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

Cone Beam CT Derived Laser-Guided Percutaneous Lung Ablation: Minimizing Needle-Related Complications Under General Anesthesia with Lung Separation

RATIONALE AND OBJECTIVES

Percutaneous lung tumor ablations are mostly performed in computed tomography (CT) rooms under local anesthesia with conscious sedation. However, maintaining the breath-hold phase during this can be challenging, affecting image quality and increasing complications. With the advent of hybrid operating rooms (HORs), this procedure can be performed with endotracheal tube (ETGA) intubation under general anesthesia with lung separation, ensuring precise imaging in a single-stage setting. Lung separation provides surgical exposure of one lung while ensuring ample gas exchange with the other. This study evaluated tumor ablations performed in an HOR equipped with cone beam CT and laser guidance.

MATERIALS AND METHODS

This retrospective study included patients who underwent lung tumor ablation under general anesthesia with an ETGA in an HOR between July 2020 and May 2023. Anesthesia considerations, perioperative management, and postoperative follow-ups were evaluated.

RESULTS

65 patients (78 tumors) underwent ablation using two types of lung ventilation methods including a single-lumen tube with a blocker (SLT/BL) (n = 15) and double-lumen tube (DLT) (n = 50). Most patients experienced desaturation during the apnea phase of dynamic CT and needling. The average SpO2 value was significantly lower in the DLT group than in the SLT/BL group during the procedure (81.1% versus 88.7%, P = 0.033). Five, three, and two patients developed pneumothorax, subcutaneous emphysema, and pleural effusion, respectively.

CONCLUSION

Percutaneous ablation under general anesthesia with endotracheal intubation and lung separation performed in HORs was feasible and safe. The setup minimized complication risks and maintained a balance between patient safety and successful procedures.

Cone-beam computed tomography image-guided percutaneous microwave ablation for lung nodules in a hybrid operating room: an initial experience

OBJECTIVES

The experience of thermal ablation of lung lesions is limited, especially performing the procedure under localisation by cone-beam CT in the hybrid operation room (HOR). Here, we present the experience of microwave ablation (MWA) of lung nodules in the HOR.

METHODS

We reviewed patients who underwent image-guide percutaneous MWA for lung nodules in the HOR under general anaesthesia between July 2020 and July 2022. The workflow in the HOR including the pre-procedure preparation, anaesthesia consideration, operation methods, and postoperative care was clearly described.

RESULTS

Forty lesions in 33 patients who underwent MWA under general anaesthesia (GA) in the HOR were analysed. Twenty-seven patients had a single pulmonary nodule, and the remaining six patients had multiple nodules. The median procedure time was 41.0 min, and the median ablation time per lesion was 6.75 min. The median global operation room time was 115.0 min. The median total dose area product was 14881 μGym2. The median ablation volume was 111.6 cm3. All patients were discharged from the hospital with a median postoperative stay of 1 day. Four patients had pneumothorax, two patients had pleural effusion during the first month of outpatient follow-up, and one patient reported intercostal neuralgia during the 3-month follow-up.

CONCLUSIONS

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if we follow the workflow provided. The procedure provides an alternative to managing pulmonary nodules in patients.

CLINICAL RELEVANCE STATEMENT

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if the provided workflow is followed.

KEY POINTS

• We tested the feasibility of microwave ablation of lung lesions performed in a hybrid operating room. • To this end, we provide a description of microwave ablation of the lung under cone-beam CT localisation. • We describe a workflow by which ablation of the pulmonary nodule can be performed safely under general anaesthesia.

Trans-fissure and trans-lobar coil insertion technique for small lesions positioned inside the fissure

The objective of this study is to present a technique of localization of difficult-to-locate lesions inside the fissure by deploying a coil with one of its ends left inside the fissure, and also, to evaluate the safety and the efficiency of this localization technique. Ten (10) patients with lesions in the fissure were identified during discussion at the multidisciplinary team meeting (MDT) and were recruited in the study. Attending surgeons verified that the lesions were unable to be located with minimally invasive approaches. These patients underwent localization of their lesion/s inside the fissure with a coil which was inserted through an adjacent lobe, through the fissure and inside the lesion with the other end protruding inside the fissure. All patients were next subjected to resection of their lesions with minimally invasive approaches. All patients had their lesions resected (with wedge resection or segmentectomies) with adequate margins (R0 resection). No conversion to thoracotomy was necessitated to attempt to palpate the lesion. Small, localized pneumothorax was noted in 7 patients; whereas, all patients had small laceration of their lung parenchyma along the course of the needle without, however, any action needed for these sequalae. The presented technique offers precise localization which leads to successful and safe resection of difficult-to-locate lesions inside the fissure via minimally invasive approaches. The clinical implications of this technique are numerous and its utilization can augment the successful performance of minimally invasive techniques for lesions situated inside the fissure.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative CT-Guided Coil Localization of Lung Nodule Resection: A Single-Center Experience

BACKGROUND

The increased use of computed tomography (CT) for lung cancer screening has led to an increase in the incidence of lung nodules. However, accurately localizing small or deep-seated nodules remains challenging and often requires image-guided techniques. CT-guided coil localization has emerged as a popular method for precise localization.

