- Case Report
- Open Access
Bronchopleural fistula after non small cell lung cancer radiofrequency ablation: what it implying to us?
- Weimiao Li†1,
- Lijun Huang†1,
- Yong Han†1,
- Yongan Zhou1,
- Qiang Lu1Email author and
- Xiaofei Li1Email author
© Li et al.; licensee BioMed Central Ltd. 2013
- Received: 3 November 2013
- Accepted: 25 November 2013
- Published: 10 December 2013
Radiofrequency ablation (RFA) is an alternative method to treat the inoperable NSCLC and there were few serious complications after RFA therapy have been reported. Here, we reported a NSCLC patient endured empyema after treatment by RFA for one month. There was a 20 × 25 × 20 mm mass on the right middle lobe by CT scan before RFA and a huge gas cavity with liquid was found in the right chest cavity after RFA treatment for twenty- eight days. A hole in the right middle lobe was found with large amount of pus in the pleural cavity as well as the bronchopleural fistula (BPF) during the operation. Results from the postoperative pathology showed a multiple small foci differentiated adenocarcinoma, partial bronchiolar-alveolar carcinoma, 0.5 cm away around the hole at the same time. It is difficult to diagnose and treat the rare complication of BPF, while, the larger field of ablation might be helpful to postpone the tumor local progression. Therefore, surgery was a good option for BPF especially when an empyema occurred.
The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/8028049341122276.
- Non–small cell lung cancer
- Radiofrequency ablation
- Pathological changes
Despite surgical resection was the standard treatment of localized non–small cell lung cancer (NSCLC), only 20% of all diagnosed lung cancers were suitable for potentially curative resection . Radiofrequency ablation (RFA) was proved safe and effective for the treatment of inoperable NSCLC as an alternative method . Few serious complications from RFA have been reported . We reported a NSCLC patient who was first treatment by RFA and endured empyema one month after treatment.
In recent years, the treatment of NSCLC is still not satisfying in spite of the rapid development of lung cancer research [4, 5]. In addition to the use of chemotherapy drugs , RFA is a potential local therapy used for NSCLC patients who were not suitable for surgery or refused operation [7, 8]. Several authors have assessed the performance of RFA in treatment for primary NSCLC and the complications of RFA were believed to be acceptable [9–11]. Our previous studies found that complications of RFA included pneumothorax (19.1%), hemoptysis (4.2%), hemothorax (3.0%), pneumonia (4.5%) and pericardial tamponade (0.9%), while absent of empyema. The most common complication for the lung RFA was pneumothorax. The bronchopleural fistula (BPF) was an extremely rare complication .
BPF was a serious complication and difficult for the treatment. Sakurai  and Kodama  performed bronchial occlusion using silicone filler and pleurodesis in three patients with a BPF. Abu-Hijleh and Blundin  resolved the complication through chest tube drainage. Lois M et al.  healed the air leaks through a chest tube to produce a pleural symphysis for management of persistent air leaks. In this report, thoracotomy was given with satisfied result. BPF also could be confirmed by bronchoscopy which should be performed as early as possible. We hypothesized that RFA damaged lung tumors and caused a tumoral necrosis hole. The hole resulted in the delayed BPF and ended in empyema subsequently (Figure 2).
In early reports, few patients received thoractomy after RFA and the data about pathological changes after RFA were rare . This patient, to our surprise, the postoperative pathology confirmed a multiple small foci differentiated adenocarcinoma, partial bronchiolar - alveolar carcinoma, 0.5 cm away around the hole at the same time. It indicated that tumors existed surroundings the primary tumor 1 month after RFA. Does that suggest that the primary tumor had satellite lesions, or it was caused by the RFA treatment? Was it the reason of tumor local progression? This finding would be greatly helpful for understanding the pathological changes after RFA and even for the treatment of RFA. Should a larger ablation range be given around the tumor, or improved RFA equipment be used for the ablation. It suggested that radiofrequency electrodes might be placed in the addition area more than 1 cm away surrounded the tumor mass at least, repeated RFA and expand the range of treatment might be helpful.
