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Morgan KM, Anderson KT, Johnston ME, Dasgupta R, Crowley JJ, Fahy AS, Lapidus-Krol E, Baertschiger RM, Lautz TB, Many BT, Marquart JP, Gainer H, Lal DR, Rich BS, Glick RD, MacArthur TA, Polites SF, Kastenberg ZJ, Short SS, Meyers RL, Talbot L, Abdelhafeez A, Prajapati H, Davidoff AM, Rubaclava N, Newman E, Ehrlich PF, Rothstein DH, Roach JP, Ladd P, Janek KC, Le HD, Leraas HJ, Tracy ET, Bisset L, Mora MC, Warren P, Aldrink JH, Malek MM. Interhospital variability in localization techniques for small pulmonary nodules in children: A pediatric surgical oncology research collaborative study. J Pediatr Surg 2022; 57:1013-1017. [PMID: 35307194 DOI: 10.1016/j.jpedsurg.2022.01.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary nodules that are deep within lung parenchyma and/or small in size can be challenging to localize for biopsy. This study describes current trends in performance of image-guided localization techniques for pulmonary nodules in pediatric patients. METHODS A retrospective review was performed on patients < 21 years of age undergoing localization of pulmonary nodules at 15 institutions. Localization and resection success, time in interventional radiology (IR), operating room (OR) and total anesthesia time, complications, and technical problems were compared between techniques. RESULTS 225 patients were included with an average of 1.3 lesions (range 1-5). Median nodule size and depth were 4 mm (range 0-30) and 5.4 mm (0-61), respectively. The most common localization techniques were: wire + methylene blue dye (MBD) (28%), MBD only (25%), wire only (14%), technetium-99 only (11%), coil + MBD (7%) and coil only (5%). Localization technique was associated with institution (p < 0.01); technique and institution were significantly associated with mean IR, OR, and anesthesia time (all p < 0.05). Comparing techniques, there was no difference in successful IR localization (range 92-100%, p = 0.75), successful resection (94-100%, p = 0.98), IR technical problems (p = 0.22), or operative complications (p = 0.16). CONCLUSIONS Many IR localization techniques for small pulmonary nodules in children can be successful, but there is wide variability in application by institution and in procedure time. LEVEL OF EVIDENCE Retrospective review, Level 3.
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Affiliation(s)
- Katrina M Morgan
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
| | - K Tinsley Anderson
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 7th FL, Pittsburgh, PA, United States
| | - Michael E Johnston
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Roshni Dasgupta
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - John J Crowley
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 7th FL, Pittsburgh, PA, United States
| | | | | | | | - Timothy B Lautz
- Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Benjamin T Many
- Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - John P Marquart
- Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI, United States
| | - Haley Gainer
- Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI, United States
| | - Dave R Lal
- Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI, United States
| | - Barrie S Rich
- Cohen Children's Medical Center, Queens, NY, United States
| | | | | | | | | | - Scott S Short
- University of Utah, Salt Lake City, UT, United States
| | | | | | | | | | | | | | - Erika Newman
- C.S. Mott Children's Hospital, Ann Arbor, MI, United States
| | | | | | | | - Patricia Ladd
- Children's Hospital Colorado, Aurora, CO, United States
| | - Kevin C Janek
- American Family Children's Hospital, Madison, WI, United States
| | - Hau D Le
- American Family Children's Hospital, Madison, WI, United States
| | | | | | - Logan Bisset
- Duke University Medical Center, Durham, NC, United States
| | - Maria C Mora
- Nationwide Children's Hospital, Columbus, OH, United States
| | - Patrick Warren
- Nationwide Children's Hospital, Columbus, OH, United States
| | | | - Marcus M Malek
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 7th FL, Pittsburgh, PA, United States.
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2
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Yamamichi T, Nishikawa M, Takayama K, Takase K, Kim K, Umeda S, Tayama A, Tsukada R, Nomura M, Okuyama H, Usui N. Computed tomography-guided marking using a dye-staining method for preoperative localization of tiny pulmonary lesions in children. Pediatr Surg Int 2021; 37:1265-1272. [PMID: 34091750 DOI: 10.1007/s00383-021-04930-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE It is important to confirm the existence of pulmonary metastases in pediatric patients with malignancies. Therefore, we aimed to investigate if computed tomography CT-guided marking is a feasible and safe method for the identification and resection of tiny pulmonary lesions in pediatric cancer patients. METHODS We retrospectively reviewed the medical records of pediatric cancer patients who underwent CT-guided marking procedures in our institutions between Jan 2011 and Apr 2020. After 2015, these procedures were combined with an indocyanine green (ICG) navigation-guided surgery for hepatoblastoma cases. RESULTS We targeted a total of 22 nodules in 12 patients. Of these, marking was successful in 18 (81.8%) nodules, 10 of which contained viable malignant cells. Complications caused by the marking procedures included mild pneumothorax and mild atelectasis in two patients, respectively. Of the eight resected nodules in patients with hepatoblastoma, four were ICG-positive and contained viable malignant cells. Two additional ICG-positive nodules, which were unidentified before surgery, were observed intraoperatively. CONCLUSION CT-guided marking is a feasible and safe method that can be used to identify and resect tiny pulmonary lesions in pediatric cancer patients. An ICG navigation-guided surgery is useful when combined with CT-guided marking, particularly in hepatoblastoma cases.
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Affiliation(s)
- Taku Yamamichi
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, 594-1101, Japan.
| | - Masanori Nishikawa
- Department of Clinical Radiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Keita Takayama
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, 594-1101, Japan
| | - Koki Takase
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, 594-1101, Japan
| | - Kiyokazu Kim
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, 594-1101, Japan
| | - Satoshi Umeda
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, 594-1101, Japan
| | - Ai Tayama
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, 594-1101, Japan
| | - Ryo Tsukada
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Motonari Nomura
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, 840 Murodo, Izumi, 594-1101, Japan
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3
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Facchini G, Ceccarelli L, Tomà P, Bartoloni A. Recent Imaging Advancements for Lung Metastases in Children with Sarcoma. Curr Med Imaging 2021; 17:236-243. [PMID: 33371858 DOI: 10.2174/1573405616666201228125657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 11/19/2020] [Accepted: 12/07/2020] [Indexed: 11/22/2022]
Abstract
In children and adolescents affected by musculoskeletal sarcomas (both soft tissue and bone sarcomas), the presence of lung metastases is a frequent complication, that should be known since the patient's prognosis, as management, and treatment depend on it. During the staging phase, the detection of lung metastases should be sensitive and specific, and it should be carried out by minimizing the radiation exposure. To deal with this problem, imaging has reached important goals in recent years, thanks to the development of cone-beam CT or low-dose computed tomography, with some new iterative reconstruction methods, such as Veo and ASIR. Imaging is also fundamental for the possibility to perform lung biopsies under CT guidance, with less morbidity, less time-consumption, and shorter recovery time, compared to surgical biopsies.Moreover, important results have also been demonstrated in the treatment of lung metastases, due to the improvement of new mini-invasive image-guided percutaneous thermal ablation procedures, which proved to be safe and effective also in young patients.
