Localization of pulmonary nodules for thoracoscopic resection: experience with a system using a short hookwire and suture

Virtual-assisted lung mapping in sublobar resection of small pulmonary nodules, long-term results

OBJECTIVES

The short-term efficacy of virtual-assisted lung mapping (VAL-MAP), a preoperative bronchoscopic multi-spot lung-marking technique, has been confirmed in 2 prospective multicentre studies. The objectives of this study were to analyse the local recurrence and survival of patients enrolled in these studies, long-term.

METHODS

Of the 663 patients enrolled in the 2 studies, 559 patients' follow-up data were collected. After excluding those who did not undergo VAL-MAP, whose resection was not for curative intent, who underwent concurrent resection without VAL-MAP, or who eventually underwent lobectomy instead of sublobar resection (i.e. wedge resection or segmentectomy), 422 patients were further analysed.

RESULTS

Among 264 patients with primary lung cancer, the 5-year local recurrence-free rate was 98.4%, and the 5-year overall survival (OS) rate was 94.5%. Limited to stage IA2 or less (≤2 cm in diameter; n = 238, 90.1%), the 5-year local recurrence-free and OS rates were 98.7% and 94.8%, respectively. Among 102 patients with metastatic lung tumours, the 5-year local recurrence-free rate was 93.8% and the 5-year OS rate was 81.8%. Limited to the most common (colorectal) cancer (n = 53), the 5-year local recurrence-free and OS rates were 94.9% and 82.3%, respectively.

CONCLUSIONS

VAL-MAP, which is beneficial in localizing small barely palpable pulmonary lesions and determining the appropriate resection lines, was associated with reasonable long-term outcomes.

SUBJ COLLECTION

152, 1542.

Magnetically Guided Localization Using a Guiding-Marker System® and a Handheld Magnetic Probe for Nonpalpable Breast Lesions: A Multicenter Feasibility Study in Japan

Simple Summary

In this multicenter feasibility study, non-palpable breast lesions in 89 patients were localized using a handheld cordless magnetic probe (TAKUMI) and a magnetic marker (Guiding-Marker System^®). Additionally, a dye was injected subcutaneously under ultrasound guidance to indicate the extent of the tumor. Consequently, a magnetic marker was detected in all resected specimens, and the initial surgical margin was positive only in five (6.1%) of 82 patients. Thus, the magnetic guiding localization system with ultrasound guidance is useful for the detection and excision of non-palpable breast lesions.

Abstract

Accurate pre-operative localization of nonpalpable lesions plays a pivotal role in guiding breast-conserving surgery (BCS). In this multicenter feasibility study, nonpalpable breast lesions were localized using a handheld magnetic probe (TAKUMI) and a magnetic marker (Guiding-Marker System^®). The magnetic marker was preoperatively placed within the target lesion under ultrasound or stereo-guidance. Additionally, a dye was injected subcutaneously to indicate the extent of the tumor excision. Surgeons checked for the marker within the lesion using a magnetic probe. The magnetic probe could detect the guiding marker and accurately localize the target lesion intraoperatively. All patients with breast cancer underwent wide excision with a safety margin of ≥5 mm. The presence of the guiding-marker within the resected specimen was the primary outcome and the pathological margin status and re-excision rate were the secondary outcomes. Eighty-seven patients with nonpalpable lesions who underwent BCS, from January to March of 2019 and from January to July of 2020, were recruited. The magnetic marker was detected in all resected specimens. The surgical margin was positive only in 5/82 (6.1%) patients; these patients underwent re-excision. This feasibility study demonstrated that the magnetic guiding localization system is useful for the detection and excision of nonpalpable breast lesions.

Spiral wire localization of lung nodules: procedure effectiveness and oncological usefulness

Background

In the last years, a large number of techniques and devices for localizing small pulmonary nodules prior to resection have been developed with the aim of facilitating minimally invasive surgery (VATS). However, each device presents pros and cons and there is no unanimous consensus. We report our experience with an uncommon wire system with spiral shape for percutaneous marking.

