Intraoperative ultrasonographic localization of pulmonary ground-glass opacities

Comparison of safety and effectiveness of medical adhesive and metal spring coil in preoperative localization of peripheral pulmonary nodules

Background

Accurate preoperative positioning is the key to the success of thoracoscopic surgery for small pulmonary nodules. There are many methods for locating pulmonary nodules in clinical practice, but there are currently few research reports on the value of medical adhesive localization.

Objective

To compare the clinical value of two positioning methods, medical adhesive and metal spring coil, in the preoperative application of VATS through retrospective analysis.

Methods

A total of 288 patients who underwent thoracoscopic surgery in our hospital from January 2021 to June 2024 due to the discovery of solitary pulmonary nodules during chest CT examination were included in this study. Preoperative patients were randomly divided into two groups, with 205 patients undergoing preoperative medical adhesive positioning (Group A) and 83 patients undergoing metal spring coil positioning (Group B). After the positioning was completed, record the positioning time of each group of patients and the immediate pain score 15 min after the positioning was completed, the complications located in each group of patients, and whether there was positioning failure or not.

Results

The localization success rate of the medicine adhesive positioning group [99.5% (204/205)] was higher than that of the metal spring coil positioning group [91.6% (76/83)] (P = 0.001). The positioning time of the medical adhesive positioning group was 12.00 (10.00, 14.00) min, which was shorter than the 13.00 (11.00, 16.00) min of the micro coil group (P = 0.001). The immediate pain score (2.32 ± 0.79) of the medical adhesive positioning group 15 min after positioning was significantly lower than that of the metal spring coil positioning group (3.97 ± 0.54) (P < 0.001). The incidence of complications such as pneumothorax [15.7% (13/83) vs 5.4% (11/205), P = 0.004], pulmonary hemorrhage/hemoptysis [20.5% (17/83) vs 4.9 (10/205), P < 0.001] was significantly higher in the metal coil positioning group than in the medical adhesive positioning group.

Conclusion

Preoperative medical adhesive positioning for pulmonary nodules is safe, reliable, and effective. Compared with metal spring coil positioning, it has shorter positioning time, milder pain after positioning, lower incidence of positioning related complications, and more flexible arrangement of surgical timing after positioning. It has high clinical application value.

Vein watershed analysis locational method versus computed tomography-guided percutaneous localization for detecting non-palpable peripheral pulmonary nodules: a real-world study of non-inferiority

OBJECTIVES

In recent years, with the advancement of sublobar resection, a safe, painless method for locating peripheral pulmonary nodules was needed. Previously, an alternative method of arterial watershed localization was introduced to remedy the shortcomings of preoperative computed tomography (CT)-guided localization or other methods for locating pulmonary nodules, but its technical limitations were discovered during clinical applications. Therefore, we developed a technique to localize non-subpleural nodules using basin analysis of the target vein and validated its feasibility and safety.

METHODS

We performed a retrospective analysis of surgical cases of pulmonary nodules smaller than 2 cm in our centre. The vein watershed locational method (V-WALM) was compared with CT-guided percutaneous puncture localization wedge dissection in terms of success rate, the mean duration of the operation, mean volume of intraoperative bleeding and median postoperative stay, mean postoperative drainage and mean drainage tube indwelling time.

RESULTS

V-WALM and CT-guided localization were used for localized resection of pulmonary nodules in 50 patients. The localization success rates were 94.0% for V-WALM and 90.0% for CT-guided localization, respectively, with no statistical difference noted. In addition, no statistical difference in patient population distribution between the 2 groups was noted. The operating time was 95.5 ± 26.4 min for V-WALM and 94.3 ± 37.5 min for CT-guided localization, with no statistical difference. Neither were there statistical differences in intraoperative bleeding, postoperative drainage and drainage tube indwelling time. The lymph node sampling rate of V-WALM was 48.0%, which was much higher than the 24% noted in the CT-guided localization group.

CONCLUSIONS

The results of this study demonstrate that V-WALM is a safe and feasible intraoperative localization method for peripheral lung nodules. It provides a high-precision, fast and minimally invasive approach to intraoperative localization.

Comparison of different localization needles and postures in localization of pulmonary nodules

BACKGROUND

With advancements in imaging testing and surgical procedures, an increasing number of nodules with smaller diameters and deeper locations have been deemed suitable for surgical intervention. The preoperative localization of these nodules has become essential. In this retrospective single-center study, we aimed to compare the effectiveness and patient comfort associated with the use of a four-hook needle versus a hook-wire needle for preoperative localization. Additionally, we sought to evaluate the impact of different patient postures on localization effectiveness.

METHODS

We retrospectively analyzed the data of 692 patients following preoperative CT-guided localization. The patients were categorized into different groups based on the type of localization needles used and their respective postures during localization.

RESULTS

There was no statistical difference in total complications between the four-hook needle group and the hook-wire needle group (P > 0.05). The chest pain score in the four-hook needle group was lower than the hook-wire needle group (P = 0.001). The incidence of decoupling in the four-hook needle group was significantly lower than the hook-wire needle group (P < 0.05). The four-hook needle group had better performance in terms of localization operation time, operation time, intraoperative bleeding and first-day drainage (P < 0.05). Compared with the supine and lateral groups, the prone posture group had better performance in total complications and localization operation time, and worse performance in decoupling and chest pain (P < 0.05).

CONCLUSIONS

The four-hook needle has better effectiveness on localization and comfort in patient than the hook-wire needle, which is worthy of clinical promotion and application. The patient's different postures during localization procedure may affect the localization results.

Comparison of electromagnetic navigation bronchoscopy localization and CT-guided percutaneous localization in resection of lung nodules: A protocol for systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the efficacy and safety between electromagnetic navigational bronchoscopy (ENB) and computed tomography (CT)-guided percutaneous localization before resection of pulmonary nodules.

METHODS

Pubmed, Embase, Web of Science, and the Cochrane Library databases were searched from January 1, 2000 to April 30, 2022, for relevant studies. Two reviewers conducted the search, selection, and extraction of data from eligible studies. The risk of bias was assessed using the Newcastle-Ottawa Scale. The primary outcome was the localization success rate, and the secondary outcomes were the pneumothorax incidence and localization time. The meta-analysis was performed by Review Manager 5.4. The protocol for the meta-analysis was registered on PROSPERO (Registration number: CRD42022345972).

