Image-guided techniques for localizing pulmonary nodules in thoracoscopic surgery

Augmented fluoroscopy-guided dye localization for small pulmonary nodules in hybrid operating room: intrathoracic stamping versus transbronchial marking

PURPOSE

We developed a novel augmented fluoroscopy-guided intrathoracic stamping technique for localizing small pulmonary nodules in the hybrid operating room. We conducted an observational study to investigate the feasibility of this technique and retrospectively compared two augmented fluoroscopy-guided approaches: intrathoracic and transbronchial.

METHODS

From August 2020 to March 2023, consecutive patients underwent single-stage augmented fluoroscopy-guided localization under general anaesthesia. This included intrathoracic stamping and bronchoscopic lung marking, followed by thoracoscopic resection in a hybrid operating room. Comparative analyses were performed between the two groups.

RESULTS

The data of 50 patients in the intrathoracic stamping and 67 patients in the bronchoscopic lung marking groups were analysed. No significant difference was noted in demographic data between the groups, except a larger lesion depth in the bronchoscopic lung marking group (14.7 ± 11.7 vs 11.0 ± 5.8 mm, p = 0.029). Dye localization was successfully performed in 49 intrathoracic stamping group patients (98.0%) and 67 bronchoscopic lung marking group patients (100%). No major procedure-related complications occurred in either group; however, the time flow (total anaesthesia time/global operating room time) was longer, and the radiation exposure (fluoroscopy duration/total dose area product) was larger in the bronchoscopic lung marking group.

CONCLUSIONS

Augmented fluoroscopic stamping localization under intubated general anaesthesia is feasible and safe, providing an alternative with less global operating room time and lower radiation exposure for image-guided thoracoscopic surgery in the hybrid operating room.

Single-Stage Image-Guided Percutaneous Ablation with Thoracoscopic Resection for Multiple Pulmonary Lesions in a Hybrid Operating Room: A Retrospective Study

BACKGROUND

Different approaches are required in treating patients with multiple pulmonary lesions. A multistage procedure may increase the risk of complications and patient discomfort. This study reports an initial experience with single-stage management of multiple lung lesions using percutaneous ablation with thoracoscopic resection in a hybrid operating room (HOR).

METHODS

We retrospectively evaluated patients who underwent combined ablation and resection in an HOR between May 2022 and July 2024. All patients received a single anesthesia via endotracheal tube intubation. The clinical data, operative findings, and pathological characteristics of the lung nodules were recorded.

RESULTS

A total of 22 patients were enrolled in this study. Twenty patients underwent unilateral procedures, while the other two patients underwent bilateral procedures. Ablations were performed before lung resection in 21 patients; only 1 patient underwent surgery first. The median global operating room time was 227.0 min. The median total radiation dose (dose area product) was 14,076 μGym2. The median hospital postoperative length of stay was 2 days.

CONCLUSIONS

The single-stage procedure of percutaneous ablation with thoracoscopic resection under general anesthesia in an HOR is feasible and safe. This procedure is an alternative method for managing multiple pulmonary lesions.

Unlocking the Potential of Computed Tomography-Guided Tracers in Pinpointing Lung Lesions during Surgery: A Collaborative Multi-Institutional Journey

Background: Multiple techniques exist for the preoperative localization of small, deeply located solid or subsolid pulmonary nodules to guide limited thoracoscopic resection. This study aims to conduct a multi-institutional comparison of three different tomography-guided tracers' methods. Methods: A retrospective multicenter cross-sectional study was conducted. All patients suitable for CT-guided tracers with microcoil (GROUP1, n = 58), hook wire (GROUP2, n = 86), or bioabsorbable hydrogel plug (GROUP3, n = 33) were scheduled for video-assisted thoracoscopic wedge resection. Outcome variables: successful nodule localization, safety, and the feasibility of the tracers' placement. A χ2 test or Fisher's test for expected numbers less than five and a Kruskal-Wallis test were used to analyze the categorical and continuous variables, respectively. For the power calculations, we used G*Power version 3.1.9.6. Results: One hundred seventy-seven patients underwent the localization and resection of 177 nodules detected with three different CT-guided tracers. A significant difference was recorded for cancer history (p = 0.030), respiratory function, Charlson comorbidity index (p = 0.018), lesion type (p < 0.0001), distance from pleura surface (p < 0.0001), and time between preoperative CT-guided tracers and surgical procedures (p < 0.0001). Four post-procedural complications were recorded and in GROUP2, four cases of tracer dislocations occurred. Finally, hook wire group was associated with the shortest surgical time (93 min, p = 0.001). Conclusions: All methods were feasible and efficient, resulting in a 100% success rate for the microcoils and the bioabsorbable hydrogel plugs and a 94.2% success rate for the hook wires. Our results highlight the need to choose a technique that is less stressful for the patient and helps the surgeon by extending the approach to deep nodules and resecting over the course of several days from deployment.

Contemporary Video-Assisted Thoracoscopic Lobectomy for Early-Stage Lung Cancer

The treatment of non-small cell lung cancer (NSCLC) has evolved tremendously in recent decades as innovations in medical therapies advanced concomitantly with minimally invasive surgical techniques. Despite early skepticism regarding its benefits, video-assisted thoracoscopic surgery (VATS) techniques for the surgical resection of early-stage NSCLC have now become the standard of care. After being the subject of many studies since its inception, VATS has been shown to cause less postoperative pain, have shorter recovery time, and have fewer overall complications when compared to conventional open approaches. Furthermore, some studies have shown it to have comparable oncological outcomes, though more higher evidence studies are needed. Newer technologies and improved surgical instruments, advancements in nodule localization techniques, and improved preoperative staging procedures have allowed for the development of newer, less invasive techniques such as uniportal VATS and parenchymal-sparing sublobar resections, which might further improve postoperative rates of complications in specific cases. These minimally invasive approaches have allowed surgeons to offer surgery to high-risk patients and those who would otherwise not tolerate conventional thoracotomy, though some relative contraindications still exist. This review aims to describe the evolution of VATS lobectomy, current techniques, its indications, contraindications, preoperative testing, benefits, and outcomes in patients with stage I and II NSCLC.

Nontraumatic intraoperative pulmonary nodule localization with laser guide stamping in a hybrid operating room

Lung nodule localization using conventional image-guided video-assisted thoracoscopic surgery involves lung puncture, which increases the risk of needle-related complications. We aimed to evaluate the feasibility and safety of a single-stage non-invasive laser-guided stamping localization technique followed by resection under general anesthesia in a hybrid operating room. We retrospectively reviewed consecutive patients who underwent thoracoscopic surgery for small pulmonary nodules using laser-guided dye-stamping localization methods in a hybrid operating room between June 2023 and October 2023. During the study period, 18 patients with 20 lesions underwent single-stage intraoperative image-guided stamping video-assisted thoracoscopic surgery in the hybrid operating room. The median size of the nodules was 7.4 mm (interquartile range [IQR] 5.7-9.8 mm), and median distance from the pleural surface was 9.8 mm (IQR 7.7-14.6 mm). The median localization time was 26 min (IQR 23-34 min), whereas median operation time was 69 min (IQR 62-87 min). The total median operating room time was 146 min (IQR 136-157 min). Twelve patients underwent less than two cone-beam computed tomography scans, while 6 underwent more than two scans. The total median dose area product, including cone-beam computed tomography scans, was 5731.4 uGym2. No localization-related complications were observed, and the postoperative length of stay was 1 day (IQR 1-2 days). The single-stage image-guided pleural stamping technique for localizing small pulmonary nodules in a hybrid operating room is feasible and safe. Future research with larger cohorts is required to further explore the benefits of this workflow.

