A novel technique for localization of small pulmonary nodules

CT-guided harpoon marking a ground-glass infiltrate: A case report

Physicians are facing a growing challenge in characterizing suspicious pulmonary lesions through biopsy. Video thoracoscopic surgery is crucial for conducting surgical biopsies of these nodules. However, accurately identifying small pulmonary nodules, tiny, subsolid, and deep ones, remains a significant challenge due to the absence of digital palpation. One proposed technique for localization involves using a harpoon, initially designed for mammary nodules but also applied to pulmonary nodules. In cases involving solitary pulmonary nodules, histologic characterization is often necessary also accurate descriptions through computed tomography and the patient's clinical and epidemiologic context allow for a presumptive diagnosis. In this case, during an abdominal CT scan, a 49-year-old female patient was serendipitously found to have a ground-glass infiltrate in the anteromedial segment of the lower lobe of her left lung. Despite presenting with normal lung auscultation on physical examination, the increasing prevalence of subsolid lung nodules, combined with the contemporary era of minimally invasive surgery, prompted the medical team to employ CT-guided harpoon marking for precise lesion localization. Subsequent pathology analysis confirmed the presence of lepidic pattern adenocarcinoma. This case underscores the efficacy of the CT-guided harpoon marking approach, which significantly enhances surgical precision. Such precision is paramount in formulating individualized treatment strategies and follow-up plans for patients with similar clinical presentations.

Postoperative computed tomography of insufflated lung specimens obtained by video-assisted thoracic surgery: detection and margin assessment of pulmonary nodules

Objective

To investigate the utility of computed tomography (CT) scans to detect and assess the margin status of pulmonary nodules that were insufflated after being resected by video-assisted thoracic surgery.

Materials and Methods

This was a novel multicenter study conducted at two national referral centers for thoracic diseases. Patients suspected of having lung cancer underwent video-assisted thoracic surgery for the resection of pulmonary nodules, which were submitted to postoperative CT. Measurements from the CT scans were compared with the results of the histopathological analysis.

Results

A total of 37 pulmonary nodules from 37 patients were evaluated. The mean age of the patients was 65 years (range, 36-84 years), and 27 (73%) were female. A CT analysis of insufflated specimens identified all 37 nodules, and 33 of those nodules were found to have tumor-free margins. The histopathological analysis revealed lung cancer in 30 of the nodules, all with tumor-free margins, and benign lesions in the seven remaining nodules.

Conclusion

Postoperative CT of insufflated suspicious lung lesions provides real-time detection of pulmonary nodules and satisfactory assessment of tumor margins. This initial study shows that CT of insufflated lung lesions can be a valuable tool at centers where intraoperative histopathological analysis is unavailable.

A Novel Electrochemical Sensing Platform for the Sensitive Detection and Degradation Monitoring of Methylene Blue

Methylene blue is a toxic dye that is extensively used as a colorant in textile industries. Industrial effluent containing methylene blue, when drained into water bodies without proper treatment, poses a serious threat to aquatic and human lives. In order to protect the biocycle, various methods have been established to detect and remove hazardous dyes from aqueous systems. Electrochemical methods are preferred, owing to their characteristic features of simplicity, portability, potential selectivity, cost effectiveness, and rapid responsiveness. Based on these considerations, an electrochemical sensor consisting of amino-group-functionalized, multi-walled carbon nanotubes (NH2-fMWCNTs) immobilized on a glassy carbon electrode (GCE) was developed for the sensitive detection of methylene blue in aqueous solutions. The performance of the designed sensor was analyzed by electrochemical impedance spectroscopy, cyclic voltammetry, and square wave voltammetry. The developed sensing tool demonstrated promising features of sensitivity, selectivity, stability, fast responsiveness, and the ability to work with a very small volume of the analyte, i.e., in microliters, for analysis. Amino groups rich in electrons provide a negative charge to multi-walled carbon nanotubes, which significantly enhances the electrocatalytic activity of NH2-fMWCNTs for cationic dyes such as methylene blue. Using the designed sensing platform, a linear calibration plot with a limit of detection of 0.21 nM was obtained for methylene blue under optimized conditions. The designed sensor was also employed to monitor the extent and kinetics of the degradation of methylene blue. Titania nanoparticles were used for photocatalytic degradation, and the kinetics of degradation was monitored by both UV-Visible spectroscopic and electrochemical methods. The results revealed more than 95% removal of methylene blue in a time span of just 30 min.

