Hybrid Theater Facilitates Lung-Preserving Multimodal Treatment for Multiple Pulmonary Metastases

A patient with a history of hepatocellular carcinoma was found to have multiple pulmonary metastases. Staged treatments were combined into a single operation session in the hybrid theater, encompassing bronchoscopic microwave ablation of central right upper lobe lesions and uniportal surgical wedge resections of peripheral right middle lobe lesions. All lung metastases were successfully treated with adequate margin clearance. Microwave ablation under the guidance of electromagnetic navigation bronchoscopy in the hybrid theater is a novel contribution to the multimodal operative management of multiple pulmonary neoplasms. It is a unique choice for patients with multilobar, subcentimeter metastases, and with concerns about lung function preservation. A patient with a history of hepatocellular carcinoma was found to have multiple pulmonary metastases. Staged treatments were combined into a single operation session in the hybrid theater, encompassing bronchoscopic microwave ablation of central right upper lobe lesions and uniportal surgical wedge resections of peripheral right middle lobe lesions. All lung metastases were successfully treated with adequate margin clearance. Microwave ablation under the guidance of electromagnetic navigation bronchoscopy in the hybrid theater is a novel contribution to the multimodal operative management of multiple pulmonary neoplasms. It is a unique choice for patients with multilobar, subcentimeter metastases, and with concerns about lung function preservation. Dr Ng discloses a financial relationship with Medtronic and Siemens. Dr Ng discloses a financial relationship with Medtronic and Siemens. The hybrid theater integrates real-time cone-beam computed tomography (CBCT) imaging guidance technology to facilitate precise localization of small pulmonary tumors, allowing diagnostic and therapeutic procedures to be performed in a one-step workflow. We report a novel use of the hybrid operating theater with a case of multiple pulmonary metastases managed with combined lung-preserving bronchoscopic microwave ablation and surgical resection in a single setting. A 68-year-old man had a history of recurrent hepatocellular carcinoma with liver transplantation in 2018. One-year surveillance positron emission tomography scan revealed two acetate-avid nodules in the periphery of the right middle lobe and two subcentimeter nodules (9 mm and 5 mm) deep in the anterior segment of the right upper lobe (RUL). Reconstruction with three-dimensional software (Synapse 3D; Fujifilm, Tokyo, Japan) showed anterior segmentectomy of RUL nodules would result in large lung volume loss of 383 mL with a 6.2 mm resection margin (Figure 1) as well as difficulties associated with intraoperative localization. With the intention of lung preservation, a combined bronchoscopic microwave ablation of RUL lesions and surgical resection of right middle lobe lesions was performed. Under general anesthesia with single-lumen endotracheal intubation, on-table fluoroscopy and CBCT scan (Artis Zeego PURE platform; Siemens Healthineer, Erlangen, Germany) confirmed successful navigation by electromagnetic navigation bronchoscopy to within 0.5 cm of the smaller medial RUL lesion. Deployment of the microwave catheter (Emprint; Medtronic, Minneapolis, MN) and calculations showed that both lesions in the RUL were within the predicted ablation zone with good margins (Figure 2). Microwave energy of 100W for 10 minutes was delivered, with a 10-minute postablation CBCT showing capture of both lesions with minimum margin of 4.75 mm (Figure 3A) The endoscopic catheters were removed uneventfully, and the total ablation operative time was 80 minutes.Figure 3(A) Cone-beam computed tomography 10 minutes after ablation showing the ablated area covering both right upper lobe (RUL) lesions, with a minimum ablation margin of 10.48 mm for the large lesion and 4.75 mm for the smaller lesion achieved. (B) Intraoperative photograph showing the postablation whitish changes over the medial aspect of right upper lobe (arrow), and to a lesser degree, the parietal pleura over the mediastinum (asterisk).View Large Image Figure ViewerDownload Hi-res image Download (PPT) In the same operating room setting, after changing to a double-lumen endobronchial tube and repositioning to the left decubitus position, uniportal video-assisted thoracoscopy revealed a whitish postablation area at the medial aspect RUL. Interestingly, the corresponding mediastinum also showed a lesser area of focal heat-related changes (Figure 3B). Wedge resection of both right middle lobe metastatic lesions was performed. The patient recovered uneventfully, and was discharged on postoperative day 2. The right middle lobe lesions were confirmed to be metastatic hepatocellular carcinoma with clear resection margins. A computed