Requiring Chest Tube Placement Research Articles

Chest radiograph after fluoroscopic guided line placement: No longer necessary

PurposeHistorically, a chest radiograph was obtained after central line placement in the operating room. Recent retrospective studies have questioned the need for this radiograph. The prevailing current practice at our center is to order chest radiograph only for symptomatic patients. This study examines the outcomes of selective chest radiography after fluoroscopic guided central line placement. MethodsAfter obtaining institutional review board approval, a single institution retrospective chart review of patients undergoing central venous catheter placement by the pediatric surgery or interventional radiology service between January 2010 and July 2014 was performed. Outcome measures included CXR within 24h of catheter placement, reason for chest radiograph, complication, and complication requiring intervention. ResultsIn the study population 622 catheters were placed under fluoroscopy. A chest radiograph was performed in 118 (19%) patients within 24h of the line placement with 25 (4%) of these patients being symptomatic in the recovery room. One patient required chest tube for shortness of breath and pleural effusion. Four symptomatic patients (0.6%) were found to have a pneumothorax, none of which required chest tube placement. There were no re-operations because of mal-position of the catheter. In the 504 patients with no postoperative chest x-ray, there were no adverse outcomes. At our institution the current average charge of a chest radiograph is $283, thus we produced savings of $142,632 for the study period without adverse events. ConclusionAfter placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient.

Pneumothorax with prolonged chest tube requirement after CT-guided percutaneous lung biopsy: incidence and risk factors.

To evaluate the incidence and risk factors of pneumothoraces requiring prolonged maintenance of a chest tube following CT-guided percutaneous lung biopsy in a retrospective, single-centre case series. All patients undergoing CT-guided percutaneous lung biopsies between June 2012 and May 2014 who required chest tube insertion for symptomatic or enlarging pneumothoraces were identified. Based on chest tube dwell time, patients were divided into two groups: short term (0-2days) or prolonged (3 or more days). The following risk factors were stratified between groups: patient demographics, target lesion characteristics, and procedural/periprocedural technique and outcomes. A total of 2337 patients underwent lung biopsy; 543 developed pneumothorax (23.2%), 187 required chest tube placement (8.0%), and 55 required a chest tube for 3days or more (2.9% of all biopsies, 29.9% of all chest tubes). The median chest tube dwell time for short-term and prolonged groups was 1.0days and 4.7days, respectively. The transfissural needle path predicted prolonged chest tube requirement (OR: 2.5; p = 0.023). Other factors were not significantly different between groups. Of patients undergoing CT-guided lung biopsy, 2.9% required a chest tube for 3 or more days. Transfissural needle path during biopsy was a risk factor for prolonged chest tube requirement. • CT-guided percutaneous lung biopsy (CPLB) is an important method for diagnosing lung lesions • A total of 2.9% of patients require a chest tube for ≥3days following CPLB • Transfissural needle path is a risk factor for prolonged chest tube time.

Effects of a Multidisciplinary Approach to Improve Volume of Diagnostic Material in CT-Guided Lung Biopsies.

BackgroundRecent publications have emphasized the importance of a multidisciplinary strategy for maximum conservation and utilization of lung biopsy material for advanced testing, which may determine therapy. This paper quantifies the effect of a multidisciplinary strategy implemented to optimize and increase tissue volume in CT-guided transthoracic needle core lung biopsies. The strategy was three-pronged: (1) once there was confidence diagnostic tissue had been obtained and if safe for the patient, additional biopsy passes were performed to further increase volume of biopsy material, (2) biopsy material was placed in multiple cassettes for processing, and (3) all tissue ribbons were conserved when cutting blocks in the histology laboratory. This study quantifies the effects of strategies #1 and #2.DesignThis retrospective analysis comparing CT-guided lung biopsies from 2007 and 2012 (before and after multidisciplinary approach implementation) was performed at a single institution. Patient medical records were reviewed and main variables analyzed include biopsy sample size, radiologist, number of blocks submitted, diagnosis, and complications. The biopsy sample size measured was considered to be directly proportional to tissue volume in the block.ResultsBiopsy sample size increased 2.5 fold with the average total biopsy sample size increasing from 1.0 cm (0.9–1.1 cm) in 2007 to 2.5 cm (2.3–2.8 cm) in 2012 (P<0.0001). The improvement was statistically significant for each individual radiologist. During the same time, the rate of pneumothorax requiring chest tube placement decreased from 15% to 7% (P = 0.065). No other major complications were identified. The proportion of tumor within the biopsy material was similar at 28% (23%–33%) and 35% (30%–40%) for 2007 and 2012, respectively. The number of cases with at least two blocks available for testing increased from 10.7% to 96.4% (P<0.0001).ConclusionsThe effect of this multidisciplinary strategy to CT-guided lung biopsies was effective in significantly increasing tissue volume and number of blocks available for advanced diagnostic testing.

