The preoperative assessment of subpleural lung cancer movement to distinguish thoracic wall adhesion or invasion using four-dimensional computed-tomography

The preoperative assessment of thoracic wall adhesions using four-dimensional computed tomography

OBJECTIVE

Pleural adhesions are challenging during lung cancer surgery and may be associated with a long surgery time and excessive blood loss due to pleural adhesiolysis. We used preoperative four-dimensional computed tomography to quantitatively assess parietal pleural adhesions and determine its diagnostic accuracy.

METHODS

A total of 216 patients with lung cancer underwent four-dimensional computed tomography during the study period. Pleural adhesions were subsequently confirmed by surgery in 85 of these patients, whereas 126 patients had no adhesions. The movements of the tumor or target vessels (α) was tracked. Receiver-operating characteristic curve analysis was used to identify the relationship between adhesions and (α).

RESULTS

The movement of (α) was smaller in patients with adhesions than in those without adhesions. The greater the adhesion, the shorter the movement distance (p < 0.001). Receiver-operating characteristic curve analysis demonstrated an area under the curve for the moving (α) point at 0.71 (95% confidence interval: 0.62-0.80) in the upper lung field and at 0.75 (95% confidence interval: 0.64-0.85) in the lower field. To identify adhesions, a cut off of 11.3 mm (sensitivity = 43.6%, specificity = 93.2%) in the upper lung field and a cut off of 41.2 mm (sensitivity = 71.4%, specificity = 66.0%) in the lower lung field were established.

CONCLUSIONS

Four-dimensional computed tomography is a novel and helpful modality for predicting the presence of parietal pleural adhesions. To obtain robust evidence, further accumulation of cases and re-examination of the analysis methods are needed.

Preoperative evaluation of pleural adhesion in patients with lung tumors using four-dimensional computed tomography performed during natural breathing

The presence of pleural adhesions increases blood loss, occurrence of pulmonary fistulation due to lung injury, and operative time and may complicate thoracoscopic surgery. Recently, it has been reported that four-dimensional computed tomography (4D-CT) synchronized with breathing predicts pleural adhesion. These studies have been performed by asking the patients to maintain a constant respiratory rhythm at the time of scanning. However, many patients face difficulty in doing so, particularly elderly individuals and patients with respiratory dysfunction. We examined the utility of 4D-CT performed while maintaining a natural breathing pattern, which reduces patient burden, in detecting pleural adhesions.A total of 36 patients with a lung tumor near the pleura underwent 4D-CT during free breathing. The migration distance between the lesion and the nearest point on the chest wall on 4D-CT was measured. A sufficient distance indicated the absence of adhesion in that area. The presence of actual adhesions was evaluated and confirmed by intraoperative thoracoscopic findings.There were 7 cases determined to have adhesion by 4D-CT, and 4 of them had actual adhesions confirmed during surgery. The sensitivity and specificity were 80.0% and 90.3%, respectively. The mean migration distance of tumors was 0.8 ± 0.2 cm in the 5 cases with adhesion and 2.6 ± 1.8 cm in the 31 cases without adhesion (P = .01).These results suggest that 4D-CT is a convenient and useful technique for the preoperative assessment of pleural adhesion.

Preoperative prediction of the localization of a solitary fibrous tumor using four-dimensional computed tomography: a case report

Solitary fibrous tumors of the pleura (SFTP) are relatively rare primary pleural tumors. Four-dimensional computed tomography (4D-CT) is reportedly useful in assessing parietal pleural invasion and adhesion in patients with lung cancer. We report a case in which 4D-CT was performed to evaluate SFTP localization and parietal pleural invasion and adhesions. A 62-year-old female presented with an abnormality on a chest radiograph. Chest CT revealed a well-demarcated solid nodule in the left lower lobe adjacent to the pleura. We considered that the tumor was intrapulmonary or arose from the visceral pleura, without adhesion or invasion to the chest wall based on 4D-CT. Primary lung cancer was suspected, and the tumor was resected. Pathological diagnosis revealed an SFTP. This case suggests that 4D-CT is useful in predicting the localization of SFTP and other thoracic tumors, assessing chest wall adhesion and invasion, and making surgical strategies.