RESULTS

Five cohort studies comprising 441 patients (ENB group: 185, CT group: 256) were analyzed. Compared with the CT-guided group, the ENB-guided group was associated with lower pneumothorax incidence (relative ratio = 0.16, 95% confidence interval [CI]: 0.04-0.65, P = .01). No significant differences were found in location success rates (relative ratio = 1.01, 95% CI: 0.98-1.05, P = .38) and localization time (mean difference = 0.99, 95% CI: -5.73 to 7.71, P = .77) between the ENB group and CT group.

CONCLUSION

Both ENB and CT-guided are valuable technologies in localizing lung nodules before video-assisted thoracoscopic surgery based on current investigations. ENB achieved a lower pneumothorax rate than the CT-guided group. In our opinion, there is no perfect method, and decision-making should be given the actual circumstances of each institute. Future prospective studies in the form of a randomized trial are needed to confirm their clinical value.

Comparison between one-stage and two-stage CT-guided localization of lung nodules with surgical resection: a single medical center experience

BACKGROUND

This retrospective study aimed to compare the efficacy and safety of one-stage computed tomography (OSCT)- to that of two-stage computed tomography (TSCT)-guided localization for the surgical removal of small lung nodules.

METHODS

We collected data from patients with ipsilateral pulmonary nodules who underwent localization before surgical removal at Veteran General Hospital Kaohsiung between October 2017 and January 2022. The patients were divided into the OSCT and TSCT groups.

RESULTS

We found that OSCT significantly reduced the localization time and risky time compared to TSCT, and the success rate of localization and incidence of pneumothorax were similar in both groups. However, the time spent under general anesthesia was longer in the OSCT group than in the TSCT group.

CONCLUSIONS

The OSCT-guided approach to localize pulmonary nodules in hybrid operation room is a safe and effective technique for the surgical removal of small lung nodules.

Comparison of laser guidance and freehand hook-wire for CT-guided preoperative localization of pulmonary nodules

PURPOSE

In VATS surgery, precise preoperative localization is particularly crucial when dealing with small-diameter pulmonary nodules located deep within the lung parenchyma. The purpose of this study was to compare the efficacy and safety of laser guidance and freehand hook-wire for CT-guided preoperative localization of pulmonary nodules.

METHODS

This retrospective study was conducted on 164 patients who received either laser guidance or freehand hook-wire localization prior to Uni-port VATS from September 1st, 2022 to September 30th, 2023 at The First Affiliated Hospital of Soochow University. Patients were divided into laser guidance group and freehand group based on which technology was used. Preoperative localization data from all patients were compiled. The localization success and complication rates associated with the two groups were compared. The risk factors for common complications were analyzed.

RESULTS

The average time of the localization duration in the laser guidance group was shorter than the freehand group (p<0.001), and the average CT scan times in the laser guidance group was less than that in the freehand group (p<0.001). The hook-wire was closer to the nodule in the laser guidance group (p<0.001). After the localization of pulmonary nodules, a CT scan showed 14 cases of minor pneumothorax (22.58%) in the laser guidance group and 21 cases (20.59%) in the freehand group, indicating no statistical difference between the two groups (p=0.763). CT scans in the laser guidance group showed pulmonary minor hemorrhage in 8 cases (12.90%) and 6 cases (5.88%) in the freehand group, indicating no statistically significant difference between the two groups (p=0.119). Three patients (4.84%) in the laser guidance group and six patients (5.88%) in the freehand group had hook-wire dislodgement, showing no statistical difference between the two groups (p=0.776).

CONCLUSION

The laser guidance localization method possessed a greater precision and less localization duration and CT scan times compared to the freehand method. However, laser guidance group and freehand group do not differ in the appearance of complications such as pulmonary hemorrhage, pneumothorax and hook-wire dislodgement.

Management of screening-detected ground glass nodules: a narrative review

Wide-scale application of low-dose computed tomography (LDCT) in lung cancer screening has led to an increased detection of ground glass nodule (GGN) lesions. However, there is still no clear management plan for these lesions after detection. Clinicians are usually faced with a dilemma in choosing the best initial management approach that not only limits overtreatment but also avoids the possibility of lesions growing into invasive carcinoma. Most current and past guidelines favor surveillance with computed tomography (CT) as the initial management approach based on the notion that the majority of GGN lesions are indolent tumors. Immediate surgery is generally considered overtreatment and is usually only recommended when the lesion grows in size, persists, or increases its solid component during follow-up CT surveillance. However, due to evolution of surgery to minimal invasive procedures, such as uniportal video-assisted thoracic surgery, and the development of enhanced recovery after thoracic surgery protocols, modern surgery is now safer and associated with less postoperative mortality. Additionally, intraoperative frozen sections can be used to guide resection, making initial management via surgery more attractive than before. Based on these developments, this review recommends that immediate surgery should be considered at the same level as follow-up CT surveillance when making multidisciplinary team decisions for screening-detected GGNs, as it provides both a diagnostic and treatment role.

A robotic system for transthoracic puncture of pulmonary nodules based on gated respiratory compensation

BACKGROUND AND OBJECTIVE

With the urgent demands for rapid and precise localization of pulmonary nodules in procedures such as transthoracic puncture biopsy and thoracoscopic surgery, many surgical navigation and robotic systems are applied in the clinical practice of thoracic operation. However, current available positioning methods have certain limitations, including high radiation exposure, large errors from respiratory, complicated and time-consuming procedures, etc. METHODS: To address these issues, a preoperative computed tomography (CT) image-guided robotic system for transthoracic puncture was proposed in this study. Firstly, an algorithm for puncture path planning based on constraints from clinical knowledge was developed. This algorithm enables the calculation of Pareto optimal solutions for multiple clinical targets concerning puncture angle, puncture length, and distance from hazardous areas. Secondly, to eradicate intraoperative radiation exposure, a fast registration method based on preoperative CT and gated respiration compensation was proposed. The registration process could be completed by the direct selection of points on the skin near the sternum using a hand-held probe. Gating detection and joint optimization algorithms are then performed on the collected point cloud data to compensate for errors from respiratory motion. Thirdly, to enhance accuracy and intraoperative safety, the puncture guide was utilized as an end effector to restrict the movement of the optically tracked needle, then risky actions with patient contact would be strictly limited.