An injectable fluorescent and iodinated hydrogel for preoperative localization and dual image-guided surgery of pulmonary nodules

The widespread use of video-assisted thoracoscopic surgery (VATS) has triggered the rapid expansion in the field of computed tomography (CT)-guided preoperative localization and near-infrared (NIR) fluorescence image-guided surgery. However, its broader application has been hindered by the absence of ideal imaging contrasts that are biocompatible, minimally invasive, highly resolvable, and perfectly localized within the diseased tissue. To achieve this goal, we synthesize a dextran-based fluorescent and iodinated hydrogel, which can be injected into the tissue and imaged with both CT and NIR fluorescence modalities. By finely tuning the physical parameters such as gelation time and composition of iodinated oil (X-ray contrast agent) and indocyanine green (ICG, NIR fluorescence dye), we optimize the hydrogel for prolonged localization at the injected site without losing the dual-imaging capability. We validate the effectiveness of the developed injectable dual-imaging platform by performing image-guided resection of pulmonary nodules on tumor-bearing rabbits, which are preoperatively localized with the hydrogel. The injectable dual-imaging marker, therefore, can emerge as a powerful tool for surgical guidance.

Lung microwave ablation: Post-procedure imaging features and evolution of pulmonary ground-glass nodule-like lung cancer

PURPOSE

To retrospectively examine the imaging characteristics of chest-computed tomography (CT) following percutaneous microwave ablation (MWA) of the ground-glass nodule (GGN)-like lung cancer and its dynamic evolution over time.

MATERIALS AND METHODS

From June 2020 to May 2021, 147 patients with 152 GGNs (51 pure GGNs and 101 mixed GGNs, mean size 15.0 ± 6.3 mm) were enrolled in this study. One hundred and forty-seven patients underwent MWA procedures. The imaging characteristics were evaluated at predetermined time intervals: immediately after the procedure, 24-48 h, 1, 3, 6, 12, and ≥18 months (47 GGNs).

RESULTS

This study population included 147 patients with 152 GGNs, as indicated by the results: 43.5% (66/152) adenocarcinoma in situ, 41.4% (63/152) minimally invasive adenocarcinoma, and 15.1% (23/152) invasive adenocarcinoma. Immediate post-procedure tumor-level analysis revealed that the most common CT features were ground-glass opacities (93.4%, 142/152), hyperdensity within the nodule (90.7%, 138/152), and fried egg sign or reversed halo sign (46.7%, 71/152). Subsequently, 24-48 h post-procedure, ground-glass attenuations, hyperdensity, and the fried egg sign remained the most frequent CT findings, with incidence rates of 75.0% (114/152), 71.0% (108/152), and 54.0% (82/152), respectively. Cavitation, pleural thickening, and consolidation were less frequent findings. At 1 month after the procedure, consolidation of the ablation region was the most common imaging feature. From 3 to 12 months after the procedure, the most common imaging characteristics were consolidation, involutional parenchymal bands and pleural thickening. At ≥18 months after the procedure, imaging features of the ablation zone revealed three changes: involuting fibrosis (80.8%, 38/47), consolidation nodules (12.8%, 6/47), and disappearance (6.4%, 3/47).

CONCLUSIONS

This study outlined the anticipated CT imaging characteristics of GGN-like lung cancer following MWA. Diagnostic and interventional radiologists should be familiar with the expected imaging characteristics and dynamic evolution post-MWA in order to interpret imaging changes with a reference image.

Augmented reality navigation-guided intraoperative pulmonary nodule localization: a pilot study

Background

With the increasing number of small pulmonary nodules detected, effective localization of pulmonary nodules has become an issue. The goal of this study is to determine the safety and feasibility of a newly developed augmented reality navigation technology for intraoperative localization of small pulmonary nodules.

Methods

We conducted a prospective single-center feasibility study of a novel augmented reality navigation system and lung localization (LungBrella) marker on ten patients between July and October 2020. For augmented reality navigation-guided localization, a preoperative chest computed tomography scan was performed to generate 3-dimensional (3D) virtual images and individualized localization plan, which were uploaded into Hololens (a head-mounted augmented reality device). Under the guidance of established procedure plan displayed by HoloLens, localization marker was placed in operating room. Segmentectomy or wedge resection was subsequently performed. The primary endpoint was the localization procedure success rate, and the secondary endpoints were localization time, operation time, and complications.

Results

Localization was successful in seven of the ten procedures. Due to different reasons, failures were noted in three cases, after which immediate adjustments were made. In the successful cases, the LungBrella marker was positioned at a median of 5.8 mm (range, 0-10 mm) from the edge of the nodule. Median localization time was 9.4 min (range, 5-19 min), and median operation time was 172.9 min (range, 105-200 min). There were no complications during the entire process.

Conclusions

This exploratory study suggests that augmented reality navigation-guided pulmonary nodule localization is a safe and feasible technique (ClinicalTrials.gov identifier, NCT04211051).

Pulmonary Recruitment Prior to Intraoperative Multiple Pulmonary Ground-Glass Nodule Localization Increases the Localization Accuracy-A Retrospective Study

The standard treatment for early-stage lung cancer is complete tumor excision by limited resection of the lung. Preoperative localization is used before video-assisted thoracoscopic surgery (VATS) to improve the accuracy of pulmonary nodule excision. However, lung atelectasis and hypoxia resulting from controlling apnea during the localization procedure may affect the localization accuracy. Pre-procedural pulmonary recruitment may improve the respiratory mechanics and oxygenation during localization. In this study, we investigated the potential benefits of pre-localization pulmonary recruitment prior to pulmonary ground-glass nodule localization in a hybrid operating room. We hypothesized that pre-localization pulmonary recruitment would increase the localization accuracy, improve oxygenation, and prevent the need for re-inflation during the localization procedure. We retrospectively enrolled patients with multiple pulmonary nodule localizations before surgical intervention in our hybrid operating room. We compared the localization accuracy between patients who had undergone pre-procedure pulmonary recruitment and patients who had not. Saturation, re-inflation rate, apnea time, procedure-related pneumothorax, and procedure time were also recorded as secondary outcomes. The patients who had undergone pre-procedure recruitment had better saturation, shorter procedure time, and higher localization accuracy. The pre-procedure pulmonary recruitment maneuver was effective in increasing regional lung ventilation, leading to improved oxygenation and localization accuracy.

