Invasive pulmonary aspergillosis secondary to microwave ablation: a multicenter retrospective study

Figures & data

Table 2. Demographic and clinical characteristics of patients.

Characteristics	Patients undergoing MWA (n = 1596)	Patients with IPA (n = 23)	P value
Gender			.037
Male	984 (61.7)	19 (82.6)
Female	612 (38.3)	4 (17.4)
Smoking history
Yes	587 (36.8)	19 (82.6)	<.001
Smoking index >400	381 (23.9)	15 (65.2)	<.001
Underlying disease
COPD	97 (6.1)	13 (56.5)	<.001
Cardiovascular disease	286 (17.9)	7 (30.4)	.175
Malnutrition	153 (9.6)	4 (17.4)	.260
DM	113 (7.1)	2 (8.7)	1.000
HBV	74 (4.6)	1 (4.3)	1.000
Lung tumours			<.001
Primary	931 (58.3)	23 (100.0)
Metastatic	665 (41.7)	0 (0.0)
Perioperative chemotherapy	716 (44.9)	15 (65.2)	.027

Data are presented as number (%) or mean ± SD, unless stated otherwise.

HBV: hepatitis B virus infection.

Table 3. Tumor, ablation, and complication characteristics of 25 lesions in 23 patients with IPA.

Characteristics	Lesion (25)
Mean size of tumor (cm)	3.85 ± 1.50 (1.8–7.2)
Site of tumor
Right upper lobe	10 (40.0)
Right middle lobe	1 (4.0)
Right lower lobe	5 (20.0)
Left upper lobe	7 (28.0)
Left lower lobe	2 (8.0)
Power of ablation
50 W	1 (4.0)
60 W	5 (20.0)
70 W	19 (76.0)
Number of antennae
One	10 (40.0)
Two
Mean time of ablation (min)	13.70 ± 6.63 (4.0–28.0)
GGO size 24–48 hours after ablation (cm)	6.44 ± 1.76 (2.9–9.8)
Complication related to ablation
Postablation syndrome	16 (69.6)
Pneumothorax	9 (39.1)
Pleural effusion	10 (43.5)
Hemoptysis	3 (13.0)
Atelectasis	3 (13.0)

Data are presented as number (%) or mean ± SD (range), unless stated otherwise.

GGO: ground-glass opacity.

Table 4. Symptoms and laboratory and radiological findings of 23 patients with IPA.

Symptom:
Interval between symptom and MWA (days)	21.09 ± 10.90 (7.0–48.0)
Fever	22 (95.7)
≥39 °C	13 (56.5)
<39 °C	9 (39.1)
Cough	23 (100)
Sputum	22 (95.7)
≥100 mL/24 h	12 (52.2)
<100 mL/24 h	10 (43.5)
Hemoptysis	3 (13.0)
Laboratory
White blood cell, 10^9 /L	13.39 ± 3.16 (7.65–19.37)
Hemoglobin, g/dL	10.54 ± 2.94 (6.6–13.7)
Thrombocyte, 10^9/L	340.53 ± 123.02 (108–592)
Positive GM test	14 (60.1)
Radiological findings (chest CT):
Interval between CT and MWA (days)	28.78 ± 9.56 (13.0–54.0)
Mean size of lesions (cm)	7.36 ± 1.94 (4.70–11.10)
Cavitation	20 (87.0)
Infiltration	6 (26.1)
Nodule	6 (26.1)
Consolidation	5 (21.7)
BRF	3 (13.0)

Data are presented as number (%) or mean ± SD (range), unless stated otherwise.

GM: galactomannan; BRF: bronchopleural fistula.

Table 5. Diagnosis, antifungal therapy, and outcomes in 23 patients with IPA after lung MWA.

