A new protocol for concomitant needle aspiration biopsy and localization of solitary pulmonary nodules

Easy Intra-Operative Localization of Pulmonary Nodules during Uniportal Video-Assisted Thoracoscopy: Experience with Hydrogel Plugs at Our Institution

Background: The diffusion of lung cancer screening programs has increased the detection of both solid and ground-glass opacity (GGO) sub-centimetric lesions, leading to the necessity for histological diagnoses. A percutaneous CT-guided biopsy may be challenging, thus making surgical excision a valid diagnostic alternative. CT-guided hydrogel plug deployment (BioSentry^®) was recently proposed to simplify intraoperative nodule localization. Here, we report our initial experience. Methods: We evaluated 62 patients with single, small, peripheral, non-subpleural pulmonary GGO that was suspicious for cancer. All lesions were preoperatively marked, using CT-guidance, with a hydrogel plug (BioSentry^®). Then, a uniportal video-assisted thoracoscopy (uniVATS) wedge resection was performed. If cancer was confirmed at the frozen section, a major lung resection was then performed. The study’s end points were the rates of intraoperative localization and of successful resection. Results: The hydrogel plug was correctly placed in 54 of the 62 cases, leading to an effective resection of the target lesion. In the remaining eight cases, the plug was displaced, and so the identification of pleural erosions due to the previous percutaneous procedure guided the resection. The uniVATS resection success rate was 98.3%. Conclusions: CT-guided hydrogel plug placement allowed for the successful detection of lung GGOs and resection with the uniVATS approach. This device allowed us to obtain lung cancer diagnoses and successfully treat 85.4% of cases.

Dynamic contrast-enhanced CT compared with positron emission tomography CT to characterise solitary pulmonary nodules: the SPUtNIk diagnostic accuracy study and economic modelling

BACKGROUND

Current pathways recommend positron emission tomography-computerised tomography for the characterisation of solitary pulmonary nodules. Dynamic contrast-enhanced computerised tomography may be a more cost-effective approach.

OBJECTIVES

To determine the diagnostic performances of dynamic contrast-enhanced computerised tomography and positron emission tomography-computerised tomography in the NHS for solitary pulmonary nodules. Systematic reviews and a health economic evaluation contributed to the decision-analytic modelling to assess the likely costs and health outcomes resulting from incorporation of dynamic contrast-enhanced computerised tomography into management strategies.

DESIGN

Multicentre comparative accuracy trial.

SETTING

Secondary or tertiary outpatient settings at 16 hospitals in the UK.

PARTICIPANTS

Participants with solitary pulmonary nodules of ≥ 8 mm and of ≤ 30 mm in size with no malignancy in the previous 2 years were included.

INTERVENTIONS

Baseline positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography with 2 years' follow-up.

MAIN OUTCOME MEASURES

Primary outcome measures were sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computerised tomography. Incremental cost-effectiveness ratios compared management strategies that used dynamic contrast-enhanced computerised tomography with management strategies that did not use dynamic contrast-enhanced computerised tomography.

RESULTS

A total of 380 patients were recruited (median age 69 years). Of 312 patients with matched dynamic contrast-enhanced computer tomography and positron emission tomography-computerised tomography examinations, 191 (61%) were cancer patients. The sensitivity, specificity and diagnostic accuracy for positron emission tomography-computerised tomography and dynamic contrast-enhanced computer tomography were 72.8% (95% confidence interval 66.1% to 78.6%), 81.8% (95% confidence interval 74.0% to 87.7%), 76.3% (95% confidence interval 71.3% to 80.7%) and 95.3% (95% confidence interval 91.3% to 97.5%), 29.8% (95% confidence interval 22.3% to 38.4%) and 69.9% (95% confidence interval 64.6% to 74.7%), respectively. Exploratory modelling showed that maximum standardised uptake values had the best diagnostic accuracy, with an area under the curve of 0.87, which increased to 0.90 if combined with dynamic contrast-enhanced computerised tomography peak enhancement. The economic analysis showed that, over 24 months, dynamic contrast-enhanced computerised tomography was less costly (£3305, 95% confidence interval £2952 to £3746) than positron emission tomography-computerised tomography (£4013, 95% confidence interval £3673 to £4498) or a strategy combining the two tests (£4058, 95% confidence interval £3702 to £4547). Positron emission tomography-computerised tomography led to more patients with malignant nodules being correctly managed, 0.44 on average (95% confidence interval 0.39 to 0.49), compared with 0.40 (95% confidence interval 0.35 to 0.45); using both tests further increased this (0.47, 95% confidence interval 0.42 to 0.51).

LIMITATIONS

The high prevalence of malignancy in nodules observed in this trial, compared with that observed in nodules identified within screening programmes, limits the generalisation of the current results to nodules identified by screening.

