Image-guided localization of small lung nodules in video-assisted thoracic surgery

Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BACKGROUND

Video-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.

METHODS

Retrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.

RESULTS

30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).

CONCLUSIONS

We demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

Image-guided video-assisted thoracoscopic surgery (iVATS): a single center experience and review

Lung cancer screening techniques using low-dose computed tomography (LDCT) scans have improved over the last decade. This means that there is an increased rate of detection of small, often non-palpable, nodules and ground-glass opacities. Obtaining a definitive diagnosis of these nodules using techniques such as percutaneous image-guided biopsy or intraoperative localization is challenging, and these nodules have traditionally undergone routine surveillance. Image-guided video-assisted thoracoscopic surgery (iVATS), which is performed in a hybrid operating room, has made it more feasible to biopsy and resect these nodules. The first thoracic surgery hybrid operative room was introduced at our institution at Brigham and Women's Hospital. Herein, we describe our experience implementing this technique including the methods we used to train key personnel such as radiologists, surgeons, and anesthesiologists to ensure that this technique successfully translated to a clinical setting. We review the benefits of iVATS, which includes decreased rate of fiducial dislodgement, real-time imaging which facilitates successful fiducial placement, and smaller sized resection of lung parenchyma. We will also describe the comparisons between traditional diagnostic methods and iVATS, patient selection criteria and important technical details. Some centers describe alternative techniques for several of the technical aspects, including patient positioning, which we also mention. Lastly, we describe adverse events after iVATS, which are comparable to those seen after a standard VATS.

Transbronchial microwave ablation of lung nodules with electromagnetic navigation bronchoscopy guidance-a novel technique and initial experience with 30 cases

Background

Microwave ablation of lung nodules may provide a faster, larger and more predictable ablation zone than other energy sources, while bronchoscopic transbronchial ablation has theoretical advantage of fewer pleural-based complications than percutaneous approach. Our study aims to determine whether the novel combination of bronchoscopic approach and microwave ablation in management of lung nodules is technically feasible, safe and effective.

Methods

This is a retrospective analysis of a single center experience in electromagnetic navigation bronchoscopy microwave ablation in hybrid operating room. Patients had high surgical risks while lung nodules were either proven malignant or radiologically suspicious. Primary endpoints include technical feasibility and safety.

Results

Total of 30 lung nodules from 25 patients were treated. Mean nodule size was 15.1 mm, and bronchus directly leads to the nodules (bronchus sign positive) in only half of them. Technical success rate was 100%, although some nodules required double ablation for adequate coverage. Mean minimal ablation margin was 5.51 mm. The mean actual ablation zone volume was -21.4% compared to predicted, likely due to significant tissue contraction ranging from 0-43%. There was no significant heat sink effect. Mean hospital stay was 1.73 days, and only 1 patient stayed for more than 3 days. Complications included pain (13.3%), pneumothorax requiring drainage (6.67%), post-ablation reaction (6.67%), pleural effusion (3.33%) and hemoptysis (3.33%). After median follow up of 12 months, none of the nodules had evidence of progression.

Conclusions

Bronchoscopic transbronchial microwave ablation is safe and feasible for treatment of malignant lung nodules. Prospective study on clinical application of this novel technique is warranted.

A hybrid, image-based and biomechanics-based registration approach to markerless intraoperative nodule localization during video-assisted thoracoscopic surgery

The resection of small, low-dense or deep lung nodules during video-assisted thoracoscopic surgery (VATS) is surgically challenging. Nodule localization methods in clinical practice typically rely on the preoperative placement of markers, which may lead to clinical complications. We propose a markerless lung nodule localization framework for VATS based on a hybrid method combining intraoperative cone-beam CT (CBCT) imaging, free-form deformation image registration, and a poroelastic lung model with allowance for air evacuation. The difficult problem of estimating intraoperative lung deformations is decomposed into two more tractable sub-problems: (i) estimating the deformation due the change of patient pose from preoperative CT (supine) to intraoperative CBCT (lateral decubitus); and (ii) estimating the pneumothorax deformation, i.e. a collapse of the lung within the thoracic cage. We were able to demonstrate the feasibility of our localization framework with a retrospective validation study on 5 VATS clinical cases. Average initial errors in the range of 22 to 38 mm were reduced to the range of 4 to 14 mm, corresponding to an error correction in the range of 63 to 85%. To our knowledge, this is the first markerless lung deformation compensation method dedicated to VATS and validated on actual clinical data.

