Clin Transl Oncol (2013) 15:830–835
DOI 10.1007/s12094-013-1011-7
RESEARCH ARTICLE
Study of survival in patients with malignant lung lesions treated
with radiofrequency
J. M. Galbis Caravajal • J. Jornet Fayos • M. Cuenca Torres • E. Mollá Olmos
M. Estors Guerrero • F. Sánchez Garcı́a • N. J. Martinez Hernandez •
R. Esturi Navarro • A. Pastor del Campo • M. Vaño Molina
Received: 4 December 2012 / Accepted: 21 January 2013 / Published online: 22 March 2013
Ó Federación de Sociedades Españolas de Oncologı́a (FESEO) 2013
Abstract
Objective To report on the survival of a series of patients
with primary and metastatic lung tumours treated with
radiofrequency (RF). Four years ago we published our
preliminary experience with the use of this technique.
Materials and methods For a period of 8 years we have
treated 59 patients (by means of a total of 70 procedures)
with primary or metastatic pulmonary neoplastic lesions,
which fulfilled inclusion criteria to perform the technique.
They were in all cases non-surgical lesions that had been
either previously treated or not. The technique was
J. M. Galbis Caravajal
M. Estors Guerrero

N. J. Martinez Hernandez
Department of Thoracic Surgery, La Ribera University Hospital,
Alcira, Valencia, Spain
J. M. Galbis Caravajal
M. Estors Guerrero

N. J. Martinez Hernandez
School of Medicine, San Vicente Mártir Catholic University,
Valencia, Spain
J. M. Galbis Caravajal (&)
Servicio de Cirugı́a Torácica, Hospital Universitario de La
Ribera, Crt. Corbera Km1, 46600 Alcira, Valencia, Spain
e-mail: jgalbis@hospital-ribera.com
J. Jornet Fayos
E. Mollá Olmos
A. Pastor del Campo

M. Vaño Molina
Department of Radiodiagnostics, La Ribera University Hospital,
Alcira, Valencia, Spain
M. Cuenca Torres
Research and Educational Unit, La Ribera University Hospital,
Alcira, Valencia, Spain
F. Sánchez Garcı́a
R. Esturi Navarro
Department of Anaesthesia Intensive Care and Pain
Management, La Ribera University Hospital, Alcira,
Valencia, Spain
123
•
performed in the radiology suite, under conscious analgo-
sedation. We treated primary pulmonary lesions, neoplastic
recurrences, or metastases with curative or palliative
intention (pain management).
Results Current global survival rate is 19 patients (32 %)
with a mean of 26.61 ± 3.17 months (range: 20.38 ±
32.83) and a median of 16.00 ± 3.57 (range: 8.99–23.00).
If we establish the difference between primary and meta-
static tumours, mean survival is 27.62 ± 4.12 months in
primary tumours (median: 16.00) vs. 24.65 ± 4.47 months
in metastatic tumours (median: 16.00). When we studied
the survival in those cases with a curative intent, mean
survival in primary tumours was 30.97 ± 4.57 months
(median: 21.00) vs. 25.14 ± 4.68 (median: 16.00) months
in metastatic tumours.
Conclusions RF ablation of lung lesions is a minimally
invasive procedure that is useful in primary tumours
(especially in stage I) and metastatic ones. RF has proven
its usefulness in the multidisciplinary treatment of this
pathology due to the low incidence of serious complica-
tions and survival obtained, considering that patients are
elderly with significant comorbidity.
Keywords Radiofrequency ablation
Primary lung
carcinoma
Lung metastases
Introduction
Bronchogenic carcinoma (BC) remains the leading cause
of death in men and women [1]. Surgical resection is the
treatment of choice in early stages of BC and in pulmonary
metastatic disease, provided preoperative evaluation and
staging allow it [2]. In the early stages of BC, 5-year sur-
vival rate exceeds 70 % with the previous treatment and in
Clin Transl Oncol (2013) 15:830–835 831

