Terrance T. Healey

Distinguishing characteristics between pandemic 2009-2010 influenza A (H1N1) and other viruses in patients hospitalized with respiratory illness.

Background Differences in clinical presentation and outcomes among patients infected with pandemic 2009 influenza A H1N1 (pH1N1) compared to other respiratory viruses have not been fully elucidated. Methodology/Principal Findings A retrospective study was performed of all hospitalized patients at the peak of the pH1N1 season in whom a single respiratory virus was detected by a molecular assay targeting 18 viruses/subtypes (RVP, Luminex xTAG). Fifty-two percent (615/1192) of patients from October, 2009 to December, 2009 had a single respiratory virus (291 pH1N1; 207 rhinovirus; 45 RSV A/B; 37 parainfluenza; 27 adenovirus; 6 coronavirus; and 2 metapneumovirus). No seasonal influenza A or B was detected. Individuals with pH1N1, compared to other viruses, were more likely to present with fever (92% & 70%), cough (92% & 86%), sore throat (32% & 16%), nausea (31% & 8%), vomiting (39% & 30%), abdominal pain (14% & 7%), and a lower white blood count (8,500/L & 13,600/L, all p-values<0.05). In patients with cough and gastrointestinal complaints, the presence of subjective fever/chills independently raised the likelihood of pH1N1 (OR 10). Fifty-five percent (336/615) of our cohort received antibacterial agents, 63% (385/615) received oseltamivir, and 41% (252/615) received steroids. The mortality rate of our cohort was 1% (7/615) and was higher in individuals with pH1N1 compared to other viruses (2.1% & 0.3%, respectively; p = 0.04). Conclusions/Significance During the peak pandemic 2009–2010 influenza season in Rhode Island, nearly half of patients admitted with influenza-like symptoms had respiratory viruses other than influenza A. A high proportion of patients were treated with antibiotics and pH1N1 infection had higher mortality compared to other respiratory viruses.

Microwave ablation devices for interventional oncology

Microwave ablation is one of the several options in the ablation armamentarium for the treatment of malignancy, offering several potential benefits when compared with other ablation, radiation, surgical and medical treatment modalities. The basic microwave system consists of the generator, power distribution system and antennas. Often under image (computed tomography or ultrasound) guidance, a needle-like antenna is inserted percutaneously into the tumor, where local microwave electromagnetic radiation is emitted from the probe’s active tip, producing frictional tissue heating, capable of causing cell death by coagulation necrosis. Half of the microwave ablation systems use a 915 MHz generator and the other half use a 2450 MHz generator. To date, there are no completed clinical trials comparing microwave devices head-to-head. Prospective comparisons of microwave technology with other treatment alternatives, as well as head-to-head comparison with each microwave device, is needed if this promising field will garner more widespread support and use in the oncology community.

Radiofrequency ablation: a safe and effective treatment in nonoperative patients with early-stage lung cancer.

Surgical resection remains the treatment of choice for patients with early-stage non-small cell lung cancer. However, some patients are not surgical candidates because of medical problems. Therefore, alternative therapies are considered in these medically inoperable patients. Radiofrequency ablation has been used clinically for more than 12 years, with many studies reporting its safety and efficacy. Because there are no large prospective clinical trials comparing the efficacy and long-term survival of the different treatment modalities, the choice of therapy is often based on a combination of tumor location, available technology and expertise, and patient preference. Here we review the principles, procedure, follow up, and clinical outcomes published to date on radiofrequency ablation in the treatment of early-stage non-small cell lung cancer.

Use of endobronchial valves for the treatment of bronchopleural fistulas after thermal ablation of lung neoplasms.

Persistent air leaks resulting from bronchopleural fistulas (BPFs) are a rare but serious side effect of thermal ablation. Traditionally, BPFs are treated with surgery; however, patients receiving ablation are often poor surgical candidates and require minimally invasive treatment. The present report describes four cases of BPFs following ablation, which were treated with endobronchial valves (EBVs). In three of the four patients, the pneumothoraces resolved after valve placement. One patient required further treatment with pleurodesis. EBVs can selectively block inspiratory airflow while allowing expiratory flow with drainage of air and secretions. In select patients, EBVs are a viable treatment option for BPFs.