Methods

We recorded 102 consecutive CT-guided spiral wire localizations in our Institution, and we evaluated the efficacy of the method according to 4 success rates (SR): (I) successful targeting rate (SR-1): number of successful targeting procedures/number of all localizations; (II) successful localization in operative field (SR-2): (number of successful targeting procedures -number of dislodgements in operative field)/number of all localizations; (III) successful VATS rate (SR-3): number of successful VATS procedures/(number of localizations-number of thoracotomies not due to wire dislocation); (IV) successful curative rate (SR-4): number of neoplastic nodules resected with curative intent with free margins (R0) on definitive tissue diagnosis/number of neoplastic nodules resected with curative intent. Complications rate was recorded as well.

Results

SR-1: 100%, SR-2: 97.1%, SR-3: 100%, SR-4: 100%. Asymptomatic pneumothorax and minimal parenchymal hemorrhage were observed in 5 (4.9%) and 19 (18.6%) cases, respectively.

Conclusions

Spiral wire localization showed very good results in terms of feasibility, stability in operative field and contributed to effective use of VATS during wedge resection performed for malignant nodules. In the era of widespread radiological investigations (as it is happening in lung cancer screening) and evolutions in cancer treatments, this appears to be clinically relevant.

Precise sublobar lung resection for small pulmonary nodules: localization and beyond

Early-stage primary lung cancer is increasingly detected by computed tomographic (CT) screening and the radicality of sublobar lung resection (wedge resection and segmentectomy) has been suggested. However, identification of a tumor intraoperatively becomes more difficult, the earlier a nodule is detected. A solution to this challenge is localization techniques. There are many techniques to localize small pulmonary nodules, including that replacing surgeon's tactile sensation, visualizing the tumor using ultrasound, and various types of lung markings that are placed percutaneously under CT guidance or bronchoscopically. The most commonly used technique is CT-guided placement of a hookwire, but there are concerns about potentially fatal air embolism. Bronchoscopic localization, especially using electromagnetic navigation bronchoscopy with or without intraoperative cone-beam CT imaging, has been increasingly reported. Beyond localization, the concept of lung "mapping" is emerging. In sublobar lung resection, in addition to localization of the targeted tumor, acquisition of sufficient resection margins is critical to prevent local recurrence. Virtual-assisted lung mapping (VAL-MAP) has evolved from bronchoscopic dye localization, but by placing multiple dye marks, it provides two-dimensional geometric information on the lung. Moreover, to ensure deep resection margins, the newly developed technique of VAL-MAP 2.0 combining dye marks and intrabronchial placement of a microcoil enables three-dimensional lung mapping. This allows for intraoperative navigation of lung resection under a fluoroscope. Development of this field, such as using a new technology of augmented reality, will further enhance the accuracy and convenience of lung resection in the near future.

Migration of a hookwire used as a video-assisted thoracoscopic surgery marker into the splenic artery

We present a case in which a hookwire that was used as a video-assisted thoracoscopic (VATS) surgery marker migrated into the splenic artery. The patient was a 70-year-old man with an 18-mm ground glass nodule (GGN) in the right S2. As the GGN was not located in the peripheral part of the lung, a percutaneous hookwire was placed as a marker under CT-guided just before the surgery. We performed VATS right S2 segmentectomy to remove the GGN and the marker; however, we could not locate the marker in the specimen. Histopathological examination revealed adenocarcinoma, TisN0M0, stage 0. CT findings after surgery showed that the marker had migrated into the splenic artery. We followed up the patient, and CT examination conducted 1, 3 and 6 months after the surgery showed no further migration and no damage of the splenic artery. We report the complication of percutaneous hookwire migration into a blood vessel.

Gamma Probe-Guided Thoracoscopic Surgery of Small Pulmonary Nodules

Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for the diagnosis and treatment of peripheral pulmonary nodules. We developed a new radioguided surgical technique for the detection during VATS of pulmonary nodules smaller than 2 cm, situated deep in the lung parenchyma and neither visible nor palpable with endoscopic instruments. The procedure is divided into two phases. Two hours before surgery 0.3 ml of a solution composed of 0.2 mL of 99mTc-labeled human serum albumin microspheres (5–10 MBq) and 0.1 mL of non-ionic contrast is injected into the lesion under CT guidance. Then the patient is submitted to VATS. During thoracoscopy a collimated probe of 11 mm diameter connected to a gamma ray detector is introduced via an 11.5 mm trocar and the pleural surface of the suspected area is scanned. A hot spot indicates the presence of the radiolabeled nodule and hence the area to be resected. We treated 39 patients with small pulmonary nodules (mean size, 8.3 mm; range, 4–19 mm). The patients were 27 men and 12 women (mean age, 60.8 years; range, 13–80 years). Nineteen patients had a history of synchronous or metachronous malignancy. In all cases the nodule was detected and resected and the resection margins were pathologically free of tumor. Histological examination showed 21 benign and 18 malignant lesions (7 metastases and 11 primary lung cancers). Nine patients with a frozen section-based histopathological diagnosis of lung cancer without functional contraindications underwent a completion lobectomy by open surgery in the same surgical session. In conclusion, the radiolocalization of small pulmonary nodules by gamma probe during VATS is a safe and easy procedure, with fewer complications and a lower failure rate than other localization techniques.