Anterior corpectomy via the mini-open, extreme lateral, transpsoas approach combined with short-segment posterior fixation for single-level traumatic lumbar burst fractures: analysis of health-related quality of life outcomes and patient satisfaction.

The authors present clinical outcome data and satisfaction of patients who underwent minimally invasive vertebral body corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach and posterior short-segment instrumentation for lumbar burst fractures. Patients with unstable lumbar burst fractures who underwent corpectomy and anterior column reconstruction via a mini-open, extreme lateral, transpsoas approach with short-segment posterior fixation were reviewed retrospectively. Demographic information, operative parameters, perioperative radiographic measurements, and complications were analyzed. Patient-reported outcome instruments (Oswestry Disability Index [ODI], 12-Item Short Form Health Survey [SF-12]) and an anterior scar-specific patient satisfaction questionnaire were recorded at the latest follow-up. Twelve patients (7 men, 5 women, average age 42 years, range 22-68 years) met the inclusion criteria. Lumbar corpectomies with anterior column support were performed (L-1, n = 8; L-2, n = 2; L-3, n = 2) and supplemented with short-segment posterior instrumentation (4 open, 8 percutaneous). Four patients had preoperative neurological deficits, all of which improved after surgery. No new neurological complications were noted. The anterior incision on average was 6.4 cm (range 5-8 cm) in length, caused mild pain and disability, and was aesthetically acceptable to the large majority of patients. Three patients required chest tube placement for pleural violation, and 1 patient required reoperation for cage subsidence/hardware failure. Average clinical follow-up was 38 months (range 16-68 months), and average radiographic follow-up was 37 months (range 6-68 months). Preoperative lumbar lordosis and focal lordosis were significantly improved/maintained after surgery. Patients were satisfied with their outcomes, had minimal/moderate disability (average ODI score 20, range 0-52), and had good physical (SF-12 physical component score 41.7% ± 10.4%) and mental health outcomes (SF-12 mental component score 50.2% ± 11.6%) after surgery. Anterior corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach supplemented by short-segment posterior instrumentation is a safe, effective alternative to conventional approaches in the treatment of single-level unstable burst fractures and is associated with excellent functional outcomes and patient satisfaction.

Radio-Guided Localization and Resection of Small or Ill-Defined Pulmonary Lesions

Screening programs have increased the identification of small or indistinct pulmonary lesions that are difficult to localize. We report our experience in their preoperative localization by radiotracer and resection. Patients with pulmonary nodules of subsolid morphology or smaller than 1 cm, deeper 1 cm below the visceral pleura, or both underwent computed tomography (CT)-guided injection of radiotracer technetium 99m macroaggregates in the vicinity of the lesion. During the operation, a handheld gamma probe was used to detect the hot spot where the radioactive tracer was localized, and this area was resected. From November 2007 to May 2013, 112 patients (58 men; median age 62 years) underwent preoperative radiotracer injection with a successful marking in all patients. Adverse events included 33 (29.4%) pneumothoraces (one requiring chest tube placement), 23 (20.5%) parenchymal hemorrhage suffusions, and 1 (0.9%) allergic reaction to contrast medium. In all cases except two, the gamma probe revealed pulmonary lesions. Overall, 123 pulmonary nodules were localized and resected. The mean distance from the pleura was 12 mm (range, 0 to 39 mm). Pulmonary resection was performed by thoracoscopy in 70 (62.5%) cases, thoracotomy in 36 (32.1%), and conversion of thoracoscopy to thoracotomy in 6 (5.4%). The mean nodule size was 9 mm (range, 3 to 24 mm). Histology showed 14 (11.4%) benign lesions and 109 (88.6%) malignant lesions (85 primary lung cancers and 24 metastases). Radiotracer localization of pulmonary lesions is a simple and feasible procedure with a high rate of success. Optimal candidates are patients with suspicious-looking nodules detected by screening or incidental CT resulting frm the high rate of nonsolid morphology and small size.