Management of ground-glass opacities and sub-solid pulmonary nodules: a surgeon's perspective

The regular use of high-resolution computed tomogram scans has led to an increase in the detection of asymptomatic ground-glass opacities and sub-solid nodules at an early stage. Different growth patterns of these lesions are making decision-making a real challenge. With growing experience and improving radiology interventions, management of these lesions is changing constantly. However, with variations in growth patterns and outcomes, immediate treatment options as well as follow-up surveillance and subsequent interventions can be confounding for the clinicians. This mini review describes algorithms for managing these ground-glass opacities (GGOs) and sub-solid nodules (SSNs) with a focus on the surgical options.

Using the robotic platform in the therapy of multifocal ground glass opacities

Due to their association with invasive adenocarcinoma, ground glass opacities that reach 3 cm in size, develop a solid component ≥2 mm on mediastinal windows, or exhibit ≥25% annual growth warrant operative resection. Minimally invasive techniques are preferred given that approximately one third of patients will present with multifocal focal disease and may require additional operations. A robotic-assisted thoracoscopic surgical approach can be used with percutaneous or bronchoscopic localization techniques and are compatible with developing intraoperative molecular targeting techniques.

A new preoperative localization of pulmonary nodules guided by mixed reality: a pilot study of an animal model

Background

With the popularity of high-resolution computed tomography (HRCT), more and more pulmonary nodules are being discovered. Video-assisted thoracoscopic surgery (VATS) has become the first choice for surgical treatment of pulmonary nodules. The use of accurate preoperative localization is crucial for successful resection in VATS. At present, there are many kinds of preoperative localization methods, but there are certain disadvantages. This study aimed to evaluate the feasibility and safety of mixed reality (MR)-guided pulmonary nodules localization, which is a new method that can benefit patients to a greater extent.

Methods

By constructing an animal model of pulmonary nodules localization, 28 cases of pulmonary nodules were located by MR-guided localization. We recorded the localization accuracy, localization time, insertion attempts, and incidence of complications related to localization under MR-guidance.

Results

All 28 nodules were successfully located: the deviation of MR-guided localization was 5.71±2.59 mm, localization time was 8.07±1.44 min, and insertion attempts was 1. A pneumothorax and localizer dislodgement occurred in 1 case, respectively.

Conclusions

Since preoperative localization is critical for VATS resection of pulmonary nodules, we investigated a new localization method. As indicated by our study, MR-guided localization of pulmonary nodules is feasible and safe, which is worthy of further research and promotion. We have also registered corresponding clinical trials to further investigate and help to improve our understanding of this technique.

Evaluation of the radiofrequency identification lung marking system: a multicenter study in Japan

BACKGROUND

The radiofrequency identification (RFID) lung marking system is a novel technique using near-field radio-communication technology. The purpose of this study was to investigate the utility and feasibility of this system in the resection of small pulmonary nodules.

METHODS

We retrospectively reviewed clinical records of 182 patients who underwent sublobar resection with the RFID marking system between March 2020 and November 2021 in six tertial hospitals in Japan. Target markings were bronchoscopically made within 3 days before surgery. The contribution of the procedure to the surgery and safety was evaluated.

RESULTS

Target nodule average diameter and depth from the lung surface were 10.9 ± 5.4 mm and 14.6 ± 9.9 mm, respectively. Radiologically, one third of nodules appeared as pure ground-glass nodules (GGNs) on CT. The average distance from target nodule to RFID tag was 8.9 ± 7.1 mm. All surgical procedures were completed by video-assisted thoracoscopic surgery. Planned resection was achieved in all cases without any complications. The surgeons evaluated this system as helpful in 93% (necessary: 67%, useful; 26%) of cases. Nodule radiological features (p < 0.001) and type of surgery (p = 0.0013) were associated with the degree of contribution. In most cases, identification of the RFID tag was required within 1 min despite adhesion (p = 0.27).

CONCLUSION

The RFID lung marking system was found to be safe and effective during successful sublobar resection. Patients with pure GGNs are the best candidates for the system.

Preoperative Localization for Small Pulmonary Nodules Using Anchor with Scaled Suture System

PURPOSES

This study aimed to describe a new localization technique developed using an anchor with a scaled suture (AWSS) system and to characterize the localization results and post-operative outcomes to evaluate its safety and effectiveness.

METHODS

This retrospective study was conducted at our centre from October 2020 to December 2021. In total, 328 small pulmonary nodules (sPNs) who underwent pre-operative computed tomography (CT)-guided AWSS system localization followed by wedge resection by video-assisted thoracoscopic surgery (VATS) were enrolled in this study.

RESULTS

CT-guided AWSS system implantations targeting 328 sPNs were successfully performed. The time spent performing localization was 12.4 ± 4.9 min. After puncture localization, the incidences of pneumothorax, pulmonary haemorrhage, and chest pain were 19.2% (63/328), 25.9% (85/328), and 0.9% (3/328), respectively. The incidence of overall complications was 42.7%. According to the CIRSE classification, there were no major complications. The median localization-VATS interval time was 7 h (range, 1-75 h). In 328 cases (100%), the location of the lesion was determined by palpation of the four-paw anchor in the lung and was successfully resected by VATS, and the correct diagnosis was obtained.

CONCLUSION

In this series, CT-guided pre-operative localization of pulmonary nodules with the AWSS system was safe and had a high positioning accuracy and success rate.

Localization Technique Using Mixture of Indigo Carmine and Lipiodol of Pulmonary Nodule via Bronchoscopic Navigation

Background and Objectives: As the number of minimally invasive surgeries, including video-assisted thoracoscopic surgery, increases, small, deeply located lung nodules are difficult to visualize or palpate; therefore, localization is important. We studied the use of a mixture of indigo—carmine and lipiodol, coupled with a transbronchial approach—to achieve accurate localization and minimize patient discomfort and complications. Materials and Methods: A total of 60 patients were enrolled from May 2019 to April 2022, and surgery was performed after the bronchoscopy procedure. Wedge resection or segmentectomy was performed, depending on the location and size of the lesion. Results: In 58/60 (96.7%) patients, the localization of the nodules was successful after localization, and 2/60 required c-arm assistance. None of the patients complained of discomfort during the procedure; in all cases, margins were found to be free from carcinoma, as determined by the final pathology results. Conclusions: We recommend this localization technique using mixture of indigo carmine and lipiodol, in concert with the transbronchial approach, because the procedure time is short, patient’s discomfort is low, and success rate is high.

How effective is indocyanine green (ICG) in localization of malignant pulmonary nodules? A systematic review and meta-analysis

Background

Video-Assisted and Robotic-Assisted techniques become constantly more prominent practice in thoracic surgery for lung cancer. Furthermore, the increased frequency in detection of small lung cancers makes the intra-operative identification of these cancers even more challenging. Indocyanine Green (ICG) is one of the most commonly used dyes that assists surgeons identify small lung cancers intra-operatively. Our study aimed to evaluate the effectiveness and safety of ICG in lung cancer detection.