	IPA Certainty	Risk factor	Chest CT	Type of specimen	Species	Co-infection	Antifungal drug	Adjuvant therapy	Treatment response	Outcome
1	Proven	COPD	Cavitation	Intracavitary fluid, Sputum	A. fumigatus	None	Voriconazole, Itraconazole	Intracavitary lavage	success	alive
2	Probable	Chronic liver disease	Consolidation, Infiltration, BRF	Sputum	A. fumigatus	K. pneumoniae	Voriconazole	Thoracic drainage	failure	dead (infection)
3	Proven	COPD	Cavitation	Histopathological examination, Sputum	A. fumigatus	A. baumannii, S. aureus	Voriconazole	Intracavitary lavage	success	alive
4	Probable	Chemo, DM	Cavitation, Nodules	Sputum	A. fumigatus	None	Voriconazole	None	success	dead (cancer)
5	Probable	Chemo, COPD	Cavitation, BRF	Sputum	A. fumigatus	None	Voriconazole, Itraconazole	Thoracic drainage	success	alive
6	Probable	Chemo, COPD	Cavitation	Sputum	A. fumigatus	None	Voriconazole, Itraconazole	Thoracic drainage	success	dead (cancer)
7	Proven	malnutrition	Cavitation, Infiltration, BRF	Intracavitary fluid, Sputum	A. fumigatus	None	Voriconazole	Intracavitary lavage	failure	dead (infection)
8	Probable	Chemo	Cavitation, Nodules, Infiltration	Sputum	A. fumigatus	None	Voriconazole	Bronchial artery embolization	success	alive
9	Proven	Chemo, COPD	Cavitation	Intracavitary fluid, Sputum	A. fumigatus	K. pneumoniae, Viridans Streptococci	Voriconazole	Intracavitary lavage	success	dead (cancer)
10	Probable	Chemo malnutrition	Cavitation, Consolidation, Infiltration	Sputum	A. fumigatus	S. aureus, E. coli	Voriconazole	None	failure	dead (infection)
11	Probable	Chemo, COPD	Cavitation, Nodules	Sputum	A. fumigatus	None	Itraconazole	None	success	alive
12	Probable	Chemo, COPD, DM	Cavitation, Infiltration	Sputum	A. fumigatus	None	Voriconazole	None	failure	dead (infection)
13	Probable	malnutrition	Consolidation	Sputum	A. fumigatus	None	Voriconazole, Itraconazole	Thoracic drainage	success	alive
14	Proven	Chemo	Cavitation, Nodules	Intracavitary fluid, Sputum	A. fumigatus	None	Voriconazole, Itraconazole	Intracavitary lavage	success	dead (cancer)
15	Probable	Chemo	Cavitation	Sputum	A. fumigatus	None	Voriconazole	None	success	alive
16	Probable	Chemo, COPD	Cavitation	Sputum	A. niger	None	Voriconazole	Thoracic drainage	success	alive
17	Probable	COPD	Cavitation	Sputum	A. fumigatus	None	Voriconazole	None	success	dead (cancer)
18	Proven	COPD	Cavitation, Nodules, Infiltration	Intracavitary fluid, Sputum	A. fumigatus	Acinetobacter lwoffii	Voriconazole	Intracavitary lavage	success	alive
19	Probable	COPD	Cavitation	Sputum	A. fumigatus	K. pneumoniae	Voriconazole	None	failure	dead (hemoptysis)
20	Probable	Chemo	Consolidation	Sputum	A. fumigatus	E. coli	Voriconazole	None	success	alive
21	Probable	malnutrition, COPD	Cavitation, Consolidation	Sputum	A. fumigatus, A. flavus	Viridans streptococci, N. pneumoniae	Voriconazole	None	failure	dead (hemoptysis)
22	Probable	COPD	Cavitation	Sputum	A. terreus	None	Voriconazole	None	success	alive
23	Probable	Chemo	Cavitation, Nodules	Sputum	A. fumigatus	None	Voriconazole	None	success	alive

Chemo: chemotherapy.

Figure 1. (a) A contrast-enhanced CT scan showing a single neoplasm, 3.5 × 2.4 cm, adjacent to mediastinal pleural in the right upper lobe before MWA. (b) MWA was performed at a power of 70 W for an accumulated total time of 11 min. (c) A follow-up CT scan at 24 hours after MWA showing a GGO-like reaction band around the lesion that almost surrounded the entire tumor. (d) At 28 days after MWA, the ablation zone was replaced by a large uneven thick-walled cavity containing a mass of irregular consolidation surrounded by patchy infiltration. (e) A chest CT scan at 6 weeks after MWA showing shrinkage of the cavity, incrassation of the wall, and aggravated infiltration. (f) A chest CT scan at 6 weeks after MWA also showing multiple patchy infiltrations and nodules scattered in both lung fields.

Figure 2. (a) A chest CT image showing a primary tumor 4.5 cm in diameter abutting the thoracic aorta and left lower pulmonary artery in the superior segment of the left lower lobe. (b) Despite a mild pneumothorax, MWA was successfully completed with a power of 70 W for a total of 21 min. (c) A CT scan 3 weeks after MWA showing a thin-walled cavity with an irregular luminal surface in the ablation zone. (d) The same CT scan 3 weeks after MWA showing coexistence of the cavity and nodules with a halo sign in the left upper lobe. (e) The same CT scan 3 weeks after MWA showing consolidation with cavitation in the right upper lobe and an uneven think-walled cavity containing pedunculated contents in the left lower lobe. (f) A CT scan 5 weeks after MWA showing diffuse consolidations with cavitation, infiltrations and nodules in bilateral lungs. (g) The CT scan 5 weeks after MWA showing the cavity emptying inside, as well as nodules enlarged and cavitated in the left upper lobe.

Table 1. Criteria for proven and probable invasive pulmonary aspergillosis.

Category	Type of criteria	Criteria
Proven IPA	Microscopic analysis: sterile material	Histopathologic or cytopathologic examination showing hyphae from needle aspiration or biopsy specimen with evidence of associated tissue damage
	Culture: sterile material	Positive culture result for a sample obtained by sterile procedure from normally sterile and clinically or radiologically abnormal site consistent with infection
Probable IPA	Host factors	Underlying disease, including chronic liver disease, COPD, and/or DM
		Neutropenia after perioperative chemotherapy
		Malnutrition
		Fever refractory to appropriate broad-spectrum antibacterial treatment
	Clinical criteria (signs on CT)	Dense, well-circumscribed lesion(s) with or without a halo sign
		Air-crescent sign
		Cavity
	Mycological criteria
	Direct test	Aspergillus in sputum or bronchoalveolar lavage fluid indicated by 1 of the following: Presence of fungal elements indicating Aspergillus Recovery by culture of Aspergillus
	Indirect tests	Galactomannan antigen detected in plasma, serum, or bronchoalveolar lavage fluid

COPD: chronic obstructive pulmonary disease; DM: diabetes mellitus.