Comparison of CT-guided localization using hook wire or coil before thoracoscopic surgery for ground glass nodules

Randomized comparison of the four-hook anchor device and hook-wire use for the preoperative localization of pulmonary nodules

OBJECTIVE

To compare the efficacy and safety of preoperative localization of small pulmonary nodules (SPNs) with 4-hook anchor device and hook-wire before video-assisted thoracoscopic surgery.

METHODS

Patients with SPNs scheduled for computed tomography-guided nodule localization before video-assisted thoracoscopic surgery between May 2021 and June 2021 at our center were randomized to either 4-hook anchor group or hook-wire group. The primary end point was intraoperative localization success.

RESULTS

After randomization, 28 patients with 34 SPNs were assigned to the 4-hook anchor group and 28 patients with 34 SPNs to the hook-wire group. The operative localization success rate was significantly greater in the 4-hook anchor group than in the hook-wire group (94.1% [32/34] vs 64.7% [22/34]; P = .007). All lesions in the 2 groups were successfully resected under thoracoscopy, but 4 patients in the hook-wire group who required transition from wedge resection to segmentectomy or lobectomy because of unsuccessful localization. Total localization-related complication rate was significantly lower in the 4-hook anchor group than in the hook-wire group (10.3% [3/28] vs 50.0% [14/28]; P = .004). The rate of chest pain requiring analgesia after the localization procedure was significantly lower in the 4-hook anchor group than in the hook-wire group (0 vs 5/28, 17.9%; P = .026). There were no significant differences in localization technical success rate, operative blood loss, hospital stay length and hospital cost between the 2 groups (all P > .05).

CONCLUSIONS

The use of the 4-hook anchor device for SPN localization offers advantages over the traditional hook-wire technique.

Feasibility and safety of computed tomography-guided intrapulmonary injection of indocyanine green for localization of peripheral pulmonary ground-glass nodules

Background

The early surgical intervention for pulmonary ground-glass nodules (GGNs) has become increasingly important, but accurate identification of these nodules during thoracoscopic surgery poses challenges due to the need for sublobar resections and reliance on visual and tactile perception alone. The prognosis of the procedure is closely tied to the use of precise positioning technology. Thus, it is crucial to develop an accurate positioning technology that can improve patient prognosis.

Methods

Clinical data from the cardiothoracic department of a tertiary hospital in Shanghai were collected and analyzed between January 2020 and December 2021. The patients were categorized into 2 groups: an indocyanine green (ICG) group and a hook-wire group. Outcome measures including success rate, complications, procedure time, localization-related pain, and interval time were assessed. Adverse events and reactions were reported and compared between the 2 groups.

Results

A total of 62 patients (17 males and 45 females, aged 50.5±13.2 years) were in the ICG group, while 66 patients (23 males and 43 females, aged 48.4±12.9 years) were localized in the hook-wire group. The success rate was comparable between the 2 groups. However, the ICG group showed significant advantages over the hook-wire group in terms of procedure time (22.6±4.4 vs. 24.1±4.9 min; P=0.012), localization-related pain (P<0.001), and interval time [median and interquartile range (IQR): 3 (0.7, 104.9) vs. 1.2 (0.5, 3.3) h; P<0.001]. In the ICG group, there were 11 cases of pneumothorax, 4 cases of hemothorax, and 2 cases of ICG diffusion. In the hook-wire group, there were 24 cases of pneumothorax, 25 cases of hemothorax, and 2 cases of dislodgement. The ICG group had fewer complications, including pneumothorax (P=0.018) and hemothorax (P=0.007), compared to the hook-wire group.

Conclusions

Computed tomography (CT)-guided intrapulmonary injection of ICG for preoperative localization of peripheral pulmonary GGNs is a practical and safe technique. It offers advantages in terms of reduced procedure time, localization-related pain, and interval time compared to the hook-wire method. Moreover, the ICG technique results in fewer complications, making it a valuable preoperative localization technique worthy of popularization.

Safety and effectiveness of simultaneous localization of multiple lung nodules using coils and risk factors for pneumothorax: a retrospective study

BACKGROUND

Localization of lung nodule before video-assisted thoracoscopic surgery (VATS) can help the surgeon to quickly and accurately find the lesion during surgery.

PURPOSE

To evaluate the safety and effectiveness of using coils to simultaneously locate multiple lung nodules under computed tomography guidance and to clarify the risk factors for pneumothorax.