Table 1 Inoperability criteria for BC according to the American Table 2 Contingency table: type of tumour/RF intent
College of Surgeons Oncology Group
Lung tumour Total
Major criteria (1 criterion indicates inoperability)
Pulmonar Metastatic
FEV1 B50 % of predicted
DLCO C50 % of predicted RF goal
Minor criteria (2 criteria indicate inoperability) Curative
Age C75 years Count 31 21 52
FEV1 51–60 % of predicted % Within RF intent 59.6 % 40.4 % 100.0 %
DLCO 51–60 % of predicted Palliative
Pulmonary HT Count 5 2 7
Left ventricular ejection fraction B40 % % Within RF intent 71.4 % 28.6 % 100.0 %
PCO2 [45 mmHg Total
O2 saturation by pulse oximetry B88 % Count 36 23 59
PO2 B55 mmHg % Within RF intent 61.0 % 39.0 % 100.0 %

the case of lung metastases 36 % after complete resection
[3]. But many patients are not candidates for surgery [4]
(Table 1): the increase in life expectancy in developed
countries makes patients increasingly older at the time of
diagnosis, which added to present comorbidity increases
the number of contraindications to surgery.
The recent development of ‘‘minimally invasive’’ [5]
therapies opened a new perspective in the treatment of BC
(early stage) and non-surgical pulmonary metastatic
lesions. The ablation of lesions by radiofrequency (RF) was
considered one of the minimally invasive therapies [6] and
was used successfully in the treatment of carcinomas of
multiple localizations [7].
The technique based on the evidence of an adequate
local control of disease in a selected population [8] has also
found use in the palliation of symptoms and as comple-
mentary with other therapies.
The application of RF in the lung has been favored by
the physical and chemical characteristics of the lung
parenchyma, which allows an adequate distribution of the
ionic agitation caused by the percutaneous guide with
appropriate target tissue destruction and necrosis [9].
Our hospital, with expertise on the procedure in the lungs,
receives patients from various centers for evaluation and
implementation of the procedure. This has allowed us to
accumulate a number of cases that we analyze in this paper. We
published our preliminary findings with this technique 4 years
ago [10], and discussed the procedure itself. The aim of this
paper is to present the survival of the current series of patients.
Materials and methods
Patient selection
We have treated 59 patients (with a total of 70 procedures)
with neoplastic primary or metastatic lung lesions in the
course of 8 years, with a curative intent (local treatment of
the lesion with the aim to destroy it) or palliative intention
(local treatment of a lesion aiming to avoid complications
from growth involving adjacent structures).
Ablation was performed with curative intent in 52 cases
(Table 2). This paper presents patients with malignant pri-
mary or secondary lung tumours, although from a functional
standpoint the application of RF in both groups is the same.
Anesthetic technique
All patients were evaluated at pre-anesthesia consultation
with a complete preoperative study. They were informed of
the anesthetic technique, possible complications and signed
the informed consent form.
We conducted a conscious analgosedation, with mini-
mal depression of the level of consciousness allowing the
patient to stay awake without the need for respiratory
support, so that the patient could receive and respond to
simple commands, combined or not with other techniques
(Table 3). The objective was to administer conscious
sedation to the patient in a safe, comfortable way with a
quick recovery and minimal effects.
No anesthetic complications were observed except in
two orotracheal intubations: a case of uncontrollable pain
and lack of cooperation of the patient and another case of
severe bronchospasm.
Table 3 Anesthetic technique
Anesthetic technique Frequency Percentage
Sedation 42 71.2
Sedation ? paravertebral block 13 22.0
Sedation ? CPAP 2 3.4
Orotracheal intubation 2 3.4
Total 59 100.0