Usefulness of normal saline for sealing the needle track after CT-guided lung biopsy

To determine whether the use of normal saline for sealing the needle track can reduce the incidence of pneumothorax and chest tube placement after computed tomography (CT)-guided lung biopsy. A prospective, randomised, controlled trial enrolling 322 patients was conducted. All patients were randomly assigned to one of two groups: those in whom the needle track was not sealed with normal saline (n=161, Group A) and those who did receive normal saline (n=161, Group B). CT-guided biopsy was performed with coaxial technique. Normal saline, which ranged from 1-3ml, was injected while the trocar needle was being withdrawn. Patient characteristics, lesion, and procedure variables were analysed as potential risk variables for occurrence of pneumothorax and chest tube placement. The incidence of pneumothorax was 26.1% in Group A and 6.2% in Group B (p<0.001). Nine patients in Group A and one patient in Group B required chest tube placement (p=0.010). Using multiple logistic regression analysis, smaller lesion size, greater needle-pleural angle, longer lesion-pleural distance, presence of emphysema, and no sealing the needle track with normal saline were significantly associated with an increased risk of pneumothorax, and that the latter three factors were also associated with an increased risk of pneumothorax requiring chest tube placement. Normal saline for sealing the needle track significantly reduces the incidence of pneumothorax and prevents subsequent chest tube placement after CT-guided lung biopsy.

Development of a prediction model and risk score for procedure-related complications in patients undergoing percutaneous computed tomography-guided lung biopsy.

To propose a risk score predicting the potential occurrence of procedure-related complications in patients undergoing computed tomography (CT)-guided lung biopsy. Institution review board approval was obtained. A total of 342 CT-guided lung biopsies were retrospectively evaluated taking into account procedure-related complications and associated risk factors, including patient gender and age, previous radiation therapy (RT) and/or chemotherapy (CHT), lesion size, depth and location, incomplete pulmonary fissures, associated diffuse lung diseases, previous pneumothorax (PNX), lung volumes, punctured fissures, thoracic access, needle size and operator experience. Complications were assessed on chest X-ray and/or CT scans. Stepwise logistic regression was used to identify risk factors, to evaluate their correlation with procedure-related complications and to calculate models of risk (MoRs). PNX requiring chest tube placement occurred in 39 patients (11.4%), high-grade pulmonary parenchymal haemorrhage occurred in 62 patients (18.1%) and haemothorax occurred in 12 patients (3.5%). Risk factors increasing the incidence of complications were lesion size (P = 0.01), lesion depth (P = 0.01) and incomplete pulmonary fissures (P = 0.01); previous chemo-radiation therapy was correlated to a lower incidence of complications (P = 0.01). MoR for PNX was as follows: risk base line = 60%; age = +0.15%/year; punctured fissures = +20%; incomplete fissures = +9%; previous CHT/RT = -10%. MoR for parenchymal haemorrhage was as follows: risk base line = 20%, lesion depth = +0.8%/mm; age = +0.25%/year; incomplete fissures = +15%. MoR for haemothorax was as follows: risk base line = 1%; previous PNX = +20%; incomplete fissures = 7%; both previous PNX and incomplete fissures = +67%. This study provides MoRs to predict the risk of complications in patients undergoing CT-guided percutaneous lung biopsies.