RESULTS

The proposed system was evaluated through phantom experiments on our custom-designed simulation test platform for patient respiratory motion to assess its accuracy and feasibility. The results demonstrated an average target point error (TPE) of 2.46 ± 0.68 mm and an angle error (AE) of 1.49 ± 0.45° for the robotic system.

CONCLUSIONS

In conclusion, our proposed system ensures accuracy, surgical efficiency, and safety while also reducing needle insertions and radiation exposure in transthoracic puncture procedures, thus offering substantial potential for clinical application.

Intraoperative lung ultrasound improves subcentimetric pulmonary nodule localization during VATS: Results of a retrospective analysis

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) resection of deep-seated lung nodules smaller than 1 cm is extremely challenging. Several methods have been proposed to overcome this limitation but with not neglectable complications. Intraoperative lung ultrasound (ILU) is the latest minimally invasive proposed technique. The aim of the current study was to analyze the accuracy and efficacy of ILU associated with VATS to visualize solitary and deep-seated pulmonary nodules smaller than 1 cm.

METHODS

Patients with subcentimetric solitary and deep-seated pulmonary nodules were included in this retrospective study from November 2020 to December 2022. Patients who received VATS aided with ILU were considered as group A and patients who received conventional VATS as group B (control group). The rate of nodule identification and the time for localization with VATS alone and with VATS aided with ILU in each group were analyzed.

RESULTS

A total of 43 patients received VATS aided with ILU (group A) and 31 patients received conventional VATS (group B). Mean operative time was lower in group A (p < 0.05). In group A all the nodules were correctly identified, while in group B in one case the localization failed. The time to identify the lesion was lower in group A (7.1 ± 2.2 vs. 13.8 ± 4.6; p < 0.05). During hospitalization three patients (6.5%; p < 0.05) in group B presented air leaks that were conservatively managed.

CONCLUSION

Intracavitary VATS-US is a reliable, feasible, real-time and effective method of localization of parenchymal lung nodules during selected wedge resection procedures.

Intraoperative Contrast-Enhanced Ultrasonography (Io-CEUS) in Minimally Invasive Thoracic Surgery for Characterization of Pulmonary Tumours: A Clinical Feasibility Study

BACKGROUND

The intraoperative detection of solitary pulmonary nodules (SPNs) continues to be a major challenge, especially in minimally invasive video-assisted thoracic surgery (VATS). The location, size, and intraoperative frozen section result of SPNs are decisive regarding the extent of lung resection. This feasibility study investigates the technical applicability of intraoperative contrast-enhanced ultrasonography (Io-CEUS) in minimally invasive thoracic surgery.

METHODS

In this prospective, monocentric clinical feasibility study, n = 30 patients who underwent Io-CEUS during elective minimally invasive lung resection for SPNs between October 2021 and February 2023. The primary endpoint was the technical feasibility of Io-CEUS during VATS. Secondary endpoints were defined as the detection and characterization of SPNs.

RESULTS

In all patients (female, n = 13; mean age, 63 ± 8.6 years) Io-CEUS could be performed without problems during VATS. All SPNs were detected by Io-CEUS (100%). SPNs had a mean size of 2.2 cm (0.5-4.5 cm) and a mean distance to the lung surface of 2.0 cm (0-6.4 cm). B-mode, colour-coded Doppler sonography, and contrast-enhanced ultrasound were used to characterize all tumours intraoperatively. Significant differences were found, especially in vascularization as well as in contrast agent behaviour, depending on the tumour entity. After successful lung resection, a pathologic examination confirmed the presence of lung carcinomas (n = 17), lung metastases (n = 10), and benign lung tumours (n = 3).

CONCLUSIONS

The technical feasibility of Io-CEUS was confirmed in VATS before resection regarding the detection of suspicious SPNs. In particular, the use of Doppler sonography and contrast agent kinetics revealed intraoperative specific aspects depending on the tumour entity. Further studies on Io-CEUS and the application of an endoscopic probe for VATS will follow.

Using the robotic platform in the therapy of multifocal ground glass opacities

Due to their association with invasive adenocarcinoma, ground glass opacities that reach 3 cm in size, develop a solid component ≥2 mm on mediastinal windows, or exhibit ≥25% annual growth warrant operative resection. Minimally invasive techniques are preferred given that approximately one third of patients will present with multifocal focal disease and may require additional operations. A robotic-assisted thoracoscopic surgical approach can be used with percutaneous or bronchoscopic localization techniques and are compatible with developing intraoperative molecular targeting techniques.

State of the Art in Lung Nodule Localization

Lung nodule and ground-glass opacity localization for diagnostic and therapeutic purposes is often a challenge for thoracic surgeons. While there are several adjuncts and techniques in the surgeon's armamentarium that can be helpful, accurate localization persists as a problem without a perfect solution. The last several decades have seen tremendous improvement in our ability to perform major operations with minimally invasive procedures and resulting lower morbidity. However, technological advances have not been as widely realized for lung nodule localization to complement minimally invasive surgery. This review describes the latest advances in lung nodule localization technology while also demonstrating that more efforts in this area are needed.

Ultrasound location of ground-glass opacity during thoracoscopic surgery

OBJECTIVES

Application of video-assisted thoracoscopy brought lung surgery into the minimally invasive era; the lack of tactile feedback using VATS, remains a disadvantage because surgeons are unable to locate lesions with a finger or device. This study aimed to investigate the effectiveness, the applicability and the utility of intraoperative ultrasound (IU), for the localization of small ground-glass opacity (GGO) lesions in the parenchyma, as a guide in finding their margins in a deflated lung.