METHODS

A retrospective analysis was conducted on a cohort of patients who underwent CT-guided coil localization followed by surgical resection of lung nodules at the National University Hospital, Singapore, between 2015 and 2021. The study examined the rates of successful localization, procedural complications, and postoperative length of stay. Descriptive statistics were employed for data analysis.

RESULTS

This retrospective study included 55 patients with pulmonary nodules, of whom 76.4% had a history of previous malignancy. A total of 58 nodules were successfully localized using coil placement and distributed across various lung lobes. The average dimensions of the nodules were 8.4 ± 3.2 mm × 10.1 ± 4.0 mm, with an average distance of 10.9 ± 9.0 mm from the pleura. Surgical resection of the coiled nodules resulted in an average resected volume of 91.1 ± 76.0 cm3 and a resection margin of 9.5 ± 7.3 mm. Failed localization occurred in only 3.6% of cases. Procedural complications were observed in 21.8% of patients, including hemothorax, persistent air leaks, pneumothoraces, pleural effusion, pneumonia, and atelectasis, all of which were appropriately managed. The average length of postoperative hospital stay was 6.7 ± 15.9 days.

CONCLUSION

Preoperative CT-guided coil localization is a reliable and safe technique for accurately localizing lung nodules before surgical resection. The high success rate of this approach enables precise intraoperative planning. Despite procedural complications, their manageable nature and the absence of major adverse events highlight the safety of this technique. Incorporating CT-guided coil localization into routine clinical practice can significantly enhance surgical planning, improve patient outcomes, and optimize resource utilization.

Canadian Association of Radiologists/Canadian Association of Interventional Radiologists/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions

Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association of Interventional Radiologists and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.

Hemorrhagic shock caused by preoperative computed tomography-guided microcoil localization of lung nodules: a case report

Background

Video-assisted thoracoscopic surgery (VATS) is an emerging technology in minimally invasive surgery, which has become recognized as standard treatments for early-stage lung cancer. Microcoil localization is considered to be a safe and effective way of preoperative localization, and is essential to facilitate VATS wedge-resection for lung nodules.

Case presentation

Here we report a rare case of a 28-year-old female who developed hemorrhagic shock caused by delayed pneumothorax after preoperative computed tomography (CT)-guided microcoil localization. The thoracic CT revealed hydropneumothorax in the right thoracic cavity at 10 h after microcoil localization, and the patient later had significant decreased hemoglobin level (87 g/L). Emergency thoracoscopic exploration demonstrated that the hemorrhagic shock was induced by delayed pneumothorax, which led to the fracture of an adhesive pleura cord and an aberrant vessel. Electrocoagulation hemostasis was then performed for the fractured vessel and the patient gradually recovered from the hypovolemic shock.

Conclusions

Microcoil localization is a relatively safe and effective way of preoperative localization of lung nodules, however, hemorrhagic shock could be induced by rupture of pleural aberrant vessels subsequent to puncture related pneumothorax. Shorten the time interval between localization and thoracoscopic surgery, extend the monitoring time after localization might help to reduce the risk of these 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.

Safety and Efficacy of Cone-Beam Computed Tomography-Guided Lung Tumor Localization with a Near-Infrared Marker: A Retrospective Study of 175 Patients

Preoperative localization holds promise for overcoming the limitations of video-assisted thoracoscopic surgery (VATS) in the treatment of impalpable lung nodules. The purpose of this study was to assess the safety and efficacy of cone-beam computed tomography (CBCT)-guided localization using near-infrared (NIR) marking. Between 2017 and 2021, patients presenting with a solitary pulmonary nodule (SPN) who had undergone CBCT-guided lesion localization with indocyanine green (ICG) in a hybrid operating room were included. The primary outcomes were the efficacy of localization and the occurrence of complications. The study cohort consisted of 175 patients with the mean age of 58.76 years. The mean size and depth of the 175 SPNs were 8.34 mm and 5.3 mm, respectively. The mean time required for lesion marking was 14.71 min. Upon thoracoscopic inspection, the NIR tattoo was detected in the vast majority of the study participants (98.3%). An utility thoracotomy to allow digital palpation was required in two of the three patients in whom the tattoo was not identifiable. The perioperative survival rate was 100%, and the mean length of hospital stay was 3.09 days. We conclude that needle localization with ICG injection is a safe and feasible technique to localize SPNs prior to resection.

CT-guided microcoil localization of pulmonary nodules: the effect of the position of microcoil proximal end on the incidence of microcoil dislocation

OBJECTIVES

To evaluate the effect of the position of microcoil proximal end on the incidence of microcoil dislocation during CT-guided microcoil localization of pulmonary nodules (PNs).

METHODS

This retrospective study included all patients with PNs who received CT-guided microcoil localization before video-assisted thoracoscopic urgery (VATS) resection from June 2016 to December 2019 in our institution. The microcoil distal end was less than 1 cm away from the nodule, and the microcoil proximal end was in the pleural cavity (the pleural cavity group) or chest wall (the chest wall group). The length of microcoil outside the pleura was measured and divided into less than 0.5 cm (group A), 0.5 to 2 cm (group B) and more than 2 cm (group C). Microcoil dislocation was defined as complete retraction into the lung (type I) or complete withdrawal from the lung (type II). The rate of microcoil dislocation between different groups was compared.

