Intraoperative electromagnetic navigational bronchoscopic localization of small, deep, or subsolid pulmonary nodules

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.

Clinical application of CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization in thoracoscopic lung nodule resection: a single-centre retrospective study

BACKGROUND

Today, the detection rate of lung nodules is increasing. Some of these nodules may become malignant. Thus, timely resection of potentially malignant nodules is essential. However, Identifying the location of nonsurface or soft-textured nodules during surgery is challenging. Various localization techniques have been developed to accurately identify lung nodules. Common methods include preoperative CT-guided percutaneous placement of hook wires and microcoils. Nonetheless, these procedures may cause complications such as pneumothorax and haemothorax. Other methods regarding localization of pulmonary nodules have their own drawbacks. We conducted a clinical study which was retrospective to identify a safe, accurate and suitable method for determining lung nodule localization. To evaluate the clinical value of CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization in thoracoscopic lung nodule resection.

METHODS

We retrospectively collected the clinical data of 120 patients who underwent lung nodule localization and resection surgery at the Department of Thoracic Surgery, First Affiliated Hospital of Bengbu Medical College, from January 2020 to January 2022. Among them, 30 patients underwent CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization, 30 patients underwent only CT-assisted body surface localization, 30 patients underwent only intraoperative stereotactic anatomical localization, and 30 patients underwent CT-guided percutaneous microcoil localization. The success rates, complication rates, and localization times of the four lung nodule localization methods were statistically analysed.

RESULTS

The success rates of CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization and CT-guided percutaneous microcoil localization were both 96.7%, which were significantly higher than the 70.0% success rate in the CT-assisted body surface localization group (P < 0.05). The complication rate in the combined group was 0%, which was significantly lower than the 60% in the microcoil localization group (P < 0.05). The localization time for the combined group was 17.73 ± 2.52 min, which was significantly less than that (27.27 ± 7.61 min) for the microcoil localization group (P < 0.05).

CONCLUSIONS

CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization is a safe, painless, accurate, and reliable method for lung nodule localization.

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.

An injectable fluorescent and iodinated hydrogel for preoperative localization and dual image-guided surgery of pulmonary nodules

The widespread use of video-assisted thoracoscopic surgery (VATS) has triggered the rapid expansion in the field of computed tomography (CT)-guided preoperative localization and near-infrared (NIR) fluorescence image-guided surgery. However, its broader application has been hindered by the absence of ideal imaging contrasts that are biocompatible, minimally invasive, highly resolvable, and perfectly localized within the diseased tissue. To achieve this goal, we synthesize a dextran-based fluorescent and iodinated hydrogel, which can be injected into the tissue and imaged with both CT and NIR fluorescence modalities. By finely tuning the physical parameters such as gelation time and composition of iodinated oil (X-ray contrast agent) and indocyanine green (ICG, NIR fluorescence dye), we optimize the hydrogel for prolonged localization at the injected site without losing the dual-imaging capability. We validate the effectiveness of the developed injectable dual-imaging platform by performing image-guided resection of pulmonary nodules on tumor-bearing rabbits, which are preoperatively localized with the hydrogel. The injectable dual-imaging marker, therefore, can emerge as a powerful tool for surgical guidance.

Chemical Localization With Robotic Bronchoscopy: Can It Aid Resection of Subsolid Lung Nodules?

INTRODUCTION

Subsolid nodules or those located deep in lung parenchyma are difficult to localize using minimally invasive thoracic surgery. While image-guided percutaneous needle localization has been performed, it is inconvenient and has potential complications. In this study, the role of chemical localization using robotic bronchoscopy to facilitate resection was evaluated.

METHODS

Consecutive patients undergoing surgical resection for lung nodules between 8/2019-3/2022 were included. Patients with subsolid lung nodules, or small nodules deep in lung parenchyma that were deemed difficult to localize, were chemically localized (CL) using robotic bronchoscopy before resection. Clinico-demographic data were obtained retrospectively using a prospectively maintained database.

RESULTS

Localization of lung nodules before resection was performed in 139 patients while 110 patients were not localized. Daily activity score was higher for localized patients. Nodules in the localized group were smaller (P < 0.001) and had similar solid:ground glass ratio. In the localized group, larger margins were observed, and no re-resection of the parenchymal margin was required. Twenty patients in the non-localized group required re-resection intraoperatively due to close pathological margins or inability to locate the nodule in the resected specimen. Operative time was a median of 10-15 min longer for localized patients, P < 0.001. Length of stay was shorter in the localized group (P < 0.05).

CONCLUSIONS

Chemical localization of lung nodules using robotic bronchoscopy appears to be a safe and effective method of identifying the location of nodules with small size and less density and aids increased tumor margins intraoperatively.

Treatment strategies for malignant pulmonary nodule: beyond lobectomy. Point-counterpoint

PURPOSE OF REVIEW

Technological advancement in low-dose computed tomography resulted in an increased incidental discovery of early-stage lung cancer and multifocal ground glass opacity. The demand for parenchyma-preserving treatment strategies is greater now than ever. Pulmonary ablative therapy is a groundbreaking technique to offer local ablative treatment in a lung-sparing manner. It has become a promising technique in lung cancer management with its diverse applicability. In this article, we will review the current development of ablative therapy in lung and look into the future of this innovative technique.

RECENT FINDINGS

Current literature suggests that ablative therapy offers comparable local disease control to other local therapies and stereotactic body radiation therapy (SBRT), with a low risk of complications. In particular, bronchoscopic microwave ablation (BMWA) has considerably fewer pleural-based complications due to the avoidance of pleural puncture. BMWA can be considered in the multidisciplinary treatment pathway as it allows re-ablation and allows SBRT after BMWA.

