Usefulness and complications of computed tomography-guided lipiodol marking for fluoroscopy-assisted thoracoscopic resection of small pulmonary nodules: Experience with 174 nodules

CT-guided percutaneous marking of small pulmonary nodules with [99mTc]Tc-Macrosalb is very accurate and allows minimally invasive lung-sparing resection: a single-centre quality control

PURPOSE

The detection of small lung nodules in thoracoscopic procedure is difficult when the lesions are not located within the outer border of the lung. In the case of ground-glass opacities, it is often impossible to palpate the lesion. Marking lung nodules using a radiotracer is a known technique. We analysed the accuracy and safety of the technique and the potential benefits of operating in a hybrid operating room.

METHODS

57 patients, including 33 (58%) females with a median age of 67 years (range 21-82) were included. In 27 patients, we marked and resected the lesion in a hybrid room. In 30 patients, the lesion was marked at the department of radiology the day before resection. [99mTc]Tc-Macrosalb (Pulmocis®) was used at an activity of 1 MBq in the hybrid room and at an activity of 3 MBq the day before to get technical feasible results. Radioactivity was detected using the Neoprobe® detection system.

RESULTS

Precise detection and resection of the nodules was possible in 95% of the lesions and in 93% of the patients. Complete thoracoscopic resection was possible in 90% of the patients. Total conversion rate was 10%, but conversion due to failure of the marking of the nodule was observed in only 5% of the patients. Histology revealed 28 (37%) primary lung cancers, 24 (32%) metastases and 21 (28%) benign lesions. In 13 (23%) patients, minor complications were observed. None of them required additional interventions.

CONCLUSION

The radio-guided detection of small pulmonary nodules is very accurate and safe after CT-guided injection of [99mTc]Tc-Macrosalb. Performing the operation in a hybrid room has several logistic advantages and allows using lower technetium-99m activities. The technique allows minimally invasive lung sparing resection and prevents overtreatment of benign and metastatic lesions.

The efficacy and safety of CT-guided localization of pulmonary nodules by medical adhesives containing methylene blue before surgery

Background

The accurate preoperative localization of pulmonary nodules is essential for a successful video-assisted thoracic surgery (VATS). The aim of this research was to clarify the efficacy and safety of CT-guided localization of pulmonary nodules by mixture of methylene blue and medical adhesive.

Methods

Between January 2020 and January 2021, 103 subjects who have received the CT-guidance pulmonary nodules localization operation were included and retrospectively analyzed. The data on efficiency and complications of preoperative localization using medical adhesives mixed with methylene blue mixture were collected and analyzed.

Results

103 patients with 111 localized pulmonary nodules were included, 95 of whom had one nodule and 8 of whom had two nodules. The nodule localization success rate reaches as high as 100 %. The mean diameter of pulmonary nodules was 9.50 ± 3.67 mm. The mean distance of pulmonary nodule and pleural surface was 19.95 ± 14.92 mm. The mean depth of localized adhesive in the lung parenchyma was 18.99 ± 11.62 mm, and the mean time required for localization was 16.98 ± 5.72 min. The average time from the nodule localization to VATS surgery was 16.97 ± 7.34 h. The common complications of localization were minor pulmonary hemorrhage (9.74 %) and mild pneumothorax (15.53 %). Besides, pulmonary hemorrhage was related with depths of medical adhesives and nodules in lung parenchyma (p = 0.018 and 0.002, respectively).

Conclusion

Medical adhesive mixed with methylene blue is safe and effective in pulmonary nodules localization for VATS, and surgeons have flexibility in scheduling the procedure.

[The role of endoscopy in the management of peripheral pulmonary nodules, part 2: Treatment]

The management of peripheral lung nodules is challenging, requiring specialized skills and sophisticated technologies. The diagnosis now appears accessible to advanced endoscopy (see Part 1), which can also guide treatment of these nodules; this second part provides an overview of endoscopy techniques that can enhance surgical treatment through preoperative marking, and stereotactic radiotherapy treatment through fiduciary marker placement. Finally, we will discuss how, in the near future, these advanced endoscopic techniques will help to implement ablation strategy.

Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BACKGROUND

Video-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.

METHODS

Retrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.

RESULTS

30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).

CONCLUSIONS

We demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

Radio-Guided Lung Surgery: A Feasible Approach for a Cancer Precision Medicine

BACKGROUND

Radio-guided surgery is a reliable approach used for localizing ground-glass opacities, lung nodules, and metastatic lymph nodes. Lung nodules, lymph node metastatic involvement, and ground-glass opacities often represent a challenge for surgical management and clinical work-up.

METHODS

PubMed research was conducted from January 1997 to June 2023 using the keywords "radioguided surgery and lung cancer".

RESULTS

Different studies were conducted with different tracers: technetium-99m-albumin macroaggregates, cyanoacrylate combined to technetium-99m-sulfur colloid, indium-111-pentetreotide, and fluorine-18-deoxyglucose. A study proposed naphthalocyanine radio-labeled with copper-64. Radio-guided surgery has been demonstrated to be a reliable approach in localizing a lesion, and has a low radiological burden for personnel exposure and low morbidity. The lack of necessity to conduct radio-guided surgery under fluoroscopy or echography makes this radio-guided surgery an easy way of performing precise surgical procedures.

CONCLUSIONS

Radio-guided surgery is a feasible approach useful for the intraoperative localization of ground-glass opacities, lung nodules, and metastatic lymph nodes. It is a valid alternative to the existing approaches due to its low cost, associated low morbidity, the possibility to perform the procedure after several hours, the low radiation dose applied, and the small amount of time that is required to perform it.

Evaluation of the radiofrequency identification lung marking system: a multicenter study in Japan

BACKGROUND

The radiofrequency identification (RFID) lung marking system is a novel technique using near-field radio-communication technology. The purpose of this study was to investigate the utility and feasibility of this system in the resection of small pulmonary nodules.

METHODS

We retrospectively reviewed clinical records of 182 patients who underwent sublobar resection with the RFID marking system between March 2020 and November 2021 in six tertial hospitals in Japan. Target markings were bronchoscopically made within 3 days before surgery. The contribution of the procedure to the surgery and safety was evaluated.

RESULTS

Target nodule average diameter and depth from the lung surface were 10.9 ± 5.4 mm and 14.6 ± 9.9 mm, respectively. Radiologically, one third of nodules appeared as pure ground-glass nodules (GGNs) on CT. The average distance from target nodule to RFID tag was 8.9 ± 7.1 mm. All surgical procedures were completed by video-assisted thoracoscopic surgery. Planned resection was achieved in all cases without any complications. The surgeons evaluated this system as helpful in 93% (necessary: 67%, useful; 26%) of cases. Nodule radiological features (p < 0.001) and type of surgery (p = 0.0013) were associated with the degree of contribution. In most cases, identification of the RFID tag was required within 1 min despite adhesion (p = 0.27).

CONCLUSION

The RFID lung marking system was found to be safe and effective during successful sublobar resection. Patients with pure GGNs are the best candidates for the system.