Methods

We performed a systematic review of the literature by screening the databases of MEDLINE, EMBASE, CENTRAL and Scopus until 30th April 2022 and the first 300 articles of Google Scholar for any suitable grey literature. We included any study that investigated the effectiveness of ICG in lung cancer detection. We excluded studies that explored the use of ICG only in identification of intersegmental planes, lymph node mapping, case reports and non-English articles. We aimed to perform a meta-analysis on test accuracy studies using hierarchical summary receiver operating characteristic (HSROC) and the bivariate random-effects models. In cases where the data for a localization technique was not sufficient for that analysis, it was presented with tables with narrative purposes. Each study was assessed for Risk of Bias (RoB) and Applicability using the QUADAS-2 tool.

Results

We found 30 eligible studies that included a total of 1,776 patients who underwent ICG localization of pulmonary nodules. We identified three ICG localization techniques: CT-guided, endobronchial and intravenous. From the 30 studies, 13 investigated CT-guided localization, 12 explored an endobronchial method while 8 studies administered ICG intravenously the median reported success rate was 94.3% (IQR: 91.4%-100%) and 98.3% (IQR: 94%-100%) for the first two techniques respectively. Intravenous ICG lung cancer localization showed Sensitivity of 88% (95% CI: 59%-0.97%) and Specificity of 25% (95% CI: 0.04%-0.74%). There were 15.2% (150/989) patients who experienced complications from CT guided ICG localization. No ICG-related complications were reported in endobronchial or intravenous techniques.

Conclusion

Our study provides a comprehensive review of the literature on ICG localization techniques for lung cancer. Current evidence suggests that ICG is boh effective and safe. Further prospective research with standardized protocols across multiple thoracic units is required in order to accurately validate these findings.

Fluorescence-guided lung nodule identification during minimally invasive lung resections

In the last few years, minimally invasive surgery has become the standard routine practice to manage lung nodules. Particularly in the case of robotic thoracic surgery, the identification of the lung nodules that do not surface on the visceral pleura could be challenging. Therefore, together with the evolution of surgical instruments to provide the best option in terms of invasiveness, lung nodule localization techniques should be improved to achieve the best outcomes in terms of safety and sensibility. In this review, we aim to overview all principal techniques used to detect the lung nodules that do not present the visceral pleura retraction. We investigate the accuracy of fluorescence guided thoracic surgery in nodule detection and the differences among the most common tracers used.

Raman-Guided Bronchoscopy: Feasibility and Detection Depth Studies Using Ex Vivo Lung Tissues and SERS Nanoparticle Tags

Image-guided and robotic bronchoscopy is currently under intense research and development for a broad range of clinical applications, especially for minimally invasive biopsy and surgery of peripheral pulmonary nodules or lesions that are frequently discovered by CT or MRI scans. Optical imaging and spectroscopic modalities at the near-infrared (NIR) window hold great promise for bronchoscopic navigation and guidance because of their high detection sensitivity and molecular/cellular specificity. However, light scattering and background interference are two major factors limiting the depth of tissue penetration of photons, and diseased lesions such as small tumors buried under the tissue surface often cannot be detected. Here we report the use of a miniaturized Raman device that is inserted into one of the bronchoscope channels for sensitive detection of “phantom” tumors using fresh pig lung tissues and surface-enhanced Raman scattering (SERS) nanoparticle tags. The ex vivo results demonstrate not only the feasibility of using Raman spectroscopy for endoscopic guidance, but also show that ultrabright SERS nanoparticles allow detection through a bronchial wall of 0.85 mm in thickness and a 5 mm-thick layer of lung tissue (approaching the fourth-generation airway). This work highlights the prospects and potential of Raman-guided bronchoscopy for minimally invasive imaging and detection of lung lesions.

Lung nodule localization in hybrid room before minimally invasive thoracic surgery: series of 20 cases and literature review

Objective

To describe an experience in the preoperative localization of small pulmonary nodules and ground-glass lesions to guide minimally invasive thoracic surgery; in addition, a literature review was conducted, including the main advantages and disadvantages of the different agents used, and site marking in a hybrid operating room.

Methods

A retrospective search was conducted in a Interventional Radiology Department database, between March 2015 and May 2019, to identify patients undergoing preoperative percutaneous marking of lung injuries measuring up to 25mm.

Results

A total of 20 patients were included and submitted to descriptive analysis. All patients were marked in a hybrid room, at the same surgical-anesthetic time. Most often used markers were guidewire, Lipiodol^® and microcoils. Despite one case of coil displacement, two cases of pneumothorax, and one case of hypotension after marking, all lesions were identified and resected accordingly from all patients.

Conclusion

Preoperative percutaneous localization of lung injuries in hybrid room is an effective and a safe technique, which can have decisive impact on surgical resection. The choice of marker and of the operating room scenario should be based on availability and experience of service. Multidisciplinary discussions with surgical teams, pathologists, and interventional radiologists are crucial to improve outcome of patients.

[Application and Progress of Electromagnetic Navigation Bronchoscopy in Department of Thoracic Surgery]

Lung cancer ranks the first cancer-related morbidity and mortality in China. With the development and penetration of imaging technology, increasing small pulmonary peripheral Nodules (SPPNs) have been detected. However, precise location and diagnosis of SPPNs is still a tough problem for clinical diagnosis and treatment in department of thoracic surgery. With the development of electromagnetic navigation bronchoscopy (ENB), it provides a novel minimally invasive method for the diagnosis and treatment of SPPNs. In this review, we summarized the application and progress of ENB in preoperative positioning, diagnosis, and local treatment, then, discussed the clinical application of ENB in the hybrid operating room.
.

Preoperative radio-guided localization of lung nodules with I-125 seeds: experience with 32 patients at a single institution

OBJECTIVES

Videothoracoscopic visualization and/or palpation of pulmonary nodules may be difficult due to their location, small size or limited solid component. The purpose of this study is to present our experience with computed tomography (CT)-guided preoperative localization of pulmonary nodules by percutaneous marking with radio-labelled iodine-125 seeds.

METHODS

A total of 34 pulmonary nodules were marked under CT with the placement of 33 radio-labelled iodine-125 seeds in 32 consecutive patients.

RESULTS

All patients underwent biportal video-assisted thoracic surgery (VATS) and in no case was conversion to thoracotomy necessary. A total of 88.2% of the lung nodules were successfully resected. In the remaining 11.8%, migration of the seed to the pleural cavity occurred, although these nodules were still resected during VATS. Of all the patients with pneumothorax after the marking procedure, only one required chest tube placement (3.1%). No major postoperative complications were observed.

CONCLUSIONS

Preoperative marking of pulmonary nodules with I-125 seeds under CT guidance is a feasible and safe technique that allows their intraoperative identification and resection.

Percutaneous Electromagnetic Transthoracic Nodule Localization for Ground Glass Nodules

Background

A recent increase in the incidental detection of ground glass nodules (GGNs) has created a need for improved diagnostic accuracy in screening for malignancies. However, surgical diagnosis remains challenging, especially via video-assisted thoracoscopic surgery (VATS). Herein, we present the efficacy of a novel electrical navigation system for perioperative percutaneous transthoracic nodule localization.

Methods

Eighteen patients with GGNs who underwent electromagnetic navigated percutaneous transthoracic needle localization (ETTNL), followed by 1-stage diagnostic wedge resections via VATS between January and December 2020, were included in the analysis. Data on patient characteristics, nodules, procedures, and pathological diagnoses were collected and retrospectively reviewed.