Methylene Blue-Current Knowledge, Fluorescent Properties, and Its Future Use

Methylene blue is a fluorescent dye discovered in 1876 and has since been used in different scientific fields. Only recently has methylene blue been used for intraoperative fluorescent imaging. Here, the authors review the emerging role of methylene blue, not only as a dye used in clinical practice, but also as a fluorophore in a surgical setting. We discuss the promising potential of methylene blue together with the challenges and limitations among specific surgical techniques. A literature review of PubMed and Medline was conducted based on the historical, current and future usage of methylene blue within the field of medicine. We reviewed not only the current usage of methylene blue, but we also tried to grasp its' function as a fluorophore in five main domains. These domains include the near-infrared imaging visualization of ureters, parathyroid gland identification, pancreatic tumors imaging, detection of breast cancer tumor margins, as well as breast cancer sentinel node biopsy. Methylene blue is used in countless clinical procedures with a relatively low risk for patients. Usage of its fluorescent properties is still at an early stage and more pre-clinical, as well as clinical research, must be performed to fully understand its potentials and limitations.

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.

Image-guided Preoperative Localization of Pulmonary Nodules for Video-assisted and Robotically Assisted Surgery

Video-assisted thoracic surgery (VATS) and robotically assisted surgery are used increasingly for minimally invasive diagnostic and therapeutic resection of pulmonary nodules. Unsuccessful localization of small, impalpable, or deep pulmonary nodules can necessitate conversion from VATS to open thoracotomy. Preoperative localization techniques performed by radiologists have improved the success rates of VATS resection for small and subsolid nodules. Any center at which VATS diagnostic resection of indeterminate pulmonary nodules is performed should be supported by radiologists who offer preoperative nodule localization. Many techniques have been described, including image-guided injection of radioisotopes and radiopaque liquids and placement of metallic wires, coils, and fiducial markers. These markers enable the surgeon to visualize the position of an impalpable nodule intraoperatively. This article provides details on how to perform each percutaneous localization technique, and a group of national experts with established nodule localization programs describe their preferred approaches. Special reference is made to equipment required, optimization of marker placement, prevention of technique-specific complications, and postprocedural treatment. This comprehensive unbiased review provides valuable information for those who are considering implementation or optimization of a nodule localization program according to workflow patterns, surgeon preference, and institutional resources in a particular center. ^©RSNA, 2019.

Benefits of Electromagnetic Navigational Bronchoscopy for Identifying Pulmonary Nodules for Robotic Resections

Objective

The ability to localize pulmonary nodules via the robotic thoracic technique can be challenging at times. This is most evident when nodules are small and/or ground glass in nature. Information regarding methods available to localize these difficult nodules, while maintaining a minimally invasive robotic approach, is limited.

Methods

We describe a diagnostic and therapeutic method of combining electromagnetic navigational bronchoscopy with a total minimally invasive robotic approach that identifies these difficult-to-localize pulmonary nodules. The technique entails the use of electromagnetic navigational bronchoscopy to place a pleural dye marker with a subsequent pulmonary resection via a robotic thoracic approach.

Results

A cohort of 15 patients from August 2014 to December 2015 was reviewed. These patients underwent the combined approach of electromagnetic navigational bronchoscopy followed by a robotic pulmonary resection. Fourteen of the 15 patients had a successful combined procedure, which was confirmed with pathology. The range of the nodules was 0.8 to 2 cm. Methylene blue was used for pleural dye marking. On one occasion, the pleural dye was not able to be deciphered. There were no complications from either the electromagnetic navigational bronchoscopy or robotic portions of the procedure.

Conclusions

Pleural dye marking via electromagnetic navigational bronchoscopy can provide an effective method for localizing pulmonary nodules, while maintaining a minimally invasive robotic approach. This tactic allows one to obtain diagnostic tissue more efficiently, while limiting the potential inability to localize a nodule.

Volumetric assessment in malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a highly malignant pleural neoplasm with a dismal prognosis. Multimodality approach including surgery and chemotherapy are utilized to treat patients with resectable disease. Clinical staging allows for selection of patients for treatment strategies, but has not been found to be prognostic and is plagued by high interobserver variability. Tumor volume measurement on cross-sectional imaging has emerged as a potential quantitative tool with prognostic significance. This review focuses on volumetric assessment from cross-sectional imaging (CT, MRI, ¹⁸F-FDG PET/CT) and the potential prognostic benefit and applications.

CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is standard of care for small lung resections at many centres. Computed tomography (CT)-guided insertion of microcoils can aid surgeons in performing VATS resections for non-palpable lung nodules deep to the lung surface.

METHODS

Retrospective analysis of CT-guided microcoil insertions prior to VATS lung resection at a single institution from October 2008 to January 2014.

RESULTS

A total of 63 patients were included (37% male, mean age 61.6±11.4 years). Forty-two patients (67%) had a history of smoking, with 10 current smokers. Sixty one (97%) patients underwent wedge resection and 3 (5%) patients had segmentectomy. Three (5%) patients required intra-operative staple line re-resection for positive or close margins. Eleven (17%) patients had a completion lobectomy, 5 of which were during the same anaesthetic. The average time between the CT-guided insertion and start of operation was 136.6±89.0 min, and average operative time was 84.0±53.3 min. The intra-operative complication rate was 5% (n=3), including 1 episode of hemoptysis, and 2 conversions to thoracotomy. The post-operative complication rate was 8% (5 patients), and included 2 air leaks, 1 hemothorax (drop in hemoglobin), 1 post chest tube removal pneumothorax, and one venous infarction of the lingula after lingula-sparing lobectomy requiring completion lobectomy. . Average post-operative length of stay was 2.2 days. A diagnosis was made for all patients.

CONCLUSIONS

CT-guided microcoil insertion followed by VATS lobectomy is safe, with short operative times, short length of stay and 100% diagnosis of small pulmonary nodules. This technique will become more important in the future with increasing numbers of small nodules detected on CT as part of lung cancer screening programs.

Value of radial probe endobronchial ultrasound-guided localization of solitary pulmonary nodules with the combination of ultrathin bronchoscopy and methylene blue prior to video-assisted thoracoscopic surgery

The aim of this study was to assess the clinical value of radial probe endobronchial ultrasound (RP-EBUS)-guided localization of solitary pulmonary nodules (SPNs) with the combination of ultrathin bronchoscopy and methylene blue prior to video-assisted thoracoscopic surgery (VATS). An ultrathin bronchoscope was used to localize the lesions under RP-EBUS guidance in 48 patients (18 men and 30 women; age range, 41–72 years; mean age, 54 years), who subsequently underwent VATS resection. The lesion size, distance from the parietal pleura, localization time and complications were evaluated. The RP-EBUS-guided localization success rate was 72.9%. The lesion size ± standard deviation was 12.8±4.2 mm and the mean distance from the parietal pleura was 11.2±9.7 mm. The mean localization time was 15.7±8.3 min. The major complication of RP-EBUS-guided localization was asymptomatic hemorrhage in 4 patients (8.3%). The VATS resection success rate was 95.8%. In terms of pathological type, the 48 lesions included atypical adenomatous hyperplasia (n=4), adenocarcinoma in situ (n=5), minimally invasive adenocarcinoma (n=7), adenocarcinoma (n=18), squamous cell carcinoma (n=1), inflammation (n=6), hamartoma (n=4) and tuberculosis (n=3). Therefore, RP-EBUS-guided localization with the combination of an ultrathin bronchoscope and methylene blue prior to VATS resection is a promising technique for SPNs, it plays an important role in the accurate localization of SPNs and it is an effective and safe technique to assist VATS resection of such nodules.

A Simple and Safe Technique for CT Guided Lung Nodule Marking prior to Video Assisted Thoracoscopic Surgical Resection Revisited

Aim. We describe our experience of a simple, safe, and reproducible technique for lung nodule marking prethoracoscopic metastasectomy. Thoracoscopic lung nodule resection reduces patient discomfort, complications, higher level of care, hospital stay, and cost; however, small deeply placed lung nodules are difficult to locate and resect thoracoscopically. Materials and Methods. We describe and review the success of our novel technique, where nodules are identified on a low dose CT and marked with methylene blue using CT fluoroscopy guidance immediately prior to surgery. Results. 30 nodules were marked with a mean size of 8 mm (4-18 mm) located at a mean depth of 17 mm, distributed through both lungs. Dye was detected at the pleural surface in 97% of the patients and at the nodule in 93%. There were no major complications. Thoracoscopic resection was possible in 90%. Conclusion. This is a simple and safe method of lung nodule marking to facilitate thoracoscopic resection in cases where this may not be technically possible due to nodule location.