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Affiliation(s)
- Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Ceccarelli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Paolo Tomà
- Department of Imaging, IRCCS Ospedale Pediatrico Bambino Gesu, Rome, Italy
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4
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Morgan KM, Crowley JJ, Many BT, Lautz TB, Malek MM. Microcoil localization as an effective adjunct to thoracoscopic resection of pulmonary nodules in children. J Pediatr Surg 2021; 56:142-145. [PMID: 33109347 DOI: 10.1016/j.jpedsurg.2020.09.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Thoracoscopic excision of pulmonary nodules is often required for diagnostic or therapeutic purposes, however subpleural and sub-centimeter nodules can be difficult to visualize. Various CT-guided localization techniques have been described, though there is minimal published pediatric data regarding the use of microcoils. We hypothesize that microcoil localization facilitates thoracoscopic resection of pulmonary nodules in children. METHODS A multi-institutional retrospective review of children who underwent preoperative CT-guided localization of lung nodules was conducted from 2012 to 2019. A combination of methylene blue dye (MBD), wires, and microcoils were utilized for CT-guided localization. When microcoils were utilized, fluoroscopy assisted in lesion identification and resection. RESULTS Eighteen patients (mean age 13 years, range 2-21 years) underwent thoracoscopic resection of 24 preoperatively localized pulmonary nodules. Mean size and depth of the lesions were 5.5 mm and 10 mm, respectively. Microcoil placement was successful 95% of the time and assisted in lesion localization in 88% of cases. Wire localization was not a durable technique, as 3 of 5 wires became dislodged upon lung isolation. CONCLUSIONS Preoperative CT-guided localization with microcoils can assist in fluoroscopic-guided resection of pulmonary nodules in children. This technique avoids the pitfall of wire dislodgement, and provides surgeons an additional technique to localize sub-centimeter, subpleural nodules. TYPE OF STUDY Retrospective Review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Katrina M Morgan
- University of Pittsburgh Medical Center (UPMC), General Surgery Department, Pittsburg, PA.
| | - John J Crowley
- UPMC Children's Hospital of Pittsburgh, Radiology Department, Pittsburgh, PA
| | - Benjamin T Many
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL
| | - Timothy B Lautz
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL
| | - Marcus M Malek
- UPMC Children's Hospital of Pittsburgh, Pediatric Surgery Department, Pittsburgh, PA
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5
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Heran MKS, Cardarelli-Leite L, d'Ortenzio R, Skarsgard ED. Initial experience of the use of ethylene-vinyl alcohol polymer (EVOH) as an alternative technique for lung nodule localization prior to VATS. J Pediatr Surg 2020; 55:2824-2827. [PMID: 32768314 DOI: 10.1016/j.jpedsurg.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/25/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
Identifying pulmonary nodules for resection that are small or are deep within the lung parenchyma is a frequently encountered challenge during video-assisted thoracoscopic surgery (VATS). Several image-guided localizing techniques have been described; however, there is limited literature on using these techniques in pediatric patients. We assessed the feasibility of using a commercially available ethylene-vinyl alcohol polymer (EVOH) as an alternative technique for lung nodule localization prior to VATS. We describe our experience of successful EVOH lung nodule localization in three pediatric patients with an oncologic history presenting with new lung nodules.
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Affiliation(s)
- Manraj K S Heran
- Department of Radiology, University of British Columbia, Vancouver V6H 3V4, Canada.
| | | | - Robert d'Ortenzio
- Department of Radiology, University of British Columbia, Vancouver V6H 3V4, Canada
| | - Erik D Skarsgard
- Division of Pediatric General Surgery, University of British Columbia, Vancouver V6H 3V4, Canada
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6
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Paredes P, Suils J, Danús M, Delgado Bolton R, Sánchez-Lorente D, Rodríguez Martínez D, Goñi E. Diagnosis and radio-guided surgery of lung nodules. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2020.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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7
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Paredes P, Suils J, Danús M, Delgado Bolton RC, Sánchez-Lorente D, Rodríguez Martínez D, Goñi E. Diagnosis and radio-guided surgery of lung nodules. Rev Esp Med Nucl Imagen Mol 2020; 39:327-336. [PMID: 32773359 DOI: 10.1016/j.remn.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- P Paredes
- Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, España.
| | - J Suils
- Servicio de Medicina Nuclear, IDI-Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - M Danús
- Servicio de Imagen para el Diagnóstico, Medicina Nuclear, Hospital Universitari Sant Joan de Reus, Reus, Tarragona, España
| | - R C Delgado Bolton
- Servicio de Medicina Nuclear, Hospital Universitario San Pedro, Logroño, España
| | - D Sánchez-Lorente
- Servicio de Cirugía Torácica (ICR), Hospital Clínic Barcelona, España
| | - D Rodríguez Martínez
- Servicio de Imagen para el Diagnóstico, Radiología. Hospital Universitari Sant Joan de Reus, Tarragona, España
| | - E Goñi
- Servicio de Medicina Nuclear, Complejo Hospitalario de Navarra, Pamplona, España
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8
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Sheikh F, Brandt RJ, Tsapakos MJ, Baertschiger RM, Croitoru DP. CT-guided blood tattoo for thoracoscopic excision of lung lesions in pediatric patients. J Thorac Dis 2020; 12:4284-4291. [PMID: 32944340 PMCID: PMC7475583 DOI: 10.21037/jtd-19-3800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To describe a single-institutional experience with an innovative technique using CT-guided injection of autologous blood for localization of nonpleural-based pulmonary nodules prior to thoracoscopic excisional biopsy in pediatric patients. Methods A retrospective review of all patients under the age of 18 with lung lesions suspected to be malignant that were not pleural-based lesions and were not of adequate size to visualize at thoracoscopy, who underwent CT-guided blood tattoo (CGBT) localization between 2006-2019. CGBT was performed under general anesthesia by injecting 0.5-10 mL of autologous blood into the area of the lesions. The patients were then immediately transferred from interventional radiology to the operating room for thoracoscopic excision of the lesion. Demographics, location of lesions, indication for biopsy, and pathology were reviewed. Results In eleven pediatric patients (ages ranging from 4-18 years), preoperative CGBT localization of pulmonary nodules resulted in successful thoracoscopic excisional biopsy. All resections were diagnostic and 82% (9/11 cases) represented a metastatic malignancy as confirmed by pathology. Malignant nodules ranged from 2 to 14 mm in size, while a 13 mm nodule in a patient with history of AML was determined to be an organizing pneumonia and a 12 mm nodule in a second patient revealed a caseating granuloma consistent with Crohn's disease. One patient with a failed attempt at excisional biopsy without preoperative localization then underwent CGBT one week later with successful thoracoscopic excision of the nodule. Conclusions CT-guided blood tattoo is a safe option for localization of nonpleural-based lung nodules prior to thoracoscopic excision in pediatric patients.
