treatment with itraconazole for 6 weeks, and postural drainage. The second case, a 65-year-old man, was confirmed with primary lung squamous cell carcinoma. Voriconazole administration using intravenous infusion combined with intracavitary lavage was therapeutically effective after MWA at 1 year follow-up. The third case was a 61-year-old woman with primary lung adenocarcinoma. Delayed pneumothorax and bronchopleural fistula secondary to IPA persisted. The patient died from secondary multiple organ function failure. Despite its very low incidence, the significance of early diagnosis and early administration of antifungal therapy should be highlighted because of the relentless severity of IPA in patients undergoing MWA.     

Chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis (CPA) is a group of consuming diseases usually presenting with prolonged and relapsing cough, dyspnoea and weight loss. Acute symptoms such as haemoptysis and bronchial or pulmonary haemorrhage may occasionally occur. CPA affects patients with underlying pulmonary conditions, for example, chronic obstructive pulmonary disease or mycobacteriosis or common immunosuppressive conditions such as diabetes. Precise epidemiology is unknown, and while prevalence is considered low the chronic and relapsing nature of the disease challenges the treating physician. Diagnostics largely rely on serologic Aspergillus precipitins and findings on thoracic computed tomography. The latter are manifold comprising cavity formation, pleural involvement and sometimes aspergilloma. Other markers for aspergillosis are less helpful, in part due to the non‐ or semi‐invasive nature of these forms of Aspergillus infection. Various antifungals were shown to be effective in CPA treatment. Azoles are the most frequently applied antifungals in the outpatient setting, but are now compromised by findings of Aspergillus resistance. Long‐term prognosis is not fully elucidated and may be driven by the underlying morbidities. Prospective registry‐type studies may be suitable to systematically broaden our CPA knowledge base. This article gives an overview of the available literature and proposes a clinical working algorithm for CPA management.     

Radiofrequency and microwave ablation of lung tumors

Lung cancer is the most common cause of cancer‐related mortality in the United States. Surgical resection remains the standard treatment for early stage, non‐small cell lung cancer, and limited pulmonary metastases. However, many patients with resectable disease have significant co‐morbidities which preclude surgical resection. Radiofrequency and microwave ablation are emerging modalities of treatment for these high‐risk patients. Here, we review the principles, common devices in use, and treatment results of ablative therapy for lung tumors. J. Surg. Oncol. 2009;100:645–650. © 2009 Wiley‐Liss, Inc.     

Chronic pulmonary aspergillosis in a tertiary care centre in Spain: A retrospective,observational study

The aim of this study was to describe the characteristics of patients with chronic pulmonary aspergillosis (CPA) in a tertiary care centre in Spain. Retrospective cohort study of all patients diagnosed with CPA between January 2010 and December 2015. The patients were identified through the Microbiology Registry. Demographic, clinical, laboratory, radiological, microbiological and clinical data were recorded. Patients were followed up for 12 months. Fifty‐three patients were included; median age was 61.5 years. Forty‐seven had a lung condition, 25 suffered from COPD, 19 an active malignancy, 10 had previous pulmonary tuberculosis and 9 lung interstitial disease. Twenty‐eight patients presented with chronic cavitary pulmonary form (CCPA) and 20 with subacute invasive aspergillosis (SAIA). Species identified were A fumigatus (34), A niger (5), A terreus (4) and A flavus (3). All‐cause 1‐year mortality was 56%. Predictors of mortality were cancer history (OR, 9.5; 95% CI, 2.54‐35.51; P < 0.01) and SAIA (OR, 5.49; 95% CI, 1.49‐19.82; P < 0.01). Previous pulmonary tuberculosis, surgery for the treatment of CPA and CCPA were found to be associated with lower mortality (OR, 0.05; 95% CI, <0.01‐0.47; P < 0.01; OR, 0.16; 95% CI, 0.03‐0.88; P = 0.035 and OR 0.2, 95% CI, 0.01‐0.67; P = 0.01, respectively). This is the first study providing an overview of the features of CPA in patients from Spain. CCPA was the most frequent form of CPA and A fumigatus the most frequently isolated species. Patients with cancer history and SAIA had a worse prognosis.     