SUMMARY

With the benefits which ablative therapy offers and its ability to incorporate into the multidisciplinary management pathway, we foresee ablative therapy, especially BMWA gaining significance in lung cancer treatment. Future directions on developing novel automated navigation platforms and the latest form of ablative energy would further enhance clinical outcomes for our patients.

Application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection

PURPOSE

To explore the application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection.

METHODS

The clinical data of 90 patients who had small pulmonary nodules and received thoracoscopic sublobar resection during the period from September 2021 to October 2022 in the Department of Thoracic Surgery, Juxian People's Hospital, Shandong Province, were retrospectively analyzed.

RESULTS

The diameters of 95 pulmonary nodules in the 90 patients in the whole group ranged from 0.40 to 1.24 cm, and their distances from the visceral pleura ranged from 0.51 to 2.15 cm. In these patients, percutaneous lung puncture was successfully performed under local anesthesia, through which coils were implanted in the nodules and medical adhesive was injected around the nodules, with a success rate of localization of 100%. Localization complications included 10 cases of asymptomatic pneumothorax, 9 cases of intrapulmonary hemorrhage, 5 cases of severe pain, and 1 case of pleural reaction, all of which required no special treatment. After preoperative localization, the success rate of resection of pulmonary nodules was 100%, and sufficient surgical margins were obtained.

CONCLUSION

CT-guided localization using a coil in combination with medical adhesive is a safe, effective, and simple localization method that can meet the requirements of thoracic surgeons for intraoperative localization; for small pulmonary nodules, especially those small-sized and deep-located ground-glass nodules containing few solid mass, this method has important clinical application value, which is a preoperative localization technique worthy of wide application in clinical practice.

Efficacy of Near-Infrared Fluorescence Video-Assisted Thoracoscopic Surgery for Small Pulmonary Nodule Resection with Indocyanine Green Inhalation: A Randomized Clinical Trial

BACKGROUND

Small pulmonary nodules (<3 cm) can sometimes be unrecognizable and nonpalpable in video-assisted thoracoscopic surgery (VATS). Near-infrared fluorescence (NIF) VATS after indocyanine green (ICG) inhalation may effectively guide surgeons to locate the nodules.

OBJECTIVE

This study aimed to investigate the safety, feasibility, and efficacy of ICG inhalation-based NIF imaging for guiding small pulmonary nodule resections.

METHODS

Between February and May 2021, the first-stage, non-randomized trial enrolled 21 patients with different nodule depth, ICG inhalation doses, post-inhalation surgery times, and nodule types at a tertiary referral hospital. Between May 2021 and May 2022, the second-stage randomized trial enrolled 56 patients, who were randomly assigned to the fluorescence VATS (FLVATS) or the white-light VATS (WLVATS) group. The ratio of effective guidance and the time consumption for nodule localization were compared.

RESULTS

The first-stage trial proved this new method is safe and feasible, and established a standardized protocol with optimized nodule depth (≤1 cm), ICG dose (0.20-0.25 mg/kg), and surgery window (50-90 min after ICG inhalation). In the second-stage trial, the FLVATS achieved 87.1% helpful nodule localization guidance, which was significantly higher than the WLVATS (59.1%, p < 0.05). The mean nodule locating time (standard deviation) was 1.8 [0.9] and 3.3 [2.3] min, respectively. Surgeons adopting FLVATS were significantly faster (p < 0.01), especially when locating small ground-glass opacities (1.3 [0.6] min vs. 7.0 [3.5] min, p < 0.05). Five of 31 nodules (16.1%) were only detectable by FLVATS, whereas both white light and palpation failed.

CONCLUSIONS

This new method is safe and feasible for small pulmonary nodule resection. It significantly improves nodule localization rates with less time consumption, and hence is highly worthy for clinical promotion. Clinical Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2100047326.

Use of Indocyanine Green Fluorescence Imaging in Thoracic and Esophageal Surgery

BACKGROUND

Fluorescence imaging using indocyanine green in thoracic and esophageal surgery is gaining popularity because of the potential to facilitate surgical planning, to stage disease, and to reduce postoperative complications. To optimize use of fluorescence imaging in thoracic and esophageal surgery, an expert panel sought to establish a set of recommendations at a consensus meeting.

METHODS

The panel included 12 experts in thoracic and upper gastrointestinal surgery from Asia-Pacific countries. Before meeting, 7 focus areas were defined: intersegmental plane identification for sublobar resections; pulmonary nodule localization; lung tumor detection; bullous lesion detection; lymphatic mapping of lung tumors; evaluation of gastric conduit perfusion; and lymphatic mapping in esophageal surgical procedures. A literature search of the PubMed database was conducted using keywords indocyanine green, fluorescence, thoracic, surgery, and esophagectomy. At the meeting, panelists addressed each focus area by discussing the most relevant evidence and their clinical experiences. Consensus statements were derived from the proceedings, followed by further discussions, revisions, finalization, and unanimous agreement. Each statement was assigned a level of evidence and a grade of recommendation.

RESULTS

A total of 9 consensus recommendations were established. Identification of the intersegmental plane for sublobar resections, localization of pulmonary nodules, lymphatic mapping in lung tumors, and assessment of gastric conduit perfusion were applications of fluorescence imaging that have the most robust current evidence.

CONCLUSIONS

Based on best available evidence and expert opinions, these consensus recommendations may facilitate thoracic and esophageal surgery using fluorescence imaging.

The primary application of indocyanine green fluorescence imaging in surgical oncology

Background

Indocyanine green (ICG) is a nontoxic, albumin-bound, liver-metabolized fluorescent iodide dye that has been widely utilized in clinical applications since the mid-1950s. However, after the 1970s, in-depth research on the fluorescence properties of ICG greatly expanded its application in the medical field.