CT-guided localization of small pulmonary nodules using adjacent microcoil implantation prior to video-assisted thoracoscopic surgical resection

OBJECTIVES

To describe and assess the localization of small peripheral pulmonary nodules prior to video-assisted thoracoscopic surgical (VATS) resection using the implantation of microcoils.

METHODS

Ninety-two patients with 101 pulmonary nodules underwent computed tomography (CT)-guided implantation of microcoils proximal to each nodule. Patients were randomly assigned to undergo entire microcoil or leaving-microcoil-end implantations. The complications and efficacy of the two implantation methods were evaluated. VATS resection of lung tissue containing each pulmonary lesion and microcoil were performed in the direction of the microcoil marker. Histopathological analysis was performed for the resected pulmonary lesions.

RESULTS

CT-guided microcoil implantation was successful in 99/101 cases, and the placement of microcoils within 1 cm of the nodules was not disruptive. There was no difference in the complications and efficacy associated with the entire implantation method (performed for 51/99 nodules) versus the leaving-microcoil-end implantation method (performed for 48/99 nodules). All nodules were successfully removed using VATS resection. Asymptomatic pneumothorax occurred in 16 patients and mild pulmonary haemorrhage occurred in nine patients. However, none of these patients required further surgical treatment.

CONCLUSIONS

Preoperative localization of small pulmonary nodules using a refined percutaneous microcoil implantation method was found to be safe and useful prior to VATS resection.

KEY POINTS

• An increasing number of small, indeterminate pulmonary lesions need to be characterized. • Entire microcoil and leaving-microcoil-end implantation methods were described for nodule localization. • Adjacent microcoil localization prior to video-assisted thoracoscopic surgical resection involved minimal intervention. • Preoperative microcoil localization facilitates the definitive resection of small pulmonary nodules.

Feasibility of preoperative (125)I seed-guided tumoural tracer injection using freehand SPECT for sentinel lymph node mapping in non-palpable breast cancer

Background

This study was designed to explore the feasibility of replacing the conventional peri-/intratumoural ultrasound (US)-guided technetium-99m albumin nanocolloid (^99mTc-nanocolloid) administration by an injection of the same tracer guided by a freehand single-photon emission computed tomography (SPECT) device in patients with non-palpable breast cancer with an iodine-125 (¹²⁵I) seed as tumour marker, who are scheduled for a sentinel lymph node biopsy (SLNB). This approach aimed to decrease the workload of the radiology department, avoiding a second US-guided procedure.

Methods

In ten patients, the implanted ¹²⁵I seed was primarily localised using freehand SPECT and subsequently verified by conventional US in order to inject the ^99mTc-nanocolloid. The following 34 patients were injected using only freehand SPECT localisation. In these patients, additional SPECT/CT was acquired to measure the distance between the ^99mTc-nanocolloid injection depot and the ¹²⁵I seed. In retrospect, a group of 21 patients with US-guided ^99mTc-nanocolloid administrations was included as a control group.

Results

The depth difference measured by US and freehand SPECT in ten patients was 1.6 ± 1.6 mm. In the following 36 ¹²⁵I seeds (34 patients), the average difference between the ¹²⁵I seed and the centre of the ^99mTc-nanocolloid injection depot was 10.9 ± 6.8 mm. In the retrospective study, the average distance between the ¹²⁵I seed and the centre of the ^99mTc-nanocolloid injection depot as measured in SPECT/CT was 9.7 ± 6.5 mm and was not significantly different compared to the freehand SPECT-guided group (two-sample Student's t test, p = 0.52).

Conclusion

We conclude that using freehand SPECT for ^99mTc-nanocolloid administration in patients with non-palpable breast cancer with previously implanted ¹²⁵I seed is feasible. This technique may improve daily clinical logistics, reducing the workload of the radiology department.