CONCLUSIONS

Findings from this research indicate that positron emission tomography-computerised tomography is more accurate than dynamic contrast-enhanced computerised tomography for the characterisation of solitary pulmonary nodules. A combination of maximum standardised uptake value and peak enhancement had the highest accuracy with a small increase in costs. Findings from this research also indicate that a combined positron emission tomography-dynamic contrast-enhanced computerised tomography approach with a slightly higher willingness to pay to avoid missing small cancers or to avoid a 'watch and wait' policy may be an approach to consider.

FUTURE WORK

Integration of the dynamic contrast-enhanced component into the positron emission tomography-computerised tomography examination and the feasibility of dynamic contrast-enhanced computerised tomography at lung screening for the characterisation of solitary pulmonary nodules should be explored, together with a lower radiation dose protocol.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018112215 and CRD42019124299, and the trial is registered as ISRCTN30784948 and ClinicalTrials.gov NCT02013063.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 17. See the NIHR Journals Library website for further project information.

Image-guided video-assisted thoracoscopic resection (iVATS): Translation to clinical practice-real-world experience

OBJECTIVE

We developed a novel approach for localization and resection of lung nodules, using image-guided video-assisted thoracoscopic surgery (iVATS). We report our experience of translating iVATS into clinical care.

METHODS

Methodology and workflow for iVATS developed as part of the Phase I/II trial were used to train surgeons, radiologists, anesthesiologists, and radiology technologists. Radiation dose, time from induction to incision, placement of T-bar to incision and incision to closure, hospital stay, and complication rates were recorded.

RESULTS

Fifty patients underwent iVATS for resection of 54 nodules in a clinical hybrid operating room (OR) by six surgeons. Fifty-two (97%) nodules were successfully resected. Forty-two (84%) patients underwent wedge resection, four (7%) lobectomies, and two (4%) segmentectomy all with lymph node dissection. Median time from induction to incision was 89 minutes (range: 13-256 minutes); T-bar placement was 14 minutes (10-29 minutes); and incision to closure, 107 minutes (41-302 minutes). Average and total procedure radiation dose were: median = 6 mSieverts (range: 2.9-35 mSieverts). No deaths were reported and median length of stay was 3 days (range: 1-12 days).

CONCLUSIONS

Translation of iVATS into clinical practice has been initiated using a safe step-wise process, combining intraoperative C-arm computed tomography scanning and thoracoscopic surgery in a hybrid OR.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Computed tomography-guided preoperative localization of small lung nodules with indocyanine green

Background Small, deep-seated lung nodules and sub-solid nodules are often difficult to locate without marking. Purpose To evaluate the success and complication rates associated with the use of indocyanine green (ICG) to localize pulmonary nodules before resection. Material and Methods This retrospective study was approved by our institutional review board. Informed consent for performing preoperative localization using ICG marking was obtained from all patients. Thirty-seven patients (14 men, 23 women; mean age = 63.1 years; age range = 10-82 years) with small peripheral pulmonary nodules underwent computed tomography (CT)-guided ICG marking immediately before surgery between March 2007 and June 2016. The procedural details and complication rates associated with ICG marking are described. Results The average nodule size and depth were 9.1 mm (range = 2-22 mm) and 9.9 mm (range = 0-33 mm), respectively. Marking was detected at the pleural surface in 35 patients (95%). Three cases of mild pneumothorax (8%), five cases of cough (14%), and one case of mild bloody sputum (3%) with no clinical significance were noted. There were no severe complications. The average duration required to perform the marking was 19.4 min (range = 12-41 min). Conclusion Our results indicate that CT-guided ICG marking is safe and useful for detecting the location of small pulmonary nodules preoperatively.

Computed Tomography-Assisted Thoracoscopic Surgery: A Novel, Innovative Approach in Patients With Deep Intrapulmonary Lesions of Unknown Malignant Status

OBJECTIVES

Minimally invasive resection of small, deep intrapulmonary lesions can be challenging due to the difficulty of localizing them during video-assisted thoracoscopic surgery (VATS). We report our preliminary results evaluating the feasibility of an image-guided, minimally invasive, 1-stop-shop approach for the resection of small, deep intrapulmonary lesions in a hybrid operating room (OR).

MATERIALS AND METHODS

Fifteen patients (5 men, 10 women; mean age, 63 years) with a total of 16 solitary, deep intrapulmonary nodules of unknown malignant status were identified for intraoperative wire marking. Patients were placed on the operating table for resection by VATS. A marking wire was placed within the lesion under 3D laser and fluoroscopic guidance using a cone beam computed tomography system. Then, wedge resection by VATS was performed in the same setting without repositioning the patient.

