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Radiofrequency Ablation of Metastatic Mediastinal Lymph Nodes during Cooling and Temperature Monitoring of the Tracheal Mucosa to Prevent Thermal Tracheal Damage: Initial Experience¹

¹ From the Departments of Radiology (T.H., K.Y., H.M., H.G., T.M., S.H., H.F., N. Tajiri, S.K.), Gastroenterological Surgery, Transplant, and Surgical Oncology (Y.N., T.Y., Y.S., S.A., N. Tanaka), and Anesthesiology and Resuscitology (H.N., M.H., K.M.), Okayama University Medical School, 2-5-1 Shikatacho, Okayama 700-8558, Japan. Received February 11, 2005; revision requested April 11; revision received April 19; accepted June 1. Address correspondence to T.H. (e-mail: takaoh{at}tc4.so-net.ne.jp).

View larger version (156K): [in a new window]   Figure 1a. (a) The endotracheal tube used for cooling and temperature monitoring of the tracheal mucosa. The thermocouple passes through the evacuation lumen (small arrows). The tip of the thermocouple (large arrow) extends from an opening (arrowhead) in the lumen and is attached to the surface of the inflated cuff with a piece of adhesive dressing. (b) Time curve of the temperature of tracheal mucosa measured with thermocouple. Before ablation, the temperature is decreased to 24°C. After RF application is initiated, the temperature increases rapidly to 33°C and then an exchange of saline decreases the temperature nearly to baseline. The temperature increase and subsequent decrease by saline exchange are repeated throughout RF application.

View larger version (18K): [in a new window]   Figure 1b. (a) The endotracheal tube used for cooling and temperature monitoring of the tracheal mucosa. The thermocouple passes through the evacuation lumen (small arrows). The tip of the thermocouple (large arrow) extends from an opening (arrowhead) in the lumen and is attached to the surface of the inflated cuff with a piece of adhesive dressing. (b) Time curve of the temperature of tracheal mucosa measured with thermocouple. Before ablation, the temperature is decreased to 24°C. After RF application is initiated, the temperature increases rapidly to 33°C and then an exchange of saline decreases the temperature nearly to baseline. The temperature increase and subsequent decrease by saline exchange are repeated throughout RF application.

View larger version (102K): [in a new window]   Figure 2a. Metastatic mediastinal lymph node from esophageal cancer in a 60-year-old man. (a) Contrast material–enhanced transverse CT image obtained before ablation shows metastatic lymph node (arrow) of 1.8 cm in largest diameter in contact with the trachea in left superior mediastinum. Arrowhead = subcutaneously reconstructed stomach. (b) Transverse CT fluoroscopic image obtained during ablation shows the electrode (arrow) inserted into the lymph node immediately above the jugular notch of the sternum through the reconstructed stomach. Note the cuff inflated with saline (arrowheads) inside the trachea. The saline is contaminated by air bubbles. (c) Transverse contrast-enhanced CT image at 16 months shows the lymph node (arrow) decreasing in size without contrast enhancement, which indicates complete ablation.

View larger version (120K): [in a new window]   Figure 2b. Metastatic mediastinal lymph node from esophageal cancer in a 60-year-old man. (a) Contrast material–enhanced transverse CT image obtained before ablation shows metastatic lymph node (arrow) of 1.8 cm in largest diameter in contact with the trachea in left superior mediastinum. Arrowhead = subcutaneously reconstructed stomach. (b) Transverse CT fluoroscopic image obtained during ablation shows the electrode (arrow) inserted into the lymph node immediately above the jugular notch of the sternum through the reconstructed stomach. Note the cuff inflated with saline (arrowheads) inside the trachea. The saline is contaminated by air bubbles. (c) Transverse contrast-enhanced CT image at 16 months shows the lymph node (arrow) decreasing in size without contrast enhancement, which indicates complete ablation.