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Affiliation(s)
- Fariha Sheikh
- Department of Surgery, Division of Pediatric Surgery, Abdominal Imaging Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ryan J Brandt
- Department of Radiology, Abdominal Imaging Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael J Tsapakos
- Department of Radiology, Abdominal Imaging Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Reto M Baertschiger
- Department of Surgery, Division of Pediatric Surgery, Abdominal Imaging Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Daniel P Croitoru
- Department of Surgery, Division of Pediatric Surgery, Abdominal Imaging Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Casey AM, Deterding RR, Young LR, Fishman MP, Fiorino EK, Liptzin DR. Overview of the ChILD Research Network: A roadmap for progress and success in defining rare diseases. Pediatr Pulmonol 2020; 55:1819-1827. [PMID: 32533913 DOI: 10.1002/ppul.24808] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/21/2020] [Indexed: 11/08/2022]
Abstract
Children's interstitial and diffuse lung diseases are a diverse group of rare lung disorders that present in childhood with diffuse pulmonary infiltrates and respiratory signs and symptoms. Children with these disorders face high morbidity and mortality and their families must cope with overwhelming uncertainty. Physicians caring for these patients are challenged by a paucity of directed therapies, or even understanding of natural history. Through the establishment of the Children's Interstitial Lung Disease Foundation Research Network and the Children's Interstitial Lung Disease Foundation significant progress has been made through collaboration and research. This review outlines the past and current successes in the new and rapidly growing field of Children's Interstitial and Diffuse Lung Disease.
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Affiliation(s)
- Alicia M Casey
- Division of Pulmonary Medicine, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Robin R Deterding
- Section of Pediatric Pulmonology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Lisa R Young
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Martha P Fishman
- Division of Pulmonary Medicine, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts
| | - Elizabeth K Fiorino
- Division of Pediatric Pulmonology, Weill Cornell Medicine and NewYork-Presbyterian Phyllis and David Komansky Children's Hospital, New York, New York
| | - Deborah R Liptzin
- Section of Pediatric Pulmonology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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10
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Pulmonary Metastasectomy in Pediatric Solid Tumors. CHILDREN-BASEL 2019; 6:children6010006. [PMID: 30626161 PMCID: PMC6352020 DOI: 10.3390/children6010006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 12/24/2018] [Accepted: 12/24/2018] [Indexed: 11/16/2022]
Abstract
Metastatic disease and the complications of treating metastatic disease are the primary causes of mortality in children with solid malignancies. Nearly 25% of children with solid tumors have metastatic disease at initial diagnosis and another 20% develop metastases during or after treatment. The most common location of these metastases is the lung. The role of surgery in metastatic disease depends greatly on the histology of the primary. In general, tumors that are refractory to adjuvant therapies are most appropriate for pulmonary metastasectomy. This article will summarize the indications for metastasectomy in pediatric solid tumors and discuss the ongoing debate over the technique of metastasectomy in osteosarcoma.
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11
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Polites SF, Fahy AS, Sunnock WA, Potter DD, Klinkner DB, Moir CR, Shen KR, Ishitani MB. Use of radiotracer labeling of pulmonary nodules to facilitate excisional biopsy and metastasectomy in children with solid tumors. J Pediatr Surg 2018; 53:1369-1373. [PMID: 28689886 DOI: 10.1016/j.jpedsurg.2017.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/06/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE Excision of suspected pulmonary metastases in children is challenging in the setting of multiple nodules or nodules that are small, deep, or soft. This study describes preoperative technetium macro-aggregated albumin (Tc 99m MAA) localization of pulmonary lesions to aid in intraoperative identification and resection. METHODS Patients with past or present pediatric solid tumors who underwent resection of pulmonary nodules following CT-guided Tc 99m MAA labeling were identified. The primary outcomes were successful preoperative localization and subsequent resection. RESULTS Metastasectomy following Tc 99m MAA localization was performed 15 times in 11 patients from 2014 to 2016. Mean age was 13years; the most common diagnosis was osteosarcoma (33%). Tc 99m MAA labeling was attempted in 24 nodules with mean nodule diameter 6±5mm and mean depth from the pleural surface of 12±17mm; localization was successful in 23 nodules (96%). Subsequent resection was performed by thoracotomy in 12 cases and thoracoscopy in 3. All labeled nodules were identified intraoperatively; two were not resected and 17 of the 21 nodules resected demonstrated metastatic disease on pathology. CONCLUSION Tc 99m MAA labeling of pulmonary nodules in children is effective in facilitating resection of sub-centimeter intraparenchymal metastases identified on preoperative imaging. Furthermore, this technique allows for thoracoscopic metastasectomy in select patients. TYPE OF STUDY/LEVEL OF EVIDENCE Case Series/Level IV.
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Affiliation(s)
| | | | | | | | | | | | - K Robert Shen
- Division of Thoracic Surgery, Mayo Clinic, Rochester, MN
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12
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McDaniel JD, Racadio JM, Patel MN, Johnson ND, Kukreja K. CT-guided localization of pulmonary nodules in children prior to video-assisted thoracoscopic surgical resection utilizing a combination of two previously described techniques. Pediatr Radiol 2018; 48:626-631. [PMID: 29362842 DOI: 10.1007/s00247-018-4069-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 12/01/2017] [Accepted: 01/03/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pulmonary nodules in pediatric oncology patients can present a diagnostic and treatment dilemma. Imaging findings are often nonspecific and tissue diagnosis may be required for appropriate treatment. The smaller subpleural nodules may not be visualized and cannot be palpated during video-assisted thoracoscopic surgical (VATS) resection. Preoperative localization has been beneficial in obtaining an adequate pathological specimen. OBJECTIVE This study presents experience in a large pediatric hospital using CT-guided preoperative localization of pulmonary nodules combining two previously utilized techniques, hook wire and methylene blue blood patch localization. MATERIALS AND METHODS A search of the electronic medical record utilizing a medical record search application was performed to identify all patients who underwent preoperative lung nodule localization during a 12.5-year period (July 1999 through January 2012). A retrospective chart review of these patients was then performed. Pre- and postoperative imaging, interventional radiology procedural images and reports, surgical reports, and pathology reports were obtained and evaluated. RESULTS Thirty-five patients, with 40 nodules, who underwent preoperative CT-guided lung nodule localization were identified. Patients ranged in age from 8 months to 21 years. The pulmonary nodules ranged in size from 1.4 mm to 18 mm. Twelve nodules were localized using a Kopans breast lesion localization needle with hook wire, 4 were localized using a methylene blue blood patch, and 24 were localized using the combination of these two techniques. The technical success rate of all procedures was 100%. A pathological diagnosis was determined in 39 patients (97.5%). There were 6 (15.0%) minor complications and no major complications. CONCLUSION CT-guided lung nodule localization using the combined techniques of methylene blue blood patch and hook wire is safe, technically feasible and successful in children. Using this combination of techniques will consistently yield a pathological diagnosis, is currently the preferred technique at our tertiary pediatric hospital and could be considered the new best practice.