Computed tomography-guided localization of pulmonary nodules prior to thoracoscopic surgery

With the increasing awareness of physical examination, the detection rate of pulmonary nodules is gradually increasing. For pulmonary nodules recommended for management by video-assisted thoracic surgery (VATS), preoperative localization of the nodule is required if its location is difficult to determine intraoperatively by palpation. The computed tomography (CT)-guided preoperative localization technique is the most widely used method with low operational difficulty and high efficiency, which can include hook wire, microcoil, medical dye, medical surgical adhesive, combined application, and emerging localization techniques according to the material classification. Each method has its corresponding advantages and disadvantages, but there is still a lack of unified guidelines or standards for the selection of CT-guided preoperative localization methods in clinical practice. This review summarizes the operation precautions, advantages, and shortcomings of the above localization techniques in order to provide references for clinical application.

Localization Technique Using Mixture of Indigo Carmine and Lipiodol of Pulmonary Nodule via Bronchoscopic Navigation

Background and Objectives: As the number of minimally invasive surgeries, including video-assisted thoracoscopic surgery, increases, small, deeply located lung nodules are difficult to visualize or palpate; therefore, localization is important. We studied the use of a mixture of indigo—carmine and lipiodol, coupled with a transbronchial approach—to achieve accurate localization and minimize patient discomfort and complications. Materials and Methods: A total of 60 patients were enrolled from May 2019 to April 2022, and surgery was performed after the bronchoscopy procedure. Wedge resection or segmentectomy was performed, depending on the location and size of the lesion. Results: In 58/60 (96.7%) patients, the localization of the nodules was successful after localization, and 2/60 required c-arm assistance. None of the patients complained of discomfort during the procedure; in all cases, margins were found to be free from carcinoma, as determined by the final pathology results. Conclusions: We recommend this localization technique using mixture of indigo carmine and lipiodol, in concert with the transbronchial approach, because the procedure time is short, patient’s discomfort is low, and success rate is high.

Novel Intraoperative CT-Guided Marking Using O-arm System in Video-Assisted Thoracoscopic Surgery: An Easy, Safe, Time-Saving, Practical Method

OBJECTIVE

With the increased frequency of small lung tumor detection, there has been a similar increase in limited surgery, such as wedge resection. To identify such small lung tumors, we use a computed tomography (CT)-guided intraoperative marking method using the O-arm Surgical Imaging System. We retrospectively investigated its usefulness.

METHODS

Of 1,043 cases of thoracic surgery performed at our department between May 2017 and June 2021, O-arm System marking was used in 30 cases (2.9%), totaling 39 lesions. Tumor location was predicted preoperatively based on 3-dimensional CT and anatomic positioning. Visceral pleura near the tumor was marked with a metal clip, and the O-arm System was brought to the surgical site. CT was taken after the tumor side lung was fully re-expanded and clamped. After confirming the tumor and the clip locations, the clip was repositioned as necessary and marked in the same way. If the marking was successful, the clips were used as markers when performing lung resection.

RESULTS

Marking was successful in all cases. The average number of targets was 1.3, the average number of O-arm insertions was 1.3, and the average total number of marking clips was 2.6. In all cases, we checked the specimens, and if the tumor was palpable, the resection margin was also checked. No intraoperative or postoperative complications were observed in any patients.

CONCLUSIONS

If the O-arm System is available, this technique is a noninvasive, simple, and useful method that could be widely used in clinical practice with a low dose of radiation.

Near-Infrared Fluorescence Tumor-Targeted Imaging in Lung Cancer: A Systematic Review

Lung cancer is the most common cancer type worldwide, with non-small cell lung cancer (NSCLC) being the most common subtype. Non-disseminated NSCLC is mainly treated with surgical resection. The intraoperative detection of lung cancer can be challenging, since small and deeply located pulmonary nodules can be invisible under white light. Due to the increasing use of minimally invasive surgical techniques, tactile information is often reduced. Therefore, several intraoperative imaging techniques have been tested to localize pulmonary nodules, of which near-infrared (NIR) fluorescence is an emerging modality. In this systematic review, the available literature on fluorescence imaging of lung cancers is presented, which shows that NIR fluorescence-guided lung surgery has the potential to identify the tumor during surgery, detect additional lesions and prevent tumor-positive resection margins.

Preoperative radio-guided localization of lung nodules with I-125 seeds: experience with 32 patients at a single institution

OBJECTIVES

Videothoracoscopic visualization and/or palpation of pulmonary nodules may be difficult due to their location, small size or limited solid component. The purpose of this study is to present our experience with computed tomography (CT)-guided preoperative localization of pulmonary nodules by percutaneous marking with radio-labelled iodine-125 seeds.

METHODS

A total of 34 pulmonary nodules were marked under CT with the placement of 33 radio-labelled iodine-125 seeds in 32 consecutive patients.

RESULTS

All patients underwent biportal video-assisted thoracic surgery (VATS) and in no case was conversion to thoracotomy necessary. A total of 88.2% of the lung nodules were successfully resected. In the remaining 11.8%, migration of the seed to the pleural cavity occurred, although these nodules were still resected during VATS. Of all the patients with pneumothorax after the marking procedure, only one required chest tube placement (3.1%). No major postoperative complications were observed.

CONCLUSIONS

Preoperative marking of pulmonary nodules with I-125 seeds under CT guidance is a feasible and safe technique that allows their intraoperative identification and resection.

Clinical value and application of preoperative CT-guided hookwire localization of solitary pulmonary nodules for video-assisted thoracic surgery

BACKGROUND

Video-assisted thoracic surgery (VATS) is a minimally invasive technique for the diagnosis and management of small pulmonary nodular lesions However, the identification of some lung nodules remains difficult.

OBJECTIVE

This research aimed to investigate the clinical value of preoperative computed tomography (CT)-guided hookwire localization of solitary pulmonary nodules (SPNs) for thoracoscopic resection.

METHODS

Seventy-one patients with 74 SPNs underwent VATS wedge resection after CT-guided hookwire localization. The mean diameter of the SPNs was 8.50 ± 4.53 mm,,besides, the mean distance from the SPNs to the parietal pleura was 16.81 ± 5.23 mm.

RESULTS

Sixty-nine of the 74 nodules were successfully localized using a CT-guided hookwire. The success rate of CT-guided localization was 93.2%. The average localization time was 15.23 ± 7.21 min per lesion. Seven patients (9.5%) had asymptomatic pneumothorax and 10 (13.5%) had minimal needle tract parenchymal hemorrhages after localization no clinical intervention was required for these patients. The rate of success for VATS wedge resection of the SPNs was 100%. Histological analysis of the SPNs revealed malignant disease in 67.4% of the patients.

CONCLUSIONS

Preoperative CT-guided hookwire localization for thoracoscopic resection is a safe and effective operation for the identification and stable fixation of SPNs.