Methods

In our mini-review, we searched the relevant literature on common oncology surgeries from PubMed, including lung cancer, breast cancer, gastric cancer, colorectal cancer, liver cancer, and pituitary tumors, using keywords such as indocyanine green, fluorescence imaging technology, and near-infrared fluorescence imaging. In addition, the application of targeted ICG photothermal technology in tumor therapy is briefly mentioned.

Results

In this mini-review, we analyzed studies on ICG fluorescence imaging in common surgical oncology and offered a thorough analysis of each form of cancer or tumor.

Conclusion

ICG has demonstrated significant potential in the detection and treatment of tumors in current clinical practice, although many applications are still in the preliminary stages, and multicenter studies are still required to more precisely define its indications, effectiveness, and safety.

Intraoperative electromagnetic navigation bronchoscopy (IENB) to localize peripheral lung lesions: A new technique in the pediatric oncology population

BACKGROUND

The utility, diagnostic yield and accuracy of lung biopsies in pediatric oncology patients are variable. Here we describe our preliminary results using intraoperative electromagnetic navigation bronchoscopy (IENB) for peripheral lung lesions to increase the surgical yield and accuracy in pediatric oncology patients.

METHODS

From May 2018 until October 2020 all surgical lung biopsies on pediatric oncology patients were performed using IENB technology. IENB and tattooing with methylene blue dye, Indocyanine green dye or both followed by Video-assisted Thoracoscopic Surgery (VATS) was performed in the same setting. Data were collected retrospectively. Data points included diagnosis, technical success, pathologic diagnosis and alteration in treatment management and complications.

RESULTS

A total of 10 biopsy procedures were performed on 8 patients during the study. The youngest patient was 7 years old. All had successful IENB with tattooing. All biopsies were diagnostic. No procedures were converted to open. There were no technical failures or procedure complications. One patient had a total of 11 biopsies, 6 from the right lung and 5 from the left, performed at 2 separate procedures. Another had 2 biopsies, one from the right lung and one from the left performed at the same operation. In 7 of the 8 patients treatment changes were made based on results of their biopsy.

CONCLUSION

Here we present the first described experience of IENB and tattooing of peripheral lung lesions in the pediatric population. We have shown that IENB for peripheral lung lesion localization is a safe and effective technique in pediatric oncology.

How effective is indocyanine green (ICG) in localization of malignant pulmonary nodules? A systematic review and meta-analysis

Background

Video-Assisted and Robotic-Assisted techniques become constantly more prominent practice in thoracic surgery for lung cancer. Furthermore, the increased frequency in detection of small lung cancers makes the intra-operative identification of these cancers even more challenging. Indocyanine Green (ICG) is one of the most commonly used dyes that assists surgeons identify small lung cancers intra-operatively. Our study aimed to evaluate the effectiveness and safety of ICG in lung cancer detection.

Methods

We performed a systematic review of the literature by screening the databases of MEDLINE, EMBASE, CENTRAL and Scopus until 30th April 2022 and the first 300 articles of Google Scholar for any suitable grey literature. We included any study that investigated the effectiveness of ICG in lung cancer detection. We excluded studies that explored the use of ICG only in identification of intersegmental planes, lymph node mapping, case reports and non-English articles. We aimed to perform a meta-analysis on test accuracy studies using hierarchical summary receiver operating characteristic (HSROC) and the bivariate random-effects models. In cases where the data for a localization technique was not sufficient for that analysis, it was presented with tables with narrative purposes. Each study was assessed for Risk of Bias (RoB) and Applicability using the QUADAS-2 tool.

Results

We found 30 eligible studies that included a total of 1,776 patients who underwent ICG localization of pulmonary nodules. We identified three ICG localization techniques: CT-guided, endobronchial and intravenous. From the 30 studies, 13 investigated CT-guided localization, 12 explored an endobronchial method while 8 studies administered ICG intravenously the median reported success rate was 94.3% (IQR: 91.4%-100%) and 98.3% (IQR: 94%-100%) for the first two techniques respectively. Intravenous ICG lung cancer localization showed Sensitivity of 88% (95% CI: 59%-0.97%) and Specificity of 25% (95% CI: 0.04%-0.74%). There were 15.2% (150/989) patients who experienced complications from CT guided ICG localization. No ICG-related complications were reported in endobronchial or intravenous techniques.

Conclusion

Our study provides a comprehensive review of the literature on ICG localization techniques for lung cancer. Current evidence suggests that ICG is boh effective and safe. Further prospective research with standardized protocols across multiple thoracic units is required in order to accurately validate these findings.

Fluorescence-guided lung nodule identification during minimally invasive lung resections

In the last few years, minimally invasive surgery has become the standard routine practice to manage lung nodules. Particularly in the case of robotic thoracic surgery, the identification of the lung nodules that do not surface on the visceral pleura could be challenging. Therefore, together with the evolution of surgical instruments to provide the best option in terms of invasiveness, lung nodule localization techniques should be improved to achieve the best outcomes in terms of safety and sensibility. In this review, we aim to overview all principal techniques used to detect the lung nodules that do not present the visceral pleura retraction. We investigate the accuracy of fluorescence guided thoracic surgery in nodule detection and the differences among the most common tracers used.

Raman-Guided Bronchoscopy: Feasibility and Detection Depth Studies Using Ex Vivo Lung Tissues and SERS Nanoparticle Tags

Image-guided and robotic bronchoscopy is currently under intense research and development for a broad range of clinical applications, especially for minimally invasive biopsy and surgery of peripheral pulmonary nodules or lesions that are frequently discovered by CT or MRI scans. Optical imaging and spectroscopic modalities at the near-infrared (NIR) window hold great promise for bronchoscopic navigation and guidance because of their high detection sensitivity and molecular/cellular specificity. However, light scattering and background interference are two major factors limiting the depth of tissue penetration of photons, and diseased lesions such as small tumors buried under the tissue surface often cannot be detected. Here we report the use of a miniaturized Raman device that is inserted into one of the bronchoscope channels for sensitive detection of “phantom” tumors using fresh pig lung tissues and surface-enhanced Raman scattering (SERS) nanoparticle tags. The ex vivo results demonstrate not only the feasibility of using Raman spectroscopy for endoscopic guidance, but also show that ultrabright SERS nanoparticles allow detection through a bronchial wall of 0.85 mm in thickness and a 5 mm-thick layer of lung tissue (approaching the fourth-generation airway). This work highlights the prospects and potential of Raman-guided bronchoscopy for minimally invasive imaging and detection of lung lesions.