View larger version (96K): [in a new window]   Figure 2c. Metastatic mediastinal lymph node from esophageal cancer in a 60-year-old man. (a) Contrast material–enhanced transverse CT image obtained before ablation shows metastatic lymph node (arrow) of 1.8 cm in largest diameter in contact with the trachea in left superior mediastinum. Arrowhead = subcutaneously reconstructed stomach. (b) Transverse CT fluoroscopic image obtained during ablation shows the electrode (arrow) inserted into the lymph node immediately above the jugular notch of the sternum through the reconstructed stomach. Note the cuff inflated with saline (arrowheads) inside the trachea. The saline is contaminated by air bubbles. (c) Transverse contrast-enhanced CT image at 16 months shows the lymph node (arrow) decreasing in size without contrast enhancement, which indicates complete ablation.

View larger version (150K): [in a new window]   Figure 3a. Metastatic mdiastinal lymph node from esophageal cancer in a 57-year-old man. (a) Transverse CT fluoroscopic image obtained during ablation with patient in prone position shows the electrode inserted into the lymph node (arrows) along the vertebral body from the posterior chest wall. Note the cuff inflated with saline (arrowheads) inside the trachea. The saline is contaminated by air bubbles. (b) Transverse contrast-enhanced CT image at 9 months shows the lymph node (arrows) decreasing in size without contrast enhancement, which indicates complete ablation. Arrowhead = lung metastasis. (c) Transverse contrast-enhanced CT image at 11 months shows the lymph node (arrows) enlarging with contrast enhancement, which indicates local progression. Arrowhead = lung metastasis.

View larger version (122K): [in a new window]   Figure 3b. Metastatic mdiastinal lymph node from esophageal cancer in a 57-year-old man. (a) Transverse CT fluoroscopic image obtained during ablation with patient in prone position shows the electrode inserted into the lymph node (arrows) along the vertebral body from the posterior chest wall. Note the cuff inflated with saline (arrowheads) inside the trachea. The saline is contaminated by air bubbles. (b) Transverse contrast-enhanced CT image at 9 months shows the lymph node (arrows) decreasing in size without contrast enhancement, which indicates complete ablation. Arrowhead = lung metastasis. (c) Transverse contrast-enhanced CT image at 11 months shows the lymph node (arrows) enlarging with contrast enhancement, which indicates local progression. Arrowhead = lung metastasis.

View larger version (104K): [in a new window]   Figure 3c. Metastatic mdiastinal lymph node from esophageal cancer in a 57-year-old man. (a) Transverse CT fluoroscopic image obtained during ablation with patient in prone position shows the electrode inserted into the lymph node (arrows) along the vertebral body from the posterior chest wall. Note the cuff inflated with saline (arrowheads) inside the trachea. The saline is contaminated by air bubbles. (b) Transverse contrast-enhanced CT image at 9 months shows the lymph node (arrows) decreasing in size without contrast enhancement, which indicates complete ablation. Arrowhead = lung metastasis. (c) Transverse contrast-enhanced CT image at 11 months shows the lymph node (arrows) enlarging with contrast enhancement, which indicates local progression. Arrowhead = lung metastasis.

View larger version (115K): [in a new window]   Figure 4a. Metastatic mediastinal lymph node from esophageal cancer in a 75-year-old man. (a) Transverse CT fluoroscopic image obtained during second ablation session shows the electrode (large arrow) inserted into the lymph node immediately above the jugular notch of the sternum. Note that the cuff (arrowheads) is not inflated inside the trachea at this level. Small arrow = feeding tube inside the reconstructed stomach. (b) Transverse contrast-enhanced CT image 1 month after second ablation shows air leakage (large arrow) from a defect in the posterior tracheal wall. The periphery of the lymph node (arrowhead) shows contrast enhancement, which indicates incomplete ablation. Small arrow = reconstructed stomach.

View larger version (116K): [in a new window]   Figure 4b. Metastatic mediastinal lymph node from esophageal cancer in a 75-year-old man. (a) Transverse CT fluoroscopic image obtained during second ablation session shows the electrode (large arrow) inserted into the lymph node immediately above the jugular notch of the sternum. Note that the cuff (arrowheads) is not inflated inside the trachea at this level. Small arrow = feeding tube inside the reconstructed stomach. (b) Transverse contrast-enhanced CT image 1 month after second ablation shows air leakage (large arrow) from a defect in the posterior tracheal wall. The periphery of the lymph node (arrowhead) shows contrast enhancement, which indicates incomplete ablation. Small arrow = reconstructed stomach.