Overcoming perceived hurdles in lung cancer screening: the low risk of complications of image-guided transthoracic needle biopsy.

Overcoming perceived hurdles in lung cancer screening: the low risk of complications of image-guided transthoracic needle biopsy.

Radiofrequency Ablation of Lung Metastases from Adenoid Cystic Carcinoma of the Head and Neck: Retrospective Evaluation of Nine Patients

PurposeTo retrospectively evaluate the outcomes of radiofrequency (RF) ablation of lung metastases from head and neck adenoid cystic carcinoma (ACC). Materials and MethodsNine patients (two men and seven women; mean age, 61.6 y) with 45 lung metastases (mean diameter, 1.1 cm; range, 0.4–2.7 cm) from head and neck ACC underwent RF ablation in 30 sessions. Primary endpoints were technical success, technique effectiveness, and procedural complications. Secondary endpoints included overall survival (OS). ResultsRF ablation was technically successful for all 45 metastases. The median tumor follow-up period was 37.1 months (range, 12.9–128.3 mo). Local progression occurred in six tumors, two of which were treated again and subsequently showed complete response. Major complications (pneumothorax requiring chest tube placement) occurred in five sessions (16.7%). The median patient follow-up period was 61.6 months (range, 20.5–134.5 mo). Two patients died of disease progression at 38.9 and 61.6 months after RF ablation, respectively, whereas the other seven remained alive at the end of the study. OS rates from the initial RF ablation were 100% at 3 years and 83.3% at 5 years (mean survival time, 106.4 mo). OS rates from the treatment of the primary site were 100% at 5 years and 62.5% at 10 years (mean survival time, 210.1 mo). ConclusionsRadiofrequency ablation is an acceptable and effective local treatment for lung metastases from head and neck ACC. However, further study is needed to evaluate its effect on patient survival.

Abstract No. 446 - Diagnostic yield of CT-guided percutaneous core biopsy of groundglass pulmonary lesions