Results

Of the 18 nodules, 17 were successfully localized. Nine nodules were pure GGNs, and the remaining 9 were part-solid GGNs. The median nodule size was 9.0 mm (range, 4.0-20.0 mm); and the median depth from the visceral pleura was 5.2 mm (range, 0.0-14.4 mm). The median procedure time was 10 minutes (range, 7-20 minutes). The final pathologic results showed benign lesions in 3 cases and malignant lesions in 15 cases.

Conclusion

Perioperative ETTNL appears to be an effective method for the localization of GGNs, providing guidance for a 1-stage VATS procedure.

Nonintubated versus intubated “one-stage” preoperative localization and thoracoscopic lung resection

Objective

Nonintubated anesthesia, electromagnetic navigation (EMN)-guided preoperative localization, and uniportal video-assisted thoracic surgery (VATS) are recent innovations in minimally invasive thoracic surgery. This study aimed to explore the feasibility of applying nonintubated anesthesia in a “one-stage” localization and resection workflow.

Methods

Patients who underwent EMN-guided preoperative percutaneous localization with indocyanine green (ICG) and uniportal VATS were included. Perioperative data were compared between patients receiving nonintubated anesthesia and those receiving general anesthesia with endotracheal intubation.

Results

Forty-six patients with a total of 50 nodules were included in the study. Overall, finger palpation could be avoided in 94% of the nodules, whereas fluorescent green signals with a clear border on the pleural surface were noted in 91.3% (21 of 23) of nodules in the nonintubated group and 88.9% (24 of 27) of nodules in the intubated group. Intraoperatively, the nonintubated group had a lower median pH (7.33 [interquartile range (IQR), 7.28-7.40] vs 7.41 [IQR, 7.38-7.44]; P = .003), higher median arterial CO₂ (45.5 [IQR, 41.1-58.7] mm Hg vs 38.4 [IQR, 35.3-40.6] mm Hg; P < .001), and lower arterial oxygen (322 [IQR, 211-433] mm Hg vs 426 [IQR, 355-471] mm Hg; P = .005) levels compared with the intubated group. The nonintubated group also had a shorter median registration time (2.0 [IQR, 1.0-3.0] minutes vs 3.0 [IQR, 2.0-8.0] minutes; P = .008) and total time in the operating room (150 [IQR, 130-175] minutes vs 170 [IQR, 135-203] minutes; P = .035), whereas no between-group differences were seen in localization and operative time. The duration of chest drainage, postoperative complications, pathologic diagnosis, and margins were similar in the 2 groups.

Conclusions

Nonintubated “one-stage” EMN-guided percutaneous ICG localization and uniportal VATS can be an option for selected patients undergoing treatment for small peripheral nodules.

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

背景与目的

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

方法

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

结果

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

结论

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

[Preliminary Study of CT Three-dimensional Reconstruction Combined with Ground Glass Nodules of Natural Lung Collapse in Thoracoscopic Pulmonary Segmental Resection]

BACKGROUND

Computed tomography (CT) three-dimensional reconstruction technology is increasingly used in preoperative planning of patients with ground glass nodule (GGN), but how to accurately locate the nodule and ensure the safe resection edge is still a difficult problem for clinicians. The purpose of this study was to investigate the accuracy, convenience and safety of CT three-dimensional reconstruction combined with intraoperative natural collapse localization in total thoracoscopic segmental pneumonectomy.

METHODS

A total of 45 patients with radiographic findings of pulmonary GGN admitted from July 2019 to December 2019 were selected as the study group. All patients received thin-slice CT scan and underwent preoperative three-dimensional reconstruction. After anesthesia, the small thoracic operation opening and the airway of the patients were quickly opened, and the lung was rapidly and naturally collapsed by pressure difference. GGN were positioned according to the natural marker line, and marked with 3-0 prolene line. After specimen removal, the distance between the GGN and the suture mark, the distance between the GGN and the incision margin were measured, and the incision margin was routinely examined. The general clinical data, pathological data and postoperative complications were counted and compared with 45 consecutive patients who were located with hookwire positioning needle in the same period.

RESULTS

The average localization time of non-invasive GGN with natural lung collapse during operation was 6.9 min, and the localization accuracy was 90.6%. There were 2 cases of extensive pleural adhesion and 1 case of emphysema. Postoperative pathology was confirmed as lung adenocarcinoma, and the examination of incision margin was negative. No GGNs were scanned again after surgery, and the precise resection rate of lung segment was 100.0%.

CONCLUSIONS

CT three-dimensional reconstruction combined with GGN localization of natural lung collapse during operation can shorten the time of searching for GGN during operation and guarantee the safety of the incision margin. It is a more economical and convenient localization method and makes pulmonary segment resection more accurate.

[Expert Consensus on Technical Specifications of Domestic Electromagnetic Navigation Bronchoscopy System in Diagnosis, Localization and Treatment (2021 Edition)]

Electromagnetic navigation bronchoscopy (ENB) is a novel type of bronchoscopy based on electromagnetic positioning technique combined with virtual bronchoscopy, three-dimensional computed tomography (CT) imaging and respiratory gating technique, which has been widely applied in clinic practice. In recent years, the domestic electromagnetic navigation system has also been developed rapidly, and its effectiveness and safety in the diagnosis, localization, and treatment of peripheral pulmonary lesions have been initially verified. In order to optimize and standardize the technical specifications of domestic ENB and guide its application in clinical practice, the consensus statement has been organized and written in a collaborative effort by the Professional Committee on Respiratory Equipment Technology of Chinese Medical Equipment Association and the Expert Group on Technical of Domestic Electromagnetic Navigation Bronchoscopy.
.

Fluorescent and Iodized Emulsion for Preoperative Localization of Pulmonary Nodules

OBJECTIVE

This study was conducted to develop a fluorescent iodized emulsion comprising indocyanine green (ICG) solution and lipiodol (ethiodized oil) and evaluate its feasibility for use in a clinical setting.

BACKGROUND

ICG use for the preoperative localization of pulmonary nodules is limited in terms of penetration depth and diffusion.

METHODS

First, fluorescent microscopy was used to investigate the distribution of ICG-lipiodol emulsions prepared using different methods. The emulsions were injected in 15 lung lobes of 3 rabbits under computed tomography fluoroscopy guidance; evaluation with imaging and radiography was conducted after thoracotomy. Subsequently, the emulsions were used to preoperatively localize 29 pulmonary nodules in 24 human subjects, and wedge resections were performed using fluorescent imaging and C-arm fluoroscopy.

RESULTS

The optimal emulsion of 10% ICG and 90% lipiodol mixed through 90 passages had even distribution and the highest signal intensity under fluorescent microscopy; it also had the best consistency in the rabbit lungs, which persisted for 24 hours at the injection site. In human subjects, the mean diameter of pulmonary nodules was 0.9 ± 0.4 cm, and depth from the pleura was 1.2 ± 0.8 cm. All emulsion types injected were well localized around the target nodules without any side effects or procedure-related complications. Wedge resection with minimally invasive approach was successful in all pulmonary nodules with a free resection margin.