RESULTS

A total of 519 consecutive patients with 571 PNs were included in this study. According to the position of microcoils proximal end on post-marking CT, there were 95 microcoils in the pleural cavity group and 476 in the chest wall group. The number of microcoils in group A, B, and C were 67, 448 and 56, respectively. VATS showed dislocation of 42 microcoils, of which 30 were type II and 12 were type I. There was no statistical difference in the rate of microcoil dislocation between the pleural cavity group and the chest wall group (6.3% vs 7.6%, x² = 0.18, p = 0.433). The difference in the rate of microcoil dislocation among group A, B, and C was statistically significant (11.9%, 5.8%, and 14.3% for group A, B, and C, respectively, x² = 7.60, p = 0.008). In group A, 75% (6/8) of dislocations were type I, while all eight dislocations were type II in group C.

CONCLUSIONS

During CT-guided microcoil localization of PNs, placing the microcoil proximal end in the pleura cavity or chest wall had no significant effect on the incidence of microcoil dislocation. The length of microcoil outside the pleura should be 0.5 to 2 cm to reduce the rate of microcoil dislocation.

ADVANCES IN KNOWLEDGE:

CT-guided microcoil localization can effectively guide VATS to resect invisible and impalpable PNs. Microcoil dislocation is the main cause of localization failure. The length of microcoil outside the pleura is significantly correlated with the rate and type of microcoil dislocation. Placing the microcoil proximal end in the pleura cavity or chest wall has no significant effect on the rate of microcoil dislocation.

Preoperative non-invasive visual localization of synchronous multiple lung cancers using three-dimensional computed tomography lung reconstruction

BACKGROUND

Synchronous multiple primary lung cancers are becoming more common with increasing use of computed tomography for screening. Intraoperative localization and resection of ill-defined pulmonary ground-glass opacities during thoracoscopic resection is challenging. This study aimed to determine the clinical feasibility of non-invasive visual localization of these nodules by three-dimensional computed tomography lung reconstruction before sublobar resection.

METHODS

Forty-four patients with synchronous multiple primary lung cancers underwent thoracoscopic pulmonary resection at our institution between June 2017 and August 2019. Preadmission computed tomography images were downloaded and reconstructed into a three-dimensional model. Small nodules (< 15 mm) were localized non-invasively by three-dimensional computed tomography lung reconstruction before surgery. Patient demographics, nodule characteristics, procedural details, pathological data, and outcomes were obtained from the medical records.

RESULTS

One hundred and twenty-one pulmonary nodules from the 44 patients were scheduled for video-assisted thoracic surgery; 54 (44.6%) were pure ground-glass opacities and 57 (47.1%) were mixed ground-glass opacities. One hundred and seventeen nodules were localized preoperatively. The mean nodule diameter was 7.67 ± 3.87 mm. The mean distance from the nodule to the pleura was 14.84 ± 14.43 mm. All nodules were removed successfully by wedge resection (27 patients), lobectomy (26 patients), or segmentectomy (25 patients). Most lesions (85.1%) were malignant. Paraffin pathology revealed 12 cases of atypical adenomatous hyperplasia (9.92%), 13 of adenocarcinoma in situ (10.74%), 16 of minimally invasive adenocarcinoma (13.22%), and 73 of invasive adenocarcinoma (60.33%).

CONCLUSIONS

Three-dimensional computed tomography lung reconstruction is a feasible and alternative method of visual localization for small lung nodules before sublobar resection in some suitable patients.

The role of virtual-assisted lung mapping 2.0 combining microcoils and dye marks in deep lung resection

OBJECTIVES

Virtual-assisted lung mapping 2.0 is a novel preoperative bronchoscopic lung mapping technique combining the multiple dye marks of conventional virtual-assisted lung mapping with intrabronchial microcoils to navigate thoracoscopic deep lung resection. This study's purpose was to evaluate the feasibility of virtual-assisted lung mapping 2.0 in resecting deeply located pulmonary nodules with adequate margins.

METHODS

A multicenter, prospective single-arm study was performed from 2019 to 2020 in 8 institutions. The selection criteria were barely identifiable nodules requiring sublobar lung resections, nodules requiring resection lines reaching the inner 2/3 of the pulmonary lobe on computed tomography images in wedge resection, or the nodule center located in the inner 2/3 of the pulmonary lobe in wedge resection or segmentectomy. Resection margins larger than 2 cm or the nodule diameter were considered successful resection. Bronchoscopic placement of multiple dye marks and microcoil(s) was conducted 0 to 2 days before surgery.

RESULTS

We analyzed 65 lesions in 64 patients. The diameter and depth of the targeted nodules and the minimum required resection depth reported as median (interquartile range) were 9 (7-13) mm, 11 (5-15) mm, and 30 (25-35) mm, respectively. Among 60 wedge resections and 5 segmentectomies, successful resection was achieved in 64 of 65 resections (98.5%; 95% confidence interval, 91.7-100). Among 75 microcoils placed, 3 showed major displacement after bronchoscopic placement. There were no severe adverse events associated with the virtual-assisted lung mapping procedure.

CONCLUSIONS

This study demonstrated that virtual-assisted lung mapping 2.0 can facilitate successful resections for deep pulmonary nodules, overcoming the limitations of conventional virtual-assisted lung mapping.