PurposeThe purpose of the study is to determine the sensitivity, specificity and accuracy of CT-guided percutaneous core biopsy of groundglass pulmonary lesions.Materials and MethodsA retrospective review of 1873 consecutive CT-guided lung biopsies at our institution between January 1, 2008 and January 31, 2014 was performed. 77 cases (4%) of groundglass pulmonary lesion biopsy were identified and selected for further review. The average patient age was 77 years and 42% of the patients had a previous diagnosis of lung cancer. Pathologic diagnosis from the core biopsy and any subsequent surgical pathology data were recorded. The cases were also reviewed for complications including pneumothorax and hemorrhage.Results51 (66%) of the biopsied lesions were positive for malignancy, 17 (22%) demonstrated benign pathology, 6 (8%) were suspicious for malignancy, and 3 (4%) were non-diagnostic. 28 of the patients with biopsies positive for malignancy subsequently underwent surgical resection with surgical pathology concordant in all cases. There was 1 false negative biopsy, proven to be malignancy following surgical resection. The overall diagnostic yield was 96%. The sensitivity of biopsy was 96% in cases confirmed with surgical pathology. 3 patients (4%) developed pneumothorax requiring chest tube placement. All 23 patients with core biopsy positive for malignancy who did not undergo surgical resection were treated with external beam radiation therapy.ConclusionCT-guided percutaneous biopsy is high yield for ground-glass pulmonary lesions, with high diagnostic accuracy and low complication rate. PurposeThe purpose of the study is to determine the sensitivity, specificity and accuracy of CT-guided percutaneous core biopsy of groundglass pulmonary lesions. The purpose of the study is to determine the sensitivity, specificity and accuracy of CT-guided percutaneous core biopsy of groundglass pulmonary lesions. Materials and MethodsA retrospective review of 1873 consecutive CT-guided lung biopsies at our institution between January 1, 2008 and January 31, 2014 was performed. 77 cases (4%) of groundglass pulmonary lesion biopsy were identified and selected for further review. The average patient age was 77 years and 42% of the patients had a previous diagnosis of lung cancer. Pathologic diagnosis from the core biopsy and any subsequent surgical pathology data were recorded. The cases were also reviewed for complications including pneumothorax and hemorrhage. A retrospective review of 1873 consecutive CT-guided lung biopsies at our institution between January 1, 2008 and January 31, 2014 was performed. 77 cases (4%) of groundglass pulmonary lesion biopsy were identified and selected for further review. The average patient age was 77 years and 42% of the patients had a previous diagnosis of lung cancer. Pathologic diagnosis from the core biopsy and any subsequent surgical pathology data were recorded. The cases were also reviewed for complications including pneumothorax and hemorrhage. Results51 (66%) of the biopsied lesions were positive for malignancy, 17 (22%) demonstrated benign pathology, 6 (8%) were suspicious for malignancy, and 3 (4%) were non-diagnostic. 28 of the patients with biopsies positive for malignancy subsequently underwent surgical resection with surgical pathology concordant in all cases. There was 1 false negative biopsy, proven to be malignancy following surgical resection. The overall diagnostic yield was 96%. The sensitivity of biopsy was 96% in cases confirmed with surgical pathology. 3 patients (4%) developed pneumothorax requiring chest tube placement. All 23 patients with core biopsy positive for malignancy who did not undergo surgical resection were treated with external beam radiation therapy. 51 (66%) of the biopsied lesions were positive for malignancy, 17 (22%) demonstrated benign pathology, 6 (8%) were suspicious for malignancy, and 3 (4%) were non-diagnostic. 28 of the patients with biopsies positive for malignancy subsequently underwent surgical resection with surgical pathology concordant in all cases. There was 1 false negative biopsy, proven to be malignancy following surgical resection. The overall diagnostic yield was 96%. The sensitivity of biopsy was 96% in cases confirmed with surgical pathology. 3 patients (4%) developed pneumothorax requiring chest tube placement. All 23 patients with core biopsy positive for malignancy who did not undergo surgical resection were treated with external beam radiation therapy. ConclusionCT-guided percutaneous biopsy is high yield for ground-glass pulmonary lesions, with high diagnostic accuracy and low complication rate. CT-guided percutaneous biopsy is high yield for ground-glass pulmonary lesions, with high diagnostic accuracy and low complication rate.

Trends, Predictors, and Outcomes of Iatrogenic Pneumothorax Requiring Chest Tube Placement in United States

Trends, Predictors, and Outcomes of Iatrogenic Pneumothorax Requiring Chest Tube Placement in United States

Percutaneous Radiofrequency Ablation for Pulmonary Metastases from Esophageal Cancer: Retrospective Evaluation of 21 Patients

PurposeTo evaluate retrospectively outcomes after radiofrequency (RF) ablation for pulmonary metastases from esophageal cancer. Materials and MethodsThis study included 21 consecutive patients who met inclusion criteria (all men; mean age, 66.0 y) and had pulmonary metastases from esophageal cancer. There were 31 tumors (mean size, 1.7 cm) that were treated with 27 planned ablation sessions. At the initial RF ablation sessions, 3 patients had viable extrapulmonary recurrences, and 18 patients had viable recurrences confined to the lung. Primary study endpoints included patient survival and the determination of prognostic factors. Secondary endpoints included local efficacy and safety of the treatment. The log-rank test was used to identify prognostic factors. Adverse events were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.0. ResultsMedian follow-up duration after the initial RF ablation was 22.4 months (range, 6.2–76.1 mo). Estimated overall survival rates were 85.7% at 1 year, 54.8% at 2 years, and 38.4% at 3 years after the initial RF ablation session. The presence of viable extrapulmonary recurrences at the initial RF ablation session was an unfavorable prognostic factor (P < .001). Local tumor progression was observed in 25.8% (8 of 31) of tumors and occurred 2.6–10.0 months (median, 4.8 mo) after RF ablation. Grade 3 adverse events occurred in 7.4% (2 of 27) of sessions, including pleural effusion requiring chest tube placement and pneumoderma requiring surgical intervention. No grade 4 or greater adverse events occurred. ConclusionsRF ablation is a promising treatment option for patients with pulmonary metastases from esophageal cancer.