Clear vision through the haze: A practical approach to ground-glass opacity

Ground-glass opacity (GGO) is a common, nonspecific imaging finding on chest computed tomography that may occur in a variety of pulmonary diseases. GGO may be the result of partial filling of alveolar spaces, thickening of the alveolar walls or septal interstitium, or a combination of partial filling of alveolar spaces and thickening of the alveolar walls and septal interstitium at the histopathologic level. Diseases that commonly manifest on chest computed tomography as GGO include pulmonary edema, alveolar hemorrhage, nonspecific interstitial pneumonia, hypersensitivity pneumonitis, and pulmonary alveolar proteinosis. Generating an extensive list of possible causes of GGO in radiologic reports would not be helpful to referring physicians. Preferably, a more concise and focused list of differential diagnostic possibilities may be constructed using a systematic approach to further classify GGO based on morphology, distribution, and ancillary imaging findings, such as the presence of cysts, traction bronchiectasis, and air trapping. Correlation with clinical history, such as the chronicity of symptoms, the patients immune status, and preexisting medical conditions is vital. By thorough analysis of imaging patterns and consideration of relevant clinical information, the radiologist can generate a succinct and useful imaging differential diagnosis when confronted with the nonspecific finding of GGO.

Microwave Ablation for Lung Neoplasms: A Retrospective Analysis of Long-Term Results

PURPOSE To determine the long-term safety and efficacy of microwave (MW) ablation in the treatment of lung tumors at a single academic medical center. MATERIALS AND METHODS Retrospective review was performed of 108 patients (42 female; mean age, 72.5 y ± 10.3 [standard deviation]) who underwent computed tomography (CT)-guided percutaneous MW ablation for a single lung malignancy. Eighty-two were primary non-small-cell lung cancers and 24 were metastatic tumors (9 colorectal carcinoma, 2 renal-cell carcinoma, 4 sarcoma, 2 lung, and 7 other). Mean maximum tumor diameter was 29.6 mm ± 17.2. Patient clinical and imaging data were reviewed. Statistical analysis was performed by Kaplan-Meier modeling and logistic regression. RESULTS Odds of primary technical success were 11.1 times higher for tumors < 3 cm vs those > 3 cm (95% confidence interval [CI], 2.97-41.1; P = .0003). For every millimeter increase in original tumor maximal diameter (OMD), the odds of not attaining success increased by 7% (95% CI, 3%-10%; P = .0002). For every millimeter increase in OMD, the odds of complications increased by 3% (95% CI, 0.1%-5%; P = .04). Median time to tumor recurrence was 62 months (95% CI, 29, upper bound not reached; range, 0.2-96.6 mo). Recurrence rates were estimated at 22%, 36%, and 44% at 1, 2, and 3 years, respectively. Recurrence rates were estimated at 31% at 13 months for tumors > 3 cm and 17% for those < 3 cm. Complications included pneumothorax (32%), unplanned hospital admission (28%), pain (20%), infection (7%), and postablation syndrome (4%). CONCLUSIONS This study further supports the safe and effective use of MW ablation for the treatment of lung tumors.

Case records of the Massachusetts General Hospital. Case 1-2011. A 35-year-old man with fever, bacteremia, and a mass in the left atrium.

Dr. John Chorba (Medicine): A 35-year-old man was admitted to the hospital because of fever, bacteremia, and a mass in the left atrium. The patient was healthy until 13 days before admission when shaking chills developed, associated with rigors, intermittent fevers (temperatures of up to 38.9°C), frontal headache, nonproductive cough, nausea, vomiting, and weight loss. Six days before admission, he was seen at another hospital. On examination, the temperature was 37.7°C, the blood pressure 119/68 mm Hg, the pulse 108 beats per minute, and the oxygen saturation 98% while he was breathing ambient air. The physical examination was normal. Laboratory-test results are shown in Table 1. Urinalysis revealed 10 to 15 red cells and 1 to 3 white cells per high-power field and was otherwise normal. A chest radiograph was normal. Computed tomography (CT) of the abdomen and pelvis reportedly revealed multiple foci of diminished enhancement in the right renal cortex, with mild perinephric fat stranding, thought to represent acute pyelonephritis, and no hydronephrosis or abscess. The patient was admitted to the other hospital. Cultures of the urine and blood were obtained, and levofloxacin was administered. On the second day, rigors were observed and the administration of vancomycin and ceftriaxone was begun. Ultrasonography of the abdomen was normal. Bloodculture results are shown in Table 2. Ampicillin was added, but fevers and rigors persisted. On the third day, a chest radiograph and CT scans of the head were normal. On the fourth day, ertapenem was begun and all other antibiotics were discontinued. The next day, a repeat CT scan of the abdomen and pelvis showed findings that were thought to be consistent with evolving pyelonephritis. On the seventh day, transesophageal echocardiography reportedly revealed a mobile, rectangular echodensity (1.6 cm by 0.5 cm) attached to the nonseptal side of the left atrium, an echodensity in the left atrial appendage, a mildly thickened mitral valve with possible vegetation, and additional echogenic material in the wall of the descending thoracic aorta. A chest radiograph and abdominal ultrasonogram were normal. The patient was transferred to this hospital. The patient had had septic bursitis caused by methicillin-sensitive Staphylococcus aureus 4 years earlier, L4–L5 vertebral diskectomy 6 years earlier, and multiple dental Case 1-2011: A 35-Year-Old Man with Fever, Bacteremia, and a Mass in the Left Atrium