Migration of a nodule localisation marker to the contralateral lung

Video-assisted thoracoscopic surgery (VATS) has been increasingly used to resect lung nodules avoiding thoracotomy thus reducing morbidity and hospitalisation time. One of the main challenges is to localise the target, because very often they are not palpable and small. Various nodule localisation techniques have been used to assist VATS resection including metallic marker implantation adjacent to the lesion of interest. These markers have been known to migrate, more often in the pleural space. We report an unusual case of metallic marker migration to the contralateral lung.

CT-guided preoperative localization of ground glass nodule: comparison between the application of embolization microcoil and the locating needle designed for pulmonary nodules

OBJECTIVES

To compare the efficacy and safety of pre-operative localization of ground glass nodule (GGN) using embolization microcoils and the locating needles designed for pulmonary nodules.

METHODS

From June 2019 to December 2020, 429 patients who received CT-guided localization of single GGN before video-assisted thoracoscopic surgery (VATS) were enrolled. The diameter and depth of GGNs were 0.84 ± 0.39 cm and 1.66 ± 1.37 cm. Among 429 cases, the first 221 GGNs were marked with microcoils (the microcoil group), and the remaining 208 GGNs were marked with the locating needles designed for pulmonary nodules (the locating needle group). SPSS 17.0 statistical software was used to compare the marking success rate, marking time, marking-related complications between two groups. p values < 0.05 were considered statistically significant.

RESULTS

The marking time in the microcoil group was longer than that in the locating needle group (11.1 ± 3.9 vs 8.2 ± 2.0 min, t = -7.87, p = 0.000). The marking success rate in the microcoil group was lower than that in the locating needle group (91.4% vs 98.6%, χ² = 11.27, p = 0.001). In the microcoil group, marking failures included 16 cases of microcoil dislocation and 3 cases of unsatisfactory microcoil position, while all 3 cases of marking failure in the locating needle group were due to unsatisfactory anchor position. No significant differences in the incidence of total complications (23.1% vs 22.1%), pneumothorax (18.1% vs 19.2%), hemorrhage (9.5% vs 9.1%), and hemoptysis (1.8% vs 1.4%) were observed between the two groups. All the complications were minor and did not need special treatment. Except for one case in the microcoil group, which was converted to thoracotomy, the remaining 428 GGNs were successfully resected by VATS.

CONCLUSIONS

It is safe and effective to perform pre-operative localization of GGN using either embolization microcoil or the locating needle designed for pulmonary nodules. The locating needle is superior to microcoil for marking GGN in terms of procedure time and the success rate. The complication rate of both methods is similar.

ADVANCES IN KNOWLEDGE

The locating needle designed for pulmonary nodules has recently been used to mark pulmonary nodule. Its structure can effectively avoid dislocation after localization, and the marking process is simple and quick. Compared with localization using microcoil, it takes less time and has higher success rate to mark GGNs using the locating needle. The complication rate of both methods is similar.

CT-guided microcoil localization for pulmonary nodules in the scapula-shadowed area before Video-Assisted Thoracic Surgery

PURPOSE

To evaluate the feasibility and safety of CT-guided microcoil localization for pulmonary nodules in the scapula-shadowed area before video-assisted thoracic surgery (VATS).

MATERIALS AND METHODS

Forty-seven patients (18 males, 19 females; mean age 57.5 years) with 48 pulmonary nodules covered by the scapulae were consecutively enrolled in this study. Successful targeting, localization, and VATS were defined as implantation of microcoil at the target site on CT image obtained immediately after the marking procedure, visualization of nodule location during VATS, and complete resection of the target nodule with adequate margin, respectively. Meanwhile, the procedure-related complication rate was also recorded.

RESULTS

The rates of successful targeting and localization were 95.8% (46/48) and 89.6% (43/48), respectively. Of all nodules, 47 were successfully resected with VATS (30 wedge resections; 17 anatomic resections) and 1 nodule was converted to open thoracotomy for diffuse pleural adhesion, thus the successful VATS rate was 97.9% (47/48). With respect to procedure-related complications, only minor complications (including localized pneumothorax and intrapulmonary hemorrhage) were developed and the rate of overall procedure-related complications was 37.5% (18/48), including minor pneumothorax developed in 15 of 48 nodules (31.3%) and intrapulmonary hemorrhage in 6 of 48 nodules (12.5%).

CONCLUSIONS

CT-guided microcoil technique is a safe and effective localization method prior to VATS for the nodules in the scapula-shadowed area.

Video-assisted thoracoscopic surgical wedge resection using multiplanar computed tomography reconstruction-fluoroscopy after CT guided microcoil localization

BACKGROUND

When early-stage lung cancer is diagnosed, the recommended treatment is anatomical resection using video-assisted thoracoscopic surgery (VATS) or robotic lobectomy. However, nonanatomical resection, known as wedge resection (WR), which is performed to diagnose pulmonary nodules, can be problematic for clinicians performing VATS or robotic-assisted thoracic surgery (RATS). The purpose of this study was to evaluate the safety and effectiveness of VATS WR using multiplanar computed tomography reconstruction (CT MPR)-fluoroscopy after CT guided microcoil localization to achieve complete pulmonary nodule resection.