MATERIALS AND METHODS

We included 15 consecutive patients undergoing diagnostic resection of GGOs via VATS in the Thoracic Surgery Unit of the University of 'Luigi Vanvitelli' of Naples from November 2019 to December 2021. They were under general anaesthesia, when the lung had been collapsed, the probe was placed in the region where the target lesion was thought to reside on the basis of low-dose computed tomography scanning. GGO could be identified their sizes, echo levels and posterior echo was recorded by IU when the lung was completely deflated.

RESULTS

We conducted a retrospective single-centre study. All GGOs were identified by IU. The mean size and depth were 14.1 ± 0.5 and 4.8 ± 0.3 mm, respectively. Six (40%) lesions had hyperechoic patterns, 9 (60%) had mixed echogenicity where the hyperechoic patterns were irregularly mixed with hypoechoic patterns. The final diagnoses included 2 (15%) atypical adenomatous hyperplasia; 2 (15%) adenocarcinomas in situ; 3 (23%) minimally invasive adenocarcinomas and 6 (46%) invasive adenocarcinomas.

CONCLUSIONS

The results of our study showed that IU could safely and effectively detect GGOs.

Comparison of hook-wire and medical glue for CT-guided preoperative localization of pulmonary nodules

Background

Preoperative localization is challenging due to the small diameter of pulmonary nodules or their deep location in the lung parenchyma during VATS surgery. The purpose of this study was to compare the efficacy and safety of both hook-wire and medical glue for pre-operative localization of pulmonary nodules.

Methods

In the current study, 158 patients were retrospectively analyzed (January 2019 and January 2020). The patients underwent hook-wire or medical glue for pre-operative localization of pulmonary nodules. Among them, 74 patients in the hook-wire group and 84 patients in the medical glue group underwent VATS anatomic segmentectomy or wedge resection after localization of pulmonary nodules. Pre-operative localization data from all patients were compiled. Moreover, the efficacy and safety of the two methods were evaluated according to localization success rates and localization-related complications.

Results

The success rate of localization in the medical glue group was 100% while 97.3% in the hook-wire group. After localization of the pulmonary nodules, the incidence of minor pneumothorax in the medical glue group (11.9%) was lower than that in the hook-wire group (37.8%) (p=0.01). The incidence of mild pulmonary parenchymal hemorrhage in the medical glue group (13.1%) was also lower than that in the hook-wire group (24.3%) (p=0.000). The mean time from the completion of localization to the start of surgery was also longer in the medical glue group than in the hook-wire group (p=0.000). The mean visual analog scale (VAS) scores after localization were higher in the hook-wire group than in the medical glue group (p=0.02). In both groups, parenchymal hemorrhage was significantly associated with the needle length in hook-wire localization and the depth of the medical glue in the lung parenchyma (p = 0.009 and 0.001, respectively).

Conclusion

These two localization methods are safe and effective in pre-operative pulmonary nodule localization. The medical glue localization method had a lower risk of complications, a higher localization success rate, less pain after localization and more flexibility in the arrangement of operation time.

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.

Augmented reality navigation-guided pulmonary nodule localization in a canine model

Background

The current intraoperative pulmonary nodule localization techniques require specific medical equipment or skillful operators, which limits their widespread application. Here, we present an innovative nodule localization technique in a canine lung model using augmented reality (AR) navigation.

Methods

Peripheral pulmonary lesions were artificially created in canine model. A preoperative chest computed tomography scan was performed for each animal. The acquired computed tomography images were analyzed, and an established intraoperative localization plan was uploaded into HoloLens (a head-mounted AR device). Under general anesthesia, lung localization markers were implanted in each canine, guided by the established procedure plan displayed by HoloLens. All artificial lesions and markers were removed by video-assisted wedge resection or lobectomy in a single operation.

Results

Since June 2019, 12 peripheral pulmonary lesions were artificially created in 4 canine models. All lung localization markers were precisely implanted with a median registration and implantation time of 6 minutes (range, 2–15 minutes). The average distance between pulmonary lesions and markers was 1.9±1.7 mm, based on computed tomography examination after localization. No severe pneumothorax was observed after marker implantation. After an average implantation period of 16.5 days, no marker displacement was observed.

Conclusions

The AR navigation-guided pulmonary nodule localization technique was safe and effective in a canine model. The validity and feasibility of using this technology in patients will be examined further (NCT04211051).

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.

Role of a portable gamma-camera with optical view for margins assessment of pulmonary nodules resected by radioguided surgery

PURPOSE

Radioguided occult lesion localization (ROLL) of pulmonary nodules is an alternative to hook-wire. Both required of a histological margin assessment. The activity emerging from the radiotracer allows to obtain an intraoperative scintigraphic image of the surgical specimen by a portable gamma-camera (PGC) fitted with an optical view, which provides information about the localization of the nodule in relation to the margins. The aim of this study was to evaluate the intraoperative use of a PGC for margin assessment of pulmonary nodules.

METHODS

ROLL technique was used in 38 nodules (36 pulmonary, 1 chest wall, and 1 pleural nodules). A PGC intraoperative image of the surgical specimen was obtained in 32. Scintigraphic results were compared to the histological assessment. Other factors, such as nodule size, distance from the pleural surface, or distance covered by the needle, were considered as possible factors for non-centered lesions.

RESULTS

PGC images showed that the lesion was in contact with the margins in 8/32 cases and centered in 24. In all cases in which the lesion was considered as centered by the PGC, the margins were free of involvement (NPV 100%), although the PPV is low.

CONCLUSIONS

The use of a PGC for margin assessment after pulmonary nodule resection is feasible and provides a high NPV in our series. In addition, the short intraoperative time required for its use makes the PGC a useful tool for providing supplementary information to histopathologic results. Further studies from different surgical teams are required for an external validation.

[Preliminary Study of CT Three-dimensional Reconstruction Combined with Ground Glass Nodules of Natural Lung Collapse in Thoracoscopic Pulmonary Segmental Resection]

BACKGROUND

Computed tomography (CT) three-dimensional reconstruction technology is increasingly used in preoperative planning of patients with ground glass nodule (GGN), but how to accurately locate the nodule and ensure the safe resection edge is still a difficult problem for clinicians. The purpose of this study was to investigate the accuracy, convenience and safety of CT three-dimensional reconstruction combined with intraoperative natural collapse localization in total thoracoscopic segmental pneumonectomy.