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Affiliation(s)
- Janice D McDaniel
- Department of Radiology, Division of Interventional Radiology, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308, USA.
| | - John M Racadio
- Department of Radiology, Division of Interventional Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Manish N Patel
- Department of Radiology, Division of Interventional Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Neil D Johnson
- Department of Radiology, Division of Interventional Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kamlesh Kukreja
- Department of Radiology, Division of Interventional Radiology, Texas Children's Hospital, Houston, TX, USA
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13
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CT-guided hook-wire localisation prior to video-assisted thoracoscopic surgery of pulmonary lesions. Clin Radiol 2017; 72:898.e7-898.e11. [DOI: 10.1016/j.crad.2017.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/15/2017] [Accepted: 05/22/2017] [Indexed: 12/12/2022]
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14
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Pediatric oncologic endosurgery. INTERNATIONAL JOURNAL OF SURGERY-ONCOLOGY 2017; 2:e30. [PMID: 29075678 PMCID: PMC5645938 DOI: 10.1097/ij9.0000000000000030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 04/29/2017] [Indexed: 11/26/2022]
Abstract
Despite increasing popularity of minimal-invasive techniques in the pediatric
population, their use in diagnosis and management of pediatric malignancy is still
debated. Moreover, there is limited evidence to clarify this controversy due to low
incidence of each individual type of pediatric tumor, huge diversity of the disease
entity, heterogeneity of surgical technique, and lack of well-designed studies on
pediatric oncologic minimal-invasive surgery. However, a rapid development of medical
instruments and technologies accelerated the current trend toward less invasive
surgery, including oncologic endosurgery. The aim of this article is to review
current literatures about the application of the minimal-invasive approach for
pediatric tumors and to give an overview of the current status, indications,
individual techniques, and future perspectives.
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15
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Pang X, Xue L, Chen J, Ding J. A novel hybrid technique for localization of subcentimeter lung nodules. J Thorac Dis 2017; 9:1107-1112. [PMID: 28523166 DOI: 10.21037/jtd.2017.03.75] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND It is technically challenging to locate non-visible, non-palpable subcentimeter ground-glass nodules (GGNs) of lung during video-assisted thoracic surgery (VATS). Computed tomography (CT)-guided marking of small pulmonary nodules using microcoils has been reported to be a practical method of preoperative localization, whereas dislodgement of microcoils remains to be a bothersome complication. The objective of this study was to assess the viability and effectiveness of a newly developed hybrid technique, which combines induced controllable pneumothorax and CT-guided microcoil marking procedure to reduce the risk of microcoil dislodgement. METHODS After induced minor pneumothorax, 35 patients with subcentimeter GGNs underwent CT-guided marking with microcoils prior to VATS sublobar resection or lobectomy. Histopathological analysis was performed after surgeries. RESULTS All of 37 nodules were successfully marked before VATS. Segmentectomy was performed in 8 cases, wedge resection in 19 cases and lobectomy in 8 cases. All nodules were completely removed with marking microcoils. Dislodgement of microcoils was not observed in all cases and mild pulmonary hemorrhage occurred in one case. No other complications occurred. CONCLUSIONS The newly developed hybrid technique which combines induced controllable pneumothorax and CT-guided marking using microcoils was feasible and reliable for VATS resection of subcentimeter GGNs, meanwhile significantly lowered the risk of microcoil dislocation.
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Affiliation(s)
- Xuguang Pang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Liang Xue
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jiemin Chen
- Department of Interventional Therapy, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jianyong Ding
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Heaton TE, Hammond WJ, Farber BA, Pallos V, Meyers PA, Chou AJ, Price AP, LaQuaglia MP. A 20-year retrospective analysis of CT-based pre-operative identification of pulmonary metastases in patients with osteosarcoma: A single-center review. J Pediatr Surg 2017; 52:115-119. [PMID: 27836366 PMCID: PMC5384104 DOI: 10.1016/j.jpedsurg.2016.10.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 10/20/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Cooperative studies support complete metastasectomy in osteosarcoma (OS). Pre-operative CT is used to identify and quantify metastases and can facilitate minimally invasive techniques. Here we assess the accuracy of pre-operative CT compared to findings at thoracotomy and its change over time. METHODS We reviewed OS thoracotomies performed at our institution from 1996 to 2015. The number of metastases identified on pre-operative chest CT was compared to the number of metastases seen on pathology (both metastases with viable cells and non-viable, osteoid-only metastases). RESULTS Eighty-eight patients underwent 161 thoracotomies with a median of 14days (range, 1-85) between CT and surgery, a median of 2 CT-identified lesions (range, 0-15), and a median of 4 resected lesions (range, 1-25). In 56 (34.8%) cases, more metastases were found surgically than were seen on CT, and among these, 34 (21.1%) had a greater number of viable metastases. There was poor overall correlation between CT and pathology findings (Kendall Tau-b=0.506), regardless of CT slice thickness, decade of thoracotomy, or total number of CT-identified lesions. CONCLUSIONS CT accuracy in pre-operatively quantifying OS pulmonary metastases has not improved in recent decades. Consequently, we recommend an open technique with direct lung palpation for complete identification and resection of OS pulmonary metastases. LEVEL OF EVIDENCE Level IV, retrospective study with no comparison group.
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Affiliation(s)
- Todd E. Heaton
- Pediatric Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - William J. Hammond
- Pediatric Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Benjamin A. Farber
- Pediatric Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Valerie Pallos
- Pediatric Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul A. Meyers
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander J. Chou
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anita P. Price
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michael P. LaQuaglia
- Pediatric Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Abstract
Most children who succumb to solid malignancies do so because of the burden of metastatic disease or due to complications associated with the therapy administered to treat metastatic disease. Approximately one-quarter of children with solid tumors will present with metastatic disease, and an additional 20% ultimately develop metastatic disease, most commonly in the lung. The role of surgery in the treatment of metastatic solid tumors, given its disseminated nature, is not intuitive, yet there are circumstances in which surgical resection of metastatic disease can potentially be curative. However, the utility of surgery is very much dependent on histology, and generally is most appropriate for those malignancies with histologies that are refractory to other adjuvant therapies.
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Affiliation(s)
- Todd E. Heaton
- Pediatric Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN
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Chu X, Hou X, Zhang L, Xue Z, Ren Z, Wen J, Liu Y, Ma K, Sun Y. [Clinical study of intra-operative computed tomography guided localization with a hook-wire system for small ground glass opacities in minimally invasive resection]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2015; 17:845-9. [PMID: 25539609 PMCID: PMC6000413 DOI: 10.3779/j.issn.1009-3419.2014.12.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE Localization of pulmonary ground glass small nodule is the technical difficulty of minimally invasive operation resection. The aim of this study is to evaluate the value of intraoperative computed tomography (CT)-guided localization using a hook-wire system for small ground glass opacity (GGO) in minimally invasive resection, as well as to discuss the necessity and feasibility of surgical resection of small GGOs (<10 mm) through a minimally invasive approach. METHODS The records of 32 patients with 41 small GGOs who underwent intraoperative CT-guided double-thorn hook wire localization prior to video-assisted thoracoscopic wedge resection from October 2009 to October 2013 were retrospectively reviewed. All patients received video-assisted thoracoscopic surgery (VATS) within 10 min after wire localization. The efficacy of intraoperative localization was evaluated in terms of procedure time, VATS success rate, and associated complications of localization. RESULTS A total of 32 patients (15 males and 17 females) underwent 41 VATS resections, with 2 simultaneous nodule resections performed in 3 patients, 3 lesion resections in 1 patient, and 5 lesions in a patient. Nodule diameters ranged from 2 mm-10 mm (mean: 5 mm). The distance of lung lesions from the nearest pleural surfaces ranged within 5 mm-24 mm (mean: 12.5 mm). All resections of lesions guided by the inserted hook wires were successfully performed by VATS (100% success rate). The mean procedure time for the CT-guided hook wire localization was 8.4 min (range: 4 min-18 min). The mean procedure time for VATS was 32 min (range: 14 min-98 min). The median hospital time was 8 d (range: 5 d-14 d). Results of pathological examination revealed 28 primary lung cancers, 9 atypical adenomatous hyperplasia, and 4 nonspecific chronic inflammations. No major complication related to the intraoperative hook wire localization and VATS was noted. CONCLUSIONS Intraoperative CT-guided hook wire localization is useful, particularly in small GGO localization in VATS wedge resection and has a significantly low rate of minor complications. Lung GGOs carry a 90% risk of malignancy. Aggressive surgical resection of these GGOs is necessary and feasible through the guidance of intraoperative CT localization technique.