Computed tomography-guided marking using a dye-staining method for preoperative localization of tiny pulmonary lesions in children

PURPOSE

It is important to confirm the existence of pulmonary metastases in pediatric patients with malignancies. Therefore, we aimed to investigate if computed tomography CT-guided marking is a feasible and safe method for the identification and resection of tiny pulmonary lesions in pediatric cancer patients.

METHODS

We retrospectively reviewed the medical records of pediatric cancer patients who underwent CT-guided marking procedures in our institutions between Jan 2011 and Apr 2020. After 2015, these procedures were combined with an indocyanine green (ICG) navigation-guided surgery for hepatoblastoma cases.

RESULTS

We targeted a total of 22 nodules in 12 patients. Of these, marking was successful in 18 (81.8%) nodules, 10 of which contained viable malignant cells. Complications caused by the marking procedures included mild pneumothorax and mild atelectasis in two patients, respectively. Of the eight resected nodules in patients with hepatoblastoma, four were ICG-positive and contained viable malignant cells. Two additional ICG-positive nodules, which were unidentified before surgery, were observed intraoperatively.

CONCLUSION

CT-guided marking is a feasible and safe method that can be used to identify and resect tiny pulmonary lesions in pediatric cancer patients. An ICG navigation-guided surgery is useful when combined with CT-guided marking, particularly in hepatoblastoma cases.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection

Background

Thoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.

Methods

From January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.

Results

Forty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9-14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6-16 mm). The median ENB length was 25 min (19-33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.

Conclusions

ENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Technical Advances in Segmentectomy for Lung Cancer: A Minimally Invasive Strategy for Deep, Small, and Impalpable Tumors

With the increased detection of early-stage lung cancer and the technical advancement of minimally invasive surgery (MIS) in the field of thoracic surgery, lung segmentectomy using MIS, including video- and robot-assisted thoracic surgery, has been widely adopted. However, lung segmentectomy can be technically challenging for thoracic surgeons due to (1) complex segmental and subsegmental anatomy with frequent anomalies, and (2) difficulty in localizing deep, small, and impalpable tumors, leading to difficulty in obtaining adequate margins. In this review, we summarize the published evidence and discuss key issues related to MIS segmentectomy, focusing on preoperative planning/simulation and intraoperative tumor localization. We also demonstrate two of our techniques: (1) three-dimensional computed tomography (3DCT)-based resection planning using a novel 3DCT processing software, and (2) tumor localization using a novel radiofrequency identification technology.

Identification of factors affecting the surgical margin in wedge resection using preoperative lipiodol marking

Background

The factors affecting the surgical margin distance in resection of small lung lesions after preoperative marking are still unclear. The purpose of this study was to identify these factors in wedge lung resection using a localization technique.

Methods

The subjects were 45 patients with small pulmonary nodules who underwent preoperative computed tomography-guided lipiodol marking followed by video-assisted thoracoscopic surgery between April 2017 and December 2019. Data were obtained for nodule size, depth from the pleural surface, imaging features, and procedure-related factors that could affect the surgical margin. Subjects were divided into groups with margin distances <10 and ≥10 mm. Logistic regression analysis was used to identify factors associated with the margin distance.

Results

Preoperative marking was performed using lipiodol prior to resection of 52 nodules (median size, 10.1 mm; range, 6.75-12.3 mm) in 45 patients (23 men, 22 women; median age, 65.4 years). The mean distance from the pleural surface to the pulmonary lesion was 13.8 mm (range, 5.44-22.2 mm). The 3D deviation of the radio-opaque nodule (lipiodol spot) from the lesion was the only significant difference in nodule- and procedure-related factors between the two groups. Multivariate analysis also showed that this 3D deviation was the most significant factor affecting the margin distance (odds ratio, 0.26; 95% CI, 0.08-0.81; P=0.02).

Conclusions

The findings in this study may help to ensure a sufficient surgical margin after preoperative lipiodol marking, through recognition that the 3D deviation of the radio-opaque nodule from the target lesion has a particularly important influence on the margin distance.

Fluorescent and Iodized Emulsion for Preoperative Localization of Pulmonary Nodules

OBJECTIVE

This study was conducted to develop a fluorescent iodized emulsion comprising indocyanine green (ICG) solution and lipiodol (ethiodized oil) and evaluate its feasibility for use in a clinical setting.

BACKGROUND

ICG use for the preoperative localization of pulmonary nodules is limited in terms of penetration depth and diffusion.

METHODS

First, fluorescent microscopy was used to investigate the distribution of ICG-lipiodol emulsions prepared using different methods. The emulsions were injected in 15 lung lobes of 3 rabbits under computed tomography fluoroscopy guidance; evaluation with imaging and radiography was conducted after thoracotomy. Subsequently, the emulsions were used to preoperatively localize 29 pulmonary nodules in 24 human subjects, and wedge resections were performed using fluorescent imaging and C-arm fluoroscopy.

RESULTS

The optimal emulsion of 10% ICG and 90% lipiodol mixed through 90 passages had even distribution and the highest signal intensity under fluorescent microscopy; it also had the best consistency in the rabbit lungs, which persisted for 24 hours at the injection site. In human subjects, the mean diameter of pulmonary nodules was 0.9 ± 0.4 cm, and depth from the pleura was 1.2 ± 0.8 cm. All emulsion types injected were well localized around the target nodules without any side effects or procedure-related complications. Wedge resection with minimally invasive approach was successful in all pulmonary nodules with a free resection margin.

CONCLUSIONS

A fluorescent iodized emulsion prepared by mixing ICG with lipiodol enabled accurate localization and resection of pulmonary nodules.

Perioperative identifications of non-palpable pulmonary nodules: a narrative review

Early detection of lung cancer is the key to improving treatment and prognosis of this disease, and the advent of advances in computed tomography (CT) imaging and national screening programs have improved the detection rate of very small pulmonary lesions. As such, the management of this sub-centimetric and often sub-solid lesions has become quite challenging for clinicians, especially for choosing the most suitable diagnostic method. In clinical practice, to fulfill this diagnostic yield, transthoracic needle biopsy (TTNB) is often the first choice especially for peripheral nodules. For lesions for which TTNB could present technical difficulties or failed, other diagnostic strategies are needed. In this case, video-assisted thoracic surgery (VATS) is the gold standard to reach the diagnosis of lung nodules suspect of being malignant. Nonetheless it’s often not easy the identification of such lesions during VATS because of their little dimensions, non-firm consistency, deep localization. In literature various marking techniques have been described, in order to improve intraoperative nodules detection and to reduce conversion rate to thoracotomy: CT-guided hookwire positioning, methylene blue staining, intra-operative ultrasound and electromagnetic navigation bronchoscopy are the most used. The scientific evidence on this matter is weak because there are no randomized clinical trials but only case series on single techniques with no comparison on efficacy, so there are no guidelines to refer. From this standing, in this article we conducted a narrative review of the existing literature on the subject, with the aim of outlining a framework as complete as possible. We analyzed strengths and weaknesses of the main techniques reported, so as to allow the clinician to orient himself with greater ease.