METHODS

A total of 45 patients with radiographic findings of pulmonary GGN admitted from July 2019 to December 2019 were selected as the study group. All patients received thin-slice CT scan and underwent preoperative three-dimensional reconstruction. After anesthesia, the small thoracic operation opening and the airway of the patients were quickly opened, and the lung was rapidly and naturally collapsed by pressure difference. GGN were positioned according to the natural marker line, and marked with 3-0 prolene line. After specimen removal, the distance between the GGN and the suture mark, the distance between the GGN and the incision margin were measured, and the incision margin was routinely examined. The general clinical data, pathological data and postoperative complications were counted and compared with 45 consecutive patients who were located with hookwire positioning needle in the same period.

RESULTS

The average localization time of non-invasive GGN with natural lung collapse during operation was 6.9 min, and the localization accuracy was 90.6%. There were 2 cases of extensive pleural adhesion and 1 case of emphysema. Postoperative pathology was confirmed as lung adenocarcinoma, and the examination of incision margin was negative. No GGNs were scanned again after surgery, and the precise resection rate of lung segment was 100.0%.

CONCLUSIONS

CT three-dimensional reconstruction combined with GGN localization of natural lung collapse during operation can shorten the time of searching for GGN during operation and guarantee the safety of the incision margin. It is a more economical and convenient localization method and makes pulmonary segment resection more accurate.

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.

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.

A hybrid, image-based and biomechanics-based registration approach to markerless intraoperative nodule localization during video-assisted thoracoscopic surgery

The resection of small, low-dense or deep lung nodules during video-assisted thoracoscopic surgery (VATS) is surgically challenging. Nodule localization methods in clinical practice typically rely on the preoperative placement of markers, which may lead to clinical complications. We propose a markerless lung nodule localization framework for VATS based on a hybrid method combining intraoperative cone-beam CT (CBCT) imaging, free-form deformation image registration, and a poroelastic lung model with allowance for air evacuation. The difficult problem of estimating intraoperative lung deformations is decomposed into two more tractable sub-problems: (i) estimating the deformation due the change of patient pose from preoperative CT (supine) to intraoperative CBCT (lateral decubitus); and (ii) estimating the pneumothorax deformation, i.e. a collapse of the lung within the thoracic cage. We were able to demonstrate the feasibility of our localization framework with a retrospective validation study on 5 VATS clinical cases. Average initial errors in the range of 22 to 38 mm were reduced to the range of 4 to 14 mm, corresponding to an error correction in the range of 63 to 85%. To our knowledge, this is the first markerless lung deformation compensation method dedicated to VATS and validated on actual clinical data.

Comparison of computed tomographic imaging-guided hook wire localization and electromagnetic navigation bronchoscope localization in the resection of pulmonary nodules: a retrospective cohort study

The resection of nodules by thoracoscopic surgery is difficult because the nodules may be hard to identify. Preoperative localization of pulmonary nodules is widely used in the clinic. In this study, we retrospectively compared CT-guided hook wire localization and electromagnetic navigation bronchoscopy (ENB) localization of small pulmonary nodules before resection. Patients who underwent localization with CT-guided hook wire or ENB followed by video-assisted thoracoscopic surgery (VATS) at Qilu Hospital of Shandong University between January 2016 and December 2019 were retrospectively included. Clinical parameters, complication and failure rate, and localization time were compared between two groups. A total of 157 patients underwent the localization procedure successfully. Pulmonary nodules were localized by CT-guided hook wire in 105 patients and by ENB in 52 patients. The nodule size in ENB group was smaller than that in CT-guided localization group (P < 0.001). Both CT-guided localization and ENB localization were well tolerated in all patients, while ENB localization leaded to less complications (P = 0.0058). In CT-guided localization group, 6 patients failed to be located while none failed in ENB group (P = 0.079). The procedure time was 15.15 ± 3.70 min for CT-guided localization and 21.29 ± 4.00 min for ENB localization (P < 0.001). CT-guided localization is simple and feasible for uncertain pulmonary nodules before surgery. ENB localization could identify small lung nodules with high accuracy and achieve lower incidence of complications.

The application value of computed tomography in combination with intraoperative noninvasive percutaneous ultrasonic localisation of subpleural pulmonary nodules/ground-glass opacity in uniportal video-assisted thoracoscopy

Introduction

This study investigates the application value of preoperative noninvasive computed tomography (CT) localisation, combined with intraoperative percutaneous ultrasonic localisation, in the precise positioning and excision of subpleural pulmonary nodules/ground-glass opacity in uniportal video-assisted thoracoscopic surgery (U-VATS).

Aim

To derive the precise positioning and excision of subpleural pulmonary nodules by CT combined with intraoperative percutaneous ultrasonic localisation and to avoid the complications caused by preoperative CT-guided puncture localisation, reduce physiological and psychological stress such as anxiety, CT radiation dose, and treatment cost, and to improve the treatment satisfaction of patients.

Material and methods

A total of 54 patients with subpleural pulmonary nodules/ground-glass opacity (SPN/GGO), who were treated in our hospital from June 2017 to January 2020, were enrolled in this study. The patients were randomly divided into a treatment group (n = 23), and the nodules were scanned by high-resolution CT and marked at the shortest distance on the surface of the body prior to surgery. These pulmonary nodules were relocated by ultrasound at the original CT positioning points in the same body position following the administration of general anaesthesia. Then, the hookwire puncture location was performed under real-time guidance. For the control group (n = 31), the subpleural pulmonary nodules were located by CT-guided puncture and embedding a hookwire prior to surgery. Pulmonary wedge resection was performed by U-VATS in each group. The subpleural nodules were confirmed by the naked eye and rapid pathological diagnosis after surgery. The difference in positioning success rate, positioning time, the incidence of complications, and patient anxiety scores for subpleural pulmonary nodules were compared and analysed between the two groups.