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.

Electromagnetic navigation-guided preoperative localization: the learning curve analysis

Background

The electromagnetic navigation bronchoscopy (ENB) was increasingly used to mark small pulmonary nodules (PNs) for video-assisted thoracic surgery (VATS) resection due to high effectiveness and low risk. However, no study reports the learning curve of ENB-guided preoperative localization. In the study, we aimed to describe the learning curve of ENB-guided preoperative PNs localization initially.

Methods

Consecutive PNs cases that underwent ENB localizations between October 2018 and October 2019 by the same surgeon in our center were included in the study. The cumulative sum (CUSUM) method was used to analyze the learning curve of ENB localization.

Results

A total of 89 ENB localization from 64 patients were included in this study. The learning curve was divided into 3 phases: Phase I (the initial 11 cases), Phase II (the 12th to the 47th cases), and Phase III (the 47th to the 89th cases). The success rate of ENB localization has increased with the accumulation of operational experience in 3 phases (72.73%, 91.67%, and 97.62%, P=0.049). The distance from the ENB guide wire tip to the center of the lesion in Phase I was significantly longer than those in Phase II and Phase III (2.46±1.76 vs. 1.36±0.94 and 1.47±0.97 cm, P=0.014 and 0.027, respectively). Sex, bronchus sign, and learning curve phase were independent risk factors influencing operative time (OT) (OR =8.187, 18.847, and 13.920, respectively).

Conclusions

The technical competency, which is indicated by higher success rate, localization accuracy, and shorter OT, for ENB-guided preoperative PNs localization was achieved at the 47th operation.

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.

Evaluation of Intraoperative Near-Infrared Fluorescence Visualization of the Lung Tumor Margin With Indocyanine Green Inhalation

Importance

Identification of the tumor margin during surgery is important for precise minimal resection of lung tumors. Intravenous injection of indocyanine green (ICG) has several limitations when used for intraoperative visualization of lung cancer.

Objectives

To describe a technique for intraoperative visualization of lung tumor margin using ICG inhalation and evaluate the clinical applicability of the technique in mouse and rabbit lung tumor models as well as lung specimens of patients with lung tumors.

Design, Setting, and Participants

In lung tumor models of both mice and rabbits, the distribution of inhaled ICG in the lung tumor margin was investigated in vivo and ex vivo using a near-infrared imaging system. Lung tumor margin detection via inhalation of ICG was evaluated by comparing the results obtained with those of the intravenous injection method (n = 32, each time point for 4 mice). Based on preclinical data, use of ICG inhalation to help detect the tumor margin in patients with lung cancer was also evaluated (n = 6). This diagnostic study was conducted from May 31, 2017, to March 30, 2019.

Main Outcomes and Measures

The use of tumor margin detection by inhaled ICG was evaluated by comparing the inhaled formulation with intravenous administration of ICG.

Results

From 10 minutes after inhalation of ICG to 24 hours, the distribution of ICG in the lungs was significantly higher than that in other organs (signal to noise ratio in the lungs: 39 486.4; interquartile range [IQR], 36 983.74-43 592.5). Ex vivo and histologic analysis showed that, in both lung tumor models, inhaled ICG was observed throughout the healthy lung tissue but was rarely found in tumor tissue. The difference in the fluorescent signal between healthy and tumor lung tissues was associated with the mechanical airway obstruction caused by the tumor and with alveolar macrophage uptake of the inhaled ICG in healthy tissues. Inhalation at a 20-fold lower dose of ICG had a 2-fold higher efficiency for tumor margin detection than did the intravenous injection (2.9; IQR, 2.7-3.2; P < .001).

Conclusions and Relevance

The results of this study suggest that lung-specific inhalation delivery of ICG is feasible and may be useful for the intraoperative visualization of lung tumor margin in clinical practice.

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.

Managing screening-detected subsolid nodules-the Asian perspective

The broad application of low-dose computed tomography (CT) screening has resulted in the detection of many small pulmonary nodules. In Asia, a large number of these detected nodules with a radiological ground glass pattern are reported as lung adenocarcinomas or premalignant lesions, especially among female non-smokers. In this review article, we discuss controversial issues and conditions involving these subsolid pulmonary nodules that we often face in Asia, including a lack or insufficiency of current guidelines; the roles of preoperative biopsy and imaging; the location of lesions; appropriate selection of localization techniques; the roles of dissection and sampling of frozen sections and lymph nodes; multifocal lesions; and the roles of non-surgical treatment modalities. For these complex issues, we have tried to present up-to-date evidence and our own opinions regarding the management of subsolid nodules. It is our hope that this article helps surgeons and physicians to manage the complex issues involving ground glass nodules (GGNs) in a balanced manner in their daily practice and provokes further discussion towards better guidelines and/or algorithms.

A three-dimensional printing navigational template combined with mixed reality technique for localizing pulmonary nodules

OBJECTIVES

Localizing non-palpable pulmonary nodules is challenging for thoracic surgeons. Here, we investigated the accuracy of three-dimensional (3D) printing technology combined with mixed reality (MR) for localizing ground glass opacity-dominant pulmonary nodules.

