Clinical pathway for impalpable or small lung lesions treated with coil marking and thoracoscopy

CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is standard of care for small lung resections at many centres. Computed tomography (CT)-guided insertion of microcoils can aid surgeons in performing VATS resections for non-palpable lung nodules deep to the lung surface.

METHODS

Retrospective analysis of CT-guided microcoil insertions prior to VATS lung resection at a single institution from October 2008 to January 2014.

RESULTS

A total of 63 patients were included (37% male, mean age 61.6±11.4 years). Forty-two patients (67%) had a history of smoking, with 10 current smokers. Sixty one (97%) patients underwent wedge resection and 3 (5%) patients had segmentectomy. Three (5%) patients required intra-operative staple line re-resection for positive or close margins. Eleven (17%) patients had a completion lobectomy, 5 of which were during the same anaesthetic. The average time between the CT-guided insertion and start of operation was 136.6±89.0 min, and average operative time was 84.0±53.3 min. The intra-operative complication rate was 5% (n=3), including 1 episode of hemoptysis, and 2 conversions to thoracotomy. The post-operative complication rate was 8% (5 patients), and included 2 air leaks, 1 hemothorax (drop in hemoglobin), 1 post chest tube removal pneumothorax, and one venous infarction of the lingula after lingula-sparing lobectomy requiring completion lobectomy. . Average post-operative length of stay was 2.2 days. A diagnosis was made for all patients.

CONCLUSIONS

CT-guided microcoil insertion followed by VATS lobectomy is safe, with short operative times, short length of stay and 100% diagnosis of small pulmonary nodules. This technique will become more important in the future with increasing numbers of small nodules detected on CT as part of lung cancer screening programs.

Comparisons of clinical outcomes in patients with and without a preoperative tissue diagnosis in the persistent malignant-looking, ground-glass-opacity nodules

To evaluate the clinical usefulness of surgical resection of persistent malignant-looking ground-glass-opacity nodules (GGN) without a preoperative tissue diagnosis.From September 1998 to November 2011, we retrospectively enrolled 288 patients (126 men, 162 women; mean age, 59.3 years) with lung adenocarcinoma proven by surgery and which appeared as GGN on chest computed tomography (CT, ground-glass-opacity [GGO] proportion >20%). We divided the study subjects into 2 groups: patients with a preoperative tissue diagnosis (PTD group, n = 207) and patients without a preoperative tissue diagnosis (No-PTD group, n = 81). In patients with GGN having GGO ≥ 90% (n = 140), we divided them into 2 groups: PTD group (n = 83) and No-PTD group (n = 57). The clinical and surgical outcomes were compared between the 2 groups.In 204 patients who underwent lobectomy for stage Ia lung cancer, there was no significantly different recurrence-free survival between the 2 groups (P = 0.721). A significantly lower percentage of No-PTD group waited >14 days for surgery (77.8% vs 87.9%, P = 0.030) and were hospitalized for >7 days (56.8% vs 89.9%, P < 0.001). They showed a shorter mean surgery time (136.9 vs 155.0 minutes, P = 0.019). In patients with GGN having GGO ≥ 90%, the results were the same as those of all of the study subjects.No-PTD group can gain benefits perioperatively, showing no different recurrence-free survival with PTD group in stage Ia lung cancer.

Preoperative marking of musculoskeletal tumors guided by magnetic resonance imaging

BACKGROUND

The purpose of this study was to evaluate a new stereotactic method for preoperative coil-marking of musculoskeletal tumors with use of interventional magnetic resonance imaging.

METHODS

Nine patients with a soft-tissue or bone-marrow tumor were referred to our department for preoperative marking of the extent of the lesion. In one patient, two lesions were marked. Guidance for the punctures and the delivery of the coils was provided by an open low-field magnetic resonance imaging system with horizontal access. After imaging of the extent of the lesion, magnetic resonance imaging-compatible titanium coils were placed with use of nearly real-time or step-by-step magnetic resonance imaging control. The coils were placed up to seventy-two hours before the surgery. The inclusion of the tumor borders within the area of the excision was examined with cross-sectional histological analysis of surgical specimens.

RESULTS

The tumor-marking intervention was successfully performed with the guidance of magnetic resonance imaging only in all patients. Preoperatively, nineteen coils were used to mark the ten lesions in the nine patients. All of the coils were easily located with intraoperative fluoroscopy. No coil migrated between the time of the percutaneous marking and the surgery. Histological examination of the resection borders revealed no residual tumor cells. No complications were observed, and, after a mean of twenty-three months of follow-up, no tumor had recurred.

CONCLUSIONS

Preoperative coil-marking guided by magnetic resonance imaging for exact delineation of a musculoskeletal tumor is technically feasible and can readily demonstrate the full extent of the tumor. Use of magnetic resonance fluoroscopy reduces the time needed for the intervention. We recommend the coil-marking technique.

Radioisotope marking under CT guidance and localization using a handheld gamma probe for small or indistinct pulmonary lesions

STUDY OBJECTIVES

A new marking technique was developed to localize small or indistinct pulmonary lesions, involving preoperative radioisotope injection and intraoperative detection with a handheld gamma probe.

SETTING

National hospital for respiratory disease.

METHODS

and patients: A technetium suspension (either (99m)Tc tin colloid [2 to 4 mCi, 0.5 to 2.5 mL] or (99m)Tc phytate [2 mCi, 2.0 mL]) was injected preoperatively in the vicinity of the lesion under CT guidance in 25 patients with small or indistinct pulmonary lesions. A handheld gamma probe (Navigator GPS; Tyco Healthcare Japan; Tokyo, Japan) was used to detect the hot spot where radioactivity was localized during surgery. The lesion marked by the radioisotope then was thoracoscopically resected using endostaplers.

RESULTS

The preoperative marking procedure took approximately 30 min. A small pneumothorax and mild intrapulmonary bleeding were observed in two patients and one patient, respectively, but no additional treatment was needed for these complications. The lesion was resected soon after the marking procedure in 21 patients, and on the next day in 4 patients. All lesions were easily identified during surgery as radioactive hot spots detected by the handheld gamma probe. Thoracoscopic wedge resection was successfully performed in all patients without complications.

CONCLUSION

This new marking technique for small or indistinct pulmonary lesions (radioisotope injection under CT guidance and intraoperative detection with a handheld gamma probe) seems to be safe, reliable, and convenient.