MATERIAL AND METHODS

From January 2020 to December 2020, 61 patients underwent simultaneous localization of multiple lung nodules (Group A) and 120 patients underwent localization of a single lung nodule (Group B). The demographics, information related to localization procedure, and incidence of pulmonary hemorrhage and pneumothorax were compared between the patients in Groups A and B. Group A was further divided into a pneumothorax group and non-pneumothorax group. Univariate and multivariate regression analyses were used to determine the risk factors for pneumothorax in patients who underwent simultaneous localization of multiple lung nodules using coils.

RESULTS

The success rates in Groups A and B were 96.9% and 96.7%, respectively (P = 1.000). The number of pleural punctures (P<0.001), the positioning operation time (P<0.001), the rates of pneumothorax (P<0.001), and hemorrhage (P = 0.034) were higher in Group A than in Group B. The pneumothorax and bleeding in Group A did not require special treatment. Transfissural puncture (odds ratio [OR]=16.798; P = 0.033) and the numbers of pleural punctures (OR=2.437; P = 0.013) were independent risk factors for pneumothorax caused by simultaneous localization of multiple lung nodules, and hemorrhage was a protective factor against pneumothorax (OR=0.069; P = 0.002).

CONCLUSION

Simultaneous localization of multiple lung nodules using coils under computed tomography guidance is safe and effective. Transfissural puncture and higher numbers of pleural punctures will increase the risk of pneumothorax, whereas hemorrhage will reduce the risk of pneumothorax.

Virtual navigation bronchoscopy-guided intraoperative indocyanine green localization in simultaneous surgery for multiple pulmonary nodules

Background

Accurate localization of pulmonary nodules is the main difficulty experienced in wedge resection. Commonly used localization methods have their own advantages and disadvantages. However, clinical work has demonstrated that intraoperative indocyanine green localization under electromagnetic navigation bronchoscopy/virtual navigation bronchoscopy (VNB) is more advantageous than conventional methods for patients with multiple pulmonary nodules undergoing simultaneous surgery, especially for those undergoing bilateral lung surgery.

Methods

Data of patients undergoing simultaneous surgery for multiple pulmonary nodules with preoperative methylene blue localization by computed tomography (CT)‐guided percutaneous lung puncture (methylene blue group) or intraoperative indocyanine green localization under VNB (virtual navigation group) were retrospectively analyzed. Patient characteristics, pulmonary nodule features, localization time, preoperative location time, location success rate, operation time, complication incidence, visceral pleural staining rate after localization, and pulmonary nodule primary resection success rate were compared between the two groups.

Results

The methylene blue and virtual navigation groups comprised 39 and 20 patients with 119 and 67 pulmonary nodules resected, respectively. Sex, age, number of pulmonary nodules resected simultaneously, unilateral/bilateral lung surgery, pulmonary nodule size, distance between pulmonary nodules and the visceral pleura, pulmonary nodule consolidation‐to‐tumor ratio, location of pulmonary nodules in the pulmonary lobe, postoperative pathology, visceral pleura staining rate, primary pulmonary nodule resection success rate, and surgical duration did not differ significantly between the groups (p > 0.05). The localization time of the virtual navigation group was significantly shorter than that of the methylene blue group (p < 0.05), regardless of unilateral or bilateral multiple nodules. In the methylene blue group, 25.64% (10/39) of patients presented complications, all of which were pneumothorax, whereas no complications were found in the virtual navigation group.

Conclusions

For patients with multiple pulmonary nodules undergoing simultaneous surgery, indocyanine green injection under VNB can achieve a similar effect on pulmonary nodule localization as classical methylene blue injection under CT‐guided percutaneous lung puncture, with shorter localization time and fewer complications.

The risk factors for the failure of hook wire localization of ground glass nodules prior to thoracoscopic surgery

Objectives

To retrospectively analyse the potential influencing factors of CT-guided hook wire localization failure prior to thoracoscopic resection surgery of ground glass nodules (GGNs), and determine the main risk elements for localization failure.

Methods

In all, 372 patients were included in this study, with 21 patients showing localization failure. The related parameters of patients, GGNs, and localization were analysed through univariate and multiple logistic regression analysis to determine the risk factors of localization failure.

Results

Univariate logistic regression analysis indicated that trans-fissure (odds ratio [OR] 4.896, 95% confidence interval [CI] 1.489–13.939); trans-emphysema (OR 3.538, 95% CI 1.343–8.827); localization time (OR 0.956, 95% CI 0.898–1.019); multi-nodule localization (OR 2.597, 95% CI 1.050–6.361); and pneumothorax (OR 10.326, 95% CI 3.414–44.684) were risk factors for localization failure, and the p-values of these factors were < 0.05. However, according to the results of multivariate analysis, pneumothorax (OR 5.998, 95% CI 1.680–28.342) was an exclusive risk factor for the failure of preoperative localization of GGNs.