Clinical characteristics of 45 patients with invasive pulmonary aspergillosis

BACKGROUND:

Invasive aspergillosis (IA) is a common complication in patients with hematologic malignancies. Patients with solid tumors also are at risk for IA because they may develop neutropenia as a result of chemotherapy and radiotherapy. However, studies of IA in patients with solid tumors are rare. In this study, the risk factors and clinical characteristics of pulmonary infection and death mediated by invasive pulmonary aspergillosis (IPA) as complications in patients with lung cancer were determined.

METHODS:

The authors conducted a retrospective analysis of the clinical notes from 45 patients who had IPA.

RESULTS:

Among 1711 patients with lung cancer, 45 patients contracted pulmonary aspergillosis (2.63%). There were 10 cases of proven disease and 35 cases of probable disease. In univariate analysis, the main predisposing factors were clinical stage IV disease (P = .018), chemotherapy during the month preceding infection (P = .033), and corticosteroid use (≥3 days; P = .038). In multivariate analysis, only clinical stage IV disease (P = .018) was associated with IPA. Furthermore, the mortality rate among lung cancer patients who had pulmonary aspergillosis was 51.1% (23 of 45 patients). Of the patients who died, corticosteroid therapy (P = .001) and grade 3/4 neutropenia (P = .013) were correlated statistically with pulmonary aspergillosis in patients with lung cancer.

CONCLUSIONS:

In univariate analysis, the risk factors for IPA in lung cancer included chemotherapy and corticosteroid use in the month preceding infection and clinical stage IV disease. However, in multivariate analysis, only clinical stage IV disease was identified as a risk factor for IPA. Cancer 2009. © 2009 American Cancer Society.     

US-guided microwave ablation for secondary hyperparathyroidism in patients after renal transplantation: a pilot study

Objective: To assess the safety and efficacy of ultrasound-guided microwave ablation (MWA) in the treatment of patients who develop secondary hyperparathyroidism (SHPT) after renal transplantation (RT).

Methods: In total, nine patients, each with symptomatic SHPT caused by RT and at least one enlarged parathyroid gland, underwent MWA via hydrodissection. Intact parathyroid hormone (i-PTH), serum calcium, serum phosphorus, creatinine and blood urea nitrogen concentrations, before and after MWA, were assessed and compared.

Results: Complete ablation was achieved in all patients for a total of 14 ablated parathyroid glands. The mean follow-up time was 17.2?±?1.7?months post-operation. The mean maximum diameter of the parathyroid glands was 1.3?±?0.4?cm (range: 0.4–2.0?cm). The ablation power implemented was 30?W and the mean time for each parathyroid gland to achieve complete ablation was 287.5?±?83.4?s. The mean i-PTH, serum calcium and phosphorus concentrations at one day post-MWA (69.6?pg/mL, 2.23?±?0.29?mmol/L, 1.2 2?±?0.48?mmol/L, respectively) were significantly lower than those before MWA (780.0?pg/mL, 2.62?±?0.32?mmol/L, 1.39?±?0.61?mmol/L, respectively; p?<?.01), whereas the creatinine and blood urea nitrogen concentrations before and after MWA did not differ significantly from each other (p?>?.05). No significant differences were found between the biomarker concentrations observed at one day post-MWA and at the follow-ups (p?>?.05). No major operation-related complications occurred.

Conclusion: Ultrasound-guided MWA is a safe and effective technique for destroying parathyroid gland tissue in patients who develop SHPT after RT and its clinical effects are long-lasting.     

Invasive pulmonary aspergillosis in neutropenic patients and the influence of hospital renovation

To evaluate the effects of airborne Aspergillus contamination during and after the renovation work of a Florentine haematology unit, we conducted (November 2003-January 2005) a strict programme of environmental fungal surveillance. Air samples were taken from patients' rooms, along the corridors inside the wards, along the corridor between wards and outside the building. The concentration of Aspergillus fumigatus was high along the corridor between the two haematology wards (2.98 CFU m(-3)), lower in the non-neutropenic patients' rooms and outside the hospital building (1.53 and 1.42 CFU m(-3), respectively), very low in the neutropenic patients' rooms (0.09 CFU m(-3)). During this period, three proven cases (A. fumigatus), two probable ones and two possible cases of invasive pulmonary aspergillosis were documented in 97 patients with acute leukaemia (7%). The three cases of proven aspergillosis coincided with the period of renovation work and with the period in which we have found the maximum concentration of A. fumigatus along the corridor. These data suggest a possible relationship between environmental fungal contamination and the incidence of invasive aspergillosis, and underline the importance of environmental surveillance.     