RESULTS

Complete resection with adequate safety margins was confirmed for all lesions. Marking wire placement facilitated resection in 15 of 16 lesions. Eleven lesions proved to be malignant, either primary or secondary; 5 were benign. Mean lesion size was 7.7 mm; mean distance to the pleural surface was 15.1 mm (mean lesion depth-diameter ratio, 2.2). Mean procedural time for marking wire placement was 35 minutes; mean VATS duration was 36 minutes.

CONCLUSIONS

Computed tomography-assisted thoracoscopic surgery is a new, safe, and effective procedure for minimally invasive resection of small, deeply localized intrapulmonary lesions. The benefits of computed tomography-assisted thoracoscopic surgery are 1. One-stop-shop procedure, 2. Lower risk for the patient (no patient relocation, no marking wire loss), and 3. No need to coordinate scheduling between the CT room and OR.

Remedial localization after dislodgement of primary mechanical localization in lung surgery

BACKGROUND

Unhooking or displacement of hookwire or microcoil due to technical failures is rather common. We aim to establish a new technique for remedial localization in the case of displacement or unhooking of primary mechanical localization during lung surgery.

METHODS

From February 2014 to September 2015, 18 consecutive cases of intraoperative dislodgement during video-assisted thoracoscopic surgery (VATS) were enrolled. Nodule's projection on body surface was located by analyzing computed tomography (CT) images, and a needle was inserted into thoracic cavity through this point. The lung was then inflated, and a small burn was made where the needle tip touched the visceral plural. Wedge resections were subsequently performed for these impalpable small lesions.

RESULTS

Eighteen solitary pulmonary nodules (SPNs) from 18 patients were scheduled for VATS wedge resections in this series, including 6 (33.3%) hookwire localization and 12 (66.7%) microcoil localization. Fifteen (83.3%) of 18 nodules were pure ground glass opacity (pGGO) and 3 (16.7%) mixed ground glass opacity (mGGO). The mean diameter of SPNs was 7.7±3.6 mm. The mean distance from SPN to pleura was 12.2±10.9 mm. During remedial localization, 17 (94.4%) nodules were removed successfully by wedge resection, and segmentectomy was performed only in one case with failed outcome. Paraffin pathology showed 2 (11.1%) atypical adenomatous hyperplasia (AAH), 11 (61.1%) adenocarcinoma in situ (AIS), 4 (22.2%) minimally invasive adenocarcinoma (MIA), and 1 (5.6%) inflammatory disease.

CONCLUSIONS

This remedial localization technique is practical and reliable. It is a good backup plan in the case of dislodgement, and it can help prevent extended lung resection.

Transthoracic needle aspiration in solitary pulmonary nodule

With improved awareness of public health and the recent advances in various imaging technologies, the detection rate of solitary pulmonary nodules (SPN) is continuously increasing. Transthoracic needle aspiration (TTNA) has represented a major approach for the diagnosis and differential diagnosis of pulmonary masses, owing to its simplicity and minimal invasiveness. This paper demonstrates the role of TTNA in SPN.

Extra-pleuric coaxial system for CT-guided percutaneous fine-needle aspiration biopsy (FNAB) of small (≤20 mm) lung nodules: a novel technique using multiplanar reconstruction (MPR) images

The aim of the study is to present the diagnostic feasibility, usefulness, and safety of a novel technique for coaxial CT-guided fine-needle aspiration biopsy of small (≤20 mm in diameter) lung nodules. A 18-gauge (G) (1.2 × 40 mm) needle is inserted through the skin in the depth of the thoracic wall tissues remaining outside the pleura. Its positioning is planned and adjusted using multiplanar reconstruction (MPR) images along the 18-G guide needle axis tracing a reference outline extended from the needle tip to the target nodule. When the insertion of the 18-G extra-pleuric needle (EPN) proves to be precise, a 22-G Chiba needle is then passed through the outer 18-G EPN until it reaches the thoracic lesion for the sampling procedure. Patient population included 153 males and 94 females, with a mean age of 61.3 ± 21.6 years. Mean nodule diameter was 14.1 ± 2.2 mm. The lesion depth from pleural plane ranged from 0 mm to 127 mm. An average of 1.29 aspirates were performed per lesion. The most common complication was pneumothorax in 27 cases; there were no cases of PNX requiring chest tube insertion. Intrapulmonary bleeding along the needle track was observed in 32 patients. Exploiting the advantage of MPR images, our novel technique of extra-pleuric coaxial system with a 18-G EPN allows the operator to multiple samplings of small (≤20 mm) target lesions in various locations with a thinner (22-G Chiba) needle, thus reducing the degree of pleural, parenchymal, or adjacent organs damage.