METHODS

Between January 2016 to December 2020, the medical records of patients who underwent CT-guided microcoil localization for suspicious malignant pulmonary nodules and VATS WR with CT MPR and intraoperative fluoroscopy were retrospectively reviewed.

RESULTS

All 130 patients successfully underwent CT-guided localization. The success rate of VATS WR with CT MPR-intraoperative fluoroscopy was 98.5%. Mean operation time was 58 min (range 50-84 min). The postoperative complication rate was 3.1%, and no major postoperative complications were reported. The mean postoperative length of hospital stay was 4.7 days (range 4-8 days).

CONCLUSIONS

VATS WR using CT MPR-fluoroscopy after CT guided microcoil localization is a safe and highly effective approach for complete pulmonary nodule resection. However, even in uniport VATS or recently performed robotic surgery, localization and resection of nonvisible, nonpalpable pulmonary nodules is a challenging problem. Consequently, satisfactory outcomes can be expected if this technique is used for suspicious malignant pulmonary nodule resection.

CT-Guided Microcoil Localization of Small Peripheral Pulmonary Nodules to Direct Video-Assisted Thoracoscopic Resection without the Aid of Intraoperative Fluoroscopy

OBJECTIVE

To evaluate the feasibility, safety, and effectiveness of CT-guided microcoil localization of solitary pulmonary nodules (SPNs) for guiding video-assisted thoracoscopic surgery (VATS).

MATERIALS AND METHODS

Between June 2016 and October 2019, 454 consecutive patients with 501 SPNs who received CT-guided microcoil localization before VATS in our institution were enrolled. The diameter of the nodules was 0.93 ± 0.49 cm, and the shortest distance from the nodules to the pleura was 1.41 ± 0.95 cm. The distal end of the microcoil was placed less than 1 cm away from the nodule, and the proximal end was placed outside the visceral pleura. VATS was performed under the guidance of implanted microcoils without the aid of intraoperative fluoroscopy.

RESULTS

All 501 nodules were marked with microcoils. The time required for microcoil localization was 12.8 ± 5.2 minutes. Microcoil localization-related complications occurred in 179 cases (39.4%). None of the complications required treatment. A total of 463 nodules were successfully resected under the guidance of implanted microcoils. VATS revealed 38 patients with dislocated microcoils, of which 28 underwent wedge resection (21 cases under the guidance of the bleeding points of pleural puncture, 7 cases through palpation), 5 underwent direct lobectomy, and the remaining 5 underwent a conversion to thoracotomy. In 4 cases, a portion of the microcoil remained in the lung parenchyma.

CONCLUSION

CT-guided microcoil localization of SPNs is safe and reliable. Marking the nodule and pleura simultaneously with microcoils can effectively guide the resection of SPNs using VATS without the aid of intraoperative fluoroscopy.

The utility of simultaneous CT-guided localization for multiple pulmonary nodules using microcoil before video-assisted thoracic surgery

Background

To evaluate the feasibility and safety of microcoil in simultaneous localization for multiple pulmonary nodules before video-assisted thoracic surgery (VATS).

Methods

Twenty-eight consecutive patients (26 two-nodule, 2 three-nodule; 58 nodules in total; Group A) underwent simultaneous CT-guided localization of multiple pulmonary nodules before VATS using microcoil. Successful targeting, localization, and VATS were defined as implantation of microcoil at the target site on CT image which was obtained immediately after the marking procedure, visualization of nodule location, and complete resection of the target nodule with adequate margin, respectively. Meanwhile, the clinical characteristics, localization procedure-related variables of the nodules and procedure-related complications in group A were also assessed and compared with those in a control group (221 single-localization procedures in 221 patients; Group B).

Results

Similar rates of successful targeting, localization and VATS were observed in group A and B (96.6% vs. 98.2%; 91.4% vs. 91.0%; 100% vs. 99.1%). Although the rate of overall complications (including localized pneumothorax and intrapulmonary hemorrhage) was a bit higher in group A than that in group B (32.8% vs. 30.8%, p = 0.771), only minor complications were observed in the subjects of the two groups with no need for further treatment. In addition, the duration of simultaneous localization procedures was significantly longer than that of single localization (24 ± 7.5 vs.13 ± 6 min, p < 0.001).

Conclusions

CT-guided simultaneous microcoil localization for multiple pulmonary nodules before VATS was clinically feasible and safe with acceptable increase in the procedure time. Compared with localization for a single pulmonary nodule, simultaneous microcoil localizations for multiple nodules were prone to pneumothorax and hemorrhage. However, no statistically significant differences were observed between the two groups.

Application of Modified Tailed Microcoil in Preoperative Localization of Small Pulmonary Nodules: A Retrospective Study

BACKGROUND

The localization of small pulmonary nodules (SPNs) during video-assisted thoracoscopic surgery (VATS) is challenging thoracic surgeon, especially in patients with severe pleural adhesion or visceral pleura pigmentation due to low success rate and future conversion to thoracotomy. This study aims to compare the efficacy and safety between modified microcoil and methylene blue in preoperative localization of small nodules, particularly patients with severe pleural adhesion or visceral pleura pigmentation.

MATERIALS AND METHODS

From January 2018 to February 2019 in our institute, 342 patients who underwent computed tomography-guided localization of SPN were recruited in this retrospective cohort study and divided into the modified microcoil group (n = 239) and the methylene blue group (n = 103) according to the localization method. Clinical characteristics and perioperative complications were collected to analyze.