Preoperative short hookwire placement for small pulmonary lesions: evaluation of technical success and risk factors for initial placement failure

OBJECTIVES

To retrospectively evaluate the technical success of computed tomography fluoroscopy-guided short hookwire placement before video-assisted thoracoscopic surgery and to identify the risk factors for initial placement failure.

METHODS

In total, 401 short hookwire placements for 401 lesions (mean diameter 9.3 mm) were reviewed. Technical success was defined as correct positioning of the hookwire. Possible risk factors for initial placement failure (i.e., requirement for placement of an additional hookwire or to abort the attempt) were evaluated using logistic regression analysis for all procedures, and for procedures performed via the conventional route separately.

RESULTS

Of the 401 initial placements, 383 were successful and 18 failed. Short hookwires were finally placed for 399 of 401 lesions (99.5%). Univariate logistic regression analyses revealed that in all 401 procedures only the transfissural approach was a significant independent predictor of initial placement failure (odds ratio, OR, 15.326; 95% confidence interval, CI, 5.429-43.267; p < 0.001) and for the 374 procedures performed via the conventional route only lesion size was a significant independent predictor of failure (OR 0.793, 95% CI 0.631-0.996; p = 0.046).

CONCLUSIONS

The technical success of preoperative short hookwire placement was extremely high. The transfissural approach was a predictor initial placement failure for all procedures and small lesion size was a predictor of initial placement failure for procedures performed via the conventional route.

KEY POINTS

• Technical success of preoperative short hookwire placement was extremely high. • The transfissural approach was a significant independent predictor of initial placement failure for all procedures. • Small lesion size was a significant independent predictor of initial placement failure for procedures performed via the conventional route.

Prediction of lung tumor palpability using high-resolution computed tomography

BACKGROUND

Palpation is the most important means of locating lung tumors and resecting them with sufficient margins. This study aimed to predict the palpability of pulmonary lesions using high-resolution computed tomography.

METHODS

Eighty-six pulmonary lesions were palpated in fresh resected lung specimens from July 2013 to March 2014. The following parameters were compared between 10 impalpable and 76 palpable lesions: maximum tumor size in pulmonary and bone window level settings, consolidation tumor size in pulmonary window level setting, and pleural-tumor distance. In 54 adenocarcinomas, the lepidic component and fibrosis foci rates were compared between the two groups.

RESULTS

Tumor size in bone window level setting and the consolidation tumor size were significantly smaller in the impalpable group (both p < 0.001), and an operational cutoff of 5 mm was identified by receiver-operating characteristic analysis (sensitivity/specificity was 90.0%/94.7% and 90.0%/86.9%, respectively). Pulmonary lesions were impalpable with 87.5% probability when the tumor size in bone window level setting was ≤ 5 mm and the pleural-tumor distance was ≥ 5 mm, and with 85.7% probability when the consolidation tumor size was ≤ 5 mm and the pleural-tumor distance was ≥ 5 mm. Lepidic component and fibrosis foci rates of impalpable/palpable lesions were 96.0%/52.8% and 4.0%/24.7%, respectively (both p < 0.001).

CONCLUSIONS

Tumor size in bone window level setting or a consolidation tumor size ≤ 5 mm and pleural-tumor distance ≥ 5 mm are simple criteria that are potentially useful indicators for preoperative marking to locate small-sized lepidic-predominant adenocarcinomas with few fibrotic foci.