METHODS

In this single-arm study, we prospectively enrolled patients with small pulmonary nodules (<2 cm) that required accurate localization. A 3D-printing physical navigational template was designed based on the reconstruction of computed tomography images, and a 3D model was generated through the MR glasses. We set the deviation distance as the primary end point for efficacy evaluation. Clinicopathological and surgical data were obtained for further analysis.

RESULTS

Sixteen patients with 17 non-palpable pulmonary nodules were enrolled in this study. Sixteen nodules were localized successfully (16/17; 94.1%) using this novel approach with a median deviation of 9 mm. The mean time required for localization was 25 ± 5.2 min. For the nodules in the upper/middle and lower lobes, the median deviation was 6 mm (range, 0-12.0) and 16 mm (range, 15.0-20.0), respectively. The deviation difference between the groups was significant (Z = -2.957, P = 0.003). The pathological evaluation of resection margins was negative.

CONCLUSIONS

The 3D printing navigational template combined with MR can be a feasible approach for localizing pulmonary nodules.

The feasibility of navigation bronchoscopy-guided pulmonary microcoil localization of small pulmonary nodules prior to thoracoscopic surgery

Background

Accurate preoperative localization of small pulmonary nodules facilitates the rapid and precise video-assisted thoracoscopic surgery (VATS). This study aims to evaluate the feasibility, safety, and efficacy of navigation bronchoscopy-guided pulmonary microcoil placement for preoperative pulmonary nodule localization.

Methods

Twelve lung lesions were simulated by mixing lipiodol in three porcine models. After 1 week, two microcoils per lesion were deployed under bronchoscopic guidance. Computed tomography scans were then performed 1 day, 1 week, 2 weeks, and 4 weeks after the deployment to assess the position of the microcoils relative to the lesions. Surgical resection of the simulated lesions was performed under fluoroscopy 5 weeks after the deployment and the accuracy, stability, and associated complications of the microcoil localization were evaluated. Following this, an exploratory clinical study was conducted on three patients with pure ground-glass pulmonary nodules.

Results

The mean diameter of the twelve simulated lung lesions was 9.55±2.36 mm, and the mean distance from the pleura to the lesions was 8.29±2.99 mm. Twenty-four pulmonary microcoils were implanted in the bronchi surrounding the lesions. Four weeks later, the mean distance between the microcoils and the center of the lesions was 16.12±8.97 mm and the average migration of the microcoils relative to the baseline position (1 day after implantation) was 3.48±4.56 mm. All microcoils and target lesions were successfully resected in both the animal experiment and clinical study and no complications, such as pneumothorax, were observed during marker implantation or postoperative follow-up.

Conclusions

The preoperative localization of pulmonary nodules by navigation bronchoscopy-guided microcoil placement is a safe, stable, and effective technique with minimal complication risk. This procedure can assist subsequent thoracoscopic resection.

Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique to localize deep pulmonary nodules in a hybrid operating room

Herein, we describe a Dyna-computed tomography-guided electromagnetic navigation bronchoscopy technique aimed at localizing deep pulmonary nodules. The method was implemented in a hybrid operating room and required the use of 2 markers (a near-infrared dye as a surface marker and a microcoil as a deep marker).

Three-dimensional printed navigational template for localizing small pulmonary nodules: A case-controlled study

Background

Localization of small pulmonary nodules is an inevitable challenge for the thoracic surgeon. This study aimed to investigate the accuracy of three‐dimensional (3D) printing technology for localizing small pulmonary nodules, especially ground‐glass nodules (GGNs).

Methods

This study enrolled patients with peripheral small pulmonary nodules (≤ 2 cm) who required preoperative localization. In the comparison period, patients underwent both computed tomography‐guided (CT‐G) and 3D‐printing template guided (3D‐G) localization to compare the accuracies of the two methods. In the testing period, the 3D‐printing technique was implemented alone. The 3D‐printing physical navigational template was designed based on data from perioperative CT images. Clinical data, imaging data, surgical data, and evaluation index were collected for further analysis. The learning curve of the 3D‐printing localization technique was assessed using cumulative sum (CUSUM) analysis and multiple linear regression analysis.

Results

In the comparison period (n = 14), the success rates of CT‐G and 3D‐G were 100% and 92.9% (P = 0.31), respectively; in the testing period (n = 23), the success rate of 3D‐G was 95.6%. The localization times of CT‐G, 3D‐G (comparison), and 3D‐G (testing) were 23.6 ± 5.3, 19.3 ± 6.8, and 9.8 ± 4.6 minutes, respectively. The CUSUM learning curve was modeled using the equation: Y = 0.48X²− 0.013X − 0.454 (R² = 0.89). The learning curve was composed of two phases, phase 1 (the initial 20 patients) and phase 2 (the remaining 17 patients).

Conclusions

3D printing localization has adequate accuracy and is a feasible and accessible strategy for use in localizing small pulmonary nodules, especially in right upper lobe. The use of this technique could facilitate lung nodule localization prior to surgery.

Bronchoscopic intratumoural therapies for non-small cell lung cancer

The past decade has brought remarkable improvements in the treatment of non-small cell lung cancer (NSCLC) with novel therapies, such as immune checkpoint inhibitors, although response rates remain suboptimal. Direct intratumoural injection of therapeutic agents via bronchoscopic approaches poses the unique ability to directly target the tumour microenvironment and offers several theoretical advantages over systemic delivery including decreased toxicity. Increases in understanding of the tumour microenvironment and cancer immunology have identified many potential options for intratumoural therapy, especially combination immunotherapies. Herein, we review advances in the development of novel bronchoscopic treatments for NSCLC over the past decade with a focus on the potential of intratumoural immunotherapy alone or in combination with systemic treatments.

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%.

Preoperative versus intraoperative image-guided localization of multiple ipsilateral lung nodules

OBJECTIVES

Computed tomography (CT)-guided localization of multiple ipsilateral pulmonary nodules remains challenging. Hybrid operating rooms equipped with cone-beam CT and laser navigation systems have the potential for improving clinical workflows and patient outcomes.