Percutaneous radiofrequency ablation of lung cancer presenting as ground-glass opacity.

We retrospectively evaluated the outcomes of lung cancer patients presenting with ground-glass opacity (GGO) who received radiofrequency ablation (RFA). Sixteen patients (5 men and 11 women; mean age, 72.6 years) with 17 lung cancer lesions showing GGO (mean long axis diameter, 1.6 cm) underwent a total of 20 percutaneous computed tomography (CT) fluoroscopy-guided RFA sessions, including three repeated sessions for local progression. Lung cancer with GGO was defined as a histologically confirmed malignant pulmonary lesion with a GGO component accounting for >50 % of the lesion on high-resolution CT. Procedure outcomes were evaluated. There were no major complications. Pneumothorax occurred in 15 of 20 treatment sessions: 14 were asymptomatic, and 1 required chest tube placement but resolved satisfactorily within 48 h. Minor pulmonary hemorrhage occurred in two and mild pneumonitis in one. The median tumor follow-up period was 61.5 (range 6.1-96.6) months. The effectiveness rates of the primary and secondary techniques were 100 and 100 % at 1 year, 93.3 and 100 % at 2 years, and 78.3 and 92.3 % at 3 years, respectively. The median patient follow-up period was 65.6 (range 6.1-96.6) months. One patient died owing to recurrent other cancer 11.7 months after RFA, whereas the other 15 remained alive. Overall survival and disease-specific survival rates were 93.3 and 100 % at 1 year and 93.3 and 100 % at 5 years, respectively. RFA for lung cancer with GGO was safe and effective, and resulted in promising survival rates.

Complications From Computed Tomography–Guided Core Needle Biopsy for Patients Receiving Stereotactic Body Radiation Therapy for Early-Stage Lesions of the Lung

BackgroundObtaining a tissue diagnosis has traditionally been standard practice before initiating therapy for early-stage non–small-cell lung cancer (NSCLC). In several recent studies from Europe and Asia, a substantial proportion of patients have received stereotactic body radiation therapy (SBRT) based only on the imaging characteristics of the suspicious lesion. The underlying assumption is that the risk of percutaneous needle biopsy may outweigh the benefits in a population that generally has underlying pulmonary dysfunction and other medical comorbidity. Nevertheless, there is limited information regarding biopsy-related complication rates in high-risk patients with early-stage NSCLC who are treated with SBRT. Materials and MethodsThis was a retrospective review of outcomes after biopsy in patients treated with SBRT. Complications of percutaneous core needle biopsy were analyzed in relation to patient and tumor characteristics. Each biopsy event was analyzed independently for patients with multiple biopsies. ResultsA total of 112 percutaneous biopsies were performed in 103 patients. Pneumothorax of any degree was observed in 40 patients (35%) (95% CI, 27%-45%), and 12 patients (10.7%) had a clinically significant pneumothorax requiring chest tube placement (95% CI, 6%-18%). The time to first fraction of SBRT was not different in patients who had a pneumothorax or placement of a chest tube. On multivariate analysis, age, performance status, smoking history, pack-years of smoking, chronic obstructive pulmonary disease history, and forced expiratory volume in the first second of expiration were not statistically significantly associated with chest tube placement. ConclusionComputed tomography–guided needle biopsy in a primarily medically inoperable patient population is safe, with an acceptable degree of complications.

8:18 AM Abstract No. 157 - Safety and feasibility of percutaneous microwave ablation (MVA) of lung tumors