Preoperative computed tomography-guided percutaneous localization of ground glass pulmonary opacity with polylactic acid injection

Localization of a ground glass nodule is a difficult challenge for thoracic surgeons, especially for ground glass opacities (GGOs) less than 10 mm in diameter. In this study we implement a new method for preoperative localization of pulmonary (GGOs). From October 2013 to December 2014, computed tomography-guided percutaneous polylactic acid injection localizations were performed for five pulmonary nodules in five patients (2 men and 3 women; mean age, 59.8 years; range, 54–65 years). The injection was feasible in all patients and the localization effect was excellent. The total procedure duration was 12.6 minutes (range; 10–15) and the volume of polylactic acid injected was 0.38 mL. The wedge resections were easily and successfully performed in all five cases. The cutting margin was no less than 2 cm from the lesion. This technique is promising for the determination of GGO location in thoracoscopic surgery for wedge resection.

The use of iodine seed (I-125) as a marker for the localisation of lung nodules in minimal invasive pulmonary surgery

AIM

Video assisted thoracic surgery (VATS) is an important tool in the field of thoracic pathology both for therapeutic and diagnostic purposes. The standard technique for localisation of non-visible or non-palpable lung lesions is the use of image guided insertion of a guide-wire. However, this method is associated with complications such as pneumothorax, bleeding and wire-dislocation. The aim of this study was to investigate the feasibility of using of iodine seeds (I-125) as a marker of lung lesions during VATS.

METHODS

28 consecutive patients with parenchymal lung lesions had I-125 seed localisation performed prior to VATS. After seed placement all patients underwent VATS with wedge resection.

RESULTS

During surgery all lesions could be identified and radically resected. In six (21.4%) patients the seed was not placed optimally but none of these cases were associated with seed dislocation after placement. In four and in 5 patients the placement of the I-125 seed was complicated by a haematoma and pneumothorax respectively. However, in all of these patients a wait-and-see policy would have been justified. In one patient a conversion to a thoracotomy was necessary due to seed displacement.

CONCLUSION

In patients with parenchymal lung lesions undergoing VATS and wedge resection I-125 seed localisation is a feasible technique. Complication rates are comparable to standard guide-wire localisation. Although I-125 seeds can be positioned under CT-guidance an optimal placement is of utmost importance for VATS wedge resection. Further research is needed to investigate the possible advantages of this technique.

Preoperative CT-Guided percutaneous wire localization of ground glass pulmonary nodules with a modified Kopans wire

PURPOSE

To report a technique of using a modified Kopans wire to localize ground glass pulmonary nodules prior to resection.

METHODS

CT-guided preoperative localization of ground glass nodules was performed using the modified Kopans wire.

RESULTS

In both cases, the wire successfully localized the ground glass nodule and the surgeon was able to remove the nodule during video-assisted thoracoscopic wedge resection.

CONCLUSIONS

Preoperative CT-guided insertion of the modified Kopans wire can result in successful wedge resection of ground glass nodules. The reinforced segment of the modified Kopans wire serves as an excellent source of palpation and localization for the surgeon.

Pulmonary metastasis: rationale for local treatments and techniques

The indication for pulmonary metastasectomy has been postulated based on nonrandomized clinical experiences. The postoperative survival rate of selected patients with pulmonary metastasis is acceptable; nevertheless, pulmonary metastasectomy might cure patients if the neoplastic cells are located only in the lung parenchyma. Computed tomography has been the most reliable preoperative diagnostic methods for identifying pulmonary metastasis. However, it has the limitations that small nodules often cannot be detected, or they are overestimated. Through thoracoscopy, which has largely been applied for metastasectomy in Japan, bimanual palpation during surgery cannot be performed. Considering the fact that the survival rate of the patients undergoing thoracoscopy is not significantly different from that of the patients undergoing conventional thoracotomy, pulmonary metastasectomy is a suboptimal method for eradicating the disease. Less invasive local therapy may be promising for repeat local intervention.

Video-assisted surgery for lung cancer. State of the art and personal experience

This paper reviews the role of videothoracoscopy in lung cancer, highlighting its utility in definitive staging, diagnosis, and treatment. We show exploratory videothoracoscopy to be the perfect technique for last-minute staging, looking for tumor invasion, especially parietal T3 and vascular T4 (due to videopericardioscopy), management of solitary pulmonary nodules, and the possibility of radical treatment with video-assisted thoracoscopic lobectomy. We perform an overview of the literature and analyze our experience of 1,381 patients with lung cancer. In 1,277 of them, the final decision on resectability was made by exploratory videothoracoscopy, including 91 by videopericardioscopy (only 30 were considered non-resectable on videopericardioscopy). Solitary pulmonary nodules were diagnosed in 382 cases (190 were cancer), and we performed 260 major lung resections by video-assisted thoracoscopic surgery (22 pneumonectomies, 238 lobectomies/bilobectomies).