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Affiliation(s)
- Xiangyang Chu
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Xiaobin Hou
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Lianbin Zhang
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Zhiqiang Xue
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Zhipeng Ren
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Jiaxin Wen
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Yi Liu
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Kefeng Ma
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
| | - Yu'e Sun
- Department of Thoracic Surgery, PLA General Hospital, Beijing 100853, China
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Malkan AD, Loh AH, Fernandez-Pineda I, Sandoval JA. The Role of Thoracoscopic Surgery in Pediatric Oncology. J Laparoendosc Adv Surg Tech A 2014; 24:819-26. [DOI: 10.1089/lap.2014.0252] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alpin D. Malkan
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Amos H.P. Loh
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - John A. Sandoval
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
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20
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Wire 'missing': a rare presentation of preoperative localization wire system dislocation. J Cardiothorac Surg 2014; 9:162. [PMID: 25267454 PMCID: PMC4189601 DOI: 10.1186/s13019-014-0162-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 09/25/2014] [Indexed: 11/10/2022] Open
Abstract
A full account is presented of a 53-year-old Chinese woman with a small subpleura nodule in the right upper lobe, which was successfully localized by a Dualok-wire system under computed tomography guidance preoperatively. However, during operation, the hook wire was 'missing', neither in the thorax, nor in the lung. With the help of bed-side chest film, the missing wire, which was twisted in the patient's chest wall, was localized and removed through another small incision. Posterior segmentectomy was administered, and the pulmonary lesion was pathologically diagnosed as atypical alveolar hyperplasia.
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21
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Lung tattooing combined with immediate video-assisted thoracoscopic resection (IVATR) as a single procedure in a hybrid room: our institutional experience in a pediatric population. Pediatr Radiol 2013; 43:1144-51. [PMID: 23525747 DOI: 10.1007/s00247-013-2665-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/06/2013] [Accepted: 02/12/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Analysis of small pulmonary nodules in children poses an important diagnostic and therapeutic challenge for clinicians. OBJECTIVE To review our experience of lung tattooing with immediate video-assisted thoracoscopic resection (IVATR) performed as a single procedure in a hybrid room for technical difficulties, complications and diagnostic yield of the procedure. MATERIAL AND METHODS Retrospective analysis of 31 children (16 boys, 15 girls) who underwent lung tattooing of various lesions from January 2001 to July 2011. Data were collected from the Interventional Radiology database, Electronic Patient Chart (EPC) and PACS. RESULTS A total of 34 lesions were treated in 31 children. Tattooing was performed on lung lesions with median size 3 mm and median depth 2 mm from pleura. Technical success was 91.1% and diagnostic yield was 100%. In seven children, it was combined with other interventional radiologic procedures. The median procedure time for lung tattooing and IVATR was 197 min. CONCLUSION Lung tattooing with IVATR as a single procedure in a hybrid room is safe and effective in children with several inherent advantages, including avoiding the need to move the child from the interventional radiology suite to the operating room.
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Parida L, Fernandez-Pineda I, Uffman J, Davidoff AM, Gold R, Rao BN. Thoracoscopic resection of computed tomography-localized lung nodules in children. J Pediatr Surg 2013; 48:750-6. [PMID: 23583129 PMCID: PMC4841244 DOI: 10.1016/j.jpedsurg.2012.09.051] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/05/2012] [Accepted: 09/27/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE Detection and treatment of small lung nodules are important in managing pediatric cancer. We studied the effectiveness of preoperative localization of pulmonary nodules by CT-guided needle hook wire placement followed by thoracoscopic resection in children with cancer. METHODS We reviewed records of patients who underwent thoracoscopic resection of lung nodules localized preoperatively with CT-guided needle and hook wire placement at our hospital between March 1999 and April 2010 for nodule characteristics and outcomes of procedure. RESULTS Thirty-seven patients (median age, 14years) with osteosarcoma or other cancers underwent thoracoscopic resection of needle-localized lung nodules. Lesion (median nodule size, 4mm) location was left lung (n=11), right lung (n=19), and bilateral (n=7). The procedure was successful in 36 (97.3%) patients. Five patients had a pneumothorax after localization but none required chest tube placement before thoracoscopy. All patients underwent thoracoscopy, but 4 required conversion to open thoracotomy. During thoracoscopic inspection, the hook wire slipped out of the lesion in 6 patients, of whom 1 needed thoracotomy to locate nodule. Lesions (malignant in 13 patients) were removed in all patients. Five patients with benign lesions had recurrent malignant lung nodules. CONCLUSIONS Thoracoscopic resection of preoperatively localized small lung nodules is a safe and effective procedure in children.
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Affiliation(s)
- Lalit Parida
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - John Uffman
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, USA,Department of Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, USA,Department of Surgery, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Robert Gold
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA,Department of Radiology, University of Tennessee College of Medicine, Memphis, TN, USA
| | - Bhaskar N. Rao
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN, USA,Corresponding author. Department of Surgery, MS 133, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105-3678, USA. Tel.: +1 901 595 4060; fax: +1 901 595 2207. (B.N. Rao)
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Thoracoscopic localization of intraparenchymal pulmonary nodules using direct intracavitary thoracoscopic ultrasonography prevents conversion of VATS procedures to thoracotomy in selected patients. J Thorac Cardiovasc Surg 2012; 144:1160-5. [DOI: 10.1016/j.jtcvs.2012.08.034] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2012] [Revised: 07/31/2012] [Accepted: 08/14/2012] [Indexed: 11/24/2022]
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Fernandez-Pineda I, Daw NC, McCarville B, Emanus LJ, Rao BN, Davidoff AM, Shochat SJ. Patients with osteosarcoma with a single pulmonary nodule on computed tomography: a single-institution experience. J Pediatr Surg 2012; 47:1250-4. [PMID: 22703801 PMCID: PMC3539282 DOI: 10.1016/j.jpedsurg.2012.03.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 03/06/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study is to determine if patients with osteosarcoma (OS) with metachronous metastatic pulmonary disease presenting with a single pulmonary nodule (SPN) on computed tomography (CT) were found to have other lesions at the time of thoracotomy. METHODS Data were collected retrospectively on consecutive patients with OS treated at our institution from 1982 to 2007. Patients with no evidence of disease at the end of initial therapy who subsequently relapsed in the lung were identified. RESULTS In our study, 16 (8%) of 198 patients with OS with metachronous metastatic pulmonary disease presented with a SPN on CT scan. In all patients, only 1 metastatic nodule for OS was found at the time of thoracotomy. The median time between diagnosis and first lung relapse was 23.8 months (range, 4-80 months). Eleven patients (68.7%) subsequently had a second lung relapse, but only 3 patients had involvement of the ipsilateral lung (mean time interval between first and second pulmonary relapses of 17 months; range, 2-44 months). Five-year overall survival from diagnosis was 56.2%. Seven patients (43.8%) died of disease progression. CONCLUSIONS In our experience, patients with OS with metachronous metastatic pulmonary disease presenting with a SPN on CT were not found to have additional malignant lesions at the time of thoracotomy. Consideration should be given in this group of selected patients to use a minimally invasive approach to nodule removal with image-guided localization, if needed, rather than open thoracotomy because ipsilateral metastases are not likely to be found.