tomography scan performed 2 months after the microwave ablation showed characteristic postablation intense ground-glass and consolidation changes in the RUL. His alpha-fetoprotein levels decreased from preoperative level of 10 ng/mL to less than 2 ng/mL at 3 months after the procedure. Multifocal pulmonary metastasis is traditionally a challenge to physicians and surgeons. Heterogeneity in size, location and depth, difficulty in intraoperative localization, and the need for conservation of pulmonary function often negate a patient’s candidacy for surgery. Ideally, all the four metastases should be surgically resected if possible. However, as illustrated in our case by the RUL deep lesions, which required an anterior segmentectomy, the difficulty in getting sufficient margin of resection and the loss of lung volume may preclude or make surgical resection less attractive. Percutaneous ablation could be challenging for small deep lesions, and capturing multiple lesions in the ablation zone is difficult. Right middle lobe lesions in this case were too peripheral and relatively large, and therefore less suited for percutaneous or bronchoscopic ablations. Radiotherapy of multiple lesions encompasses a large radiation field with side effects and postradiotherapy changes that could develop into complications and compromise lung function. Conventionally, multimodal management (eg, localization, video-assisted thorascopy, resection, and energy ablation) for metastases were carried out in separate locations in a staged manner with significant intermodal transfer time or treatment intervals. The hybrid operating room with CBCT can integrate these procedures into a single operation setting.1Ng C.S.H. Man Chu C. Kwok M.W.T. Yim A.P.C. Wong R.H.L. Hybrid DynaCT scan-guided localization single-port lobectomy [corrected].Chest. 2015; 147: e76-e78Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The combination of radiology, interventional bronchoscopy, and minimally invasive surgery allow a tailor-made one-stop management of pulmonary neoplasms, particularly for multiple subcentimeter lesions.2Zhao Z.R. Lau R.W.H. Ng C.S.H. Catheter-based alternative treatment for early-stage lung cancer with a high-risk for morbidity.J Thorac Dis. 2018; 10: S1864-S1870Crossref PubMed Scopus (11) Google Scholar The hybrid operating room carries high setup costs but may be cost effective in the long run, as numerous hospital admissions, operating theater sessions, general anesthesia, interdepartmental transfer, and postoperative inpatient stay can be merged into a single episode. The efficacy of the novel bronchoscopic approach to microwave ablation of peripheral lesions lies in the accurate localization of the pulmonary nodule, and delineation of the ablation zone to achieve adequate ablation margin. On-table CBCT scan allows immediate adjustment of position of the ablation catheter and planning of optimal ablation zone using dedicated software. Some nodules may be difficult to localize even with percutaneous hookwires, and these nodules contraindicate microwave ablation by the percutaneous approach.3Healey T.T. March B.T. Baird G. Dupuy D.E. Microwave ablation for lung neoplasms: a retrospective analysis of long-term results.J Vasc Interv Radiol. 2017; 28: 206-211Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Some nodules may require sacrificing a large proportion of lung volume for complete surgical resection. Endoscopic microwave ablation has the advantage of addressing both these concerns. Moreover, microwave ablation can achieve the same margin as segmentectomy in selected cases, and avoid complications from lung resection such as air leak and bleeding. Furthermore, small lesions requiring localization technique such as electromagnetic navigation bronchoscopy dye marking4Obeso A. Ng C.S.H. Electromagnetic navigation bronchoscopy in the thoracic hybrid operating room: a powerful tool for a new era.J Thorac Dis. 2018; 10: S764-S768Crossref PubMed Scopus (6) Google Scholar or percutaneous hookwire placement5Yu P.S.Y. Man Chu C. Lau R.W.H. et al.Video-assisted thoracic surgery for tiny pulmonary nodules with real-time image guidance in the hybrid theatre: the initial experience.J Thorac Dis. 2018; 10: 2933-2939Crossref PubMed Scopus (12) Google Scholar for surgical resection can be conducted within the hybrid operating room. Although bronchoscopic microwave ablation’s long-term recurrence-free survival is still being investigated, it is a promising lung-conserving alternative or adjunct to pure surgical resection in the management of multiple lung metastases, particularly when lung preservation is desirable. Performing it in the hybrid operating room in conjunction with surgery in the same session represents the state of the art in personalized therapy for select patients. This work was funded by Research Grants Council (RGC) General Research Fund HK, No. 14119019.