Intrathoracoscopic localization techniques

BACKGROUND

Several techniques for localizing pulmonary nodules have been described, but the advantages and disadvantages of each method remain unclear. We reviewed ultrasound, endofinger, finger palpation and wait and watch, radioguided, vital dye, fluoroscopic, agar marking, and needle wire methods for localizing pulmonary nodules.

METHODS

Original, peer-reviewed, and full-length articles in English were searched with PubMed and ISI Web of Sciences. Case reports and case series with less than 10 patients were excluded.

RESULTS

All localization techniques showed good reliability, but some carry a high rate of major or minor complications and drawbacks.

CONCLUSION

No ideal localization technique is available; thus, the choice still depends on surgeon's preference and local availability of both specialists and instruments.

A strategy for thoracoscopic resection of small pulmonary nodules

BACKGROUND

Preoperative procedures are often necessary to localize pulmonary nodules during thoracoscopic resection in order to reduce the necessity of resorting to thoracotomy. The aim of this report is to describe the strategy we developed to limit preoperative techniques without reducing the thoracoscopic success rate of localization.

METHODS

Between January 2000 and December 2003, 183 patients underwent video thoracoscopic resection of small pulmonary nodules. The patients were divided into two groups on the basis of the radiological features of the nodule. The subjects in group 1 were operated on directly, and endothoracic ultrasonography was performed when necessary. The subjects in group 2 underwent preoperative radionuclide labeling of the nodule.

RESULTS

In group 1, 112 out of 119 nodules (94%) were localized. Twenty-five out of 32 lesions, neither visible nor palpable, were found by endothoracic ultrasonography. In group 2, we localized 62 out of 64 nodules (97%).

CONCLUSIONS

Currently, we cannot completely avoid preoperative labeling techniques for thoracoscopic resection of small pulmonary nodules. However, correct patient selection may limit this necessity, without an increased conversion rate to thoracotomy, if endothoracic ultrasonography is available.

Ultrathin Bronchoscopic Barium Marking With Virtual Bronchoscopic Navigation for Fluoroscopy-Assisted Thoracoscopic Surgery

STUDY OBJECTIVES

To facilitate marking and to reduce its complications, we performed barium marking using an ultrathin bronchoscope with virtual bronchoscopic (VB) navigation before thoracoscopic surgery for small pulmonary peripheral lesions. We then evaluated the feasibility, safety, and efficacy of this technique.

DESIGN

A pilot study.

SETTING

A tertiary teaching hospital.

PATIENTS

The subjects were consecutive patients with small pulmonary peripheral lesions (ie, </= 10 mm) showing a CT scan-confirmed pure ground-glass opacity pattern between December 2001 and August 2003.

INTERVENTIONS

VB images to the planned marking sites near each lesion were produced from helical CT scan data. Based on these images, an ultrathin bronchoscope was advanced to the target bronchus under direct vision. Under CT scan and radiographic fluoroscopy, a catheter was inserted to the planned site via the bronchoscope, and barium sulfate suspension was instilled for marking.

RESULTS

The subjects were 23 patients (8 men and 15 women) who had a total of 31 lesions. The bronchial branching patterns seen in VB images were highly consistent with those confirmed using the ultrathin bronchoscope. Therefore, the ultrathin bronchoscope could be guided under direct vision to a median of the sixth generation bronchi (range, fourth to ninth generation bronchi) toward the planned marking sites. Marking was achieved without causing complications in any of the patients. The median marking time was 23.5 min, and the median shortest distance between the barium marker and the lesion was 4 mm (within 10 mm in 27 lesions). In patients undergoing thoracoscopic surgery, all barium-marked sites were identified by intraoperative radiographic fluoroscopy, and all lesions were resected. A pathologic examination demonstrated primary lung cancer in 17 lesions (bronchioloalveolar carcinoma, 15; adenocarcinoma, 2), atypical adenomatous hyperplasia in 12 lesions, and pneumonia in 2 lesions.