Results

A total of 22 cases of subpleural nodules were successfully located in the treatment group at a success rate of 95.6% (22/23). The average positioning time for CT in combination with ultrasound was 22.0 ±5.9 min. In the control group, 31 cases of subpleural pulmonary nodules were satisfactorily located at a success rate of 100% (31/31). The average positioning time of CT was 24.2 ±5.4 min. The difference in positioning success rate and positioning time was not statistically significant (p = 0.24; p = 0.15) between the two groups. The incidence of complications and SAS anxiety scores in the treatment group were lower compared with the control group. The difference was statistically significant (p = 0.002; p < 0.001).

Conclusions

Preoperative CT combined with intraoperative percutaneous real-time noninvasive ultrasonic localisation can accurately locate subpleural pulmonary nodules, with a high degree of safety and good tolerance in patients who are suitable for U-VATS.

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.

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.

Methylene Blue/Collagen Mixture for CT-Guided Presurgical Lung Nodule Marking: High Efficacy and Safety

PURPOSE

To assess outcomes of computed tomography (CT)-guided methylene blue/collagen marking of preoperative lung nodules before video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS).

MATERIALS AND METHODS

A retrospective cohort study assessing 25 methylene blue/collagen solution CT-guided lung nodule localization procedures on 26 nodules in 25 patients was performed. The procedures were performed by a fellowship-trained radiologist 1-2 hours before scheduled surgery under local anesthesia. Approximately 4-6 ml of methylene blue/collagen solution was injected in a perinodular location under CT guidance with a 19-gauge trocar needle and along the track to the visceral pleural surface. Post-procedural CT images confirmed appropriate lung nodule location marking.

RESULTS

Perinodular CT-guided trocar needle placement was achieved in all marking procedures (n = 26/26). Increased consolidation near the target nodule was also demonstrated in all patients on the post-procedural localized CT scans. One patient with moderate emphysema developed a small to moderate-sized pneumothorax (∼20%-30%), and an 8-Fr thoracentesis catheter was placed under CT guidance before surgery. There was no bleeding or hemoptysis in any patient. Methylene blue/collagen solution was readily visible by the thoracic surgeon in association with all target nodules. One patient required conversion to open procedure due to the proximal portion of the right lower lobe pulmonary artery segmental branch. Of the 26 identified nodules, pathology specimens confirmed the adequacy of nodule resection in all cases.

CONCLUSIONS

Preoperative CT-guided methylene blue/collagen solution injection offers a safe and highly effective technique for marking subpleural lung nodules undergoing VATS or RATS.

Diagnosis and radio-guided surgery of lung nodules

The detection of pulmonary nodules has increased in recent decades due to the introduction of lung cancer screening programs and the massively use of routine chest computed tomography in patients with malignant neoplasms. Percutaneous biopsy of these nodules does not always characterize them, so sometimes a surgical biopsy is necessary, which often requires a presurgical localization. The radioguided occult lesion localization (ROLL) described for breast lesions was first applied in the resection of pulmonary nodules in 2000, becoming an alternative to other presurgical localization techniques such as hook-wire. The technique provides high detection rate with minimal morbidity, enhancing multidisciplinary work with specialists in Radiology and Chest Surgery. The present paper describes the different pre-surgical localization techniques currently available, the methodological procedure of the ROLL technique and the collected results in 20 years of experience.

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.

Pulmonary nodules precision localization techniques

The advent of helical high-resolution CT scanners, the application of screening programs and the follow-up of patient with oncological history, led to an increasing number of diagnosis of small pulmonary nodule (less than 10 mm in maximum diameter), partially solid nodule or completely ground glass ones. Their management is controversial. Excisional biopsy by mean of video-assisted thoracic surgery is often a viable choice but to locate these lesions intraoperatively can be impossible without the aid of preoperative or intraoperative localization techniques. In this brief review we will analyze the benefit of adopting localization techniques prior to pulmonary resection for small pulmonary lesions and face the advantages and problems with the main techniques described in the literatures.

Radioguided Surgery, a Cost-Effective Strategy for Treating Solitary Pulmonary Nodules: 20-Year Experience of a Single Center

INTRODUCTION

Surgical resection with minimally invasive approach is the gold standard for both definitive diagnosis and treatment of solitary pulmonary nodules (SPNs); however, it can be difficult to pinpoint small, deep, or subsolid nodes without palpating lung parenchyma. The primary endpoint of this study is showing that radioguided surgery is a cost-effective strategy to improve the effectiveness of video-thoracoscopic localization/resection of SPNs/ground-glass opacities (GGOs). Secondary endpoints are analyzing the morbidity of this technique and tips and tricks to better manage this method.

METHODS

SPN smaller than 20 mm and/or with a distance from the visceral pleura ≥5 mm underwent minimally invasive resection after computed tomography-guided injection of a solution composed of 0.1/0.2 mL of 99Tc-labeled human serum albumin microspheres and 0.1 mL of nonionic contrast. In the operating theater, a collimated probe connected to a gamma ray detector allowed localization of the target area.

RESULTS

Between 1997 and 2018, a total of 451 patients with SPN/GGO underwent minimally invasive surgery with a radioguided technique at our hospital. The mean SPN diameter was 13 mm (range, 5-20 mm), and the mean distance from the visceral pleura was 15 mm (range, 6-29 mm). The mean time to a localizing nodule was 3 minutes (range, 1-5 minutes). No significant injection-related complications were reported; only 3.3% of patients (15 of 451) developed pneumothorax. Both 30- to 60-day and 90-day mortality were 0%. The rate of postoperative complications was 2.53% (prolonged air leak). The conversion rate to thoracotomy was 1.55% (7 of 451).

CONCLUSIONS

Our 20-year experience shows that radioguided thoracoscopic surgery is a safe and feasible strategy to treat suspicious SPN/GGO, with a success rate of 98%.

Ultrasound location of pulmonary nodules in video-assisted thoracoscopic surgery for precise sublobectomy

BACKGROUND

We investigated the clinical value of accurate sublobectomy of pulmonary nodules using video-assisted thoracoscopy (VATS). In June 2017 to June 2019, single lung nodule patients who accepted thoracoscopic resection were included. Palpation and intraoperative ultrasound (IU) were used to localize lung nodules, and the success rate, location time and safety compared. Performance of lung nodule ultrasound was assessed. The success rate of IU localization of pulmonary nodules with different properties was studied.