CONCLUSIONS

A fluorescent iodized emulsion prepared by mixing ICG with lipiodol enabled accurate localization and resection of pulmonary nodules.

Management of pulmonary ground-glass opacities: a position paper from a panel of experts of the Italian Society of Thoracic Surgery (SICT)

OBJECTIVES

A significant gap in our knowledge of how to manage pulmonary ground-glass opacities (GGOs) still exists. Accordingly, there is a lack of consensus among clinicians on this topic. The Italian Society of Thoracic Surgery (Società Italiana di Chirurgia Toracica, SICT) promoted a national expert meeting to provide insightful guidance for clinical practice. Our goal was to publish herein the final consensus document from this conference.

METHODS

The working panel of the PNR group (Pulmonary Nodules Recommendation Group, a branch of the SICT) together with 5 scientific supervisors (nominated by the SICT) identified a jury of expert thoracic surgeons who organized a multidisciplinary meeting to propose specific statements (n = 29); 73 participants discussed and voted on statements using a modified Delphi process (repeated iterations of anonymous voting over 2 rounds with electronic support) requiring 70% agreement to reach consensus on a statement.

RESULTS

Consensus was reached on several critical points in GGO management, in particular on the definition of GGO, radiological and radiometabolic evaluation, indications for a non-surgical biopsy, GGO management based on radiological characteristics, surgical strategies (extension of pulmonary resection and lymphadenectomy) and radiological surveillance. A list of 29 statements was finally approved.

CONCLUSIONS

The participants at this national expert meeting analysed this challenging topic and provided a list of suggestions for health institutions and physicians with practical indications for GGO management.

Computed Tomography-Guided Methylene Blue Localization: Single vs. Multiple Lung Nodules

Background: Preoperative localization for small invisible and impalpable pulmonary nodules is important in single-port video-assisted thoracoscopic surgery (VATS). Localization of multiple pulmonary nodules during VATS resection remains challenging. The aim of our study is to elucidate the efficacy of preoperative CT-guided methylene blue localization of both single and multiple pulmonary nodules.

Methods: Consecutive patients undergoing preoperative CT-guided methylene blue dye localization for lung nodules, followed by VATS resection, were retrospectively analyzed between January 2014 and November 2019. Chi-square tests, Fisher's exact test and independent T-test were used to compare variables between the groups. Logistic regression was used to identify risk factors for procedure-related complications.

Results: A total of 388 patients, including 337 with single nodule and 51 with multiple nodules, were analyzed. The success rate of preoperative CT-guided methylene blue localization for both single and multiple pulmonary nodules were comparable as 98.8% (333/337) vs. 100% (108/108). The procedure time was longer (23.2 ± 9.4 vs. 7.6 ± 4.8 min, p < 0.001) and risk of pneumothorax was higher (47.1 vs. 25.5%, p = 0.002) in the multiple nodule group. The procedure time (OR 1.079; 95% CI = 1.041–1.118; p < 0.001) was an independent risk factor for pneumothorax. Nodule depth (OR 2.829; 95% CI = 1.259–6.356; p = 0.011) was an independent risk factor for pulmonary hemorrhage.

Conclusions: Preoperative CT-guided methylene blue localization for both single and multiple pulmonary nodules is safe, feasible, and effective.

A novel technique for preoperative localization of pulmonary nodules using a mixture of tissue adhesive and iohexol under computed tomography guidance: A 140 patient single-center study

Background

The increase in the incidence of pulmonary nodules has made computed tomography (CT) screening a requirement for diagnosis and treatment. Small pulmonary nodule detection during video‐assisted thoracoscopic surgery (VATS) or thoracotomy is frequently challenging; however, accurate and efficient localization of nodules is critical for precise resection. Herein, we introduce and evaluate the feasibility and safety of a novel technique for preoperative pulmonary nodule localization.

Methods

From March 2018 to December 2019, 140 patients with 153 pulmonary nodules measuring <2 cm in diameter were enrolled in this study. Preoperative, CT‐guided localization was performed on each nodule with an injected mixture of tissue adhesive and iohexol. Patient and nodule characteristics, localization data, complications, surgical data, and pathological results were analyzed.

Results

All 153 nodules in 140 patients were successfully marked preoperatively and detected during surgery (n = 153/153). Mean nodule size was 8.7 ± 2.6 mm, and mean distance from nodule to pleura was 7.9 ± 8.2 mm. The mean procedural time was 8.7 ± 1.0 min. Nine patients (6.4%) underwent two simultaneous nodule localizations and two patients (1.4%) underwent three simultaneous nodule localizations. Pneumothorax (17/140, 12.1%), pain (6/140, 4.3%), and pungent odor (5/140, 3.6%) were the major complications. No patient required further treatment, and no allergic reactions or embolisms were observed.

Conclusions

Preoperative CT‐guided nodule localization using a mixture of tissue adhesive and iohexol is an efficient technique for localizing small and impalpable pulmonary lesions, including multiple pulmonary nodules. Our study demonstrates that this novel method is safe and straightforward to implement.

Initial experience of the use of ethylene-vinyl alcohol polymer (EVOH) as an alternative technique for lung nodule localization prior to VATS

Identifying pulmonary nodules for resection that are small or are deep within the lung parenchyma is a frequently encountered challenge during video-assisted thoracoscopic surgery (VATS). Several image-guided localizing techniques have been described; however, there is limited literature on using these techniques in pediatric patients. We assessed the feasibility of using a commercially available ethylene-vinyl alcohol polymer (EVOH) as an alternative technique for lung nodule localization prior to VATS. We describe our experience of successful EVOH lung nodule localization in three pediatric patients with an oncologic history presenting with new lung nodules.

CT-guided localization techniques of small pulmonary nodules: a prospective non-randomized controlled study on pulmonary nodule localization needle and methylene blue staining with surgical glue

Background

Thoracoscopic resection of small pulmonary nodules (SPNs) is challenging. Accurate preoperative computed tomography-guided localization of SPNs is key to successful rection. The aim of the present study was to evaluate the clinical value of a novel localization needle and methylene blue staining combined with surgical glue (MBSG) and to explore the risk factors for post-localization complications.

Methods

This prospective, non-randomized controlled study was conducted on 110 patients who received either MBSG or novel needle localization prior to video-assisted thoracoscopic surgery (VATS) from January 2019 to December 2019 at Shenzhen People’s Hospital. The primary endpoints were the safety and the success rates of the 2 localization techniques. The secondary endpoints were operative time and feasibility.

Results

The 110 patients were categorized into 2 groups: the MBSG group (n=84) and the pulmonary nodule localization needle group (n=26). The success rate of pre-VATS localization was 100% in both groups. No deaths or serious complications occurred during localization. The rates of pneumothorax, pulmonary hemorrhage, and localization-induced cough were 38.1%, 25%, and 7.14%, respectively, in the MBSG group, and 26.92%, 19.23%, and 0%, respectively, in the pulmonary nodule localization needle group. Differences between the 2 groups were not statistically significant (P>0.05). Total complication rate and the incidence of pain were significantly lower in the pulmonary nodule localization needle group (χ²=4.441 and 4.295, respectively; P<0.05). The difference in operative time between the 2 groups was not statistically significant (P>0.05). Dye diffusion occurred in 2 patients in the MBSG group; however, it had no impact on VATS or on the pathological analysis. Neither displacement nor dislocation was observed in the pulmonary nodule localization needle group. Logistic regression analysis showed that the localization technique was an independent risk factor for total complications (odds ratio: 2.634, 95% confidence interval: 1.022–6.789, P<0.05).