METHODS

Patients with multiple ipsilateral pulmonary nodules requiring localization were divided according to the localization method [preoperative CT-guided (POCT group) localization versus intraoperative CT-guided (IOCT group) localization]. The 2 groups were compared in terms of procedural efficacy, safety and radiation exposure.

RESULTS

Patients in the IOCT (n = 12) and POCT (n = 42) groups did not differ in terms of demographic and tumour characteristics. Moreover, the success and complication rates were similar. Notably, the IOCT approach allowed multiple nodules to be almost simultaneously localized-resulting in a shorter procedural time [mean difference (MD) -15.83 min, 95% confidence interval (CI) -7.97 to -23.69 min] and lower radiation exposure (MD -15.59 mSv, 95% CI -7.76 to -23.42 mSv) compared with the POCT approach. However, the total time under general anaesthesia was significantly longer in the IOCT group (MD 34.96 min, 95% CI 1.48-68.42 min), despite a similar operating time. The excess time under anaesthesia in the IOCT group can be attributed not only to the procedure per se but also to a longer surgical preparation time (MD 21.63 min, 95% CI 10.07-33.19 min).

CONCLUSIONS

Compared with the POCT approach, IOCT-guided localization performed in a hybrid operating room is associated with a shorter procedural time and less radiation exposure, albeit at the expense of an increased time under general anaesthesia.

Accuracy of a 3-Dimensionally Printed Navigational Template for Localizing Small Pulmonary Nodules: A Noninferiority Randomized Clinical Trial

Importance

Localization of small lung nodules are challenging because of the difficulty of nodule recognition during video-assisted thoracoscopic surgery. Using 3-dimensional (3-D) printing technology, a navigational template was recently created to assist percutaneous lung nodule localization; however, the efficacy and safety of this template have not yet been evaluated.

Objective

To assess the noninferiority of the efficacy and safety of a 3-D-printed navigational template guide for localizing small peripheral lung nodules.

Design, Setting, and Participants

This noninferiority randomized clinical trial conducted between October 2016 and October 2017 at Shanghai Pulmonary Hospital, Shanghai, China, compared the safety and precision of lung nodule localization using a template-guided approach vs the conventional computed tomography (CT)-guided approach. In total, 213 surgical candidates with small peripheral lung nodules (<2 cm) were recruited to undergo either CT- or template-guided lung nodule localization. An intention-to-treat analysis was conducted.

Interventions

Percutaneous lung nodule localization.

Main Outcomes and Measures

The primary outcome was the accuracy of lung nodule localization (localizer deviation), and secondary outcomes were procedural duration, radiation dosage, and complication rate.

Results

Of the 200 patients randomized at a ratio of 1:1 to the template- and CT-guided groups, most were women (147 vs 53), body mass index ranged from 15.4 to 37.3, the mean (SD) nodule size was 9.7 (2.9) mm, and the mean distance between the outer edge of target nodule and the pleura was 7.8 (range, 0.0-43.9) mm. In total, 190 patients underwent either CT- or template-guided lung nodule localization and subsequent surgery. Among these patients, localizer deviation did not significantly differ between the template- and CT-guided groups (mean [SD], 8.7 [6.9] vs 9.6 [5.8] mm; P = .36). The mean (SD) procedural durations were 7.4 (3.2) minutes for the template-guided group and 9.5 (3.6) minutes for the CT-guided group (P < .001). The mean (SD) radiation dose was 229 (65) mGy × cm in the template-guided group and 313 (84) mGy × cm in CT-guided group (P < .001).

Conclusions and Relevance

The use of the 3-D-printed navigational template for localization of small peripheral lung nodules showed efficacy and safety that were not substantially worse than those for the CT-guided approach while significantly simplifying the localization procedure and decreasing patient radiation exposure.

Trial Registration

ClinicalTrials.gov identifier: NCT02952261.

Electromagnetic navigational bronchoscopy-directed dye marking for locating pulmonary nodules

BACKGROUND

Small peripheral pulmonary nodules, which are usually deep-seated with no visual markers on the pleural surface, are often difficult to locate during surgery. At present, CT-guided percutaneous techniques are used to locate pulmonary nodules, but this method has many limitations. Thus, we aimed to evaluate the accuracy and feasibility of electromagnetic navigational bronchoscopy (ENB) with pleural dye to locate small peripheral pulmonary nodules before video-associated thoracic surgery (VATS).

METHODS

The ENB localisation procedure was performed under general anaesthesia in an operating room. Once the locatable guide wire, covered with a sheath, reached the ideal location, it was withdrawn and 0.2-1.0 mL of methylene blue/indocyanine green was injected through the guide sheath. Thereafter, 20-60 mL of air was instilled to disperse the dye to the pleura near the nodules. VATS was then performed immediately.

RESULTS

Study subjects included 25 patients with 28 nodules. The mean largest diameter of the pulmonary nodules was 11.8 mm (range, 6.0-24.0 mm), and the mean distance from the nearest pleural surface was 13.4 mm (range, 2.5-34.9 mm). After the ENB-guided localisation procedure was completed, the dye was visualised in 23 nodules (82.1%) using VATS. The average duration of the ENB-guided pleural dye marking procedure was 12.6 min (range, 4-30 min). The resection margins were negative in all malignant nodules. Complications unrelated to the ENB-guided localisation procedure occurred in two patients, including one case of haemorrhage and one case of slow intraoperative heart rate.

CONCLUSION

ENB can be used to safely and accurately locate small peripheral pulmonary nodules and guide surgical resection.

TRIAL REGISTRATION NUMBER

ChiCTR1900021963.