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Affiliation(s)
- Israel Fernandez-Pineda
- Department of Surgery, St Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678
| | - Najat C. Daw
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Beth McCarville
- Department of Radiological Sciences, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Liza J. Emanus
- Department of Surgery, St Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678
| | - Bhaskar N. Rao
- Department of Surgery, St Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678
| | - Andrew M. Davidoff
- Department of Surgery, St Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678
| | - Stephen J. Shochat
- Department of Surgery, St Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678,Corresponding author: (S.J. Shochat)
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25
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Heran MKS, Sangha BS, Mayo JR, Blair G, Skarsgard ED. Lung nodules in children: video-assisted thoracoscopic surgical resection after computed tomography-guided localization using a microcoil. J Pediatr Surg 2011; 46:1292-7. [PMID: 21683242 DOI: 10.1016/j.jpedsurg.2011.02.043] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 02/05/2011] [Accepted: 02/09/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lung nodules that develop in children with cancer may represent metastatic disease or other conditions potentially requiring aggressive treatment. Thoracoscopic methods have been used for nodule resection; however, lesions deep in the lung parenchyma can be difficult to visualize. Fluoroscopic-guided thoracoscopic surgical resection after computed tomography (CT)-guided localization using microcoils has been described in the adult literature and has the potential to assist in the resection of deep pulmonary nodules in children. METHODS Six patients (ages 6-15 years) with an undiagnosed pulmonary nodule were treated using a combined CT-guided microcoil localization/fluoroscopic video-assisted thoracoscopic surgical technique. Preoperatively, a platinum-fibered microcoil was deployed with the deep end of the coil placed either through or in the vicinity of the pulmonary nodule and the superficial end coiled on the pleural surface. The nodule and coil were then resected with endoscopic staplers guided by fluoroscopy and video-assisted thoracoscopic surgical. RESULTS Computed tomography-guided microcoil localization and fluoroscopic-guided thoracoscopic resection were successful and critically influenced the management of all patients. Three patients were diagnosed with malignancy (2 metastatic diseases and 1 Hodgkin disease). A diagnosis of nonmalignant disease was made in 3 patients (granuloma, eosinophilic granuloma, and aspergilloma). CONCLUSION In the pediatric population, we have successfully applied a previously described adult technique using CT-localized microcoils to direct fluoroscopic-guided thoracoscopic surgical resection of pulmonary nodules.
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Affiliation(s)
- Manraj K S Heran
- Department of Radiology, University of British Columbia, Vancouver V6H 3V4, Canada.
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Roebuck DJ, Hogan MJ, Connolly B, McLaren CA. Interventions in the Chest in Children. Tech Vasc Interv Radiol 2011; 14:8-15. [DOI: 10.1053/j.tvir.2010.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Gow KW, Chen MK, Barnhart D, Breuer C, Brown M, Calkins C, Ford H, Harmon C, Hebra A, Kane T, Keshen T, Kokoska ER, Lawlor D, Pearl R. American Pediatric Surgical Association New Technology Committee review on video-assisted thoracoscopic surgery for childhood cancer. J Pediatr Surg 2010; 45:2227-33. [PMID: 21034949 DOI: 10.1016/j.jpedsurg.2010.06.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 06/30/2010] [Accepted: 06/30/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE Although the use of minimally invasive surgical (MIS) techniques for children with cancer is being practiced by some, its role remains unclearly defined. The purpose of this review was to describe the current literature on MIS for thoracic and mediastinal lesions in children. METHODS We performed a literature search for English studies that evaluated MIS techniques for biopsy or resection in children with suspected or established cancer. Only studies with greater than 20 patients were included in the review. RESULTS Ten studies were included for review. Each represented institutional retrospective reviews of experience. Seven were single-institution studies, and 3 were multi-institutional. There were no prospective nor randomized identified. CONCLUSIONS Based on primarily retrospective and observational data, the use of MIS for children with cancer who have pulmonary and mediastinal lesions seems to be effective and safe. Ideally, prospective studies are needed to evaluate this further.
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Affiliation(s)
- Kenneth W Gow
- General and Thoracic Surgery, Seattle Children's Hospital, and University of Washington, Seattle WA, USA
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Gamba P, Midrio P, Betalli P, Snijders D, Leon FF. Video-assisted thoracoscopy in compromised pediatric patients. J Laparoendosc Adv Surg Tech A 2010; 20:69-71. [PMID: 19811063 DOI: 10.1089/lap.2009.0040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The use of video-assisted techniques (VATs) in the paediatric field has become increasingly more frequent, based on reports of prompter recovery following VATs in respect to standard techniques. Specific advantages have been documented, in particular for pediatric patients undergoing chemioradiotherapic treatment. We retrospectively reviewed data of severely compromised patients who underwent VAT for lung wedge resections and biopsies carried out in our center over a 7-year period. As far as the area of therapeutic tumor resection is concerned, the present data are consistent with the view that thoracoscopy is both an effective and safe tool in diagnostic procedures.
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Affiliation(s)
- Piergiorgio Gamba
- Pediatric Surgery, Department of Pediatrics, University of Padua, Padova, Italy.
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30
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Federici S, Ratta A, Mordenti M, Domenichelli V, Pelusi G, Italiano F, Cavagna E, Biagi LD. Successful Thoracoscopic Resection of Pulmonary Metastasis Less Than 1 cm in Size Utilizing Preoperative CT-Guided Wire Localization. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S171-3. [DOI: 10.1089/lap.2008.0162.supp] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Silvana Federici
- Department of Pediatric Surgery, Infermi Hospital, Rimini, Italy
| | - Alberto Ratta
- Department of Pediatric Surgery, Infermi Hospital, Rimini, Italy
| | | | | | - Gabriella Pelusi
- Department of Pediatric Surgery, Infermi Hospital, Rimini, Italy
| | | | - Enrico Cavagna
- Department of Radiology, Infermi Hospital, Rimini, Italy
| | - Lorenzo De Biagi
- Department of Pediatric Surgery, Infermi Hospital, Rimini, Italy
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Federici S, Ratta A, Mordenti M, Domenichell V, Pelusi G, Italiano F, Cavagna E, De Biagi L. Successful thoracoscopic resection of pulmonary metastasis less than 1 cm in size utilizing preoperative CT-guided wire localization. J Laparoendosc Adv Surg Tech A 2008. [PMID: 19061363 DOI: 10.1089/lap.2008.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Preoperative computer tomography (CT) guidance localization utilizing a percutaneous guidewire before thoracoscopic resection is safe and beneficial in children with pulmonary nodules less than 1 cm in size or located deep in the pleural surface. This paper describes a successful thoracoscopic resection of a little subpleural pulmonary metastasis of a Wilm's tumor in a 5-year-old child utilizing preoperative CT-guided wire localization of the lesion. The thoracoscopic procedure was performed with the use of two ports, the nodule was easily localized,and the pulmonary wedge resection was made by the use of an endo-GIA linear stapling device after guidewire removal. The operating time was 45 minutes and the chest tube was removed after 48 hours. The postoperative course was uneventful, and the child was discharged on postoperative day 5. This technique allows the surgeon to resect little pulmonary nodules, avoiding the need of more invasive procedures as standard thoracotomy without adjunctive morbidity and with good cosmetic results.
