Ablation of Stage I-II Non-Small Cell Lung Cancer in Patients With Interstitial Lung Disease: A Multicenter Retrospective Study.

BACKGROUND. Treatment options for patients with interstitial lung disease (ILD) who develop stage I-II non-small cell lung cancer (NSCLC) are severely limited, given that surgical resection, radiation, and systemic therapy are associated with significant morbidity and mortality. OBJECTIVE. The aim of this study was to evaluate the safety and efficacy of percutaneous ablation of stage I-II NSCLC in patients with ILD. METHODS. This retrospective study included patients with ILD and stage I-II NSCLC treated with percutaneous ablation in three health systems between October 2004 and February 2023. At each site, a single thoracic radiologist, blinded to clinical outcomes, reviewed preprocedural chest CT examinations for the presence and type of ILD according to 2018 criteria proposed by the American Thoracic Society, European Respiratory Society, Japanese Respiratory Society, and Latin American Thoracic Society. The primary outcome was 90-day major (grade ≥ 3) adverse events, based on Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Secondary outcomes were hospital length of stay (HLOS), local tumor control, and overall survival (OS). RESULTS. The study included 33 patients (19 men, 14 women; median age, 78 years; 16 patients with Eastern Cooperative Oncology Group performance status ≤ 1) with ILD who underwent 42 percutaneous ablation sessions (21 cryoablations, 11 radiofrequency ablations, 10 microwave ablations) of 43 NSCLC tumors ((median tumor size, 1.6 cm; IQR, 1.4-2.5 cm; range, 0.7-5.4 cm; 37 stage I, six stage II). The extent of lung fibrosis was 20% or less in 24 patients; 17 patients had imaging findings of definite or probable usual interstitial pneumonia. The 90-day major adverse event rate was 14% (6/42), including one CTCAE grade 4 event. No acute ILD exacerbation or death occurred within 90 days after ablation. The median HLOS was 1 day (IQR, 0-2 days). Median imaging follow-up for local tumor control was 17 months (IQR, 11-32 months). Median imaging or clinical follow-up for OS was 16 months (IQR, 6-26 months). Local tumor control and OS were 78% and 77%, respectively, at 1 year and 73% and 46% at 2 years. CONCLUSION. Percutaneous ablation appears to be a safe and effective treatment option for stage I-II NSCLC in the setting of ILD after multidisciplinary selection. CLINICAL IMPACT. Patients with ILD and stage I-II NSCLC should be considered for percutaneous ablation given that they are frequently ineligible for surgical resection, radiation, and systemic therapy.

Society of Interventional Radiology Multidisciplinary Position Statement on Percutaneous Ablation of Non-small Cell Lung Cancer and Metastatic Disease to the Lungs: Endorsed by the Canadian Association for Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology.

PURPOSE: To state the Society of Interventional Radiology's position on the use of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease to the lung. MATERIALS AND METHODS: A multidisciplinary writing group, with expertise in treating lung cancer, conducted a comprehensive literature search to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements. RESULTS: A total of 63 studies, including existing systematic reviews and meta-analysis, retrospective cohort studies, and single-arm trials were identified. The expert writing group developed and agreed on 7 recommendations on the use of image-guided thermal ablation in the lung. CONCLUSION: SIR considers image-guided thermal ablation to be an acceptable treatment option for patients with inoperable Stage I NSCLC, those with recurrent NSCLC, as well as patients with metastatic lung disease.

Society of Interventional Radiology Quality Improvement Standards on Percutaneous Ablation of Non-Small Cell Lung Cancer and Metastatic Disease to the Lungs.

PURPOSE: To provide guidance on quality improvement thresholds for outcomes and complications of image-guided thermal ablation for the treatment of early stage non-small cell lung cancer, recurrent lung cancer, and metastatic disease. MATERIALS AND METHODS: A multidisciplinary writing group conducted a comprehensive literature search to identify studies on the topic of interest. Data were extracted from relevant studies and thresholds were derived from a calculation of 2 standard deviations from the weighted mean of each outcome. A modified Delphi technique was used to achieve consensus agreement on the thresholds. RESULTS: Data from 29 studies, including systematic reviews and meta-analyses, retrospective cohort studies, and single-arm trials were extracted for calculation of the thresholds. The expert writing group agreed on thresholds for local control, overall survival and adverse events associated with image-guided thermal ablation. CONCLUSION: SIR recommends utilizing the indicator thresholds to review and assess the efficacy of ongoing quality improvement programs. When performance falls above or below specific thresholds, consideration of a review of policies and procedures to assess for potential causes, and to implement changes in practices, may be warranted.

Interventional Radiology Image-Guided Suprapubic Cystostomy Using Trocar versus Seldinger Technique: A Comparative Analysis of Outcomes and Complications.