Electromagnetic Navigation-Guided Preoperative Localization of Small Malignant Pulmonary Tumors

BACKGROUND

Thoracoscopic resection of small pulmonary nodules can be challenging, which highlights the importance of preoperative localization. We report our experience with electromagnetic navigation-guided localization.

METHODS

The clinical, radiographic, surgical, and pathologic data of patients who underwent electromagnetic navigation-guided preoperative localization for pulmonary tumors smaller than 2 cm were reviewed. Successful localization was defined as successful identification of target lesions during the thoracoscopic procedure without palpation.

RESULT

Included were 30 patients with 35 nodules. There were 31 transthoracic and 5 transbronchial approaches performed. One patient received both approaches for the same tumor, and 3 received both approaches for localization of multiple targets. The median nodule size was 1.0 cm (interquartile range [IQR], 0.8-1.2 cm), and the median distance from the pleural surface was 1.1 cm (IQR, 0.6-2.0 cm). The most commonly used marker for localization was dye (n = 18), followed by microcoils (n =15). In nodules located with microcoils, the median distance between the microcoil and nodule was 1 mm (IQR, 0-3 mm). There were no complications related to the localization procedure. Successful localization was achieved in 27 of 30 patients (90.0%) and in 32 of 35 nodules (91.4%). The pathologic diagnosis was primary pulmonary malignancy in 29 nodules and secondary pulmonary malignancy in 6.

CONCLUSIONS

Our experience with electromagnetic navigation-guided transbronchial and transthoracic preoperative localization of small, malignant pulmonary tumors shows this technique is feasible and appears to be a viable option for preoperative localization of pulmonary nodules that may be difficult to locate thoracoscopically.

Why comprehensive adoption of robotic assisted thoracic surgery is ideal for both simple and complex lung resections

Minimally invasive thoracoscopic surgical techniques have grown increasingly popular due to improved outcome measures compared to conventional rib-spreading thoracotomy. However, video-assisted thoracoscopic surgery (VATS) presents with unique technical challenges that have limited its role in certain cases. Here, we discuss our perspectives on the implementation of a successful robotic thoracic program. We will then present the case for how the adoption of robotic assisted thoracic surgery (RATS) provides the benefits of minimally invasive VATS while still retaining the technical finesse of bimanual articulating instruments and 3-dimensional imaging that is a universal component of any open surgery. We will also discuss how to overcome some of the perceived disadvantages to RATS in regard to the higher cost, lack of tactile feedback and potential safety concerns.

What's New on Quantitative CT Analysis as a Tool to Predict Growth in Persistent Pulmonary Subsolid Nodules? A Literature Review

Pulmonary subsolid nodules (SSNs) are observed not infrequently on thin-section chest computed tomography (CT) images. SSNs persisting after a follow-up period of three to six months have a high likelihood of being pre-malignant or malignant lesions. Malignant SSNs usually represent the histologic spectrum of pulmonary adenocarcinomas, and pulmonary adenocarcinomas presenting as SSNs exhibit quite heterogeneous behavior. In fact, while most lesions show an indolent course and may grow very slowly or remain stable for many years, others may exhibit significant growth in a relatively short time. Therefore, it is not yet clear which persistent SSNs should be surgically removed and for how many years stable SSNs should be monitored. In order to solve these two open issues, the use of quantitative analysis has been proposed to define the "tailored" management of persistent SSNs. The main purpose of this review was to summarize recent results about quantitative CT analysis as a diagnostic tool for predicting the behavior of persistent SSNs. Thus, a literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science databases to find original articles published from January 2014 to October 2019. The results of the selected studies are presented and compared in a narrative way.

Recent fluorescence imaging technology applications of indocyanine green in general thoracic surgery

Thoracic surgeons perform a wide variety of cancer operations, which are often associated with high morbidity and mortality. Thus, thoracic surgery involves many special challenges that require innovative solutions. The increased utilization of minimally invasive practices, poor overall cancer survival, and significant morbidity of critical operations remain key obstacles to overcome. Fluorescence imaging technology (FIT), involving the implementation of fluorescent dyes and imaging systems, is currently used as an adjunct for general thoracic surgery in many situations and includes sentinel lymph node mapping, pulmonary intersegmental plane identification, pulmonary nodule identification, pulmonary bullous lesion detection, evaluation of the anastomotic perfusion after tracheal surgery, and thoracic duct imaging for postoperative chylothorax. This technology enhances the surgeon's ability to perform operations, and has specific advantages. We review some of the key studies that demonstrate the applications of FIT in the field of general thoracic surgery, focusing on the use of indocyanine green.

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy

INTRODUCTION

Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection.

OBJECTIVE

To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study.

METHODS

NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort.

RESULTS

The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24).

CONCLUSION

In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

Quantitative CT Analysis for Predicting the Behavior of Part-Solid Nodules with Solid Components Less than 6 mm: Size, Density and Shape Descriptors

Persistent part-solid nodules (PSNs) with a solid component <6 mm usually represent minimally invasive adenocarcinomas and are significantly less aggressive than PSNs with a solid component ≥6 mm. However, not all PSNs with a small solid component behave in the same way: some nodules exhibit an indolent course, whereas others exhibit more aggressive behavior. Thus, predicting the future behavior of this subtype of PSN remains a complex and fascinating diagnostic challenge. The main purpose of this study was to apply open-source software to investigate which quantitative computed tomography (CT) features may be useful for predicting the behavior of a select group of PSNs. We retrospectively selected 50 patients with a single PSN with a solid component <6 mm and diameter <15 mm. Computerized analysis was performed using ImageJ software for each PSN and various quantitative features were calculated from the baseline CT images. The area, perimeter, mean Feret diameter, linear mass density, circularity and solidity were significantly related to nodule growth (p ≤ 0.031). Therefore, quantitative CT analysis was helpful for predicting the future behavior of a select group of PSNs with a solid component <6 mm and diameter <15 mm.