RESULTS

All SPNs were successfully marked in both groups. Location-related complications, the duration of localization procedure, and the length of hospital stay were not different between the two groups. The operation time of modified microcoil and the duration of removal of nodule in operation were both shorter than the methylene blue (p = 0.014 and p = 0.047). The analysis stratified by gender showed that similar results were found in male patients (p = 0.01 and p = 0.00), while in female patients, no significant difference was found. Additionally, in senior patients (older than 60 years), the operation time in modified microcoil groups was less than methylene blue group (p = 0.024).

CONCLUSION

Compared with methylene blue, modified microcoil achieved a shorter operation time of removal of nodule in VATS, especially for patients with pleural adhesion and the pigmentation of the lung surface as well as the male patients and the patients older than 60 years.

CT-guided microcoil localization for pulmonary nodules before VATS: a retrospective evaluation of risk factors for pleural marking failure

OBJECTIVES

To summarize the experiences of CT-guided microcoil localization before video-assisted thoracoscopic surgery (VATS) and to investigate the risk factors associated with pleural marking failure.

METHODS

Totally, 249 consecutive patients with 279 pulmonary nodules who underwent CT-guided microcoil localization prior to VATS were enrolled in this study. According to intraoperative observation, all the nodules were divided into two groups. The clinical characteristics and microcoil localization procedure-related variables of the nodules were analyzed by univariate analysis and multivariate logistic regression analysis to screen the independent factors associated with procedure results.

RESULTS

Among the 279 nodules, 28 failed to observe the proximal end of the microcoil deployed on visceral pleura during VATS. The logistic regression revealed that needle-pleura angle (≤ 30°: OR = 39.022, p = 0.003), pleura-microcoil distance (≤ 10 mm: OR = 87.054, p < 0.001; 10~20 mm: OR = 10.088, p = 0.010), and presence of pleural indentation (OR = 21.623, p < 0.001) were independent risk factors for pleural marking failure.

CONCLUSIONS

CT-guided microcoil localization for pulmonary nodules is a safe and effective procedure. Small needle-pleura angle (≤ 30°), pleura-microcoil distance (≤ 20 mm), and the presence of pleural indentation during the procedure are significant risk factors contributing to microcoil pleura marking failure.

KEY POINTS

• CT-guided microcoil localization for pulmonary nodules was a safe and effective procedure. • CT-guided microcoil localization for pulmonary nodules yielded low complication rates. • Small needle-pleura angle, short pleura-microcoil distance, and the presence of pleural indentation were contributing to pleura marking failure.

The multidisciplinary team plays an important role in the prediction of small solitary pulmonary nodules: a propensity-score-matching study

Background

According to guidelines, it is recommended that pulmonary nodules be discussed by a multidisciplinary team (MDT); however, the evidence for the effectiveness of MDT is sparse. To demonstrate the importance of the involvement of an MDT for the prediction of small solitary pulmonary nodules, we conducted this retrospective study.

Methods

The patient database of those who attended our MDT and the electronic medical record system of our hospital was used; we collected all the data from patients found with small solitary pulmonary nodules (≤2 cm), which were suspected as malignant and who received a resection of the nodules. We summarized their characteristics and analyzed them, and then compared the post-operation pathological diagnosis of the patients who attended an MDT to those who did not participate in an MDT during the same period (2017-2019.2). We also collected the follow-up data. Propensity-score-matching was utilized during the process of analysis to get a more reliable conclusion.

Results

Most of the qualified patients were female. Most of the small solitary pulmonary nodules (≤2 cm) were adenocarcinoma and located on the right upper lobe. There were no differences in the SUV value between malignant nodules and benign nodules. After propensity-score matching, the total positive prediction value of small solitary pulmonary nodules (≤2 cm) without an MDT was 69.4%, while that with MDT was 77.6%; the difference was not significant with a P value of 0.30. The negative predictive value of MDT was 76.2%.

Conclusions

In developing countries, small solitary pulmonary nodules tend to be more correctly diagnosed with MDT.

CT-guided Microcoil Pulmonary Nodule Localization prior to Video-assisted Thoracoscopic Surgery: Diagnostic Utility and Recurrence-Free Survival