OBJECTIVE: To compare two techniques-trocar and Seldinger-for performing percutaneous suprapubic cystostomy. MATERIALS AND METHODS: 125 patients, mean age 71.8 ± 16.5 years (range, 15-102 years), underwent primary suprapubic cystostomy from January 2013 to December 2018. Trocar access (N = 60) was performed as a single step using a puncture cannula without guidewire access. Seldinger access (N = 65) involved needle puncture, guidewire placement, and serial dilation. A retrospective review of patient records was conducted. RESULTS: All procedures were technically successful. Mean catheter size was 13.1 ± 2.0 and 13.9 ± 2.0 French for trocar and Seldinger, respectively (P = .044). Mean procedure time was significantly reduced using trocar technique, 12.4 ± 7.7 versus 25.7 ± 12.1 minutes (P <.001), and was associated with lower anxiolytic dose, 1.2 ± 0.8 versus 1.9 ± 1.1 mg midazolam (P = .003), and less radiation exposure, 20.2 ± 59.5 versus 100.7 ± 98.5 mGy (P <.001). Catheter occlusion was the most common complication (28.8%), followed by UTI (13.6%) and bladder spasm (8.0%). All but 2 complications were classified as Clavien-Dindo grade I or II. Catheter occlusion was more frequent in the trocar group (41.7% vs 16.9%, P = .003), while bladder spasms were more frequent in the Seldinger group (13.8% vs 1.7%, P = .018). CONCLUSION: Suprapubic cystostomy via trocar is associated with faster procedure time, lower anxiolytic dose, and less radiation. While major complications are rare, catheter occlusion is a common occurrence that may be overlooked. Although we detected more occlusions with trocar technique, this may be confounded by a catheter-tract size discrepancy.

Comparison of Double-Freeze versus Modified Triple-Freeze Pulmonary Cryoablation and Hemorrhage Volume Using Different Probe Sizes in an In Vivo Porcine Lung.

PURPOSE: To determine size of ablation zone and pulmonary hemorrhage in double-freeze (DF) vs modified triple-freeze (mTF) cryoablation protocols with different probe sizes in porcine lung. MATERIALS AND METHODS: In 10 healthy adult pigs, 20 pulmonary cryoablations were performed using either a 2.4-mm or a 1.7-mm probe. Either conventional DF or mTF protocol was used. Serial noncontrast CT scans were performed during ablations. Ablation iceball and hemorrhage volumes were measured and compared between protocols and probe sizes. RESULTS: With 1.7-mm probe, greater peak iceball volume was observed with DF compared with mTF, although difference was not statistically significant (16.1 mL ± 1.9 vs 8.8 mL ± 3.6, P = .07). With 2.4-mm probe, DF and mTF produced similar peak iceball volumes (14.0 mL ± 2.8 vs 14.6 mL ± 2.7, P = .88). Midcycle hemorrhage was significantly larger with DF with the 1.7-mm probe (94.3 mL ± 22.2 vs 19.6 mL ± 2.1, P = .02) and with both sizes combined (93.2 mL ± 17.5 vs. 50.9 mL ± 12.6, P = .048). Rate of hemorrhage increase was significantly higher in DF (10.4 mL/min vs 5.1 mL/min, P = .003). End-cycle hemorrhage was visibly larger in DF compared with mTF across probe sizes, although differences were not statistically significant (P = .14 for 1.7 mm probe, P = .18 for 2.4 mm probe, and P = .07 for both probes combined). Rate of increase in hemorrhage during the last thaw period was not statistically different between DF and mTF (3.0 mL/min vs 2.8 mL/min, P = .992). CONCLUSIONS: mTF reduced rate of midcycle hemorrhage compared with DF. With mTF, midcycle hemorrhage was significantly smaller with 1.7-mm probe; although noticeably smaller with 2.4-mm probe, statistical significance was not achieved. Iceball size was not significantly different across both protocols and probe types.

Non-small cell lung cancer clinical trials requiring biopsies with biomarker-specific results for enrollment provide unique challenges.

BACKGROUND: Clinical trials in lung cancer increasingly require patients to provide fresh tumor tissue as a prerequisite to enrollment. The effects of this requirement on enrollment rates, enrollment durations, and patient selection have not been fully elucidated. METHODS: The authors retrospectively reviewed data generated by patients who consented to 1 or more interventional lung cancer clinical trials at the University of California-Los Angeles Jonsson Comprehensive Cancer Center between January 2013 and December 2014. Trials were considered to require a biopsy when enrollment was conditional on the procurement of tissue without intervening therapy between procurement and enrollment. RESULTS: In total, 311 patients underwent 368 screening incidents for 1 or more of 19 trials. Trials that required a new biopsy had a longer median screening duration (34 vs 14 days) than trials that did not require a biopsy (P < .001). Trials that required a biopsy had a greater screen failure rate (49.1% vs 26.5%; P < .001), which was largely driven by patients who did not undergo the required biopsy or lacked the required biomarker. Worsening performance status led to the majority of screen failures (56.5%) among biomarker-eligible patients. CONCLUSIONS: Although the scientific benefits of obtaining a new biopsy and requiring specific results for trial enrollment are clear, these requirements lead to a lengthening of the screening period, which, in some patients, is associated with clinical decline before enrollment. Implications for the interpretation of data from studies of this design should be explored. Cancer 2017;123:4800-7. © 2017 American Cancer Society.