Ultrasound-guided percutaneous microwave ablation for hepatic malignancy adjacent to the gallbladder

Abstract

Purpose: The study was performed to assess the safety and efficacy of ultrasound (US)-guided percutaneous microwave (MW) ablation for hepatic malignancy adjacent to the gallbladder. Materials and methods: From January 2011 to December 2013, 49 patients with 51 hepatic tumours adjacent to the gallbladder who underwent US-guided percutaneous MW ablation were included in the study group. A total of 106 patients with 117 hepatic tumours not adjacent to the gallbladder who underwent US-guided percutaneous MW ablation were included in the control group. In the study group the temperature of marginal ablation tissue proximal to the gallbladder was monitored and controlled at 45–54?°C for 5–10?min during the ablation. Ethanol (4.5–13?mL) was injected into the marginal tissue in 27 of 51 tumours of the study group. We compared the results of ablation between the two groups. Results: All patients were successfully treated. A total of 47 of 51 tumours in the study group (92.2%) and 110 of 117 tumours in the control group (94.0%) achieved complete ablation (p?=?0.93). Local tumour progression was found in nine (17.6%) tumours in the study group and 15 (12.8%) tumours in the control group during follow-up after MW ablation (p?=?0.41). No peri-procedural major complications occurred in either group. Conclusions: Under strict temperature monitoring, US-guided percutaneous MW ablation assisted with ethanol injection appears to be safe and can achieve a high rate of complete ablation for the treatment of hepatic malignant tumours adjacent to the gallbladder.     

Invasive aspergillosis in critically ill patients: An autopsy study

Autopsy studies show that IA is among the most commonly missed diagnoses in critically ill patients. And, because of lack of unequivocal diagnostic criteria, a timely diagnosis remains challenging. We investigate the epidemiology of and the clinical risk factors for IA in critically ill patients. We conducted a retrospective, observational study of all consecutive ICU patients with evidence of IA in the postmortem examination. During the period of the study (25 years), 893 postmortem examinations were performed in the ICU. Twenty‐five patients (2.8%) were diagnosed with IA in autopsy. Only ten (40%) were classified as IA ante‐mortem, based on the initiation of antifungal treatment. The most common comorbid conditions were corticosteroid treatment (n = 14, 56%), chronic obstructive pulmonary disease (COPD) (n = 11, 44%), immunosuppression (n = 6, 24%) and haematological malignancy (n = 5, 20%). Twenty‐three patients (92%) had three or more risk factors for IA. Critically ill patients with pulmonary infiltrates, treated with high doses intravenous corticosteroids (even for a short period of time), particularly COPD patients who developed worsening respiratory insufficiency despite appropriate treatment were at the highest risk of IA.     

Ultrasound-guided microwave ablation: a promising tool in management of benign breast tumours

Purpose: Non-surgical treatments for benign breast tumours have clinical goals of stopping growth and/or reducing (removing) palpable tumours effect without leaving a surgical scar. The purpose of this non-randomised prospective clinical trial was to assess imaging and clinical outcomes of microwave ablation (MWA) in the treatment of benign breast tumours regardless of the distance from the tumour to the skin and chest wall.

Methods: With approval of the institutional ethics committee and written informed consent, 39 patients with 44 core-biopsy-proved benign breast tumours 3.0?cm or less in diameter assessed by using ultrasound (US) and contrast-enhanced ultrasound (CEUS) were prospectively recruited. US-guided MWA was performed under local anaesthesia. The patients were followed up with physical examination, ultrasound elastography and CEUS.

Results: The MWA procedure with a mean duration of 74.3?s?±?26.5 was well accepted and tolerated in 41 cases except for three cases. Of 41 tumours with follow-up data, 40 (97.5%; 95% confidence interval: 87.1%, 99.9%) showed complete ablation assessed by using CEUS. The mean volume of the ablated tumours decreased significantly (p?=?.005) during follow-up. The strain ratio 1-3 months after ablation was higher than that before ablation, and became low 6 months after ablation (p?=?.022). No epidermal burn was observed in all cases with a mean distance of 7.5?mm ±3.3 from the tumour to the skin.

Conclusions: MWA is a safe and effective minimally invasive “patient-friendly” procedure with a very short duration for the treatment of benign breast tumours.     