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Statistical study of survival arrhythmias (43 %), advanced COPD (28 %), cirrhosis
(18 %), 6 patients were older than 80.
We performed a survival analysis using the Kaplan–Meier The primary carcinoma for the metastases that we
survival plots method. The comparison of survival as a treated was: colorectal (18), kidney (3), esophagus (1), and
function of the intention of the technique (curative/pallia- larynx (1).
tive) and the type of tumour (primary/metastatic) was
performed by the Long-Rank test. Values of p B 0.05 were Complications and immediate follow-up
considered significant. The program used for statistical
analysis was SPSS 19. Complications and their treatment are shown in Table 5. In
those cases of pneumothorax that required drainage, the
catheter (8F diameter) was placed in the same radiology
Results suite.
Following the completion of the ablation, the patient
Patients was later taken to the recovery room in the hospital ward.
The mean stay was 1.79 days (range 1–20 days). The
The series includes (Table 4) 56 men with a mean age of chest tubes for pneumothorax were removed after 24 h, and
71.08 ± 9.93 years (range 43–87 years). The mean size of patients were discharged on the same day, except in two
the lesions was 2.63 ± 1.19 cm (range: 0.6–7). cases: 1 with continuous leaking for 12 days and 2 that
In 36 cases (61 %) patients had primary lung carcino- required surgical closure of the lung fistula tract.
mas, and 23 patients were treated for metastatic lesions. In
primary carcinomas, associated morbidity was varied: Survival study
ischaemic heart disease (71 %), hypertension (86 %),
Current overall survival is 19 patients (32 %) with a
mean of 26.61 ± 3.17 months (range: 20.38 ± 32.83), and
Table 4 Characteristics of patients in the study a median of 16.00 ± 3.57 (range: 8.99–23.00).
Characteristic Result In cases of curative intent, mean survival was
28.96 ± 3.43 months (range: 22.24–35.69) and median
Age
21.00 ± 5.10. In palliative cases, mean survival dropped
Mean 71.08 dramatically to: 8.71 ± 1.77 months; median: 11.00 ± 3.14
Median 72 months (Fig. 1).
Range 43–87 years
Male/female ratio 56/3
Mean tumour size 2.63 ± 1.19 cm
Range 0.6–7 cm Table 5 RF complications in our series
Intent Complication Number Treatment
Curative 52 cases
Pneumothorax 10 7 drainage/3
Palliative 7 cases conservative
Type of carcinoma Pleural effusion 12 –
Primary, stage I 32 cases Perilesional pneumonitis 9 Oral antibiotics 7 days
Primary, stage other than I 4 cases Orotracheal intubation due to 2 Immediate extubation
Metastatic 23 cases poor test tolerance after RF
Radiofrequency treatments/patient Bronchospasm 2 Bronchodilation
1 RF/patient 50 patients Intraparenchymal haemorrhage 2 Oral antibiotics
2 RF/patient 7 patients 7 days ? oral
corticosteroids
3 RF/patient 2 patients
Axonal degeneration of primary 1 –
Histology of primary carcinomas
trunk of the brachial plexus
Squamous 10 cases
Persistent air leak with 2 Surgery
Adenocarcinomas 18 cases subcutaneous emphysema
Other 8 cases Haemoptysis which requires 1 Conservative
Mean FEV1 62.79 % admission
Mean FEV1 in primary carcinomas 46.31 % Pericarditis 1 Conservative
Mean FEV1 in metastatic carcinomas 71.69 % Pulmonary embolism [1 month 1 Anticoagulation