Background CT-guided microcoil localization has been shown to reduce the need for thoracotomy or video-assisted thoracoscopic surgery (VATS) anatomic resection. However, only short-term follow-up after CT-guided microcoil localization and lung resection has been previously reported. Purpose To assess the diagnostic utility and recurrence-free survival over a minimum of 2 years following CT-guided microcoil localization and VATS. Materials and Methods Among 1950 VATS procedures performed in a single tertiary institution from October 2008 through April 2016, 124 consecutive patients with CT-guided microcoil localization were retrospectively evaluated. Patient demographics, nodule characteristics, and histopathologic findings were recorded. The primary end point was recurrence-free survival after 2 or more years of CT surveillance. Statistical analysis included Kaplan-Meier survival curves and Cox regression. Results In 124 patients (men, 35%; mean age, 65 years ± 12) with a nodule found at CT, microcoil localization and VATS resection were performed for a total of 126 nodules (mean size, 13 mm ± 6; mean distance to pleura, 20 mm ± 9). On presurgical CT evaluation, 42% (53 of 126) of nodules were solid, 33% (41 of 126) were ground glass, and 24% (30 of 126) were subsolid. VATS excisional biopsy altered cytopathologic diagnosis in 21% (five of 24) of patients with prior diagnostic premicrocoil CT-guided biopsy. At histopathologic examination, 17% (21 of 126) of the nodules were adenocarcinoma in situ, 17% (22 of 126) were minimally invasive adenocarcinoma, 30% (38 of 126) were invasive lung primary tumors, and 22% (28 of 126) were metastases. Among the 72 patients with malignancy at histopathologic examination and at least 2 years of CT surveillance, local recurrence occurred in 7% (five of 72), intrathoracic recurrence in 22% (16 of 72), and extrathoracic recurrence in 18% (13 of 72) after 2 or more years of CT surveillance. There was no recurrence for adenocarcinoma in situ, minimally invasive adenocarcinoma, or invasive lung tumors measuring less than 1 cm. After multivariable adjustment, nodule location at a distance greater than 10 mm from the pleura was an independent predictor of time to recurrence (hazard ratio, 2.9 [95% confidence interval: 1.1, 7.4]; P = .03). Conclusion CT-guided microcoil localization and video-assisted thoracoscopic surgical resection alter clinical management and were associated with excellent recurrence-free survival for superficial premalignant, minimally invasive, and small invasive lung tumors. © RSNA, 2019 Online supplemental material is available for this article.

[Advancement of Common Localization of Solitary Pulmonary Nodules for Video-assisted Thracoscopic Surgery]

最近，伴随着高分辨多层电子计算机断层扫描（computed tomography, CT）的大量普及，肺小结节的诊断也日益增多，尤其是在伴有肺癌高危因素的患者行CT筛查时尤为明显。电视辅助胸腔镜手术对于肺小结节的诊断和治疗提供了一种全新的微创治疗方式，胸腔镜手术后给患者带来的疼痛感减少、住院时间缩短、手术并发症减少等特点，使其推广更为广泛。如何精准定位及标记病灶，以助电视胸腔镜下切除病灶的方法层出不穷。本文综述近年来胸腔镜下肺小结节定位的各种技术手段，并对各种方法的利弊进行总结及分析。

Percutaneous Computed Tomography-Guided Radiotracer-Assisted Localization of Difficult Pulmonary Nodules in Uniportal Video-Assisted Thoracic Surgery

Objective: To report our institutional experience with radiotracer-assisted localization of lung nodules (RALN) in combination with uniportal video-assisted thoracoscopic surgery (UVATS). Methods: We retrospectively reviewed electronic medical records and radiology images of 27 consecutive adult patients who underwent planned UVATS lung resections combined with RALN from January 2014 to May 2017. Based on preoperative imaging, 29 nondescript nodules were marked with technetium 99 m macroaggregated albumin under computed tomography guidance before resection. Perioperative outcomes were analyzed. Results: All 29 nodules were successfully marked and resected with negative margins by UVATS; 12 (41.5%) were pure ground-glass opacities. Three patients had prior ipsilateral lung resections. There were no conversions to multiport VATS or thoracotomy. The majority (86.5%) of the nodules were malignant. The median nodule size was 8 mm (range: 3-20 mm) and depth, 56 mm (range: 22-150 mm). The majority (21/27; 77.8%) of patients underwent wedge resections alone, while 6 patients had anatomical resections. Median times were as follows: radiotracer injection to surgery, 219 minutes (range: 139-487 minutes); operative time, 85.5 minutes (32-236 minutes); chest tube removal, 1 day (range: 1-2 days); and length of stay, 2 days (range: 1-4 days). Four patients (14.8%) had a pigtail catheter placed for pneumothorax after radiotracer injection. One patient was readmitted 1 week after discharge for a spontaneous pneumothorax. There were no other morbidities or any 90-day mortality. Conclusion: RALN can be combined with UVATS to effectively resect small, deep, or low-density lung lesions that are difficult to visualize or palpate by thoracoscopy.

Value of virtual monochromatic spectral images with metal artifact reduction algorithm in dual-energy computed tomography-guided microcoil localization of pulmonary nodules

To evaluate the clinical value of virtual monochromatic spectral (VMS) images with metal artifact reduction (MAR) algorithm in dual-energy computed tomography (DECT)-guided microcoil localization of pulmonary nodules.Fifty-one patients underwent DECT after placement of microcoils on small pulmonary nodules before video-assisted thoracoscopic surgery (VATS). Optimal energy level (in keV) was defined as the level at which CT values of nodules were equivalent to those of 120 kVp images and with no serious metal artifacts. VMS images at optimal keV and at 50, 90,110, and 140 keV with and without MAR were reconstructed. Image quality was scored using a 3-point scale: 1 = excellent, minimal artifacts; 2 = good, mild artifacts; and 3 = poor, extensive artifacts. Image quality scores between the VMS-only and VMS + MAR groups were compared;74 keV was found to be the optimal level for VMS images. The image quality of the VMS + MAR images at 74 keV were significantly better than VMS-only images (1.35 ± 0.59 vs 2.11 ± 0.87, P = .005). There was no difference in image quality score among VMS + MAR images at 74 keV and higher energy levels.VMS images from DECT at 74 keV with MAR can reduce artifacts from microcoils and improve image quality for microcoil localization of pulmonary nodules.