RESULTS

A total of 33 cases with single pulmonary nodules were included in the study, and 32 cases (97%) were successfully located by IU as opposed to 16 cases (48.5%) located by palpation (P < 0.05). Clear hypoechoic ultrasound images of nodules were obtained in all 32 cases, and the diameter of pulmonary nodules on ultrasound and CT were found to have a significant correlation (R = 0.860, P = 0.000). The average positioning time of IU was lower than that of the palpation group (P < 0.05). No complications occurred during ultrasound examination. The success rate of intraoperative ultrasonic localization between the pure ground-glass opacity (p-GGO) group and the mixed-ground-glass opacity (m-GGO) group was 90%, 100% (P = 0.526).

CONCLUSIONS

In thoracoscopic surgery, IU can locate pulmonary nodules accurately, efficiently and safely, and also has a high degree of accuracy in locating different types of pulmonary nodules.

Preoperative computed tomography-guided pulmonary nodule localization augmented by laser angle guide assembly

Background

There is an increasing need for thoracic medicine specialists to master preoperative localizations after high rates of sub-centimeter nodules have been positively screened by low-dose CT. The Laser Angle Guide Assembly^® (LAGA), an innovative angle reference device for CT-guided pulmonary invasive procedures, has been developed to safely and efficiently aid in the performance of preoperative CT-guided localizations (POCTGL).

Methods

The clinical and localization data of patients who received LAGA-assisted POCTGL for pulmonary nodules between May 2015 and June 2018 were collected and analyzed.

Results

One hundred and eighty-seven patients with 266 pulmonary nodules received LAGA-assisted POCTGL. The number of lung nodules localized for one surgery ranged from 1 to 5, with >1 for 22.1% of the surgeries. The median nodule size was 6 mm. A hookwire was inserted in 32 (12%) of the nodules. Most (83.1%) of the localizations were completed with a single puncture. The median angle was 18 degrees. The median and maximum depths of the nodule to pleura were 12 and 60 mm, respectively. The median procedure time was 19 minutes. The successful targeting and field targeting rates were 100% and 98.1%, respectively. Pneumothorax was noted in 17 (6.4%) localizations that did not require chest drainage. The multivariable analyses for pneumothorax showed odds ratios of 2.4 (95% confidence interval, 1.2-4.9) for puncture times/nodule and 10.1 (95% confidence interval, 2.3-41.7) for tumors adjacent to the fissure, respectively. There was no incidence of hookwire migration.

Conclusions

LAGA enhanced the precision of POCTGL by optimizing targeting precision and decreasing repeated punctures, which minimized complications, such as pneumothorax.

Video-assisted thoracoscopic resection of lung nodules localized with a hydrogel plug

OBJECTIVES

Computed tomography (CT)-guided hydrogel plug deployment was recently proposed for lung nodule preoperative localization and simultaneous prevention of pneumothorax. We analysed our initial experience with CT-guided hydrogel plug localization of lung nodules in patients undergoing video-assisted thoracoscopic (VATS) resection.

METHODS

We retrospectively evaluated the medical notes from 27 consecutive patients (mean age 68 ± 11 SD years; men 74%) undergoing VATS lung wedge resection for biopsy or definitive treatment of 28 small pulmonary nodules (malignant 82%) at a single institution between October 2017 and July 2018. Difficult intraoperative nodule localization was anticipated with a lesion <10 mm, a depth from pleura:size ratio >1, ground-glass opacity or the judgement of the operating surgeon. All lesions were preoperatively marked by deployment of a CT-guided hydrogel plug. Study end points were frequency of postlocalization pneumothorax; feasibility of delayed surgery; rate of localization of intraoperative nodule and rate of successful VATS resection.

RESULTS

The mean sizes of the solid nodules (n = 24) and of the ground-glass opacities (n = 4) were, respectively, 10.4 ± 3.4 mm and 16.0 ± 6.2 mm. One (4%) hydrogel plug marking procedure caused a clinically relevant pneumothorax. Nodule resection was scheduled flexibly as required by patient management/operating room scheduling: same day (11 nodules) or delayed [median 6 days (range 1-60 days)]; (17 nodules). All nodules were localized intraoperatively: 25 (89%) by hydrogel plug; 3 (11%) by palpation and pleural puncture hole visible after plug displacement. All nodules were completely excised by VATS, without complications.

CONCLUSIONS

CT-guided hydrogel plug marking was valuable for VATS localization and resection of challenging lung nodules. The plug minimized clinically relevant pneumothoraxes and allowed flexible surgical schedules.

[A Preliminary Study to Evaluate the Efficacy and Safety of A Optimized Computed Tomography-guided Pulmonary Nodule Microcoil Localization Technique]

背景与目的

肺内小结节微弹簧圈穿刺定位是微创手术切除肺内小结节常用的术前定位方法，然而该方法仍有操作复杂、轻微并发症多等不足之处，我们将原有方法进行了优化。本研究旨在探讨优化后的预充式计算机断层扫描（computed tomography, CT）引导下肺内小结节微弹簧圈穿刺定位法在临床中的应用价值。

方法

对2018年9月-2019年1月间31例患者的35枚肺结节，于术前采用预充式CT引导下肺内小结节微弹簧圈穿刺定位，然后施行胸腔镜下（video-assisted thoracoscopic surgery, VATS）手术。统计分析定位操作相关数据、成功率、并发症、病理结果等。

结果

定位成功率97.1%，VATS切除成功率100%。CT定位时间平均10.1 min（5 min-31 min），微创切除病灶所需时间平均38.2 min（10 min-100 min）。术中发现微弹簧圈脱位回缩至胸壁内1例，通过充气膨肺状态下自胸壁穿刺点刺入穿刺针，成功定位肺内结节并予以切除。3例患者定位后发生微量气胸，但无需闭式引流处理。3例患者出现肺内血肿。35枚肺结节术后病理结果为：高分化腺癌15例，原位癌7例，微浸润腺癌5例，非典型腺瘤样增生4例，肺内淋巴结增生、炎性结节各2例。

结论

采用预充式微弹簧圈定位肺内小结节简便、安全、有效，值得推广。

The use of ultrasound in detecting and defining ground-glass opacities: results of an ex vivo evaluation

OBJECTIVES

To evaluate the role of ultrasound in detecting and defining ground-glass opacities (GGOs) in surgical specimens of patients undergoing thoracoscopic diagnostic resection.