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Clin Transl Oncol (2013) 15:830–835
Fig. 1 Patient survival based on RF intent
Fig. 2 Survival in cases of primary tumour/metastasis
Comparing primary and metastatic tumours (Fig. 2),
mean survival was 27.62 ± 4.12 months for primary
tumours (median: 16.00), and 24.65 ± 4.47 months for
metastatic tumours (median: 16.00).
When we studied the survival in those cases with
curative intent, mean survival in primary tumours was
30.97 ± 4.57 months (median: 21.00) vs. 25.14 ± 4.68
(median: 16.00) months in metastatic tumours.
Discussion
This paper presents patients with malignant primary or
secondary lung tumours. Although from a functional
standpoint the application of RF in both groups is the same,
results should be analyzed separately given the importance
of the findings.
833
In the case of BC, surgery continues to be the best
treatment. Table 1 reflects the criteria of inoperability for
BC established by the American College of Surgeons
Oncology Group [11]. In patients not amenable to surgery,
emerging technologies such as stereotactic radiosurgery or
RF play an increasingly prominent role [12].
Lobectomy is considered the technique of choice [11, 12]
in the surgical treatment of stage I lung cancer. Although
sublobar resection (segmentectomy/atypical resection-
wedge) is evaluated in patients who cannot tolerate lobec-
tomy, the study by the Lung Cancer Study Group [11]
showed an increase of 75 % in local recurrence and a trend
toward shorter survival in cases of sublobar resection.
Where surgery is not prescribed, the guidelines of the
American College of Chest Physicians [13] advise radio-
therapy, which has a 5-year survival rate about 40 % [14]
and can cause associated complications such as pneumo-
nitis [15]. Other techniques such as stereotactic radiosur-
gery (useful in central lesions) are still under consideration
and are offering similar results to sublobar resection [16].
In our series of lung cancer cases treated with RF,
patients had contraindications to surgery for various rea-
sons, the most common being poor respiratory functional
reserve.
A dilemma arises when considering the use of RF or
sublobar resection when lobectomy is not possible [17]. A
recent study [18] compared sublobar resection with abla-
tive therapies such as RF and determined a 3-year survival
probability of 87.1 % (sublobar) vs. 87.5 % (RF) when
treating patients with stage I lung cancer. The series was
very small (25 vs. 12 patients) but opens an interesting
debate in this patient population. In our opinion, RF with
curative intent is indicated in patients with early stage BC
where present comorbidity discourages any type of surgical
exploration or expected resection margins are less than
1 cm [19]. Surgery has shown, in other circumstances and
even with sublobar resection, few complications and has
allowed the possibility of adding a suitable mediastinal
lymphadenectomy (grade of recommendation 1B) [11]. In
our series, the mean survival of BC patients after applying
RF with curative intent was 30.97 ± 4.57 months. During
the same study period, we performed 15 sublobar resec-
tions in patients with BC stage I: the mean survival of these
patients was 54 months (median: 55.7 months).
RF is often used in stage I of BC [17], but some patients
with local tumour progression, where other therapies have
already been implemented such as surgery, chemotherapy,
or radiotherapy [20], can also benefit from this technique.
In the literature, there are no studies concerning this het-
erogeneous group, with isolated cases being mentioned in
various series, and contributing only five cases in ours.
In cases of pulmonary metastases, the potential benefit
of pulmonary metastasectomy has been widely confirmed
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834
[21, 22]. An international study published in 1997 showed
a 5-year survival of 36 % [3] after metastasectomy, and is
therefore considered as the treatment of choice whenever
possible. The criteria used to treat metastases with RF and
curative intent are the same as those applied to the surgical
treatment. In our series, the mean survival of patients
treated with curative intent was 25.14 ± 14 months.
For this reason, RF plays the most predominant role in
the management of lung metastases in patients who cannot
undergo complete resection surgery, and where local con-
trol of one or more specific lesions is sought.
In this case, the group becomes even more heteroge-
neous depending on the primary tumour, among other
variables. As we know, colorectal cancer often affects the
lungs in the course of the disease [21]. In our series, the
primary tumour of metastatic carcinoma was colorectal
cancer in most cases: current survival rates of metastatic
colorectal carcinoma and frequent metastatic recurrence, in
lung and liver, along the course of the disease, determine
the special relevance of RF in this case.
All of the above is meaningless if the technique would
cause a number of complications that would render it
unfeasible; however, morbi-mortality resulting from this
technique is very low. As we mentioned, the complications
in our series are shown in Table 5: pneumothorax is the
most frequent, as other authors have also noted [12, 23,
24]. We used a CT-guided small-caliber catheter (8F) [25]
to drain them immediately.
The protracted postablation pain mentioned by several
authors has had little impact in our series: the intervention
of the anesthesiologist delivering conscious sedation [26]
has greatly influenced this outcome using ultrasound-gui-
ded paravertebral catheters, achieving optimal pain control,
and therefore maximum patient cooperation. Moreover,
pain after RF (due to parietal pleura involvement, which is
richly innervated) has been controlled with oral analgesia
within a few days in our cases; all of them were caused by
tumours with pleural involvement.
Pleural effusion was present in 20 % of the cases
(needing only outpatient follow-up) with very good toler-
ance and subacute development [27].
Perilesional pneumonitis, attributed to the pulmonary
burn and/or bleeding secondary to the catheter insertion,
was well tolerated by the patients [28], and although
sometimes attended with fever, was easily controlled with
antibiotics. In our series, 1 patient with lesion cavitation
and dual antiagregation therapy due to added comorbidity
had a haemoptysis episode (self-limited, but requiring
admission) 2 months after the procedure. We had 2 patients
with persistent air leak who required surgery: one of them
had previously undergone thoracotomy and pulmonary
resection, using RF on a relapse; the other had the lesion
excised by atypical resection because the fistula originated
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Clin Transl Oncol (2013) 15:830–835
in the tumour where the electrode was introduced. Both
were patients with serious bullous emphysema and poor
respiratory functional reserve (FEV1 of 22 and 18 %).
There was no mortality within 30 days after completion of
the RF procedure.
The survival rate and low incidence of serious compli-
cations, considering that it refers to elderly patients with
important comorbidity, prove the usefulness of RF in the
multidisciplinary treatment of that pathology.
When the results are compared with other techniques
such as sublobar resection or BC stage I radiotherapy,
diverse expectations are raised with interesting projects for
the immediate future [29].
In conclusion, we state that RF ablation of lung lesions is
a minimally invasive procedure useful in primary tumours
(especially in stage I) and metastatic ones. Increased
population longevity, together with the effectiveness of
the treatment of disseminated disease, are variables that
encourage us to have RF more present every day as an
alternative in the management of lung malignant neoplasms.
Conflict of interest None.
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