CONCLUSIONS

This method can be readily performed without complications and is a useful marking method before thoracoscopic surgery for small pulmonary peripheral lesions.

A barium marking method using an ultrathin bronchoscope with virtual bronchoscopic navigation

CT scanning in a 77-year-old woman showed a ground-glass opacity pattern shadow(9 x 7 mm) in the right lower lobe. To allow identification of the location of the lesion during thoracoscopic surgery, preoperative barium marking was performed using an ultrathin bronchoscope and virtual bronchoscopic navigation. Virtual bronchoscopy was performed based on thin-section CT images, and virtual bronchoscopic images to the target sites were obtained. Subsequently, using virtual bronchoscopic images to right B8aiibetax, B6biibeta for navigation, an ultrathin bronchoscope was advanced to this site under direct observation. A special catheter for ultrathin bronchoscopy was advanced to sites near the lesion, and barium was infused. Barium was clearly observed by radiographic fluoroscopy during thoracoscopic surgery and was useful for determining the area for resection. Pathological examination of the resected specimen revealed atypical adenomatous hyperplasia. There were no complications with this method, and a number of target areas could be readily marked in a short time. This method may be useful before thoracoscopic surgery for small peripheral pulmonary lesions.

CT fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules

STUDY OBJECTIVE

To determine the diagnostic reliability and safety of a new marking technique using transbronchoscopic dye injection under CT fluoroscopy for preoperative localization of a small pulmonary nodule.

DESIGN

Prospective study.

SETTING

Hyogo Medical Center for Adults and Shizuoka Cancer Center in Japan.

PATIENTS

Seventeen patients who had a peripheral pulmonary nodule < 15 mm in size on CT scans that was suspected to be difficult to localize by visual inspection and manual palpation at our institutes between April 2000 and October 2002.

INTERVENTIONS

After a bronchoscope was inserted orally under local anesthesia and was introduced into the related bronchus of the target nodule, a Teflon sheath catheter with metal tip was inserted transbronchoscopically and was advanced into the visceral pleura. By monitoring CT fluoroscopy, the catheter tip was positioned at the nearest pleural surface of the nodule, and 0.5 mL indigo carmine was injected under deep inspiratory breathhold. CT scans were obtained to confirm the relationship between the injected dye area and the nodule.

MEASUREMENTS AND RESULTS

The dye injections were performed completely in all 17 patients, who subsequently underwent lung resection guided by the dye staining. There were no complications or harmful effects of the surgery. The area of injected dye was demonstrated as a hazy focal lesion about 10 mm beneath the pleura on the high-resolution CT scan, and was clearly visible as a patchy dark blue area about 20 mm in size on the visceral pleura at surgery. The mean distance between the nodule and the dye was 20 mm on the CT scan (distance range, 0 to 30 mm). The mean examination time with this technique was approximately 35 min (range, 25 to 45 min). The mean CT fluoroscopic time was 60 s (range, 30 to 120 s).

CONCLUSIONS

Our transbronchial "tattooing" technique is safe and reliable. We think it is superior to previous marking methods.

Ultrasonographic localization of occult pulmonary nodules during video-assisted thoracic surgery

The aim of our study was to evaluate the role of ultrasonography in the localization of pulmonary nodules during video-assisted thoracic surgery (VATS). Ultrasonography was performed in 35 patients for the localization of pulmonary nodules during VATS. Indication for VATS was excisional biopsy of undetermined nodules in 22 patients, single or multiple metastasectomy in 12 patients and resection of primitive pulmonary cancer in 1 patient with reduced pulmonary reserve. A laparoscopic probe with flexible head and multi-frequency transducer (5-7.5 MHz) was used. Intraoperative ultrasonography localized 37 of 40 nodules preoperatively detected by CT and/or by positron emission tomography in 35 patients. Furthermore, ultrasonography localized two nodules not visualized at spiral CT. Eighteen nodules were not visible or palpable at thoracoscopic examination and were found by intraoperative sonography only. In 6 patients in whom thoracotomy was performed, manual palpation did not reveal more lesions than ultrasonography. In our experience, ultrasonography was very helpful when lesions were not visible or palpable during thoracoscopy, showing high sensitivity (92.5%) in finding pulmonary nodules. Since it is not possible to determine preoperatively whether a localization technique will be necessary during the operation or not, and ultrasonography is a non-invasive technique, we think that, at present, this technique can be considered as the first-instance localization technique during thoracoscopic resection of pulmonary nodules.

