Case Based Lung Ablation: Top 5 Clinical and Technical Pearls

Steven Yevich, MD, MPH, of MD Anderson Cancer Center, presented, "Case-Based Lung Ablation: Top Five Clinical and Technical Pearls", a session aimed to provide essential insights into lung ablation, a rapidly growing field within interventional oncology.

During the 2023 Symposium on Clinical Interventional Oncology, Steven Yevich, MD, MPH, of MD Anderson Cancer Center, presented, "Case-Based Lung Ablation: Top Five Clinical and Technical Pearls", a session aimed to provide essential insights into lung ablation, a rapidly growing field within interventional oncology. 

Dr. Yevich expressed his excitement about the dynamic and expanding field of lung ablations and then provided a brief overview of the top 5 clinical and technical pearls below.

Clinical and Technical Pearls

1. Pneumothorax: Never Fear

●      Expectations and Management: Dr. Yevich emphasized the need to set realistic expectations regarding pneumothorax complications. He highlighted that managing these complications is not a significant challenge and can be resolved with small caliber chest tube placement.

●      Delayed Presentations: Longer follow-ups with simple x-rays were recommended to identify delayed presentations of pneumothorax.

●      Bronchopleural Fistula (BPF): For persistent pneumothorax beyond four days, Dr.Yevich stressed the importance of planning for potential BPF. He presented a technique involving the use of a small caliber needle for injection closure using gel foam or a mixture of gel foam and autologous blood.

2. Interparenchymal Hemorrhage: Plan for It

●      Bronchial Blocker: Dr. Yevich suggested using a deflated bronchial blocker into the ipsilateral main stem bronchus for managing interparenchymal hemorrhage. This allows the anesthesiologist to flush and clean the system if bleeding occurs.

●      Considerations: Planning for high-risk lesions involves considerations such as anatomy, bronchovascular bundle size, adjacent vasculature, and lesion characteristics. Techniques such as cryoablation with passive thaw were discussed as options.

3. Internal Mammary Artery: Steer Clear

●      Importance of Evaluation: Dr. Yevich stressed the importance of evaluating the internal mammary artery before the procedure to prevent bleeding complications.

●      Appearance: Internal mammary artery-induced hemothorax might have a distinct appearance, and interventions such as intraarterial embolization or percutaneous thrombin injection can be considered.

4. Brachial and Phrenic Nerves: Take Care

●      Nerve Regeneration: Dr. Yevich highlighted the potential for nerve regeneration after 6 to 12 months, particularly with cryoablation. The choice of modality depends on the proximity of nerves to the treatment area.

●      Assessment Tools: Tools such as MRI and EEG for the brachial plexus and fluoroscopy to evaluate diaphragm movement were recommended for assessing nerve damage.

5. Know Your Potential and Equipment

●      Modality Selection: Dr. Yevich emphasized the importance of being comfortable with the chosen modality (cryoablation, microwave, or radiofrequency ablation) and modifying techniques based on lesion characteristics and location.

●      Outpatient Procedures: Microwave and cryoablation were highlighted for their efficiency in outpatient procedures, while radiofrequency ablation remains a practical and consistent modality.

●      Advanced Techniques: Advanced techniques were mentioned for treating larger lesions, multiple lesions, and post-radiation cases. Collaboration with radiation oncologists was emphasized for multidisciplinary discussions on risks, complications, and recurrences.

Dr. Yevich’s talk provided valuable insights into managing complications, planning for potential issues, and making informed decisions based on specific clinical scenarios.