Purpose: Percutaneous ablation of lung tumors is a minimally invasive therapy for patients with primary or metastatic cancer who are not surgical candidates or in whom standard therapy fails. We present our experience with percutaneous MWA of lung tumors. Materials and Methods: 14 consecutive patients (3 male, 11 female), aged 64-89, underwent 17 treatments of 17 target lesions. 9/17 tumors were primary non-small cell lung carcinomas and 8/17 were metastatic (Colon n1⁄42, Hepatobiliary n1⁄41, Neuroendocrine n1⁄41, Head and Neck n1⁄44). Clinical evaluation was performed at baseline, 2 weeks, 30 days and 6 months. Response was assessed using Modified Response Evaluation Criteria in Solid Tumors (n1⁄413) at 6 months and classified as: Complete Response (CR), Partial Response (PR), or Progressive Disease (PD). Complications were reported according to Society of Interventional Radiology Grading System [1,2]. Results: Baseline Eastern Cooperative Oncology Group performance status average was 0.9 (range 0-3). Mean tumor size for 2.4 cm (N1⁄417, 1.2 cm-5.8 cm); mean tumor size was 2.6 cm (Primary N1⁄49, 1.4 cm-4.5 cm) and 2.1cm (Metastatic n1⁄48, 1.2 cm-5.8 cm). 16/17 treatments were technically successful with one unsuccessful case secondary to inability to place the probe safely through the tumor. 30 day, 6 month and 1 year survival was: 100% (n1⁄414), 100% (n1⁄411) and 100%(n1⁄47). Response rates for primary and metastatic tumors were as follows: (Primary, n1⁄46) CR 83%, PR 17%, PD 0 %, (Metastatic, n1⁄47) CR 100%, PR 0.0%, PD 0%. One case of locally progressive disease was initially treated with palliative intent. Three major and 2 minor complications: pneumothorax requiring chest tube placement (3/17), pneumothorax without chest tube (1/17), self-resolved hemoptysis (1/17). Conclusion: Percutaneous microwave ablation is a feasible and potentially safe technique for lung tumor ablation with promising response rates.

A Migrant, Round-Shape, Intrathoracic Mass

A round lesion was detected incidentally in the right intrathoracic region of 53-year-old male. Despite the fact that the lesion (39 9 45-mm in diameter) presented radiological findings consistent with benign disease— round shape with fat density (H.U.-35) (Fig. 1a, b) and no 18-FDG uptake on a PET/CT scan—a fine-needle aspiration biopsy was unsuccessfully attempted to achieve a definitive diagnosis. The procedure was complicated by pneumothorax that required chest tube placement. However, after complete pulmonary reexpansion, the mass had apparently migrated to the posterior costodiaphragmatic recess as shown by CT (Fig. 1c, d). The lesion (a white, oval, smooth lesion without a vascular pedicle; Fig. 2) was finally removed through single-port thoracoscopy, and the definitive diagnosis was pleural lipoma (central steatonecrotic core surrounded by a fibrinous sheath). Pleural lipomas are an extremely rare entity and usually arise from the parietal or mediastinal pleura [1, 2]. In the present case, the tumor originated from the visceral pleura of the great fissure and ‘‘felt down’’ within the thoracic cavity as consequence of iatrogenic pneumothorax.

Esophgeal Perforation and Bilateral Empyema Following Endoscopic EsophyX Transoral Incisionless Fundoplication.

Transoral incisionless fundoplication (TIF) has been used for endoscopic treatment of gastroesophageal reflux disease (GERD). TIF using the EsophyX device system (EndoGastric Solutions) was designed to create a full-thickness valve at the gastroesophageal junction through the insertion of multiple fasteners; it improves GERD, reduces proton pump inhibitor use, and improves quality of life. Although TIF is effective in select patients, a significant subset of patients undergoing TIF develop persistent or recurrent GERD symptoms and may need antireflux surgery to control the GERD symptoms. We now report a 48-year-old man with chronic GERD unresponsive to medical management. He underwent TIF complicated by esophageal perforation and developed mediastinitis, left pneumothorax, bilateral pleural effusions, and acute respiratory failure. He required chest tube placement and bilateral decortication for treatment of nonresolving empyemas. Additional postmarketing studies are required to assess the safety, efficacy, and clinical outcomes of this novel procedure, and patients undergoing this procedure need close postprocedural follow-up.