Conclusions

Both techniques can localize SPNs effectively prior to VATS. The pulmonary nodule localization needle technique has a lower incidence of complications.

A Surgeon's Guide for Various Lung Nodule Localization Techniques and the Newest Technologies

Preoperative image-guided localization of lung nodules is necessary for successful intraoperative localization and resection. However, current localization techniques carry significant intraoperative disadvantages for surgeons. Articles were selected through multiple search engines using key search terms and reviewed to compare results, outcomes, advantages, limitations, and complications of various localization methods. Current methods utilize microcoils, hookwires, contrast media, dyes, cyanoacrylate, radiotracers, or fluorescence tracers, which are associated with many intraoperative disadvantages even when paired with other imaging modalities including computed tomography and bronchoscopy techniques. Novel technologies including robotic bronchoscopy, 4-hook anchor, SPiN Thoracic Navigation System, superDimension, Ion Endoluminal System, and the SCOUT system are reviewed including their advantages, which may change the future direction of minimal thoracoscopic surgery with potential to improve intraoperative accuracy and efficiency.

Ground glass opacity on chest CT scans from screening to treatment: A literature review

Lung cancer is the most common cause of cancer death in the world. However, recent studies have found that patients with pulmonary ground-glass opacity (GGO) have a better prognosis. Considering its low invasiveness, sublobar resection may be an appropriate treatment of choice. Low-dose computed tomography (CT) is recommended for the high-risk groups of lung cancer. Patients with nonsolid nodule are suggested to take annual low dose CT following-up. For part-solid or solid nodules, the solid component size less or more than 8 mm is the watershed of surgical treatment. Increasing tumor size is a hint of malignancy. Biopsy can be performed for clinically highly suspected malignant nodules. The endobronchial ultrasound biopsy, CT-guide biopsy, or surgical excision are the mainstream for the diagnosis of lung nodules. But for treatment, the sublobar resection is the mainstream of pulmonary GGO. A precise localization technique makes surgeons get enough resection margin and preserve more pulmonary function of the patients. The different localization technique is suitable for different kind nodular position. For patients with pure pulmonary GGO, annual low dose CT checkup is suitable. If the tumor size or solid part of the tumors increased gradually, adequate sublobar resection after tumor localization technique may provide good prognosis and preserve more pulmonary function of the patients.

Image-localized body surface marking for the intraoperative localization of pulmonary ground-glass nodules

Background

The method of locating pulmonary nodules before operation plays a crucial role in the surgery of pulmonary ground-glass nodules (GGNs). However, the methodologies surrounding intraoperative localization remains limited, with the majority procedures requiring specific additional equipment. We report a new approach in locating pulmonary GGNs by image-localized body surface marking intraoperative (IBMI) localization.

Methods

A retrospective review of the medical records of 76 patients with pulmonary GGNs was performed. All patients underwent IBMI localization between January 2018 and March 2019. Twenty-six patients underwent CT-guided hook wire localization before IBMI localization during surgery. IBMI localization was undertaken directly without pre-treatment in the remaining patients. The efficacy and complications of this approach were analyzed and compared with other pre- or intraoperative localization methods in the current literature.

Results

The intraoperative localizations were performed successfully in 72 of all 76 patients pulmonary GGNs within a mean duration of 5.3±1.8 (range, 2.0 to 9.6) minutes. The GGNs in four cases were found to have a significant deviation (>1.5 cm) from the positioning points. All GGNs were successfully resected. Except for five cases of active chest wall bleeding (6.5%), no other intra- or postoperative complications occurred.

Conclusions

The IBMI localization approach is a safe and short-duration procedure with high success rates and fewer complications. We used it for the first time for intraoperative localization of peripheral GGNs with excellent results.

Past, present, and future perspectives of pulmonary metastasectomy for patients with advanced colorectal cancer

Over a half-century has passed since Thomford et al. proposed the selection criteria for pulmonary metastasectomy, and several prognostic factors have been identified. Although screening modalities and operations have changed dramatically, the important concepts of the selection criteria remain unchanged. Recent improvements in the survival outcomes of colorectal cancer patients undergoing pulmonary metastasectomy may be the result of strict adherence to the selection criteria for oligometastatic lung tumors, which can mimic local disease. Pulmonary metastasectomy has become an important option for selected patients with oligometastasis, based mainly on a large amount of retrospective data, but its effect on survival remains unclear. Curable pulmonary metastasis might be regarded as a "semi-local disease" under the spontaneous control of an acquired alteration in host immune status. The current practice of pulmonary metastasectomy for colorectal cancer focuses on selecting the most appropriate operation for selected patients. However, in the rapidly evolving era of immunotherapy, treatment-naïve patients for whom surgery is not suitable might be pre-conditioned by immunotherapy so that they may be considered for salvage surgery.

Simultaneous visualization of pulmonary nodules and intersegmental planes on fluorescent images in pulmonary segmentectomy

OBJECTIVES

The technique of simultaneously visualizing pulmonary nodules and the intersegmental plane using fluorescent images was developed to measure the distance between them intraoperatively.

METHODS

Patients who underwent pulmonary segmentectomy were consecutively included in this study between March 2016 and July 2019. Computed tomography or electromagnetic bronchoscopy-guided localization with indocyanine green-lipiodol emulsion was performed on the day of surgery. In the middle of the surgery, after dividing the segmental artery, vein and bronchus to a targeted segment, 0.3-0.5 mg/kg of indocyanine green was injected intravenously.

RESULTS

In total, 31 patients (17 men and 14 women with a mean age of 63.2 ± 9.8 years) were included in this study. The mean size and depth of the nodules were 1.2 ± 0.5 (range 0.3-2.5) cm and 16.4 ± 9.9 (range 1.0-42.0) mm, respectively. Pulmonary nodules and intersegmental plane of all the patients were visualized using a fluorescent thoracoscope. The resection margins were more than the size of the tumour or were 2 (mean 2.4 ± 1.2) cm in size in all patients except one. The resection margin of this patient looked sufficient on the intraoperative view. However, adenocarcinoma in situ at the resection margin was identified based on the pathological report. The mean duration of the operation was 168.7 ± 53.3 min, and the chest tube was removed on an average of 4.7 ± 1.8 days after surgery in all patients.

CONCLUSIONS

The dual visualization technique using indocyanine green could facilitate an easier measurement of the distance between pulmonary nodules and the intersegmental plane during pulmonary segmentectomy.

CT-guided blood tattoo for thoracoscopic excision of lung lesions in pediatric patients

Background

To describe a single-institutional experience with an innovative technique using CT-guided injection of autologous blood for localization of nonpleural-based pulmonary nodules prior to thoracoscopic excisional biopsy in pediatric patients.