Recent Imaging Advancements for Lung Metastases in Children with Sarcoma

In children and adolescents affected by musculoskeletal sarcomas (both soft tissue and bone sarcomas), the presence of lung metastases is a frequent complication, that should be known since the patient's prognosis, as management, and treatment depend on it. During the staging phase, the detection of lung metastases should be sensitive and specific, and it should be carried out by minimizing the radiation exposure. To deal with this problem, imaging has reached important goals in recent years, thanks to the development of cone-beam CT or low-dose computed tomography, with some new iterative reconstruction methods, such as Veo and ASIR. Imaging is also fundamental for the possibility to perform lung biopsies under CT guidance, with less morbidity, less time-consumption, and shorter recovery time, compared to surgical biopsies.Moreover, important results have also been demonstrated in the treatment of lung metastases, due to the improvement of new mini-invasive image-guided percutaneous thermal ablation procedures, which proved to be safe and effective also in young patients.

Simultaneous preoperative computed tomography-guided microcoil localizations of multiple pulmonary nodules

OBJECTIVES

To evaluate retrospectively the feasibility and safety of simultaneous multiple microcoil localizations of multiple pulmonary nodules prior to video-assisted thoracoscopic surgery (VATS).

METHODS

This retrospective cohort study enrolled 288 consecutive patients, who underwent computed tomography (CT)-guided microcoil localization and subsequent VATS at our academic hospital between July 2017 and June 2018. Of these patients, 36 with 79 pulmonary nodules undergoing simultaneous multiple microcoil localizations in the ipsilateral lung were designated the multiple localization group; the remaining 252 with 252 pulmonary nodules undergoing single microcoil localization were designated the single localization group. The main outcomes were the technical success and complication rates of the localization procedures. The Student t test and Mann-Whitney U test were used for continuous variables. The chi-squared test and logistic regression analysis were used to assess dichotomous variables.

RESULTS

The localization technical success rates of the multiple and single localization groups were 96.2% (76/79) and 98.0% (247/252), respectively (p = 0.326). The rate of any complication (pneumothorax or pulmonary hemorrhage) was significantly higher in the multiple localization than in the single localization group (55.6% vs 21.8%, respectively; p < 0.001). The incidence of pneumothorax was significantly higher in the multiple localization than in the single localization group (p < 0.001). The difference between the incidence of pulmonary hemorrhage in the 2 groups was not significant (p = 0.385).

CONCLUSIONS

Although preoperative CT-guided simultaneous microcoil localizations of multiple pulmonary nodules produced a significantly higher incidence of pneumothorax, the localizations were clinically feasible and safe.

KEY POINTS

• Simultaneous preoperative CT-guided microcoil localizations of multiple pulmonary nodules are clinically feasible and safe. • Simultaneous microcoil localizations of multiple pulmonary nodules produced a significantly higher incidence of pneumothorax.

Clock dial integrated positioning combined with single utility port video-assisted thoracoscopic surgery: a new localization method for lung tumors

Background

Preoperative localization of lung tumor mainly consisted of two methods: CT-guided percutaneous localization and electromagnetic navigation bronchoscopy-guided localization. However, these invasive methods could result in serious complications. In order to avoid the adverse effects of preoperative invasive localization, we propose a method of intraoperative noninvasive localization for lung tumors: clock dial integrated positioning (CDIP).

Methods

To retrospectively analyze the clinic data about the application of CDIP for 127 lung tumour patients in single utility port video-assisted thoracoscopic surgery (SUPVATS) between June 2017 and October 2017.

Results

One hundred and twenty-four cases (97.64%) underwent thoracoscopic surgery, which including 14 lobectomy, 107 partial resection, 2 lobectomy plus partial resection and 1 left pneumonectomy. Three cases (2.36%) underwent thoracoscopic biopsy. The mean operation time and intraoperative bleeding were 47.9±22.1 min and 70.1±40.3 mL, respectively. The mean postoperative hospital stay and chest drain duration were 3.9±2.2 and 3.6±1.8 days, respectively. There were 118 cases of malignant tumors, including adenocarcinoma (n=101), squamous cell carcinoma (n=9), large cell carcinoma (n=2), small cell lung carcinoma (n=3), and metastatic lung carcinoma (n=3). The remaining nine cases were benign tumors, including granuloma (n=3), intrapulmonary lymph node (n=2), sclerosing hemangioma (n=2), and hamartoma (n=2). The incidence of postoperative complications was 10.2%. There was no mortality, secondary operation, or conversion to open procedure due to massive intraoperative bleeding.

Conclusions

CDIP combined with SUPVATS is a safe, feasible, and effective method for the localization of lung tumors. This novel method can provide a reliable alternative technique when the marker is dislocated.

The accuracy of cone-beam computed tomography and augmented fluoroscopy-guided bronchoscopic marking of multiple small-sized pulmonary nodules in a hybrid operating room: a retrospective cohort study

Background

For the minimally invasive excision of small-sized pulmonary nodules, bronchoscopic markings are increasingly being performed owing to advancements in video-assisted thoracic surgery (VATS). Hybrid operating room equipment is utilized for bronchoscopic VATS markings. We aimed to compare the marking accuracy between bronchoscopic VATS and other marking techniques such as computed tomography-guided percutaneous marking and conventional X-ray fluoroscopy-guided bronchoscopic marking.

Methods

Patients with small-sized pulmonary nodules scheduled to undergo VATS were enrolled in the study. A mixture of 50 to 100 µL of diluted indocyanine green and iopamidol was injected adjacent to the pulmonary nodules as a VATS marker. Patients receiving each of the three image-guided techniques were categorized into group A (computed tomography-guided percutaneous injection), group B (X-ray fluoroscopy-guided virtual bronchoscopy-assisted bronchoscope injection), and group C (cone-beam computed tomography and augmented fluoroscopy-guided virtual bronchoscope-assisted bronchoscopic injection in the hybrid operating room). VATS marking accuracy and procedural complications were compared among the three groups.

Results

In total, 61 patients with 73 pulmonary nodules were eligible for analysis. VATS marking was successful for 15/16 nodules in group A, 28/30 nodules in group B, and 25/27 nodules in group C. Marking accuracy was 5.75±4.59, 15.00±14.02, and 6.05±6.11 (mm), respectively. Multiple markings were successful in 0/1 (0%), 5/6 (83.3%), and 5/5 (100.0%) nodules in groups A, B, and C, respectively. A small pneumothorax occurred in 3/15 (20.0%) patients in group A.

Conclusions

The cone-beam computed tomography and augmented fluoroscopy-guided bronchoscopic approach performed in a hybrid operating room is accurate and equivalent to the computed tomography-guided percutaneous approach, and it enables the VATS marking of multiple pulmonary nodules without causing a secondary pneumothorax.

Safety and reliability of computed tomography-guided lipiodol marking for undetectable pulmonary lesions

OBJECTIVES

This study aimed to evaluate the safety and reliability of percutaneous computed tomography (CT)-guided lipiodol marking for undetectable pulmonary lesions before video-assisted thoracic surgery (VATS).