In conclusion, diagnose and treatments of the rare complication of BPF were difficult. Surgery was a good option for BPF especially when empyema occurred. Understanding the limitations of radiofrequency may help to decrease the risks for complications, and the larger field of ablation might be helpful for delaying the tumor local progression.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ: Cancer statistics. CA Cancer J Clin. 2009, 59: 225-249. 10.3322/caac.20006.View ArticlePubMedGoogle Scholar
- Crocetti L, Lencioni R: Radiofrequency ablation of pulmonary tumors. Eur J Radiol. 2010, 75: 23-27. 10.1016/j.ejrad.2010.04.011.View ArticlePubMedGoogle Scholar
- Kashima M, Yamakado K, Takaki H, Kodama H, Yamada T, Uraki J, Nakatsuka A: Complications after 1000 lung radiofrequency ablation sessions in 420 patients: a single center's experiences. AJR Am J Roentgenol. 2011, 197: W576-580. 10.2214/AJR.11.6408.View ArticlePubMedGoogle Scholar
- Beljan Perak R, Durdov MG, Capkun V, Ivcevic V, Pavlovic A, Soljic V, Peric M: IMP3 can predict aggressive behaviour of lung adenocarcinoma. Diagnostic pathology. 2012, 7: 165-10.1186/1746-1596-7-165.PubMed CentralView ArticlePubMedGoogle Scholar
- Kayser G, Kassem A, Sienel W, Schulte-Uentrop L, Mattern D, Aumann K, Stickeler E, Werner M, Passlick B, zur Hausen A: Lactate-dehydrogenase 5 is overexpressed in non-small cell lung cancer and correlates with the expression of the transketolase-like protein 1. Diagnostic pathology. 2010, 5: 22-10.1186/1746-1596-5-22.PubMed CentralView ArticlePubMedGoogle Scholar
- Lu Q, Lu S, Huang L, Wang T, Wan Y, Zhou CX, Zhang C, Zhang Z, Li X: The expression of V-ATPase is associated with drug resistance and pathology of non-small-cell lung cancer. Diagnostic pathology. 2013, 8: 145-10.1186/1746-1596-8-145.PubMed CentralView ArticlePubMedGoogle Scholar
- Pennathur A, Abbas G, Gooding WE, Schuchert MJ, Gilbert S, Christie NA, Landreneau RJ, Luketich JD: Image-guided radiofrequency ablation of lung neoplasm in 100 consecutive patients by a thoracic surgical service. Ann Thorac Surg. 2009, 88: 1601-1606. 10.1016/j.athoracsur.2009.05.012. discussion 1607–1608PubMed CentralView ArticlePubMedGoogle Scholar
- Legras A, Mordant P, Cazes A, Riquet M: [Radiofrequency of lung metastases: Should initial pneumothorax predict treatment failure?]. 2013, Revue de pneumologie cliniqueGoogle Scholar
- Schoellnast H, Deodhar A, Hsu M, Moskowitz C, Nehmeh SA, Thornton RH, Sofocleous CT, Alago W, Downey RJ, Azzoli CG, et al.: Recurrent non-small cell lung cancer: evaluation of CT-guided radiofrequency ablation as salvage therapy. Acta Radiol. 2012, 53 (8): 893-839. 10.1258/ar.2012.110333.View ArticlePubMedGoogle Scholar
- Cannella M, Cornelis F, Descat E, Ferron S, Carteret T, Castagnede H, Palussiere J: Bronchopleural fistula after radiofrequency ablation of lung tumours. Cardiovasc Intervent Radiol. 2011, 34 (Suppl 2): S171-174.View ArticlePubMedGoogle Scholar
- Dupuy DE, DiPetrillo T, Gandhi S, Ready N, Ng T, Donat W, Mayo-Smith WW: Radiofrequency ablation followed by conventional radiotherapy for medically inoperable stage I non-small cell lung cancer. Chest. 2006, 129: 738-745. 10.1378/chest.129.3.738.View ArticlePubMedGoogle Scholar
- Huang L, Han Y, Zhao J, Wang X, Cheng Q, Li X, Xu H, Gao K: Is radiofrequency thermal ablation a safe and effective procedure in the treatment of pulmonary malignancies?. Eur J Cardiothorac Surg. 2010, 39: 348-351.View ArticleGoogle Scholar
- Sakurai J, Hiraki T, Mukai T, Mimura H, Yasui K, Gobara H, Hase S, Fujiwara H, Iguchi T, Tajiri N, et al.: Intractable pneumothorax due to bronchopleural fistula after radiofrequency ablation of lung tumors. J Vasc Interv Radiol. 2007, 18: 141-145. 10.1016/j.jvir.2006.10.011.View ArticlePubMedGoogle Scholar
- Kodama H, Yamakado K, Murashima S, Takaki H, Uraki J, Nakatsuka A, Shoumura S, Tarukawa T, Shimamoto A, Takao M, Takeda K: Intractable bronchopleural fistula caused by radiofrequency ablation: endoscopic bronchial occlusion with silicone embolic material. Br J Radiol. 2009, 82: e225-227. 10.1259/bjr/23975691.View ArticlePubMedGoogle Scholar
- Abu-Hijleh M, Blundin M: Emergency use of an endobronchial one-way valve in the management of severe air leak and massive subcutaneous emphysema. Lung. 2010, 188: 253-257. 10.1007/s00408-009-9204-0.View ArticlePubMedGoogle Scholar
- Lois M, Noppen M: Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005, 128: 3955-3965. 10.1378/chest.128.6.3955.View ArticlePubMedGoogle Scholar
- Nguyen CL, Scott WJ, Young NA, Rader T, Giles LR, Goldberg M: Radiofrequency ablation of primary lung cancer: results from an ablate and resect pilot study. Chest. 2005, 128: 3507-3511.View ArticlePubMedGoogle Scholar
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