Conclusion

CT-guided hook wire localization of GGNs prior to thoracoscopic surgery is often known to fail; however, the incidence is low. Pneumothorax is an independent risk factor for failure in the localization process.

[Comparison of Four-hook Needle and Memory Alloy Coil in Localization of Pulmonary Nodules]

背景与目的

随着肺结节微创手术的广泛开展，术前定位变得愈发关键。传统定位方式存在一定的缺陷，定位方式的改进很有必要。本研究旨在对比分析两种新型定位方式即四钩定位针和记忆合金弹簧圈在肺结节定位中应用的安全性和有效性。

方法

回顾性分析152例患者的资料，76例为四钩定位针组，76例为记忆合金弹簧圈组，术前均行肺结节定位，后行电视胸腔镜辅助肺结节楔形切除术，统计平均定位时间、定位并发症、结节切除时间等。

结果

两组患者均成功切除目标肺结节，四钩定位针组76例患者术中均找到定位装置，肺结节全部成功切除，1例因严重胸腔粘连而中转开胸行肺结节楔形切除术。记忆合金弹簧圈组76例患者肺结节均成功切除，1例因术中切除标本后未找到病灶而行妥协性扩大切除术。两组气胸、肺内出血发生率、定位成功率、结节楔形切除时间无统计学差异。四钩定位针组平均定位时间为（13.66±3.11）min，低于记忆合金弹簧圈组的（15.51±3.65）min，二者有统计学差异（P=0.001）。记忆合金弹簧圈组当结节至胸膜距离≥1.5 cm和 < 1.5 cm时，平均定位时间分别为（17.20±4.46）min、（14.91±3.15）min，二者有统计学差异（P=0.044）。

结论

四钩定位针和记忆合金弹簧圈两种新型肺结节定位方式均有较好的安全性及有效性，四钩定位针定位操作用时更短。在使用记忆合金弹簧圈定位时，对于到胸膜距离 < 1.5 cm的肺结节效果可能更佳。

A computed tomography-based nomogram to predict pneumothorax caused by preoperative localization of ground glass nodules using hook wire

OBJECTIVE

To develop and validate a CT-based nomogram to predict the occurrence of loculated pneumothorax due to hook wire placement.

METHODS

Patients (n = 177) were divided into pneumothorax (n = 72) and non-pneumothorax (n = 105) groups. Multivariable logistic regression analysis was applied to build a clinical prediction model using significant predictors identified by univariate analysis of imaging features and clinical factors. Receiver operating characteristic (ROC) was applied to evaluate the discrimination of the nomogram, which was calibrated using calibration curve.

RESULTS

Based on the results of multivariable regression analysis, transfissure approach [odds ratio (OR): 757.94; 95% confidence interval CI (21.20-27099.30) p < 0.0001], transemphysema [OR: 116.73; 95% CI (12.34-1104.04) p < 0.0001], localization of multiple nodules [OR: 8.04; 95% CI (2.09-30.89) p = 0.002], and depth of nodule [OR: 0.77; 95% CI (0.71-0.85) p < 0.0001] were independent risk factors for pneumothorax and were included in the predictive model (p < 0.05). The area under the ROC curve value for the nomogram was 0.95 [95% CI (0.92-0.98)] and the calibration curve indicated good consistency between risk predicted using the model and actual risk.

CONCLUSION

A CT-based nomogram combining imaging features and clinical factors can predict the probability of pneumothorax before localization of ground-glass nodules. The nomogram is a decision-making tool to prevent pneumothorax and determine whether to proceed with further treatment.

ADVANCES IN KNOWLEDGE

A nomogram composed of transfissure, transemphysema, multiple nodule localization, and depth of nodule has been developed to predict the probability of pneumothorax before localization of GGNs.

An update on CT screening for lung cancer: the first major targeted cancer screening programme

Screening for lung cancer with low radiation dose CT has been shown to be effective in reducing lung cancer mortality by two major randomised controlled trials. Lung cancer screening is set to become the largest targeted cancer screening programme globally, but the effectiveness of the programme is dependent on many different factors. This article describes the key evidence for lung cancer screening, the key factors important for optimisation and the progress towards implementation.