METHODS

We retrospectively analysed the cases of CT-guided lipiodol marking followed by VATS in 9 institutes from May 2006 to March 2018. Lipiodol (0.2-0.5 ml) was percutaneously injected closely adjacent to undetectable pulmonary lesions with computed-tomography guidance. Lipiodol spots were identified using C-arm-shaped fluoroscopy during VATS. We grasped the lipiodol spots, including the target lesions, with ring-shaped forceps and resected them.

RESULTS

Of 1182 lesions, 1181 (99.9%) were successfully marked. In 1 case, the injected lipiodol diffused, and no spot was created. Of the 1181 lesions, 1179 (99.8%) were successfully resected with intraoperative fluoroscopy. Two lipiodol spots were not detected because of the lipiodol distribution during the division of pleural adhesions. The mean lesion size was 9.1 mm (range 1-48 mm). The mean distance from the pleural surface was 10.2 mm (range 0-43 mm). Lipiodol marking-induced pneumothorax occurred in 495 (57.1%) of 867 cases. Of these, chest drainage was required in 59 patients (6.8%). The other complications were 19 (2.2%) cases of bloody sputum, 3 (0.35%) cases of intravascular air, 1 (0.12%) case of pneumonia and 1 (0.12%) case of cerebral infarction. There were no lipiodol marking-induced deaths or sequelae.

CONCLUSIONS

Preoperative CT-guided lipiodol marking followed by VATS resection was shown to be a safe and reliable procedure with a high success rate and acceptably low severe complication rate.

A novel fluorescent lung-marking technique using the photodynamic diagnosis endoscope system and vitamin B2

OBJECTIVES

For small pulmonary nodules that are unidentifiable by palpation or in endoscopic surgeries wherein palpation is not feasible, visualizing their location is necessary when performing pulmonary sublobar resection procedures, such as wedge resection or segmentectomy. We invented a new transbronchial lung-marking technique using the photodynamic diagnosis endoscope system and vitamin B2 and examined its feasibility and safety via porcine studies.

METHODS

We established the marking procedure in pigs and examined the marking clarity and size, fluorescence intensity and duration and possible complications. In another study, sublobar resection for virtual target lesions was performed in pigs based on the fluorescent markings. The procedure duration, marking visibility, surgical margin from the lesions and technique-related complications were assessed.

RESULTS

All 36 markings in 6 pigs were identifiable and were widely distributed over the right lung. The median diameter and fluorescence intensity at 60 min after marking were 6.0 (5.5-6.7) mm and 137.5 (122-168), respectively. All 18 markings for the 6 virtual target lesions (3 markings for each target) were clearly identified, and all target lesions were found in the resected specimens. The median duration per marking was 244 (194-255) seconds. The shortest median surgical margin from a target lesion was 11.5 (9.3-13.5) mm. No procedure-related complications were observed.

CONCLUSIONS

This novel transbronchial fluorescent lung-marking technique was useful and safe in sublobar resections for small non-palpable pulmonary lesions.

Retrospective Review of Preoperative Wire Localization for Peripheral Ground Glass Opacities

Video-assisted thoracoscopy (VATS) is performed for diagnosis and treatment of peripheral lung nodules. Localization of peripherally located ground-glass opacities (GGOs) can be challenging. We report the results and usefulness of preoperative computed tomography (CT)-guided wire localization. Records for patients who underwent CT-guided wire localization prior to VATS resection for peripherally located GGOs were analyzed. Our technique for targeting the GGOs, complications, and histopathology of GGOs is reviewed. Forty patients (mean age 68 years) underwent pulmonary resections following CT-guided wire localization. The mean diameter of the GGO was 11.0 mm. The mean distance from the pleural surface to the peripheral margin of the GGO was 18.6 mm. Complications from the wire localization included pneumothorax in 5 patients (12.5%), none of whom required insertion of a chest tube; parenchymal hemorrhage in 3 patients (7.5%); and pleural effusion requiring chest tube drainage (unrelated to the wire) in 1 patient (2.5%). The mean operative time was 74 (range: 21-186 ) minutes. Pathological examination revealed lung malignancy in 36 patients (90%). The diagnostic yield was 100%. Preoperative CT-guided wire localization for solitary or multiple peripherally located GGOs allows for determination of histopathologic diagnosis and high diagnostic yield.

A Surgeon's Guide for Various Lung Nodule Localization Techniques and the Newest Technologies

Preoperative image-guided localization of lung nodules is necessary for successful intraoperative localization and resection. However, current localization techniques carry significant intraoperative disadvantages for surgeons. Articles were selected through multiple search engines using key search terms and reviewed to compare results, outcomes, advantages, limitations, and complications of various localization methods. Current methods utilize microcoils, hookwires, contrast media, dyes, cyanoacrylate, radiotracers, or fluorescence tracers, which are associated with many intraoperative disadvantages even when paired with other imaging modalities including computed tomography and bronchoscopy techniques. Novel technologies including robotic bronchoscopy, 4-hook anchor, SPiN Thoracic Navigation System, superDimension, Ion Endoluminal System, and the SCOUT system are reviewed including their advantages, which may change the future direction of minimal thoracoscopic surgery with potential to improve intraoperative accuracy and efficiency.

Intrathoracic use of a small ultrasonic probe for localizing small lung tumors in thoracoscopic surgery: Empirical results and comparison with preoperative CT images

OBJECTIVE

To evaluate the use of a small mobile ultrasound probe to localize small lung tumors during thoracoscopic surgery under thoracic CO₂ insufflation.

METHODS

We prospectively enrolled 20 patients (26 tumors) scheduled to undergo thoracoscopic pulmonary wedge resection between April 2016 and October 2018. Ultrasonographic tumor detection was performed with an ARIETTA 850 and L51K probe (Hitachi, Tokyo, Japan). Ultrasonography was repeated after achieving adequate lung collapse under a positive intrathoracic pressure of 8-15 mmHg. The appearance on preoperative CT versus the ultrasonographic localization was compared for each tumor. The receiver operating characteristic curves were compared for the tumor dimension of the lung window, consolidation dimension of the lung window, tumor dimension of the mediastinal window (MD), and tumor depth from the lung surface.

RESULTS

The average age was 62 years (range 42-79 years), average pathological tumor size was 9 mm (range 3-22 mm), and average tumor depth was 6 mm (range 1-25 mm). Although no tumors could be visualized before lung collapse, 22 tumors (85%) were detectable with ultrasonography after lung collapse. Of these 22 tumors, 16 were well-depicted, while six were poorly delineated. MD showed the largest area under the receiver operating characteristic curve (0.81), and tumors with a MD of ≤ 6 mm had a high risk of difficult localization using ultrasonography.

CONCLUSION

This ultrasonographic method obtained high tumor detection rates, especially for tumors with a MD > 6 mm. Tumors with a MD ≤ 6 mm may require another localization method.