METHODS

We performed an observational single-centre study of all consecutive patients undergoing thoracoscopic diagnostic resection of GGOs. In each patient, the specimen was scanned with ultrasound; then, a needle was inserted into the lesion to facilitate its detection by the pathologist. We evaluated the rate of detection with ultrasound, compared the size and depth measurements of the lesions as determined from ultrasound scans with those from the histological specimens and correlated the ultrasound findings with the histological subtypes of adenocarcinomas.

RESULTS

We reviewed 17 tissue samples. The final diagnoses were 1 (6%) atypical adenomatous hyperplasia, 5 (29%) adenocarcinomas in situ, 4 (24%) minimally invasive adenocarcinomas and 7 (41%) invasive adenocarcinomas. All tumours were successfully identified using ultrasound. The size (P = 0.87) and depth (P = 0.25) of the lesions measured with ultrasound did not significantly differ from the measurements obtained from the histological specimens. In addition, ultrasound size (r = 0.945; P < 0.0001) and depth (r = 0.588; P = 0.013) were significantly correlated with the pathological measurements. All lesions with hyperechoic findings (n = 6) were pure GGOs, whereas lesions with mixed echoic (n = 11) patterns were mixed GGOs. We were unable to differentiate the histological subtypes of adenocarcinomas using the ultrasound scans.

CONCLUSIONS

Detection of GGOs on ultrasound scans is feasible, but differentiation of the histological subtypes of adenocarcinomas is not possible. The next step is to evaluate the intraoperative reproducibility of our results.

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.

Computed tomography-guided percutaneous hook wire localization of pulmonary nodular lesions before video-assisted thoracoscopic surgery: Highlighting technical aspects

OBJECTIVE

Confirming the histologic diagnosis of small pulmonary nodules or Ground-glass opacity nodules (GGNs) of unknown origin is difficult. These nodules are not always appropriate for percutaneous transthoracic needle biopsy. Preoperative localization of pulmonary lesions provides more precise target points to ensure complete surgical excision. The goal of the present study was to evaluate the validity and effectiveness of computed tomography-guided preoperative hook wire localization with our technique for video-assisted thoracoscopic surgery (VATS).

METHODS

We retrospectively investigated 113 patients who had undergone preoperative hook wire localization before VATS resection for newly present or growing pulmonary nodular lesions between May 2007 and December 2016. Procedural and perioperative outcomes were assessed to evaluate the safety and efficacy of preoperative localization technique.

RESULTS

A total of 113 pulmonary nodules were localized and successfully resected in all 113 patients. The mean diameter of nodules was 10.8 ± 6.1 mm (range, 3-28). The mean distance from the pleural surface was 20.2 ± 12.4 mm (range, 5-55). The mean procedure time of localization was 23.7 ± 6.3 min. Asymptomatic minimal pneumothorax and mild parenchymal hemorrhage occurred in 26 (23.0%) and 8 (7.1%) patients, respectively. There were 32 (28.3%) deep lung nodules, in which the distance to pleural surface was more than 25 mm. Wire dislodgement occurred in 4 (3.5%) patients. Complete resection of all lung lesions was achieved, and definite histological diagnosis was obtained in all patients. Pathologic examination revealed 42 (37.2%) primary lung cancers, 2 (1.8%) lymphomas, 53 (46.9%) metastases, 16 (14.1%) benign lesions.

CONCLUSIONS

Preoperative percutaneous hook wire localization is a dependable and useful technique to facilitate positioning small and deep pulmonary nodules for thoracoscopic complete excision and accurate diagnosis.

Safety and efficacy of computed tomography-guided dye localization using patent blue V for single lung nodule for video-assisted thoracoscopic surgery: a retrospective study

Background

For invisible or impalpable lung nodules, video-assisted thoracoscopic surgery (VATS) has some limitations; some preoperative localization has been developed to overcome this limitation. This study aimed to assess the safety and efficacy of preoperative computed tomography (CT)-guided localization with patent blue V dye.

Methods

In this retrospective study, we examined patients with solitary pulmonary nodule undergoing preoperative CT-guided patent blue V dye localization from 2013 to 2015. We analyzed patients' demographic data, nodular features, and procedures undergone.

Results

We enrolled 282 patients (282 lung nodules; mean age: 56.6±11.6 years, with female preponderance) in this study. The mean size of nodules was 0.9±0.5 cm, and mean time of localization was 24 min. The leading complications after localization were asymptomatic pneumothorax (48 patients, 17%) and localized pulmonary hemorrhage (51 patients, 18%). Other rare complications included subcutaneous emphysema and hematoma. We noted two cases with intraoperative poor or fail dye localization. Most patients underwent wedge resection (221 patients, 78.4%) and segmentectomy (36 patients, 12.8%), whereas 25 patients underwent lobectomy (8.9%) after the intraoperative frozen histopathological study confirmed malignancy. Furthermore, postoperative hospital stay was 4.8±2.0 days. Few patients experienced postoperative complications such as empyema (n=1), air leakage (n=3), and chylothorax (n=1).

Conclusions

This study establishes that CT-guided dye localization is a safe and efficient method with rare severe complications and high success rate.

Ultrasound for intraoperative localization of lung nodules during thoracoscopic surgery

In low-dose CT screening era, an ideal preoperative localization method is essential for resection of small and deep-seated pulmonary nodules by video-assisted thoracoscopic surgery (VATS). This article focuses on intraoperative ultrasonography localization method during thoracoscopy. Performing ultrasonography intraoperatively is a real-time and alternative approach to localize small, non-visible and non-palpable pulmonary lesions without injury to lung parenchyma. Its widespread usage has been limited due to the air in the lung parenchyma; however, its application can be useful in some conditions with guidance to find the lesion.