Using a dedicated lung-marker system for localization of pulmonary nodules before thoracoscopic surgery

OBJECTIVE

Our aim was to evaluate the effectiveness of a commercially available dedicated lung-marker system for localization of pulmonary nodules before video-assisted thoracoscopic surgery.

SUBJECTS AND METHODS

Guidewires were positioned under CT fluoroscopy guidance in 16 patients (11 men, five women; age range, 39-79 years; mean age, 60.4 years). We measured the size of the targeted nodule, its distance to the closest pleural surface, the angle between the introducer needle and the chest wall, and the time for performance of the procedure in each patient. Note was made of any complications after guidewire placement.

RESULTS

In the 16 patients, the average nodule size was 6.7 mm (range, 3-12 mm), the average distance to the pleural surface was 10.6 mm (range, 3-22 mm), and the average pleural puncture angle was 59 degrees (range, 25-78 degrees). The marking procedure was completed within an average of 9.5 min (range, 7-15 min). Small pneumothoraces occurred in five (31.3%) of 16 patients. In 15 (93.8%) of 16 patients, thoracoscopic resection of the targeted nodule was successful; in one patient with dyspnea (6.3%), inaccurate localization resulting in an open thoracotomy occurred because an intervening fissure was not visualized. Dislodgement of the guidewire into the pleural space occurred in one patient (6.3%).

CONCLUSION

The dedicated lung-marker system is a fast and effective method for localization of pulmonary nodules before thoracoscopic resection.

Methylene blue-stained autologous blood for needle localization and thoracoscopic resection of deep pulmonary nodules

BACKGROUND/PURPOSE

Video-assisted thoracoscopic surgery (VATS) has used a variety of preoperative techniques to localize deep pulmonary nodules including wires, plain methylene blue, colored collagen, indigo carmine, India ink, and barium. The authors describe their experience with a computed tomography (CT)-guided localization technique using autologous blood stained with methylene blue.

METHODS

The authors reviewed retrospectively children who had pulmonary nodules localized using CT guidance with a mixture containing 3 mL autologous blood stained with 0.3 mL methylene blue. Nodules were resected by standard VATS technique. Postoperative chest tube drainage was performed selectively.

RESULTS

Nineteen procedures were performed in 17 children (average age, 11 years). Operating time (range, 21 to 171 minutes) varied depending on the number of nodules resected. All resections were diagnostic, and 80% represented malignancy. Lesions averaged 0.9 cm in size (range, 0.3 to 3 cm) with an average pulmonary depth of 0.8 cm (range, 0.1 cm to 1.8 cm). One patient required conversion to an open thoracotomy because of malfunction of the endoscopic stapler. Forty percent of the children received chest tubes, and 53% were discharged home the same day.

CONCLUSION

VATS diagnostic resection of deep pulmonary nodules preoperatively localized with methylene blue stained autologous blood is safe and effective.

Preoperative localization of small pulmonary lesions with a short hook wire and suture system: experience with 168 procedures

PURPOSE

To evaluate use of a short hook wire and suture system for preoperative localization of pulmonary nodular lesions.

MATERIALS AND METHODS

Percutaneous localization of 168 lesions was performed with computed tomographic (CT) guidance in 150 patients. Patients were classified into three groups: a 3-year early-learning experience of treatment of 40 lesions mainly in one institution (group A1), a more recent 4-year experience of treatment of 88 lesions in the same institution (group A2), and the roughly synchronous recent 3-year experience of treatment of 40 lesions in a different hospital (group B).

RESULTS

The hook wire was successfully placed without dislodgment in 146 patients, accounting for 164 (97.6%) of 168 lesions. Group A2 showed a success rate of 100%. There was no difference in patients among the three groups in regard to size of lesions or their distance from the pleural surface. In patients in groups A2 and B, the proportion of nodules with ground-glass opacity and primary lung carcinoma at CT was significantly greater than that in patients in group A1. In 168 placements, nonsymptomatic pneumothorax cases were observed in 54 (32.1%), hemorrhages into the lung were observed in 25 (14.9%), and hemorrhage into the pleural space was observed in one (0.6%). No patient complained of notable pain during or after the procedure, and no serious complication was experienced. Unsuccessful placement was caused by too shallow a puncture with the introducer needle.