Three-dimensional printed navigational template for localizing small pulmonary nodules: A case-controlled study

Background

Localization of small pulmonary nodules is an inevitable challenge for the thoracic surgeon. This study aimed to investigate the accuracy of three‐dimensional (3D) printing technology for localizing small pulmonary nodules, especially ground‐glass nodules (GGNs).

Methods

This study enrolled patients with peripheral small pulmonary nodules (≤ 2 cm) who required preoperative localization. In the comparison period, patients underwent both computed tomography‐guided (CT‐G) and 3D‐printing template guided (3D‐G) localization to compare the accuracies of the two methods. In the testing period, the 3D‐printing technique was implemented alone. The 3D‐printing physical navigational template was designed based on data from perioperative CT images. Clinical data, imaging data, surgical data, and evaluation index were collected for further analysis. The learning curve of the 3D‐printing localization technique was assessed using cumulative sum (CUSUM) analysis and multiple linear regression analysis.

Results

In the comparison period (n = 14), the success rates of CT‐G and 3D‐G were 100% and 92.9% (P = 0.31), respectively; in the testing period (n = 23), the success rate of 3D‐G was 95.6%. The localization times of CT‐G, 3D‐G (comparison), and 3D‐G (testing) were 23.6 ± 5.3, 19.3 ± 6.8, and 9.8 ± 4.6 minutes, respectively. The CUSUM learning curve was modeled using the equation: Y = 0.48X²− 0.013X − 0.454 (R² = 0.89). The learning curve was composed of two phases, phase 1 (the initial 20 patients) and phase 2 (the remaining 17 patients).

Conclusions

3D printing localization has adequate accuracy and is a feasible and accessible strategy for use in localizing small pulmonary nodules, especially in right upper lobe. The use of this technique could facilitate lung nodule localization prior to surgery.

Image-guided video-assisted thoracoscopic surgery with Artis Pheno for pulmonary nodule resection

Background

One challenging aspect of video-assisted thoracoscopic surgery (VATS) is finding the small pulmonary lung nodules for resection. Pre-operative localization of nodules is important for resection. Recently, image-guided VATS (iVATS) in a hybrid room has received attention. Our study aims to compare pros and cons between traditional CT room localization and iVATS localization with Artis Pheno.

Methods

This study was a retrospective analysis in our institute (Changhua Christian Hospital, Changhua). Patients with pulmonary nodules who received localization between January 2018 and December 2018 were included in the study. There were 126 patients included in the study. Among these, 63 patients received localization in a CT room and the other 63 patients received iVATS. We measured the time from localization to skin incision, success rate, complication rate, operation time, blood loss and length of hospital stay.

Results

Time from localization to skin incision was significantly shorter in the iVATS group than in the CT room group (23.57 vs. 372.11 min, P<0.001). The CT room group had a significantly higher complication rate than the iVATS group (n=49, 77.8% vs. n=2, 3.2%, P<0.001). There were no significant differences in operation methods, operation time, blood loss and length of hospital stay.

Conclusions

iVATS provides shorter time from localization to skin incision and fewer complications than CT room localization.

Hook-wire localization versus lipiodol localization for patients with pulmonary lesions having ground-glass opacity

OBJECTIVES

Accurate and safe preoperative localization is useful for video-assisted thoracic surgery of small pulmonary lesions with ground-glass opacity (GGO). However, the optimal localization method is unclear. The aim of this study was to compare the usefulness and safety of the lipiodol and hook-wire localization techniques for video-assisted thoracic surgery of GGO lesions.

METHODS

This prospective, non-randomized comparative study was conducted between April 2014 and December 2016 at 8 qualifying university teaching hospitals. Two-hundred-fifty patients with pulmonary lesions having GGO were included. Patients were assigned in a 1:1 ratio to either the lipiodol (n = 125, 4 hospitals) or hook-wire group (n = 125, 4 hospitals) for preoperative localization procedures. Participants underwent preoperative localization via the lipiodol or hook-wire technique followed by thoracoscopic surgery. The primary endpoint was the procedure success rate.

RESULTS

The procedure success rates (hook-wire vs lipiodol group) were 94.40% versus 99.16% (P = .08). Localization-related complications occurred in 53.60% versus 48.33% of patients (P = .49). Hemorrhage rates were significantly greater in the hook-wire group than in the lipiodol group (21.6% vs 5.83%, P < .001). The lipiodol procedure time was significantly longer than that of the hook-wire technique (20.69 ± 9.34 vs 17.15 ± 7.91 minutes, P = .001). The initially positive surgical resection margin was significantly greater in the hook-wire group than in the lipiodol group (10.89% vs 2.38%, P = .02).