Methods

A retrospective review of all patients under the age of 18 with lung lesions suspected to be malignant that were not pleural-based lesions and were not of adequate size to visualize at thoracoscopy, who underwent CT-guided blood tattoo (CGBT) localization between 2006-2019. CGBT was performed under general anesthesia by injecting 0.5-10 mL of autologous blood into the area of the lesions. The patients were then immediately transferred from interventional radiology to the operating room for thoracoscopic excision of the lesion. Demographics, location of lesions, indication for biopsy, and pathology were reviewed.

Results

In eleven pediatric patients (ages ranging from 4-18 years), preoperative CGBT localization of pulmonary nodules resulted in successful thoracoscopic excisional biopsy. All resections were diagnostic and 82% (9/11 cases) represented a metastatic malignancy as confirmed by pathology. Malignant nodules ranged from 2 to 14 mm in size, while a 13 mm nodule in a patient with history of AML was determined to be an organizing pneumonia and a 12 mm nodule in a second patient revealed a caseating granuloma consistent with Crohn's disease. One patient with a failed attempt at excisional biopsy without preoperative localization then underwent CGBT one week later with successful thoracoscopic excision of the nodule.

Conclusions

CT-guided blood tattoo is a safe option for localization of nonpleural-based lung nodules prior to thoracoscopic excision in pediatric patients.

Intraoperative Detection and Assessment of Lung Nodules

Lung cancer is the most frequent cause of cancer-related death worldwide. Despite advances in systemic therapy, the 5-year survival remains humbling at 4% to 17%. For those diagnosed early, surgical therapy can yield potentially curative results. Surgical resection remains a cornerstone of medical care. Success hinges on sound oncologic resection principles. Various techniques can be used to identify pulmonary nodules. A challenge is intraoperative assessment of the surgical specimen to confirm disease localization and ensure an R0 resection. The primary tool is frozen section. Understanding the options available enhances the arsenal of thoracic surgeons and leads to better patient care.

Planting Seeds into the Lung: Image-Guided Percutaneous Localization to Guide Minimally Invasive Thoracic Surgery

Image-guided localization materials are constantly evolving, providing options for the localization of small pulmonary nodules to guide minimally invasive thoracic surgery. Several preoperative methods have been developed to localize small pulmonary lesions prior to video-assisted thoracic surgery. These localization techniques can be categorized into 4 groups according to the materials used: localization with metallic materials (hook-wire, microcoil, or spiral coil), localization with dye (methylene blue or indigo carmine), localization with contrast agents (lipiodol, barium, or iodine contrast agents), and radiotracers (technetium-99m). However, the optimal localization method has not yet been established. In this review article, we discuss the various localization techniques and the advantages and disadvantages of localization techniques as well as the available safety and efficacy data on these techniques.

Methylene Blue versus Coil-Based Computed Tomography-Guided Localization of Lung Nodules

BACKGROUND

Preoperative computed tomography (CT)-guided localization has been shown to significantly improve lung nodule video-assisted thoracoscopic surgery (VATS)-based wedge resection technical success rates. However, at present, there was insufficient research regarding the optimal approaches to localization of these nodules prior to resection. We aimed to compare the relative clinical efficacy of preoperative CT-guided methylene blue and coil-based lung nodule localization.

METHODS

In total, 91 patients with lung nodules were subjected to either CT-guided methylene blue (n = 34) or coil (n = 57) localization and VATS resection from January 2014 to December 2018. We compared baseline data, localization-associated complication rates, as well as the technical success of localization and resection between these two groups of patients.

RESULTS

In total, 42 lung nodules in 34 patients underwent methylene blue localization, with associated localization and wedge resection technical success rates of 97.6 and 97.6%, respectively. A total of 71 lung nodules in 57 patients underwent coil localization, with associated localization and wedge resection technical success rates of 94.4 and 97.2%, respectively. There were no significant differences in technical success rates of localization or wedge resection between these groups (p = 0.416 and 1.000, respectively). The coil group sustained a longer duration between localization and VATS relative to the methylene blue group (13.2 vs. 2.5 hours, p = 0.003).

CONCLUSION

Both methylene blue and coil localization can be safely and effectively implemented for conducting the diagnostic wedge resection of lung nodules. The coil-based approach is compatible with a longer period of time between localization and VATS procedures.

Pre-operative CT localization for patients with subsolid opacities expecting video-assisted thoracoscopic surgery-single center experience of fluorescent iodized emulsion and hook-wire localization technique

OBJECTIVE

To describe our clinical experience of using combination of fluorescent iodized emulsion, indocyanine green & lipiodol, and hook-wire in pre-operative CT localization of patients with subsolid lung lesions prior to video-assisted thoracoscopic surgery (VATS).

METHODS

A retrospective review between June 2018 and July 2019 of consecutive Chinese patients whom underwent VATS for subsolid lung lesions with pre-operative CT localization done with combination of fluorescent iodized emulsion and hook-wire technique in a tertiary hospital (Tuen Mun Hospital, Hong Kong SAR). The duration and complications related to the localization procedure were recorded The clinical records, operative findings and pathology reports were retrieved from the hospital electronic clinical management system.

RESULTS

Combination fluorescent iodized emulsion with hook-wire enabled accurate localization and resection of all subsolid lung lesions in VATS. No major complications were reported.

CONCLUSION

Combination of fluorescent iodized emulsion and hook-wire placement under CT guidance is a simple, safe and cost- effective procedure that enabled accurate localization and resection of subsolid nodule in VATS.

ADVANCES IN KNOWLEDGE

VATS has been the mainstay for indeterminate pulmonary nodules for diagnostic and/or curative purpose. The main problem that surgeons may encounter during operation is the difficulty in locating the target lesion particularly for subsolid lesions. Many pre-operative localization methods have been developed in this regard. With the novel technique that we described, we were able to overcome disadvantages of most described methods.

Computed tomography-guided localization for lung nodules: methylene-blue versus coil localization

PURPOSE

To compare the relative clinical efficacy of preoperative computed tomography (CT)-guided methylene-blue (MB) and coil localization for lung nodules (LNs).

MATERIAL AND METHODS

Between January 2013 and December 2018, a total of 89 patients with LNs underwent CT-guided MB or coil localization and subsequent video-assisted thoracoscopic surgery (VATS)-guided wedge resection in our hospital. We compared the technical success of localization and wedge resection between two groups.

RESULTS

In MB group, 47 LNs in 39 patients were localized, with successful localization and wedge resection rates of 97.9% and 97.9%, respectively. In the coil group, 64 LNs in 50 patients were localized, with successful localization and wedge resection rates of 96.9% and 96.9%, respectively. There were no significant differences in technical success rates of localization and wedge resection between the two groups (p = 1.000 and 1.000). The coil group sustained a longer duration between localization and VATS relative to the MB group (14.4 h vs. 1.6 h, p = .001).

CONCLUSION

Both MB and coil localization were safe and effective techniques to establish a high success rate of VATS-guided wedge resection for LNs. Relative to MB localization, coil localization might be compatible with a longer delay between localization and VATS.