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Affiliation(s)
- Silvana Federici
- Departments of Pediatric Surgery, Infermi Hospital, Rimini, Italy
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Gow KW, Saad DF, Koontz C, Wulkan ML. Minimally invasive thoracoscopic ultrasound for localization of pulmonary nodules in children. J Pediatr Surg 2008; 43:2315-22. [PMID: 19040964 DOI: 10.1016/j.jpedsurg.2008.08.031] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 08/20/2008] [Accepted: 08/25/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE Children with cancer may develop lesions in the lung that may represent metastatic disease. Thoracotomy is considered the standard approach for resection of pulmonary nodules. Recently, thoracoscopic techniques have been applied in these situations. However, nodules that are deep in the lung parenchyma may not be visible. A technique has been developed whereby minimally invasive thoracoscopic ultrasound (MITUS) may be used to guide resection of deep pulmonary nodules. METHODS We conducted a retrospective review of children undergoing MITUS at our institution. Only patients with single isolated lesions were chosen to have this diagnostic procedure performed. Patients undergo single lung ventilation. Two 5-mm ports are inserted, one for the grasper and the other for the camera. One 12-mm port is inserted for the flexible 10-mm ultrasound probe and the endoscopic stapler. The patient has CO(2) insufflation to create a 5-mm Hg pneumothorax. Twenty mL/kg of normal saline is introduced into the chest cavity for acoustic coupling. The ultrasound probe is used to isolate the nodule(s), guide resection, and check margins. The specimen is removed and placed in a removable specimen bag to reduce the chance of port site recurrence. After the lung has been inspected, irrigation is removed, and a chest tube inserted. RESULTS Eight procedures were performed on 7 patients (5 males, 2 females) with a median age of 15.2 years (range, 4-18 years). Patients had primary diagnoses of osteosarcoma (n = 4), Wilms' (n = 2), and lymphoma (n = 1). The median size of the lesions that were being isolated was 0.6 cm (range, 0.3-2.9 cm). None of the nodules removed were visible on the surface of the lung. Of the 8 procedures, 7 led to the removal of a pulmonary nodule. Of the 7 nodules isolated, 5 were removed thoracoscopically, with two requiring minithoracotomy because of anatomical limitations. The histologic evaluation on these specimens included osteosarcoma (n = 4), abscesses (n = 2), fibrosis (n = 1), and lymph node (n = 1). The median hospitalization was 2.5 days (range, 2-39 days). One patient had a prolonged hospitalization because of air leak and sepsis. CONCLUSION Minimally invasive thoracoscopic ultrasound is a real time imaging tool that helps isolate small pulmonary lesions that may otherwise be difficult to see intraoperatively. We would advocate this technique for those patients having video-assisted thoracoscopy to assist clarifying whether focal lesions are malignant, thereby guiding therapy.
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Affiliation(s)
- Kenneth W Gow
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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Thoracoscopic assessment of mediastinal tuberculous lymphadenitis in a 4-month-old child. Surg Laparosc Endosc Percutan Tech 2008; 18:322-4. [PMID: 18574429 DOI: 10.1097/sle.0b013e31816f777f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Isolated mediastinal tuberculous lymphadenitis is a relatively common entity in children, second in frequency after cervical localization. In the absence of an accompanying parenchymal lesion, mediastinal tuberculous lymphadenitis may pose a diagnostic dilemma on admission and must be distinguished from other causes of mediastinal masses. Bronchoscopy is suggested as a diagnostic tool where tuberculosis cannot be excluded by radiology or specific skin tests. Thoracotomy and excision is reported as necessary to treat the obstructive symptoms. In this report, the diagnostic and therapeutic feasibility of thoracoscopic mediastinal node biopsy in a 4-month-old presenting mediastinal tuberculous lymphadenitis is reported.
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Pursnani SK, Rausen AR, Contractor S, Nadler EP. Combined use of preoperative methylene blue dye and microcoil localization facilitates thoracoscopic wedge resection of indeterminate pulmonary nodules in children. J Laparoendosc Adv Surg Tech A 2006; 16:184-7. [PMID: 16646714 DOI: 10.1089/lap.2006.16.184] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The ability to biopsy indeterminate pulmonary lesions in children has evolved with advances in minimal access surgery. Recent advances in preoperative localization including image-guided dye injection or wire implantation have expanded the types of lesions that are accessible via minimal access surgery. We present a case of a 13-year-old boy who underwent preoperative localization using both methylene blue dye and microcoil labeling, and a subsequent thoracoscopic pulmonary wedge resection under the same anesthesia. The combined use of both dye and microcoil localization provides the advantage of superior intraoperative visualization of the lesion and the ability to use fluoroscopy to confirm the presence of the nodule in the surgical specimen. We recommend this technique for the biopsy of indeterminate pulmonary lesions that would not otherwise be accessible via a minimally invasive approach.
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Affiliation(s)
- Seema K Pursnani
- Division of Pediatric Surgery and Department of Surgery, New York University School of Medicine, New York, New York 10016, USA
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Stiles BM, Altes TA, Jones DR, Shen KR, Ailawadi G, Gay SB, Olazagasti J, Rehm PK, Daniel TM. Clinical experience with radiotracer-guided thoracoscopic biopsy of small, indeterminate lung nodules. Ann Thorac Surg 2006; 82:1191-6; discussion 1196-7. [PMID: 16996906 DOI: 10.1016/j.athoracsur.2006.04.059] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 04/19/2006] [Accepted: 04/20/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although computed tomography lung-screening programs report a 31% to 51% incidence of subcentimeter pulmonary nodules, 85% are too small to biopsy or interrogate with positron emission spectroscopy scans. We developed a technique using transthoracic percutaneous radiotracer injection with thoracoscopic radioprobe localization and excision for small pulmonary nodules. This report describes our series of the first 46 patients evaluated with this technique. METHODS Forty-six patients (79% smokers; 52% males; median age, 64 years) were evaluated. Patient selection was based on the surgeon's anticipated difficulty in thoracoscopically locating small nodules because of lesion size or location. Computed tomographic-guided injection of radiotracer solution was made into or adjacent to the nodule the day of surgery. Intraoperative gamma probe localization, followed by thoracoscopic excision of the lesion, was subsequently performed. RESULTS Median nodule size was 9 mm (range, 3 to 22 mm), and median depth was 5 mm (range, 0 to 50 mm). Forty-four (96%) of the lesions were successfully localized and excised. Median time from injection to surgery was 270 minutes. Failures were the result of inadvertent pleural or chest wall radiotracer placement. Forty-six percent (21 of 46) of the lesions were malignant, of which 71% (15 of 21) were primary lung cancers. Patients with lung cancer underwent lobectomy or segmentectomy. Fourteen of 15 were stage IA, whereas 1 was stage IIIB (6 mm primary with 4 mm intralobar metastasis). Complications were three pneumothoraces at the time of radiotracer injection. CONCLUSIONS Computed tomography-guided radiotracer localization of small pulmonary nodules combined with thoracoscopic excisional biopsy is feasible and safe. This technique successfully localized and excised the nodule in 96% of cases.