CLINICAL REGISTRATION NUMBER

University Hospital Medical Information Network Clinical Trials Registry (UMIN000036921).

CT-guided hook-wire localization of malignant pulmonary nodules for video assisted thoracoscopic surgery

Objectives

Video assisted thoracoscopic surgery (VATS) can currently be used to diagnose and treat pulmonary nodules. However, intraoperative location of pulmonary nodules in VATS is challenging due to their small diameter and deep location in the pulmonary parenchyma. The purpose of this study was to report the clinical safety and effectiveness of CT-guided hook-wire for preoperative localization of malignant pulmonary nodules smaller than 1 cm in diameter.

Methods

From February 2017 to January 2018, we collected the data of 80 patients with malignant pulmonary nodules less than 1 cm in diameter who underwent CT-guided hook-wire preoperative localization and VATS surgery. The effectiveness of preoperative localization was evaluated based on surgical duration, success rate of VATS surgery, and localization-related complications.

Results

The diameter of pulmonary nodules were 0.85 ± 0.17 mm with a distance to the pleural surface of 19.66 ± 14.10 mm. The length of the hook-wire in the lung parenchyma was 29.17 ± 13.14 mm and hook-wire dislodgement occurred in 2 patients. Complications included 27 cases of minor pneumothorax and 18 cases of mild parenchymal hemorrhage. A significant correlation was observed between the length of the hook-wire in the lung parenchyma and mild parenchymal hemorrhage (P = 0.044). The average time of hook-wire localization was 9.0 ± 2.6 min and the average operation time for VATS was 89.02 ± 23.35 min without conversion thoracotomy.

Conclusions

CT-guided hook-wire localization of the lesion during VATS resection is safe for malignant pulmonary nodules with diameter less than 1 cm.

Image-localized body surface marking for the intraoperative localization of pulmonary ground-glass nodules

Background

The method of locating pulmonary nodules before operation plays a crucial role in the surgery of pulmonary ground-glass nodules (GGNs). However, the methodologies surrounding intraoperative localization remains limited, with the majority procedures requiring specific additional equipment. We report a new approach in locating pulmonary GGNs by image-localized body surface marking intraoperative (IBMI) localization.

Methods

A retrospective review of the medical records of 76 patients with pulmonary GGNs was performed. All patients underwent IBMI localization between January 2018 and March 2019. Twenty-six patients underwent CT-guided hook wire localization before IBMI localization during surgery. IBMI localization was undertaken directly without pre-treatment in the remaining patients. The efficacy and complications of this approach were analyzed and compared with other pre- or intraoperative localization methods in the current literature.

Results

The intraoperative localizations were performed successfully in 72 of all 76 patients pulmonary GGNs within a mean duration of 5.3±1.8 (range, 2.0 to 9.6) minutes. The GGNs in four cases were found to have a significant deviation (>1.5 cm) from the positioning points. All GGNs were successfully resected. Except for five cases of active chest wall bleeding (6.5%), no other intra- or postoperative complications occurred.

Conclusions

The IBMI localization approach is a safe and short-duration procedure with high success rates and fewer complications. We used it for the first time for intraoperative localization of peripheral GGNs with excellent results.

Bilateral lung nodules resection by image-guided video-assisted thoracoscopic surgery: a case series

Background

We demonstrated the safety and feasibility of image-guided video-assisted thoracoscopic surgery (iVATS) of bilateral lung lesions in a hybrid operating room.

Methods

This study was a retrospective analysis of a case series. A total of 7 patients with 15 small lung nodules underwent bilateral iVATS between July 2018 and May 2019. All procedures were completed within a single anesthesia procedure and performed in a hybrid operating room that had a cone-beam computed tomography (CT) apparatus equipped with a laser navigation system. The lesion characteristics, operation methods, and peri-operative clinical outcomes were summarized.

Results

A total of 7 patients with 15 resected lung nodules were analyzed. The most common pathological result of our bilateral iVATS was metastasis. The median length of hospital stay was 5 days (range from 3 to 10 days). The median right chest tube duration was 2 days (range from 1 to 8 days), and the median left chest tube duration was 3 days (range from 2 to 5 days). Only one patient had a complication during his hospitalization period. There was no surgery-related mortality observed.

Conclusions

For bilateral pulmonary nodules, the iVATS procedure seems to be a feasible and cost-effective approach.

Intraoperative Detection and Assessment of Lung Nodules

Lung cancer is the most frequent cause of cancer-related death worldwide. Despite advances in systemic therapy, the 5-year survival remains humbling at 4% to 17%. For those diagnosed early, surgical therapy can yield potentially curative results. Surgical resection remains a cornerstone of medical care. Success hinges on sound oncologic resection principles. Various techniques can be used to identify pulmonary nodules. A challenge is intraoperative assessment of the surgical specimen to confirm disease localization and ensure an R0 resection. The primary tool is frozen section. Understanding the options available enhances the arsenal of thoracic surgeons and leads to better patient care.

Planting Seeds into the Lung: Image-Guided Percutaneous Localization to Guide Minimally Invasive Thoracic Surgery

Image-guided localization materials are constantly evolving, providing options for the localization of small pulmonary nodules to guide minimally invasive thoracic surgery. Several preoperative methods have been developed to localize small pulmonary lesions prior to video-assisted thoracic surgery. These localization techniques can be categorized into 4 groups according to the materials used: localization with metallic materials (hook-wire, microcoil, or spiral coil), localization with dye (methylene blue or indigo carmine), localization with contrast agents (lipiodol, barium, or iodine contrast agents), and radiotracers (technetium-99m). However, the optimal localization method has not yet been established. In this review article, we discuss the various localization techniques and the advantages and disadvantages of localization techniques as well as the available safety and efficacy data on these techniques.

Comparison of radiopaque dye materials for localization of pulmonary nodules before video-assisted thoracic surgery

Background

Although a mixture of pigments and radiopaque materials was reported to be useful material for lung nodule localization, the optimal combination has not been well investigated. The purpose of this study is to evaluate the characteristics of various combinations of pigments and radiopaque materials for localization of pulmonary nodules prior to video-assisted thoracic surgery (VATS).

Methods

We compared stability, viscosity, and visibility of 6 radiopaque dye materials of (I) mixture of indigo carmine and lipiodol; (II) mixture of indigo carmine, lipiodol, and lidocaine gel; (III) mixture of indocyanine green in water solution (w-ICG) and lipiodol; (IV) mixture of w-ICG, lipiodol, and lidocaine gel; (V) ICG in contrast medium solution (cm-ICG); and (VI) mixture of cm-ICG and lidocaine gel. Stability was evaluated by observing changes in the mixtures in the test tube with time visually and radiographically. Viscosities were measured by rotational viscometer. Materials were injected into an expanded pig-lung phantom, and area on CT and visibility on thoracoscopy camera were evaluated.

