A safe method for marking small pulmonary nodules with crystal violet

Virtual thoracoscopic imaging-assisted pleural marking of pulmonary nodules

Background

Computed tomography (CT) is now able to detect small pulmonary nodules. Surgical resection for diagnosis of these nodules is widely performed with video-assisted thoracoscopic surgery (VATS). However, it is very difficult to localize a small tumor by palpation via a small access port. In this study, we aimed to describe a novel intraoperative method for marking the location of the pulmonary nodule.

Methods

In 46 cases, a virtual thoracoscopic image was reconstructed using the CT images of the chest using volume rendering software before surgery. During thoracoscopic surgery, a pleural marker was affixed to the parietal pleura, just above the tumor, by referring to the virtual thoracoscopic image. The pleural marker dye was then transferred to the point on the visceral pleura just above the nodule. The distance between the center of the marking and the visceral pleura closest to the tumor was measured to evaluate the accuracy of the marking.

Results

The mean distance between the center of the marking and the visceral pleura closest to the tumor was 10.2 mm. In 42 cases (92%), the tumor was within 30 mm of the marked point. All tumors were fully resected. No morbidity occurred intra- or postoperatively.

Conclusions

Our pleural marking, using a virtual thoracoscopic image, identified the tumor location with high accuracy, may help surgeon to confirm whether the palpated nodule is the target one. This new procedure can assist in the localization of the pulmonary nodule with ease of application, safety, and accuracy.

Thoracoscopic anatomical lung segmentectomy using 3D computed tomography simulation without tumour markings for non-palpable and non-visualized small lung nodules

OBJECTIVES

Although wedge resection can be curative for small lung tumours, tumour marking is sometimes required for resection of non-palpable or visually undetectable lung nodules as a method for identification of tumours. Tumour marking sometimes fails and occasionally causes serious complications. We have performed many thoracoscopic segmentectomies using 3D computed tomography simulation for undetectable small lung tumours without any tumour markings. The aim of this study was to investigate whether thoracoscopic segmentectomy planned with 3D computed tomography simulation could precisely remove non-palpable and visually undetectable tumours.

METHODS

Between January 2012 and March 2016, 58 patients underwent thoracoscopic segmentectomy using 3D computed tomography simulation for non-palpable, visually undetectable tumours. Surgical outcomes were evaluated.

RESULTS

A total of 35, 14 and 9 patients underwent segmentectomy, subsegmentectomy and segmentectomy combined with adjacent subsegmentectomy, respectively. All tumours were correctly resected without tumour marking. The median tumour size and distance from the visceral pleura was 14 ± 5.2 mm (range 5-27 mm) and 11.6 mm (range 1-38.8 mm), respectively. Median values related to the procedures were operative time, 176 min (range 83-370 min); blood loss, 43 ml (range 0-419 ml); duration of chest tube placement, 1 day (range 1-8 days); and postoperative hospital stay, 5 days (range 3-12 days). Two cases were converted to open thoracotomy due to bleeding. Three cases required pleurodesis for pleural fistula. No recurrences occurred during the mean follow-up period of 44.4 months (range 5-53 months).

CONCLUSIONS

Thoracoscopic segmentectomy using 3D computed tomography simulation was feasible and could be performed to resect undetectable tumours with no tumour markings.