Clinical experiences with microwave thermal ablation of lung malignancies

Abstract

Approximately 30% of early stage lung cancer patients are not surgical candidates due to medical co-morbidities, poor cardiopulmonary function and advanced age. These patients are traditionally offered chemotherapy and radiation, which have shown relatively modest improvements in mortality. For over a decade, percutaneous image-guided ablation has emerged as a safe, cost-effective, minimally invasive treatment alternative for patients who would otherwise not qualify for surgery. Although radiofrequency ablation (RFA) is currently the most extensively studied and widely utilised technique in the treatment of lung malignancies, there is a growing body of evidence that microwave ablation (MWA) has several unique benefits over RFA and cryoablation in the lung. This article reviews our institution’s clinical experiences in the treatment of lung malignancies with MWA including patient selection, procedural technique, imaging follow-up, treatment outcomes and comparison of ablation techniques.     

The safety and efficacy of microwave ablation for the treatment of CRC pulmonary metastases

Purpose: Microwave ablation (MWA) is a recently developed thermal ablation technique that has been used for the treatment of different types of tumours. In the present study, we retrospectively evaluated the safety and efficacy of CT-guided percutaneous MWA for the treatment of colorectal cancer (CRC) pulmonary metastases.

Materials and methods: From June 2010 to June 2015, 48 unresectable lesions in 32 patients with CRC pulmonary metastases were subjected to CT-guided MWA. Imaging follow-up was with contrast-enhanced CT and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT.

Results: Oncologic imaging showed that 42 (87.5%) of the 48 lesions in the 32 patients were completely ablated. Needle track metastatic seeding was not found, and no patient deaths occurred within 30?d after ablation. The mean hospital stay was 3?d (range, 2–7?d). Pneumothorax was the most frequent complication and occurred in 6 (12.5%) of the 48 lesions. The median survival time was 31?months (95% CI: 15.4–46.6). The 1-, 2- and 3-year survival rates were 79.5%, 63.1% and 44.4%, respectively. Univariate Cox regression analysis showed that tumour size, disease-free interval (DFI) and number of tumours were significantly related to the overall survival time (p?=?.007, p?=?.022 and p?=?.030, respectively). Multivariate analysis showed that tumour size was an independent prognostic factor for survival (p?=?.017).

Conclusion: CT-guided percutaneous MWA is a safe and effective minimally invasive method for treating CRC pulmonary metastases.     

Invasive aspergillosis in a paediatric haematology department: a 15-year review

Invasive aspergillosis (IA) is an increasingly common and often fatal fungal infection in children with haematological disorders. To describe the epidemiology, diagnosis, treatment and outcome of IA in children, retrospective review of the medical records of proven and probable IA between January 1986 and December 2000 was used. Twenty-four patients with IA were identified (10 proven and 14 probable) with a median age of 8.5 years. The incidence of IA was particularly high in acute myeloblastic leukaemia (5.35%) and leukaemia relapse (4%). Twenty-two patients presented with lung involvement. Broncho-alveolar lavage led to a diagnosis in 11 cases, but diagnosis was difficult and repeated invasive explorations were required. Antifungal therapy mainly consisted of amphotericin B. Eight patients underwent open-thorax surgery without any complication. Nine patients (37.5%) were cured of IA and three are still alive. The mortality was 87.5%. Three patients died of massive haemoptysis, including two before neutropenia recovery. Four patients presented with IA recurrence and three were cured again. Despite significant progress having been made in the treatment and diagnosis of IA, it is still a devastating complication in children with haematological disorders. New antifungal therapies and strategies are promising, but objective data are still lacking.     

微波消融治疗肺转移瘤的研究进展

随着恶性肿瘤发病率的提高,肺转移瘤在临床中也越来越常见。手术切除是肺转移瘤的主要治疗方法,但大多数患者因心肺功能差、转移瘤靠近心脏及血管、转移瘤数目较多等原因无法进行手术切除,放疗、化疗、靶向治疗等治疗方法疗效不佳;微波消融术作为新兴的治疗手段,具有创伤小、并发症少、安全性高、可重复消融等优点,为肺转移瘤的治疗提供了新方法。本文就微波消融术治疗肺转移瘤的研究进展作一综述。     

Delayed complications following microwave ablation of lung tumours

The majority of complications following microwave ablation (MWA) of lung tumours are immediately evident, however, delayed complications do occasionally occur. The radiologist plays a major role in identifying and in guiding the management of these complications. This pictorial essay explores the imaging appejmironce of several potentially life‐threatening delayed complications of pulmonary MWA.