Vanishing Lung Syndrome in a Patient with HIV Infection and Heavy Marijuana Use

Vanishing lung syndrome (VLS) is a rare and distinct clinical syndrome that usually affects young men. VLS leads to severe progressive dyspnea and is characterized by extensive, asymmetric, peripheral, and predominantly upper lobe giant lung bullae. Case reports have suggested an additive role of marijuana use in the development of this disease in young male tobacco smokers. We herein report a case of a 65-year-old Hispanic male previously diagnosed with severe emphysema and acquired immune deficiency syndrome (AIDS), with a history of intravenous heroin use and active marijuana smoking who presents to the emergency department with severe progressive shortness of breath he was found to have multiple large subpleural bullae occupying more than one-third of the hemithorax on chest computerized tomography (CT), characteristic of vanishing lung syndrome. The patient was mechanically ventilated and later developed a pneumothorax requiring chest tube placement and referral for surgical bullectomy. Surgical bullectomy has shown high success rates in alleviating the debilitating symptoms and preventing the life threatening complications of this rare syndrome. This case further emphasizes the importance of recognizing VLS in patients with severe emphysema and heavy marijuana smoking.

Radiofrequency ablation as treatment for pulmonary metastasis of colorectal cancer

Radiofrequency ablation (RFA) causes focal coagulation necrosis in tissue. Its first clinical application was reported in 2000, and RFA has since been commonly used in both primary and metastatic lung cancer. The procedure is typically performed using computed tomography guidance, and the techniques for introducing the electrode to the tumor are simple and resemble those used in percutaneous lung biopsy. The most common complication is pneumothorax, which occurs in up to 50% of procedures; chest tube placement for pneumothorax is required in up to 25% of procedures. Other severe complications, such as pleural effusion requiring chest tube placement, infection, and nerve injury, are rare. The local efficacy depends on tumor size, and local progression after RFA is not rare, occurring in 10% or more of patients. The local progression rate is particularly high for tumors > 3 cm. Repeat RFA may be used to treat local progression. Short- to mid-term survival after RFA appears promising and is approximately 85%-95% at 1 year and 45%-55% at 3 years. Long-term survival data are sparse. Better survival may be expected for patients with small metastasis, low carcinoembryonic antigen levels, and/or no extrapulmonary metastasis. The notable advantages of RFA are that it is simple and minimally invasive; preserves pulmonary function; can be repeated; and is applicable regardless of previous treatments. Its most substantial limitation is limited local efficacy. Although surgery is still the method of choice for treatment with curative intent, the ultimate application of RFA may be to replace metastasectomy for small metastases. Randomized trials comparing RFA with surgery are needed.

Tract Embolization With Gelatin Sponge Slurry for Prevention of Pneumothorax After Percutaneous Computed Tomography-Guided Lung Biopsy

To determine the effect of embolization with absorbable gelatin sponge slurry on the incidence of pneumothorax (PTX) and need for chest tube placement after percutaneous lung biopsy. Seven hundred fifty-two percutaneous lung biopsy procedures and fiducial seed placements were performed using computed tomography (CT)-guidance at a single institution. A retrospective review was performed including 145 patients with embolization (19.28%) of the tract with gelatin sponge slurry during needle withdrawal and 607 patients who did not undergo tract embolization. Patient- and lesion-related characteristics were collected through the electronic health record and PACS. Outcome measures included the occurrence of PTX during or after the biopsy procedure and the need for chest tube placement. Analysis was performed by multivariate logistic regression. Although tract embolization did not significantly decrease the chances of developing PTX (p = 0.06), it did decrease the likelihood of progressing to requiring chest tube insertion. Without tract embolization, 10.7% of cases required a chest tube, whereas only 6.9% of the patients whose tract was embolized needed a chest tube (p = 0.01). A history of emphysema was associated with 151% increased odds of PTX requiring chest tube placement after lung biopsy (p = 0.009). Tract length >24 mm was associated with a 262% increase in the odds of requiring chest tube placement (p = 0.003). Embolization of the needle tract during percutaneous lung biopsy with gelfoam slurry significantly decreased the odds of requiring a chest tube for PTX and should be considered for all patients, particularly those with emphysema and deep lesions.