Results

Separation could be seen 15 min after preparation in (I) and (III), and 1 h after preparation in (II), both visually and radiographically. In (IV), separation could be seen on the photographs but not on the X-ray images from 3 h after preparation. (V) and (VI) showed no changes within the 2-day observation period. The viscosities of the materials were (I) 0.2±0.1, (II) 2.9±0.1, (III) 0.2±0.1, (IV) 2.6±0.1, (V) 0.2±0.1, and (VI) 1.2±0.1 dPa·s. The area on CT showed very strong negative correlation with viscosity (r=−0.97). The injection point of each material was easily detected on thoracoscopy camera.

Conclusions

Radiopaque dye materials appear useful for localizing pulmonary nodules before VATS; their diffusion in the lung parenchyma can be suppressed by using materials of high viscosity.

Preoperative Computed Tomography-Guided Localization for Pulmonary Nodules with Glue and Dye

BACKGROUND

This study was aimed to describe a new localization technique developed using medical glue and methylene blue dye, and characterized the localization results and postoperative outcome to evaluate its safety and usefulness.

METHODS

This retrospective study was conducted at our center from January 2016 to April 2018. Totally 346 consecutive patients with 383 nodules who underwent preoperative computed tomography (CT)-guided medical glue and methylene blue dye localization, followed by lung resection, were enrolled in this study.

RESULTS

Mean nodule size was 7.7 ± 3.7 mm (range: 2-30 mm), with a mean depth from pleura or fissure of 9.4 ± 9.3 mm (range: 0-60 mm). The success rate of CT-guided localization for pulmonary nodules was 99.5% (381/383) of the nodules. Localization-related complications included mild pneumothorax in 16 (4.6%) patients, mild hemothorax in 7 (2.0%) patients, and hemoptysis in 1 (0.3%) patient. Pleural reaction occurred in 7 (2.0%) and pain in 25 (7.2%) patients. All 383 nodules were resected successfully, with conversion to thoracotomy only required in two patients for adhesion and calcification of lymph nodes. All patients recovered well postoperatively, with a short postoperative hospital stay (3.7 ± 2.0 days) and a low complication rate (2.6%, 9/346).

CONCLUSION

CT-guided medical glue and methylene blue dye localization prior to video-assisted thoracoscopic surgery (VATS) lung resection was a novel, safe, and technically feasible method, with a high-technical success rate and a low-complication rate. It allowed surgeons to easily locate and detect the nodules and estimate the surgical margin.

Preresection Stained Glue Injection to Localize Pulmonary Small Nodules and Ground-glass Opacities

Objective:

We sought to introduce a localization procedure (methylene blue-stained N-butyl cyanoacrylate and N-octyl cyanoacrylate glue) in localizing pulmonary small nodules and ground-glass opacities before thoracoscopic resection, and to evaluate its efficacy.

Methods:

A total of 20 patients with pulmonary small nodules and/or ground-glass opacities, who underwent video-assisted thoracoscopic surgery from August 1, 2017 to March 1 2018, were included in the study.

Results:

A total of 24 lesions in 20 patients underwent blue-stained glue localization. The success rate of localization was 100%, with a mean dose of 0.04±0.01 mL blue dye and 1 mL glue used for each lesion. The average time for the whole localization procedure was 15.4±6.3 minutes. All lesions were intraoperatively localized by visual inspection in combination with palpation. The complications related to the localization procedure included mild pneumothorax occurring in 9 patients and minor pulmonary hematoma in 4 patients. No pain or distress was reported.

Conclusions:

Blue-stained glue injection is technically feasible and safe to localize pulmonary small nodules and ground-glass opacities before thoracoscopic resection.

Image-guided Preoperative Localization of Pulmonary Nodules for Video-assisted and Robotically Assisted Surgery

Video-assisted thoracic surgery (VATS) and robotically assisted surgery are used increasingly for minimally invasive diagnostic and therapeutic resection of pulmonary nodules. Unsuccessful localization of small, impalpable, or deep pulmonary nodules can necessitate conversion from VATS to open thoracotomy. Preoperative localization techniques performed by radiologists have improved the success rates of VATS resection for small and subsolid nodules. Any center at which VATS diagnostic resection of indeterminate pulmonary nodules is performed should be supported by radiologists who offer preoperative nodule localization. Many techniques have been described, including image-guided injection of radioisotopes and radiopaque liquids and placement of metallic wires, coils, and fiducial markers. These markers enable the surgeon to visualize the position of an impalpable nodule intraoperatively. This article provides details on how to perform each percutaneous localization technique, and a group of national experts with established nodule localization programs describe their preferred approaches. Special reference is made to equipment required, optimization of marker placement, prevention of technique-specific complications, and postprocedural treatment. This comprehensive unbiased review provides valuable information for those who are considering implementation or optimization of a nodule localization program according to workflow patterns, surgeon preference, and institutional resources in a particular center. ^©RSNA, 2019.

Placement of markers to assist minimally invasive resection of peripheral lung lesions

With development of lung cancer screening programs and increased utilization of radiographic imaging there is significantly higher detection of smaller lung nodules and subsolid lesions. These nodules could be malignant and pose a diagnostic challenge. Video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery (RATS) represent minimally invasive methods for tissue sampling. Intraoperative identification of these lesions maybe difficult, requiring marking prior to surgery. We review different techniques for the placement of markers to assist in the resection of peripheral lung lesions (PLL).

A simple and efficient method to perform preoperative pulmonary nodule localization: CT-guided patent blue dye injection

OBJECTIVE

To assess the efficacy of computed tomography (CT)-guided localization with the injection of a low dose of patent blue dye (PBD) for the thoracoscopic resection of pulmonary nodules.

MATERIALS AND METHODS

Overall, 125 consecutive patients underwent CT-guided localization with injection of a lower dose of PBD between June 2015 and June 2016. The total injection dose relative to the distance between nodules and the visceral pleura was recorded. The clinical and radiological characteristics, technical details, pathological results and procedure-related complications were reviewed.

RESULTS

A total of 137 indeterminate pulmonary nodules were identified. The mean nodule size was 9.5 (3.0-22.0) mm. The mean injection dose of PBD relative to the distance between nodules and the visceral pleura was classified as follows: 0.07 ml: <1 cm, 0.1 ml: 1-2 cm and 0.18 ml: >2 cm. The mean time of CT-guided localization was 16.5 (10-50) min. The mean time interval from localization to surgery was 188 (24-1440) min. Pneumothorax developed in 50 patients (40%), and focal parenchymal hemorrhage occurred in 16 patients (12.8%) after localization. No patient required chest tube placement or emergent resuscitation. The success rate of dye marking was 98.5% (135/137). Malignancies, including 82 lung cancers, were diagnosed in 97 nodules (70.8%).

CONCLUSION

The injection of a lower dose PBD based on the distance to the visceral pleura can be successful with nodular localization and may facilitate thoracoscopic surgery, even in cases with a long interval from localization to surgery.

