Percutaneous radiofrequency ablation of pulmonary tumors—Is there a difference between treatment under general anaesthesia and under conscious sedation?
Introduction
Primary lung cancer is one of the most common malignancies and represents one of the most common cancer-related deaths in Europe—causing more deaths than both breast, colorectal and prostate cancer together. Additionally, the lungs are the second most frequent site of metastases from extra-pulmonary cancer and may represent the only site of distant metastases [1]. Until recently, treatment options (depending on tumor stage, local extension and patients comorbidities) included a combination of surgery, chemotherapy and/or radiation therapy. Surgery in primary lung tumors is regarded as the treatment of choice, if patients suffer from localized disease, but only up to 25% of tumors are regarded as resectable with curative intention [2]. Furthermore, it has been shown, that even in pulmonary metastases of colorectal cancer, melanoma, renal cell carcinoma and some other tumors resection improves patients survival compared to medical treatment alone [3]. However, open thoracic surgery is a very invasive procedure with considerable morbidity and mortality. Moreover, it requires general anaesthesia and a prolonged hospital stay [4]. Especially older patients suffering from other diseases (e.g. cardiac and cardiopulmonary diseases) are often not suitable candidates for surgery. Possible alternative, less invasive and lung-sparing therapeutical options for these patients include video-assisted thoracoscopy (VATS) and minimal-invasive, local ablative techniques like cryoablation, laser ablation, microwave- and radiofrequency ablation [5], [6], [7]. At present, radiofrequency ablation is the most frequently used thermal ablative technique. Especially percutaneous in situ ablation of primary and secondary lung lesions using radiofrequency ablation is an evolving minimally invasive therapy.
There are different opinions regarding the type of sedation of the patients during therapy, and some groups prefer general anaesthesia [8], while others advocate analgo-sedation [5], [9]. Due to the distinct movements of the lungs during in- and expiration the targeting of the tumor using a percutaneous access for the RF-probes is sometimes quite difficult, especially in patients unable to cooperate properly or in patients unable to hold their breath long enough to enable the interventional radiologist to target the lesion. Therefore, general anaesthesia is regarded as very useful. Double-lumen endotracheal tubes make it possible to have a “breath-hold” of the treated lung for a longer period during hyperoxigenation, while the other lung is still ventilated. In addition, the anaesthesiologist has to take care for the patients vital signs and monitoring, while the interventional radiologist is able to concentrate only on the therapeutic procedure. General anaesthesia, on the other hand, is associated with higher costs, a longer hospital stay and the anaesthesiology team may not be available when needed. Therefore the purpose of our retrospective study was to evaluate the safetiness regarding procedure-related complications, the duration of hospitalization and the local tumor control rate after percutaneous RFA using general anaesthesia versus the use of conscious analgo-sedation.
Section snippets
Inclusion criteria
No established, strict criteria currently exist for proper patient selection for RFA of lung tumors. For this study in-/exclusion criteria adapted from the RITA International, multicenter trial on RFA of lung tumors were used (Table 1) since this criteria meet typical oncological considerations in minimal-invasive tumor therapy.
The study was approved by the local ethics committee, with informed consent obtained by each patient, and each case was discussed by an interdisciplinary tumor board.
Results
Targeting the lesion and performing the procedure was possible in all 11/11 treatments under general anaesthesia, while in 2/15 treatments under conscious sedation the targeting of the lesion was not possible due to restlessness/limited cooperation of the patient (1/2) and due to inability of holding the breath while needle positioning. In these two patients the therapy was performed under general anaesthesia in a second step. Complete ablation cycles (target temperature or roll-off) were
Discussion
The results regarding the overall complication rates of about 50% with the lack of severe, life-threatening complications and the high percentage of local tumor control (86%) during the observation period did not differ from results shown in other publications [5], [8], [10]. Long-term patients survival was not determined in our study due to a follow-up not longer than 36 month (mean 18 months) and due to a completely different objective of this study. The very good feasibility and technical
Conclusion
Due to the lack of difference between feasibility of the intervention, the results and complication rate of RFA of pulmonary lesions performed under general anaesthesia versus conscious analgo-sedation there is no need to do these interventions under general anaesthesia. Possible exemptions are restless and in spite of AS agitated patients and patients unable to hold their breath for needle positioning.
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2022, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Parenteral opioids also have been administered in association with an epidural block11 in patients likely to suffer severe pain (tumor near the pleura) or upon patient request. Hoffmann7 compared GA with conscious analgosedation in 21 patients who underwent 26 RFA procedures and found no difference in the incidence of complications. It was, therefore, concluded that GA was not necessary in patients treated with RFA, except if the patient remained restless or agitated despite analgosedation.
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These authors equally contributed to this work.