The Utility of Near-Infrared Fluorescence and Indocyanine Green During Robotic Pulmonary Resection

During minimally invasive pulmonary resection, it is often difficult to localize pulmonary nodules that are small (<2 cm), low-density/subsolid on imaging, or deep to the visceral pleura. The use of near-infrared fluorescence (NIF) imaging for localizing pulmonary nodules using indocyanine green (ICG) contrast is an emerging technology that is increasingly utilized during pulmonary resection. When administered via electromagnetic navigational bronchoscopy (ENB), ICG can accurately localize pulmonary nodules. When injected intravenously (IV), ICG can also help delineate the intersegmental plane. Research is ongoing regarding the utility of ICG for identification of the sentinel lymph node in lung cancer.

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).

Preoperative CT versus intraoperative hybrid DynaCT imaging for localization of small pulmonary nodules: a randomized controlled trial

BACKGROUND

Localization of small and/or deep pulmonary nodules before thoracoscopic exploration is paramount to minimize the likelihood of unplanned conversion to thoracotomy. As far as the percutaneous approach is concerned, the most common workflow consists of preoperative computed tomography (POCT) imaging-guided tumor marking (performed in an interventional CT suite) followed by their removal in an operating room (OR). However, the advent of hybrid ORs has allowed intraoperative computed tomography (IOCT)-guided lesion localization. This single center, open-label, randomized, controlled clinical trial aims to compare the efficacy and safety of IOCT versus POCT.

METHODS/DESIGN

The study sample will consist of patients presenting with small and/or deep pulmonary nodules who will be randomly allocated to either POCT or IOCT. The time required to complete lesion localization will be the primary efficacy outcome. The following parameters will serve as secondary endpoints: rate of successful targeting during localization and in the operating field, time at risk, operating time, length of time under anesthesia, global OR utilization time, complication (pneumothorax and hemorrhage) rates, and radiation exposure.

DISCUSSION

Owing to the increased availability of HORs, our data will be crucial to clarify the feasibility and safety of IOCT versus the traditional POCT approach.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03395964 . Registered on October 8, 2018.

Electromagnetic Transthoracic Nodule Localization for Minimally Invasive Pulmonary Resection

BACKGROUND

Increased use of chest computed tomography and the institution of lung cancer screening have increased the detection of ground-glass and small pulmonary nodules. Intraoperative localization of these lesions via a minimally invasive thoracoscopic approach can be challenging. We present the feasibility of perioperative transthoracic percutaneous nodule localization using a novel electromagnetic navigation platform.

METHODS

This is a multicenter retrospective analysis of a prospectively collected database of patients who underwent perioperative electromagnetic transthoracic nodule localization before attempted minimally invasive resection between July 2016 and March 2018. Localization was performed using methylene blue or a mixture of methylene blue and the patient's blood (1:1 ratio). Patient, nodule, and procedure characteristics were collected and reported.

RESULTS

Thirty-one nodules were resected from 30 patients. Twenty-nine of 31 nodules (94%) were successfully localized. Minimally invasive resection was successful in 93% of patients (28/30); 7% (2/30) required conversion to thoracotomy. The median nodule size was 13 mm (interquartile range 25%-75%, 9.5-15.5), and the median depth from the surface of the visceral pleura to the nodule was 10 mm (interquartile range 25%-75%, 5.0-15.9). Seventy-one percent (22/31) of nodules were malignant. No complications associated with nodule localization were reported.

CONCLUSIONS

The use of intraoperative electromagnetic transthoracic nodule localization before thoracoscopic resection of small and/or difficult to palpate lung nodules is safe and effective, potentially eliminating the need for direct nodule palpation. Use of this technique aids in minimally invasive localization and resection of small, deep, and/or ground-glass lung nodules.

Individualized Strategies for Intraoperative Localization of Non-palpable Pulmonary Nodules in a Hybrid Operating Room

Background: Precise preoperative localization of small pulmonary nodules is a key prerequisite to their successful excision. With the advent of hybrid operating rooms (HORs), a patient-tailored approach encompassing simultaneous localization and removal of small pulmonary nodules has become feasible. In this study, we describe our individualized image-guided video assisted thoracoscopic surgery (iVATS) strategies implemented within a HOR environment. Specifically, localization was performed through different marking approaches (single- vs. double-marker) and access routes [percutaneous technique with Dyna-computed tomography (DynaCT) imaging vs. electromagnetic navigation bronchoscopy (ENB)]. Methods: Between April 2017 and November 2018, a total of 159 consecutive patients (harboring 174 pulmonary nodules) were treated with iVATS. The marking approach and access route were individually tailored according to lesion localization and its distance from the pleural surface. The efficacy and safety of our iVATS technique were determined through a retrospective review of clinical charts. Results: All of the localization procedures were performed in a HOR by a single team of thoracic surgeons. The mean tumor size on preoperative CT was 8.28 mm (95% confidence interval [CI]: 7.6-8.96 mm), whereas their mean distance from the pleural surface was 9.44 mm (95% CI: 8.11-10.77 mm). Of the 174 tumors, 150 were localized through a percutaneous DynaCT-guided approach (single-marker: 139, dual-marker: 11), whereas localization in the remaining 24 was accomplished via the ENB-guided approach (single-marker: 4; dual-marker: 20). The mean localization time was 17.78 min (95% CI:16.17-19.39 min). The overall localization success rate was 95.9%. We failed to localize a total of seven nodules either because of technical complications (pneumothorax, n = 3; microcoil dislodgement; n = 1) or machine failure (n = 3). No operative deaths were observed, and the mean length of postoperative stay was 3.65 days (95% CI: 3.19-4.11 days). Conclusions: The use of tailored marking approaches and access routes allowed us to individualize the iVATS procedure for small pulmonary nodules, ultimately promoting a more patient-centered workflow.