Uniportal VATS Coil-Assisted Resections for GGOs

Backgrounds

Although uniportal video-assisted thoracic surgery (VATS) theoretically allows the direct palpation of any zone of the lung through a small incision, sometimes it can be difficult to localize pure ground-glass opacities anyway. The aim of this study is to evaluate the usefulness and safety of preoperative computed tomography (CT)-guided microcoil localization of GGO nodules in patients undergoing uniportal VATS lung resection.

Methods

The clinical data and CT images of 30 consecutive patients (30 pulmonary nodules) who underwent preoperative CT-guided coil localization and subsequent uniportal VATS resection, from January 2017 to October 2018, were reviewed.

Results

All the CT-localization procedures have been performed with success (30/30) and the mean procedure time was 35±15 minutes. The mean size of the nodules was 15,53±6,72 mm, and the mean distance of the nodules from the pleural surface was 19,08±12,08 mm. Eleven nodules (36,7%) were pure ground-glass opacities and 19 (63,3%) were mixed ground-glass with a solid component of 50% or more. In 5 cases, the localization procedure was complicated by asymptomatic pneumothoraxes and in 1 case the pneumothorax required chest tube insertion. In any case a conversion to thoracotomy was avoided because all nodules were identified and resected through uniportal VATS.

Conclusions

Preoperative CT-guided coil localization seems to be a feasible, safe, and accurate procedure. It makes uniportal VATS an easy approach even for resecting small, deep, and impalpable nodules.

Clinical analysis of percutaneous computed tomography-guided injection of cyanoacrylate for localization of 115 small pulmonary lesions in 113 asymptomatic patients

Objective

This study was performed to assess the clinical feasibility, safety, and effectiveness of a computed tomography (CT)–guided cyanoacrylate injection system and investigate the relationship between clinical features and pathologic characteristics of diminutive pulmonary lesions.

Methods

In total, 115 pulmonary nodules from 113 patients (63 female, 50 male) with a diameter of <20 mm were percutaneously localized with a CT-guided cyanoacrylate injection system and then resected.

Results

Of the pure ground-glass opacities (GGOs), 16.0% were atypical adenomatous hyperplasia (AAH), 18.7% were adenocarcinoma in situ (AIS), 49.3% were lung adenocarcinoma (ADC), and 16.0% were benign inflammatory fibrosis/fibrotic scars. Of the mixed GGOs, 18.2% were AAH, 22.7% were AIS, 22.7% were ADC, and 36.4% were benign lesions. Lesions of >10 mm and those located in relation to vessels were significantly more likely to be malignant. The success rate of both the cyanoacrylate injection system and video-assisted thoracoscopic surgery was 100% with no severe complications.

Conclusions

Preoperative localization of small pulmonary nodules using a cyanoacrylate injection system is a safe, simple, and useful technique.

Radioguided lung lesion localization: introducing a fluoroscopy system in a SPECT/CT scan

PURPOSE

The purpose was to report our experience in the use of radiotracer localization and resection of small, indistinct, or nonpalpable pulmonary lesions. We developed an innovative technique implementing a fluoroscopy system on a single-photon emission computed tomography/computed tomography (SPECT/CT) scan that allowed to perform CT-guided injection of radiotracer directly on SPECT/CT.

PATIENTS AND METHODS

Patients were selected for the radiotracer procedure in presence of difficulties in locating nodules with video-assisted thoracoscopic surgery (VATS). Overall, 0.2 ml of technetium-99m macroaggregated albumin and 0.3 ml of nonionic iodinated contrast were injected under CT guidance. During the VATS procedure, an endoscopic gamma detecting probe was introduced to scan the lung surface. The area of major radioactivity, which matched with the area of the nodule, was resected.

RESULTS

Between January 2016 and October 2018, 37 patients underwent CT-guided radiotracer injection. The mean nodule size was 11 mm. CT nodule morphology characteristics were as follows: 15 nodules were ground glass, 12 were solid, and 10 were partly solid. No significant adverse events occurred. In one patient, the surgeons decided for an open thoracotomy after unsuccessfully VATS. Overall, lobectomy was performed in two patients, segmentectomy in one, and wedge resection in 33 patients. No mortality occurred. The pathological diagnosis was 15 (42%) primary lung cancer, eight (22%) metastases, and 13 (36%) benign lesions.

CONCLUSION

Radioguided pulmonary nodule localization is a reliable procedure with a high rate of success, minimal complications, and lower risk of failures, with no associated mortality or significant morbidity. Our SPECT/CT system is the first to benefit from the technological improvement with successfully implementation and application of fluoroscopy to SPECT/CT.

Simultaneous cone beam computed tomography-guided bronchoscopic marking and video-assisted thoracoscopic wedge resection in a hybrid operating room

The increasing need for pulmonary resection by video‐assisted thoracoscopic surgery (VATS) has presented a greater opportunity to detect small‐sized pulmonary nodules by computed tomography (CT). In cases where it is difficult to identify tumor localization intraoperatively, it is necessary to place the VATS marker near the pulmonary nodules before surgery. Conventional percutaneous or bronchoscopic VATS marker placement under local anesthesia is accompanied by patient pain. We clinically applied a new technique to place VATS markers using a bronchoscope under general anesthesia in a hybrid operating room. Multiple pulmonary nodules were successfully marked and securely excised simultaneously by VATS. This technique enables secure, minimally invasive resection of multiple small‐sized pulmonary nodules without causing distress to the patient.

Comparison between the application of microcoil and hookwire for localizing pulmonary nodules

OBJECTIVES

To compare the efficacy and safety of localization of small pulmonary nodules with microcoil and hookwire prior to surgical resection.

METHODS

A total of 112 patients who underwent preoperative computed tomography (CT)-guided localization of small pulmonary nodules were enrolled in this single-center retrospective non-randomized cohort study between June 2016 and June 2017. Seventy-nine patients who underwent percutaneous localization with microcoils formed the microcoil group; the remaining 33 patients underwent percutaneous localization with hookwires (hookwire group). The primary outcomes were the success and complication rates of the procedure. Student's t test was used for continuous variables, whereas chi-square analysis and logistic regression were used for dichotomous variables.

RESULTS

Video-assisted thoracoscopic surgery (VATS) was successfully performed in all cases, without conversion to thoracotomy. The localization success rate was 94.9% (75/79) in the microcoil group and 93.9% (31/33) in the hookwire group (p = 0.836). Hookwire group (p = 0.000) and nodule location of the lower lobe (p = 0.012) were associated with an increased incidence of pneumothorax. Hookwire group (p = 0.027) and decreased nodule diameter (p = 0.024) were associated with an increased incidence of moderate to severe chest pain, as well as an increased incidence of overall complications.

CONCLUSIONS

Although the deployment of the microcoil was more complex and required more time than hookwire placement, microcoil localization was associated with fewer complications.

KEY POINTS

• CT-guided percutaneous localization using a microcoil and that using a hookwire are equally effective for localizing small pulmonary nodules prior to resection with video-assisted thoracoscopic surgery. • Lung nodule localization using a microcoil was associated with fewer complications than localization using a hookwire.