The Role of Inferior Vena Cava Filters in Pulmonary Embolism.

Pulmonary embolism (PE) is a cause of significant morbidity and mortality, with an estimated 600,000 cases of clinically significant PE in the United States annually, and roughly 200,000 deaths per annum directly attributable to PE. By far the most frequent cause of PE is deep vein thrombosis originating in the lower extremities, which travels to the pulmonary vasculature. The mainstay of treatment is anticoagulation, but multiple additional treatments exist for patients in whom anticoagulation is inadequate or contraindicated. The absolute indications for inferior vena cava (IVC) filtration are narrow, but many filters are placed in patients with relative indications. There is growing concern for overuse of IVC filters, with a relatively low rate of retrieval. It is essential for interventional radiologists to understand the appropriate and correct use and retrieval of IVC filters. Familiarity with placement techniques, protocols and techniques for retrieval, current and emerging technologies, and the clinical model for management of venous thromboembolism, will ensure that interventional radiologists remain an integral member of the care team for these often complex patients.

Defining New Metrics in Microwave Ablation of Pulmonary Tumors: Ablation Work and Ablation Resistance Score.

PURPOSE: To investigate pulmonary microwave ablation metrics including ablation work, ablation resistance score, and involution. MATERIALS AND METHODS: Retrospective review was performed of 98 pulmonary tumor ablations using the NeuWave Certus Microwave Ablation System (NeuWave Medical, Madison, Wisconsin) in 71 patients (32 men and 39 women; mean age, 64.7 y ± 11.5). Ablation work was defined as sum of (power) * (time) * (number of antennas) for all phases during an ablation procedure. Ablation zone was measured on CT at 3 time points: after procedure, 1-3 months (mean 47 d), and 3-12 months (mean 292 d). Ablation zones were scored based on location for pulmonary lobe (upper = 1, middle/lingula = 2, lower = 3) and region (peripheral = 1, parenchymal = 2, central = 3), and the 2 were summed for ablation resistance score. RESULTS: Ablation zone on CT at 1-3 months was significantly smaller in regions with higher ablation resistance score (P < .05). There was a significant correlation between ablation work and ablation zone measured on CT performed after procedure (P < .001), at 1-3 months (P < .001), and at 3-12 months (P < .05). Ablation zone significantly decreased from after procedure to 1-3 months (P < .001) and from 1-3 months to 3-12 months (P < .001), with change from after procedure to 1-3 months significantly greater (P < .01). CONCLUSIONS: Pulmonary microwave ablation zone is significantly smaller in regions with higher ablation resistance score. Ablation work correlates to ablation zone with a nonlinear involution pattern in the first year and may be useful for planning before the procedure.

ACR Appropriateness Criteria® Intensive Care Unit Patients.

Portable chest radiography is a fundamental and frequently utilized examination in the critically ill patient population. The chest radiograph often represents a timely investigation of new or rapidly evolving clinical findings and an evaluation of proper positioning of support tubes and catheters. Thoughtful consideration of the use of this simple yet valuable resource is crucial as medical cost containment becomes even more mandatory. This review addresses the role of chest radiography in the intensive care unit on the basis of the existing literature and as formed by a consensus of an expert panel on thoracic imaging through the American College of Radiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Imaging-histologic discordance at percutaneous biopsy of the lung.

RATIONALE AND OBJECTIVES: The purpose of this study was to quantify the degree of imaging-histologic discordance in a cohort of patients undergoing computed tomography (CT)-guided lung biopsy for focal lung disease. MATERIALS AND METHODS: A retrospective review was performed of 186 patients who underwent percutaneous lung biopsy of a parenchymal lesion at our institution between January and December 2009. Diagnostic radiology reports of CT or positron emission tomography-CTs performed before biopsy were used to classify the lesion as malignant or benign by five readers. Pathology reports of the biopsied lesions were classified by three readers. Inter-reader agreement and imaging-histologic concordance were quantified using kappa statistics. Discordant benign cases were then revisited to determine downstream effects. RESULTS: Inter-reader agreement on report content was substantial or almost perfect with kappas >0.783. Kappas for concordance were as follows: malignant (0.448), primary lung cancer (0.517), metastatic disease to lung (0.449), benign (0.510), and overall agreement (0.381). Of the twelve discordant benign cases that were revisited, four were found to be false negatives, resulting in a delay in diagnosis. CONCLUSIONS: Our study of imaging-histologic discordance in percutaneous biopsy of lung lesions supports the need for imaging report standardization and improved integration and communication between the fields of radiology and pathology.