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Affiliation(s)
- Brendon M Stiles
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-0679, USA
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Abstract
This article describes the historical development of pediatric pulmonary metastasectomy but demonstrates that progress has been slow in understanding its proper applications. Because many pediatric metastatic tumors are rare, surgeons have grouped together patients of different histologies for the generation and analysis of case series. By examining tumor types individually, however, it is seen that certain histologies (adrenocortical carcinoma, alveolar soft part sarcoma, osteosarcoma) mandate surgical metastasectomy for patient survival. Other pediatric tumors (Wilms tumor, Ewing's sarcoma) are radiation sensitive, and the application of metastasectomy is controversial. In the case of still other types of tumor (neuroblastoma, differentiated thyroid cancer, rhabdomyosarcoma), metastasectomy is seldom performed except in highly unusual situations. Techniques for minimally invasive biopsy and for muscle-sparing thoracotomy are described for pediatric patients.
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Affiliation(s)
- Mark L Kayton
- Division of Pediatric Surgery, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Eichfeld U, Dietrich A, Ott R, Kloeppel R. Video-assisted thoracoscopic surgery for pulmonary nodules after computed tomography-guided marking with a spiral wire. Ann Thorac Surg 2005; 79:313-6; discussion 316-7. [PMID: 15620965 DOI: 10.1016/j.athoracsur.2003.10.122] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2003] [Indexed: 10/26/2022]
Abstract
PURPOSE Peripheral pulmonary nodules are preferably removed by minimally invasive techniques, such as video-assisted thoracoscopic (VATS) surgery. These nodules should be marked preoperatively for better intraoperative detection and removal. DESCRIPTION Twenty-two cases with a single pulmonary nodule requiring surgical removal for histologic examination were included in a prospective study. Guided by computed tomography, nodules were marked preoperatively using a laser marker system and fixed with a spiral wire. The marked nodules were removed by VATS surgery immediately after the marking. EVALUATION The marking wire was placed in all 22 patients without any complications. The marked nodule was completely removed by VATS surgery in 19 patients. Conversion to thoracotomy was necessary in 3 patients, twice because of thoracoscopy-related problems and once because of a marking failure. The average times for the marking procedure and operation were 24 minutes and 32 minutes, respectively. CONCLUSIONS This new method of computed tomography-guided nodule marking with a spiral wire and subsequent VATS surgery is very efficient in terms of localization and stable fixation of subpleural pulmonary nodules.
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Affiliation(s)
- Uwe Eichfeld
- Clinic for Abdominal, Transplant, Vascular and Thoracic Surgery, Leipzig University, Leipzig, Germany.
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Cahill AM, Baskin KM, Kaye RD, Fitz CR, Towbin RB. CT-guided Percutaneous Lung Biopsy in Children. J Vasc Interv Radiol 2004; 15:955-60. [PMID: 15361563 DOI: 10.1097/01.rvi.0000130814.63277.f2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To describe techniques and evaluate outcomes of computed tomography (CT)-guided percutaneous lung biopsy in children. MATERIALS AND METHODS Between April 1992 and June 2003, 64 patients (32 male, 32 female) with a mean age of 10.8 years (0.6-20 years) were referred for 75 lung biopsies. Most biopsies were performed for suspected malignancy (n = 24; 32%) or to distinguish posttransplantation lymphoproliferative disorder from fungal infection in immunocompromised patients (n = 17; 23%). All children referred to the pediatric interventionalists in two children's hospitals for CT-guided biopsy of parenchymal or pleural-based lesions in the thorax were studied. Prospectively gathered procedural data were reviewed for medical history and indications for procedure, admission status, type of anesthesia, technical approach (core vs aspiration biopsy), procedural modifications, lesion size, number of passes required, and immediate complications. Medical records were retrospectively reviewed for diagnostic outcome, impact on patient management, and delayed complications. RESULTS Procedures were performed under deep sedation whenever possible (n = 61; 81%) with use of a coaxial core biopsy technique (n = 56; 75%), a fine needle aspiration biopsy technique (n = 15; 20%), or both (n = 4; 5%). Mean lesion diameters were 2.5 cm (range, 1-10 cm) in the core biopsy group and 1.0 cm (range, 0.5-1.7 cm) in the aspiration biopsy group. Sixty-four biopsies (85%) were diagnostic. There was one major complication (1.3%), a tension pneumothorax treated with intraprocedural placement of a chest tube. CONCLUSION Percutaneous CT-guided lung biopsy is a safe and accurate diagnostic procedure in children that obviates open surgical biopsy in most patients.
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Affiliation(s)
- Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Daniel TM, Altes TA, Rehm PK, Williams MB, Jones DR, Stolin AV, Gay SB. A novel technique for localization and excisional biopsy of small or Ill-defined pulmonary lesions. Ann Thorac Surg 2004; 77:1756-62; discussion 1762. [PMID: 15111180 DOI: 10.1016/j.athoracsur.2003.10.099] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2003] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this study was to develop and evaluate radiotracer-guided localization of small or ill-defined pulmonary nodules for thoracoscopic excisional biopsy. METHODS This study consisted of two parts: a laboratory study in rats to determine the most suitable radiotracer, and a pilot study in humans to determine the feasibility of radiotracer lung nodule localization. The right lung of 12 rats was injected with a technetium 99m (Tc 99m) based radiotracer solution: 4 each with macroaggregated albumin (MAA), unfiltered sulfur colloid (SC), and pertechnetate (TcO(4)). Serial imaging was performed using a small animal gamma camera for 4 hours following injection. In 13 patients, computed tomographic (CT) guided injection of Tc 99m MAA solution was made into or adjacent to a pulmonary nodule suspicious for primary lung cancer. Gamma probe localization of the nodule was performed during subsequent thoracoscopic surgery. RESULTS In the animal model, MAA provided more precise localization than SC or TcO(4) and was selected for the human study. In the human series, all 13 patients had successful gamma probe localization of their lesion. There were no radiologic or surgical complications. Seven of 13 nodules were malignant, and five of these nodules were stage IA primary lung carcinomas. CONCLUSIONS Computed tomographic-guided radiotracer localization of small or ill-defined pulmonary nodules using Tc 99 m MAA before thoracoscopic excisional biopsy is feasible and may make excisional biopsy the preferred management strategy for the management of small pulmonary nodules in patients at high risk for malignancy.
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Affiliation(s)
- Thomas M Daniel
- Department of Surgery, University of Virginia Health System, Charlottesville, 22908-0679, USA.
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