Computed tomography guided percutaneous injection of a mixture of lipiodol and methylene blue in rabbit lungs: evaluation of localization ability for video-assisted thoracoscopic surgery

Preoperative localization is necessary prior to video assisted thoracoscopic surgery for the detection of small or deeply located lung nodules. We compared the localization ability of a mixture of lipiodol and methylene blue (MLM) (0.6 mL, 1:5) to methylene blue (0.5 mL) in rabbit lungs. CT-guided percutaneous injections were performed in 21 subjects with MLM and methylene blue. We measured the extent of staining on freshly excised lung and evaluated the subjective localization ability with 4 point scales at 6 and 24 hr after injections. For MLM, radio-opacity was evaluated on the fluoroscopy. We considered score 2 (acceptable) or 3 (excellent) as appropriate for localization. The staining extent of MLM was significantly smaller than methylene blue (0.6 vs 1.0 cm, P<0.001). MLM showed superior staining ability over methylene blue (2.8 vs 2.2, P=0.010). Excellent staining was achieved in 17 subjects (81%) with MLM and 8 (38%) with methylene blue (P=0.011). An acceptable or excellent radio-opacity of MLM was found in 13 subjects (62%). An appropriate localization rate of MLM was 100% with the use of the directly visible ability and radio-opacity of MLM. MLM provides a superior pulmonary localization ability over methylene blue.

Case report: Curetting osteoid osteoma of the spine using combined video-assisted thoracoscopic surgery and navigation

BACKGROUND

A spinal osteoid osteoma is a rare benign tumor. The usual treatment involves complete curettage including the nidus. In the thoracic spine, conventional open surgical treatment usually carries relatively high surgical risks because of the close anatomic relationship to the spinal cord, nerve roots, and thoracic vessels, and pulmonary complications and postoperative pain.

CASE REPORT

We report the case of a 16-year-old girl with a symptomatic osteoid osteoma at the T9 level whose lesion was currettaged using video-assisted thoracoscopic surgery (VATS) guided by a navigation system (VATS-NAV). There were no complications and the patient had immediate relief of the characteristic pain after surgery and was asymptomatic at 5 months' followup.

LITERATURE REVIEW

Progressive advances in the technology of spinal surgery have evolved to offer greater safety and less morbidity for patients. The advent of minimally invasive surgery has expanded the indications for VATS for anterior spinal disorders. Spinal navigation systems have become useful tools allowing localization and excision of the nidus of osteoid osteomas with minimal bone resection and without radiation exposure.

CLINICAL RELEVANCE

The VATS-NAV combination in our patient allowed accurate localization and guidance for complete excision of a spinal osteoid osteoma through a minimally invasive approach without compromising spinal stability.

[Locating pulmonary nodules with a computed axial tomography-guided harpoon prior to videothoracoscopic resection. Experience with 52 cases]

OBJECTIVE

Videothoracoscopic (VTC) resection of peripheral pulmonary nodules (PN) occasionally requires performing a mini-thoracotomy to locate them using palpation. The aim of this study is to evaluate the usefulness of inserting a CT-guided harpoon as a method for locating PN prior to surgery.

MATERIAL AND METHODS

A study was conducted on a total of 52 patients who were scheduled for locating 55 PN prior to surgery by inserting a CT-guided harpoon, from November 2004 to January 2011.

RESULTS

Of the 52 patients, of whom 35 had a history of cancer, 31 were male and 21 were female, with ages between 28 and 84 years (mean: 62.2 years) with a PN <20mm (mean: 9.57mm). A total of 55 harpoons were inserted (3 patients had 2 simultaneous harpoons). Using the VTC it was observed that 52 harpoons were correctly anchored to the PN. There were no complications. In the group of 35 patients with an oncology history, the nodules were malignant in 26 cases (74.3%), and there were 17 (70.6%) with malignant PN in those with no oncology history. The hospital stay varied between 4 and 72h, with 19 patients (36.5%) included in a one-day surgery program.

CONCLUSIONS

The preoperative identification of peripheral pulmonary nodules enables them to be removed directly with VTC. The insertion of a CT-guided harpoon in the PN is a safe and effective procedure that can be performed in a one-day surgery program.

Screening for lung cancer

The National Lung Screening Study has demonstrated that screening with low-dose spiral computed tomography results in fewer deaths from lung cancer compared with screening with chest radiography (CXR). Previous trials of screening with CXR and sputum cytology failed to exhibit fewer deaths compared with no screening intervention. Early computed tomography (CT) studies showed promise for CT to be a more sensitive test, yet were unable to demonstrate sufficient evidence of efficacy. This review examines the problem of early lung cancer detection, the issues presented by screening, and results of past and recent studies of lung cancer screening.