CONCLUSIONS

There was no significant difference in success rate between the hook-wire and lipiodol methods. However, the hemorrhage rate was significantly greater in the hook-wire group, whereas the hook-wire group showed greater initially positive surgical resection margins.

Devising the guidelines: the techniques of pulmonary nodule localization in uniportal video-assisted thoracic surgery-hybrid operating room in the future

Pulmonary nodules beneath the pleura can be hard to visualize or palpate, especially during the uniportal thoracoscopic surgery. Conventionally, thoracic surgeons would use adjuvant modalities to localize the lesion preoperatively, of which computed tomography-guided hookwire implantation has been adopted most widely due to its feasibility and high success rate. However, procedure-associated complications such as pneumothorax and wire dislodgement can cause patient discomfort or localization failure. Occasionally more healthy tissue is resected than needed to guarantee the lesion is removed and with an adequate margin. A thoracotomy is necessary for specific scenario. With the development of imaging technology, it is now possible to replace the traditional workflow carried out in the radiology suite by centralizing the hookwire placement and uniportal minimally-invasive pulmonary resection inside the hybrid theater which equipped with advanced imaging devices. Theoretically, the advanced intra-operative imaging-guided techniques help to precisely locate and resection pulmonary lesion in a potentially tissue-sparing and quick paradigm.

Placement of markers to assist minimally invasive resection of peripheral lung lesions

With development of lung cancer screening programs and increased utilization of radiographic imaging there is significantly higher detection of smaller lung nodules and subsolid lesions. These nodules could be malignant and pose a diagnostic challenge. Video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery (RATS) represent minimally invasive methods for tissue sampling. Intraoperative identification of these lesions maybe difficult, requiring marking prior to surgery. We review different techniques for the placement of markers to assist in the resection of peripheral lung lesions (PLL).

Hybrid operating room for the intraoperative CT-guided localization of pulmonary nodules

Video-assisted thoracic surgery (VATS) requires preoperative computed tomography (CT)-guided localization of small pulmonary nodules or ground glass opacities (GGOs). However, this traditional two-stage approach is not devoid of potential complications, including wire dislodgement, pneumothorax, and/or hemothorax. With the advent of hybrid operating rooms (HORs), simultaneous single-stage localization and removal of such lesions has become possible. Here, we review the technical developments and the state-of-the-art in the field of intraoperative CT-guided localization and resection of small pulmonary nodules performed within a HOR.

[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。

Hybrid Theater and Uniportal Video-Assisted Thoracic Surgery: The Perfect Match for Lung Nodule Localization

Cone-beam computed tomography provides unparalleled real-time imaging of the patient within the hybrid theater, which can be used for simultaneously diagnosing and localizing small pulmonary lesions for resection. Hybrid theater can guide more precise placement of electromagnetic navigation bronchoscopy tools, thereby increasing the diagnostic yield in biopsy procedures while reducing diffusion artifact in dye marking for nodule localization. Furthermore, hook-wires implantation that is widely used to assist in lesion localization for uniportal thoracoscopic surgery can take place in the hybrid suite, eliminating the common complications and discomfort associated with the conventional workflow carried out in the radiology suite.

Use of electromagnetic navigational bronchoscopy in robotic pulmonary resection

Robotic resection of pulmonary lesions has become a more common approach in the field of thoracic surgery. The greatest drawback of robotic resection is the lack of tactile feedback as compared to open approaches, making identification of intrapulmonary lesion difficult. Electromagnetic navigational bronchoscopy (navibronch) enables pre-incisional marking of pulmonary lesions for intraoperative identification. We sought to determine how effective navibronch was in our institution's robotic cases. Thirty-one patients underwent robotically assisted resection of 35 lesions with the assistance of navibronch from 7/2014 to 9/2015. Retrospective demographic and operative data were collected on these patients, and statistical analysis was conducted using ANOVA means testing, Chi-square, and non-parametric tests. The average age in this patient population was 63.7 ± 13.5 years. Eight patients (25.8%) were male. Twenty-five (80.6%) of the patients had pathology involving one lobe, with six (19.4%) in two lobes. 34 of the resections (97.1%) resulted in dye being localized to the first specimen; 34 (97.1%) were found to have the target pathology in the initial specimen. Further resection was carried out in 22 (62.9%) cases, with the final resection resulting in a segment in 2 (5.7%) and a lobe in 14 (40.0%). The mean number of lung specimens collected was 1.94 ± 0.13. The mean number of tumors in each target resection was 1.46 ± 0.66 in final pathology. Malignancy was found in 19 (54.3%) of final specimens. There were no complications related to navibronch. Navibronch is an effective technique in the identification and localization of pulmonary lesions in robotically assisted lung resections.

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.