CONCLUSION

This system with a flexible suture for preoperative localization has a high success rate.

[Hookwire localization of pulmonary nodules for video-thorascopic surgical resection]

OBJECTIVES

To assess the usefulness of a technique for inserting hookwires guided by computed tomography to locate and resect pulmonary nodules by video-assisted thoracoscopy. To describe the procedure and its complications.

PATIENTS AND METHODS

Nine pulmonary nodules were located in nine patients. All were </= 2 cm in diameter, radiologically undefined and of unknown origin. Four patients had a history of cancer. The nodules were located using the needle/hookwire system (Kopans), guided by computed tomography and were resected by video-assisted thoracic surgery.

RESULTS

The hookwire was placed correctly in 8 patients and incorrectly in 1. Thoracotomy was necessary for 1 patient. The histologic diagnosis was benign for all 9 nodules; 5 were hamartomas, 2 were necrotic or fibrotic nodules, 1 was a granuloma and 1 was an anthracotic node. Hospital stay ranged from 1 to 8 days (mean 3.3 days).

CONCLUSION

The location of pulmonary nodes by hookwire and needle for later resection by video-assisted thoracoscopic surgery is a simple, safe way to facilitate removal in some cases, for diagnosis and treatment.

Localization of pulmonary nodules using suture-ligated microcoils

Percutaneous localization of pulmonary nodules in five patients was performed utilizing suture-ligated embolization microcoils and CT guidance. Each localization was performed prior to video-assisted thoracoscopic wedge resection of the targeted nodules. Each suture-ligated microcoil was placed within 1.0 cm of the targeted pulmonary nodule. The attached suture served as a guide to direct accurate resection of the nodules. This technique is easily performed and provides a reliable alternative to nodule localization prior to thoracoscopic resection.

A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection

OBJECTIVE

Video-assisted thoracic surgery (VATS) is an interesting and emerging procedure for diagnosis and treatment of peripheral pulmonary nodules. However, thoracoscopy has limits in the detection of small nodules, below the pleural surface, deep in the lung parenchyma, which cannot be seen as much as palpated. Methods to localize such lesions, including the methylene blue injection or the introduction of a hooked-wire under the radiological vision, have some advantages but a lot of limitations. We are developing a new technique for the detection of pulmonary nodules smaller than 2 cm, deep in the lung parenchyma.

METHODS

The technique consisted of a intra-lesional injection of 0.3 ml of solution of 99m Tc-labelled human serum albumin microspheres (5-10 MBq) under the CT-scan guide, 2 h before surgery. During thoracoscopy a 11 mm diameter-collimated probe connected to a gamma ray detector (Scinti Probe MR 100 - Pol. hi.tech., Aquila - Italy), is introduced by a 11.5 mm trocar and the pleural surface of the suspected area was scanned. A hot-spot indicated the presence of the injected nodule and as a consequence, the area to be resected.

RESULTS

from June 1997 to June 1999 we treated 39 patients with small pulmonary nodules. The patients were 27 men and 12 women with a mean age of 60.8 years (range: 13-80). In 19 cases the anamnesis was positive for synchronous or metachronous malignant neoplasm. The mean surgical procedure length was 50 min (range 20-100 min). In all the cases the nodule was resected and the resection margins were pathologically free of tumour. The mean post-operative hospital stay was 3 days (range 2-6 days). Histological examination showed 21 benign lesions and 18 malignant lesions (seven metastases and 11 primary lung cancers). Nine pts with primary lung carcinoma underwent a completion lobectomy by open surgery.

CONCLUSIONS

Radiolocalization by gamma-probe allows the detection and exeresis of small nodules in a easy and safe way. Future and predictable advances in radio-marked monoclonal antibodies, as well as in the development of endoscopic beta-detector probe, will offer a more effective method for detection of primary and metastatic tumours, targets of thoracoscopic resections.

Lung nodules: improved wire for CT-guided localization

The authors designed three localization wires that increase the utility of percutaneous localization of lung nodules performed in conjunction with video-assisted thorascopic resection. In 17 patients, the custom-made wires dislodged less frequently than did commercially available wires (two of 11 vs three of six, respectively) while allowing the surgeon to apply gentle retraction pressure, which aided the resection.