VATS segmentectomy: past, present, and future

Video-assisted thoracoscopic surgery (VATS) has gradually been implemented in thoracic surgery, and the VATS approach has now been extended to technically challenging procedures, such as segmentectomy. The definition of VATS segmentectomy is changing over time, and the repertoire of segmentectomy is getting wider with increasing reports on atypical segmentectomy. VATS segmentectomy bears surgical, oncological, and technical advantages; however, there are still areas of controversy, particularly regarding oncological outcomes. The indication of VATS segmentectomy is diverse and is used for treating lung cancer, metastatic lung tumors, or a variety of nonmalignant diseases. It is particularly valuable for the lung-sparing resection of deeply located small nodules or repeated surgery for multiple lung lesions. VATS segmentectomy requires a thorough analysis of segmental anatomy and a tailored preoperative planning with the assessment of surgical margins. Technical challenges include intraoperative navigation, methods to identify and dissect the intersegmental plane, and the prevention of air leakage. This review will discuss the present state of VATS segmentectomy, with a focus on past studies, current indications and techniques, and future view.

Image-guided surgery and therapy for lung cancer: a critical review

Of the many imaging technologies, some have the potential to be used in image-guided surgery and therapy (IGS/IGT). This review of relevant papers on IGS/IGT for lung cancer indicates effective localization and IGS/IGT in early endobronchial lesions by fluorescence bronchoscopic technique. Visualization of early peripheral (nodular) tumors at operation can be achieved by a variety of imaging methods and devices which allow identification, localization and provision of intraoperative real-time images. Recent developments employing fluorescence contrasts and near infra-red light have shown encouraging feasibility and outcome in providing reliable methods for the IGS of cancer generally and lung cancer more specifically with provision of real time intraoperative imaging. The concept of the hybrid operating theater is touched upon.

Image-guided thoracic surgery in the hybrid operation room

There has been an increase in the use of image-guided technology to facilitate minimally invasive therapy. The next generation of minimally invasive therapy is focused on advancement and translation of novel image-guided technologies in therapeutic interventions, including surgery, interventional pulmonology, radiation therapy, and interventional laser therapy. To establish the efficacy of different minimally invasive therapies, we have developed a hybrid operating room, known as the guided therapeutics operating room (GTx OR) at the Toronto General Hospital. The GTx OR is equipped with multi-modality image-guidance systems, which features a dual source-dual energy computed tomography (CT) scanner, a robotic cone-beam CT (CBCT)/fluoroscopy, high-performance endobronchial ultrasound system, endoscopic surgery system, near-infrared (NIR) fluorescence imaging system, and navigation tracking systems. The novel multimodality image-guidance systems allow physicians to quickly, and accurately image patients while they are on the operating table. This yield improved outcomes since physicians are able to use image guidance during their procedures, and carry out innovative multi-modality therapeutics. Multiple preclinical translational studies pertaining to innovative minimally invasive technology is being developed in our guided therapeutics laboratory (GTx Lab). The GTx Lab is equipped with similar technology, and multimodality image-guidance systems as the GTx OR, and acts as an appropriate platform for translation of research into human clinical trials. Through the GTx Lab, we are able to perform basic research, such as the development of image-guided technologies, preclinical model testing, as well as preclinical imaging, and then translate that research into the GTx OR. This OR allows for the utilization of new technologies in cancer therapy, including molecular imaging, and other innovative imaging modalities, and therefore enables a better quality of life for patients, both during and after the procedure. In this article, we describe capabilities of the GTx systems, and discuss the first-in-human technologies used, and evaluated in GTx OR.

Tailored intraoperative localization of non-palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology

INTRODUCTION

VATS wedge resection can require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (HORs) provide real-time image acquisition capabilities allowing the intraoperative placement of markers to facilitate the removal of non-palpable nodules during VATS.

OBJECTIVES

To present our workflow based on the alternative use of two different markers according to the location of the lung lesion and report our initial results.

METHODS

All consecutive patients with non-palpable lesions requiring VATS wedge resection underwent localization of the targets in HOR. Lesions were considered non-palpable if they were small (<1 cm), deep (>1 cm from surface), subsolid, or located within a dystrophic area. Anesthetized patients were placed in lateral decubitus. Cone-beam CT (CBCT) was performed, and the needle trajectory was planned using Syngo iGuide Needle Guidance. Metal hook-wire or coil was placed, according to our workflow, close to the lesion and their position was verified by CBCT or fluoroscopy.

RESULTS

Eleven VATS wedge resections were performed in 10 patients with 12 non-palpable lesions. The localization was performed with seven hook-wires and four coils in 30 minutes (range 17-56 minutes). The median estimated total effective dose was 11.6 mSv (range 1.9-24.7 mSv). Eleven lesions were removed by VATS, and one deep nodule required a thoracotomy. No complications were observed.

CONCLUSIONS

Our experience confirms that HOR is suitable for simultaneous localization and VATS resection of 'difficult' pulmonary lesions. A versatile approach, using different devices, seems advisable for the removal of targets in every clinical scenario, reducing the VATS conversion rate.