Case 1-2011

Dr. John Chorba (Medicine): A 35-year-old man was admitted to the hospital because of fever, bacteremia, and a mass in the left atrium. The patient was healthy until 13 days before admission when shaking chills developed, associated with rigors, intermittent fevers (temperatures of up to 38.9°C), frontal headache, nonproductive cough, nausea, vomiting, and weight loss. Six days before admission, he was seen at another hospital. On examination, the temperature was 37.7°C, the blood pressure 119/68 mm Hg, the pulse 108 beats per minute, and the oxygen saturation 98% while he was breathing ambient air. The physical examination was normal. Laboratory-test results are shown in Table 1. Urinalysis revealed 10 to 15 red cells and 1 to 3 white cells per high-power field and was otherwise normal. A chest radiograph was normal. Computed tomography (CT) of the abdomen and pelvis reportedly revealed multiple foci of diminished enhancement in the right renal cortex, with mild perinephric fat stranding, thought to represent acute pyelonephritis, and no hydronephrosis or abscess. The patient was admitted to the other hospital. Cultures of the urine and blood were obtained, and levofloxacin was administered. On the second day, rigors were observed and the administration of vancomycin and ceftriaxone was begun. Ultrasonography of the abdomen was normal. Bloodculture results are shown in Table 2. Ampicillin was added, but fevers and rigors persisted. On the third day, a chest radiograph and CT scans of the head were normal. On the fourth day, ertapenem was begun and all other antibiotics were discontinued. The next day, a repeat CT scan of the abdomen and pelvis showed findings that were thought to be consistent with evolving pyelonephritis. On the seventh day, transesophageal echocardiography reportedly revealed a mobile, rectangular echodensity (1.6 cm by 0.5 cm) attached to the nonseptal side of the left atrium, an echodensity in the left atrial appendage, a mildly thickened mitral valve with possible vegetation, and additional echogenic material in the wall of the descending thoracic aorta. A chest radiograph and abdominal ultrasonogram were normal. The patient was transferred to this hospital. The patient had had septic bursitis caused by methicillin-sensitive Staphylococcus aureus 4 years earlier, L4–L5 vertebral diskectomy 6 years earlier, and multiple dental Case 1-2011: A 35-Year-Old Man with Fever, Bacteremia, and a Mass in the Left Atrium

Percutaneous Thermal Ablation for Small-Cell Lung Cancer: Initial Experience with Ten Tumors in Nine Patients

PURPOSE To evaluate outcomes in a small cohort of patients with local or disseminated small-cell lung cancer (SCLC) who received percutaneous thermal ablation therapy. MATERIALS AND METHODS Ten biopsy-proven SCLC tumors in 9 consecutive patients (5 men, 4 women; average age, 73.8 y ± 12.4) were retrospectively evaluated. Average tumor sizes were 1.8 cm ± 0.5 and 2.6 cm ± 1.2 among patients with local and disseminated disease, respectively. Microwave and radiofrequency ablation were each used for 5 tumors. None of the patients with local SCLC received adjuvant therapy following thermal ablation. Median follow-up duration was 16 months (range, 2-48 mo). Median and 1-year overall survival (OS) were compared for patients in the local and disseminated disease groups. RESULTS Median and 1-year OS were better among patients treated for local SCLC compared with disseminated disease (47.0 vs 5.5 mo and 3 [100%] vs 2 [40%], respectively). Pneumothorax occurred in 5 patients (55.6%), and 3 patients received successful outpatient thoracostomy tube placement. No patients were hospitalized, and there were no major complications. CONCLUSIONS This preliminary analysis suggests favorable outcomes in selected patients with local SCLC who undergo percutaneous thermal ablation without adjuvant therapy.

Stabilization of Mobile Pulmonary Nodules During Radiofrequency Ablation

OBJECTIVE Lung tumors can exhibit a high degree of mobility during insertion of radiofrequency applicators owing to both respiratory motion and the inherent characteristics of pulmonary parenchyma. The purpose of this report is to describe a technique used to secure lung tumors during insertion of a radiofrequency applicator. CONCLUSION As experience with percutaneous imaging-guided radiofrequency ablation increases, technical challenges become increasingly apparent. A technique whereby a mobile pulmonary tumor is anchored prior to placement of the ablation electrode is one method of overcoming such a challenge.