Surgical management of colorectal lung metastasis

Colon cancer is a systemic disease in 19% of patients and metastasizes most frequently to the liver and the lung. Survival is enhanced with complete surgical resection of pulmonary metastases. Comprehensive restaging and verification of preoperative fitness must precede resection. The operative approach is dictated by the anatomic location of the metastases, whereas the extent of resection remains a balance between complete removal of metastatic deposits while preserving as much lung parenchyma as possible. The presence of metastatic involvement of hilar and mediastinal lymph nodes is ominous. Multidisciplinary care is highly recommended. An evidence-based algorithm for the identification assessment and treatment of patients with pulmonary metastases is proposed.

Need for preoperative computed tomography-guided localization in video-assisted thoracoscopic surgery pulmonary resections of metastatic pulmonary nodules

BACKGROUND

Preoperative localization of pulmonary nodules is sometimes necessary when they are too small or distant from the surface of the visceral pleura to be detected during video-assisted thoracoscopic surgery. This study aims to present the criteria for localization and to evaluate the accuracy of the criteria.

METHODS

From April 2001 to March 2008, 178 patients with 224 nodules who underwent wedge resection of pulmonary metastatic nodules by video-assisted thoracoscopic surgery were reviewed retrospectively. Thirty-one patients (17.4%) including 35 nodules underwent thoracoscopic resection immediately after computed tomography-guided localization using hook wires. Criteria for preoperative localization were (1) maximum diameter of the nodule of 5 mm or less, (2) maximum diameter to minimum distance between the visceral pleura and inferior border of nodule of 0.5 or less, and (3) nodule with low-density image by computed tomography after chemotherapy. The accuracy of these inclusion criteria was statistically evaluated.

RESULTS

All 224 nodules were removed by wedge resection or additional segmentectomy. Nineteen nodules (54.3%) were detected in the thoracic cavity with preoperative localization. Sensitivity, specificity, positive predictive value, and negative predictive value were 11.1%, 99.5%, 66.7%, and 92.8%; 88.9%, 93.2%, 53.3%, and 99.0%; and 88.9%, 90.8%, 45.7%, and 98.9% in each preoperative finding of which a nodule met all (3 nodules), two or more (30 nodules), and one or more (35 nodules) of the three criteria, respectively.

CONCLUSIONS

This study suggests that preoperative localization should be considered before video-assisted thoracoscopic surgery operation if the pulmonary nodule meets two or more of our criteria.

Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection

PURPOSE

To prospectively assess the safety and effectiveness of computed tomography (CT)-guided placement of fiber-coated microcoils used to guide video-assisted thoracoscopic surgical (VATS) excision of small peripheral lung nodules, with successful excision as the primary outcome and successful CT-guided microcoil placement and procedural complications as secondary outcomes.

MATERIALS AND METHODS

The institutional review board approved the study protocol. Informed consent was obtained from all 69 enrolled patients (30 men, 39 women; mean age, 60.7 years +/- 10.1 [standard deviation]) with 75 nodules. At CT, one end of an 80-mm long, 0.018-inch-diameter fiber-coated microcoil was placed deep to the small peripheral lung nodule, and the other end was coiled in the pleural space. VATS excision of lung tissue, nodules, and the microcoil was performed with fluoroscopic guidance.

RESULTS

Seventy-three (97%) 4-24-mm nodules were successfully removed at fluoroscopically guided VATS excision; two nodules could not be removed. CT-guided microcoil placement was successful in all cases; however, two (3%) of 75 coils were displaced at VATS excision. Pneumothorax requiring chest tube placement occurred in two (3%) patients, and asymptomatic hemothorax occurred in one (1%) patient. The microcoil did not impede intraoperative frozen-section histopathologic analysis, which facilitated accurate clinical management in all patients. For 19 (28%) patients, the preoperative treatment plan based on bronchoscopy, needle biopsy, and positron emission tomography findings changed after VATS excision.

CONCLUSION

Microcoil localization of small peripheral lung nodules enabled fluoroscopically guided VATS resection of 97% of the nodules, with a low rate of intervention (3%) for procedural complications.