Pulmonary nodules and mini-invasive lung resection: do we have the right "tool" for their intraoperative localization?

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.

Intracorporeal direct measurement for localizing peripheral pulmonary nodules during thoracoscopy

Background

Localizing small lung nodules during thoracoscopy is challenging for thoracic surgeons. In this case series, a novel technique for intraoperative localization that combines preoperative computed tomography (CT) with direct measurement during thoracoscopy is described.

Methods

A preoperative CT within two months before surgery was mandatory for precise planning of the resection area. During thoracoscopy, intracorporeal direct measurement (ICDM) for intraoperative localization was undergone if the targeted nodule was non-palpable and non-visualized. According to the location of the targeted nodule, longitudinal, and horizontal landmarks were chosen. The distances between the nodule and these landmarks were obtained from both CT images and intraoperative measurements during thoracoscopy. Based on the measurements, the x-axis and y-axis coordinates of the nodule were calculated and marked on the visceral pleura. A thoracoscopic wedge resection with an adequate margin was performed. From July 2014 to December 2018, ICDM was applied in 27 patients with peripheral pulmonary nodules smaller than 2 cm. Their medical records were reviewed retrospectively to evaluate the feasibility and safety of this technique.

Results

Twenty-six of the twenty-seven nodules were successfully identified (96.3%). The nodules included 13 primary lung cancers, 5 metastases, and 9 benign lesions. The median nodule size was 7 mm (range, 4-17 mm), and the median distance of the nodule from the visceral pleura was 8.1 mm (range, 1.0-31.2 mm). The median localization time was 24 minutes (range, 8-109 mm). Two patients (7.4%) had a prolonged air leak, but there was no procedure-related mortality.

Conclusions

ICDM is an effective and safe method for localizing peripheral lung nodules during thoracoscopy.

Metabolic profiles of serum samples from ground glass opacity represent potential diagnostic biomarkers for lung cancer

Background

Lung cancer is a leading cause of cancer deaths worldwide. Low-dose computed tomography (LDCT) screening trials indicated that LDCT is effective for the early detection of lung cancer, but the findings were accompanied by high false positive rates. Therefore, the detection of lung cancer needs complementary blood biomarker tests to reduce false positive rates.

Methods

In order to evaluate the potential of metabolite biomarkers for diagnosing lung cancer and increasing the effectiveness of clinical interventions, serum samples from subjects participating in a low-dose CT-scan screening were analyzed by using untargeted liquid chromatography-hybrid quadrupole time-of-flight mass spectrometry (LC-Q-TOF-MS). Samples were acquired from 34 lung patients with ground glass opacity diagnosed lung cancer and 39 healthy controls.

Results

In total, we identified 9 metabolites in electron spray ionization (ESI)(+) mode and 7 metabolites in ESI(-) mode. L-(+)-gulose, phosphatidylethanolamine (PE)(22:2(13Z,16Z)/15:0), cysteinyl-glutamine, S-japonin, threoninyl-glutamine, chlorate, 3-oxoadipic acid, dukunolide A, and malonic semialdehyde levels were observed to be elevated in serum samples of lung cancer cases when compared to those of healthy controls. By contrast, 1-(2-furanylmethyl)-1H-pyrrole, 2,4-dihydroxybenzoic acid, monoethyl carbonate, guanidinosuccinic acid, pseudouridine, DIMBOA-Glc, and 4-feruloyl-1,5-quinolactone levels were lower in serum samples of lung cancer cases compared with those of healthy controls.

Conclusions

This study demonstrates evidence of early metabolic alterations that can possibly distinguish malignant ground glass opacity from benign ground glass opacity. Further studies in larger pools of samples are warranted.