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

Augmented reality guided versus computed tomography guided percutaneous lung nodule localization: a noninferiority randomized clinical trial

HYPOTHESIS

This study hypothesized that augmented reality (AR) technology has comparable accuracy and safety to conventional CT localization in guiding percutaneous transthoracic lung puncture (PTLP) to localize small pulmonary nodules.

METHODS

This study was a prospective, non-inferiority randomized clinical trial. Patients were randomly assigned between 23 May 2023, and 26 September 2023. Patients with small peripheral lung nodules (≤2 cm) were recruited. Patients were randomly assigned to either the CT-guided PTLP group or the AR-guided PTLP group, with a 1:1 allocation ratio. The primary outcome was the accuracy of lung nodule localization measured by localization error. The secondary outcomes included procedure duration, radiation exposure dosage and complications.

RESULTS

A total of 70 patients underwent either CT- or AR-guided lung nodule localization and subsequent surgeries. Localization error was smaller in the AR-guided group than in the CT-guided group (mean ± SD, 3.1 ± 4.0 mm vs. 5.4 ± 4.2 mm, P = 0.026). The mean difference of localization errors was -2.3 mm (95% CI: - 4.2 to -0.3 mm, P < 0.001 for non-inferiority). Compared to the CT-guided group, the AR-guided group demonstrated significantly lower radiation exposure (mean ± SD, 421 ± 168 vs. 694 ± 229 mGy × cm, P < 0.001) and shorter localization procedure duration (mean ± SD, 8.8 ± 2.3 vs. 14.1 ± 1.8 minutes, P < 0.001), with no statistical difference in complications.

CONCLUSIONS

The accuracy of the AR-guided approach is comparable to that of the CT-guided approach in localizing small lung nodules. Furthermore, the utilization of AR technology has been demonstrated to reduce procedural time and minimize radiation exposure for patients.

Comparative study of geometric localization technique and CT-guided percutaneous localization technique for peripheral GGO in wedge resection: a randomized controlled trial

BACKGROUND

Intraoperative localization of ground glass opacity (GGO) is a major clinical challenge. We previously introduced a novel method called geometric localization technique (GLT). We aimed to compare GLT and the mostly common used technique-CT guided percutaneous localization technique (CPLT) in terms of the effectiveness, safety and accuracy.

METHODS

In a randomized controlled trial, patients who were diagnosed with pulmonary GGO and underwent wedge resection were randomized into GLT group (localized using GLT method) and CPLT group (localized using CPLT method). Baseline data, localization related data, successful localization rate, complications, operation related data and pathological results of patients were prospectively collected. Statistical analysis was performed between the two groups.

RESULTS

A total of 455 patients in our hospital were enrolled in this study from 2022-7-6 to 2024-2-22, including 228 patients in the GLT group and 227 patients in the CPLT group. There were significant differences in terms of the successful localization rate (99.6% vs. 94.3%, χ2 = 10.667, P = 0.001), the rate of sufficient resection margin (99.6% vs. 87.2%, χ2 = 28.110, P < 0.001), and incidence of localization-related complications (0 vs. 17.6%, χ2 = 114.251, P < 0.001) between GLT group and CPLT group. In the GLT group, the distance between GGO and marked visceral pleural point was 3.9 ± 3.1 mm. In the CPLT group, the distance from punctured pleural point to GGO and the distance from anchor to GGO were 18.3 ± 11.4 mm and 4.1 ± 3.5 mm, respectively. In CPLT, one dislocation and thirteen dislodgement occurred. In multivariate regression analysis, only the localization technique was independently correlated with the successful localization rate (OR = 13.105; 95% CI: 1.688, 101.713; P = 0.014). Gender (OR = 0.239; 95% CI: 0.099, 0.579; P = 0.002), nodule size (OR = 0.864; 95% CI: 0.758, 0.984; P = 0.028), depth of nodules (OR = 0.908; 95% CI: 0.861, 0.957; P < 0.001) and the localization technique (OR = 40.809; 95% CI: 5.357, 310.855; P < 0.001) were independent variables in determining the rate of sufficient resection margin.

CONCLUSIONS

Compared with CPLT, GLT has at least comparable outcomes in terms of effectiveness and accuracy; good safety profile was the advantage of GLT.

TRIAL REGISTRATION

ChiCTR2200060527 (  https://www.chictr.org.cn ), 2022/6/4, prospectively registered.

Comparison of hook wire and microcoil preoperative localisation in subsolid pulmonary nodules: a retrospective analysis

AIM

Subsolid nodules are increasingly detected during physical examinations with computed tomography (CT) scan and video-assisted thoracoscopic surgery (VATS) is the standard treatment. This study compared the effectiveness of preoperative localisation of subsolid pulmonary nodules using a hook-wire and a microcoil under CT guidance prior to VATS.

MATERIALS AND METHODS

Patients with solitary subsolid pulmonary nodules (n = 342) underwent percutaneous puncture localisation guided by CT before VATS. Overall, 107 were localised using a hook wire (hook-wire group), and 235 patients were localised using a microcoil (microcoil group). Localisation-related indicators, complications associated with localisation surgery, and VATS-related indicators were compared between the two groups.

RESULTS

The success rate of localisation was not different between the two groups [hook-wire group: 92.52% (99/107) vs microcoil group: 96.17% (226/235), P = 0.150). The localisation time and time window between localisation and surgery were shorter in the hook-wire group than in the microcoil group (P < 0.001). However, the overall incidence of complications related to localisation surgery was greater in the hook-wire group than in the microcoil group [48.60% (52/107) vs. 31.49% (74/235), P = 0.002]. Both groups mainly underwent pulmonary lobectomy as the primary surgical procedure, with no statistically significant difference in the surgical approach between the groups (P = 0.084). Surgical time for patients who underwent pulmonary lobectomy was shorter in the microcoil group than in the hook-wire group (P = 0.023).

CONCLUSION

The effectiveness of preoperative localisation of subsolid pulmonary nodules using hook-wire and microcoils under CT guidance prior to VATS is comparable. The microcoil technique has a longer localisation time but a lower overall complication rate and shorter surgical time for pulmonary lobectomy.

The Positioning Method of Pulmonary Nodules in Thoracoscopic Surgery Based on CT Simulation Positioning System for Radiotherapy

PURPOSE

The application of wedge resection in thoracoscopic surgery is becoming more and more widely prevalent. However, achieving precise intraoperative positioning of the pulmonary nodules still poses challenges. This study proposed a method for surface positioning using a computed tomography (CT) simulation positioning system in the radiation physics room.

METHODS

After screening patients, the level of nodules was located under the CT simulation positioning system, and the pleural projection point of the nodule and the closest surface puncture point from this point to the body surface were determined by the laser positioning system. During the operation, a needle was inserted at a predetermined angle at the puncture point, leaving a pinhole in the visceral pleura. Finally, the distance between the true pleural projection point of the nodule and the pinhole was measured on the specimen.

RESULTS

The success rate of our positioning method was 97.2%. The average distance between the puncture pinhole location and the actual pleural projection point of the nodule was 8.1 mm. No related complications occurred during the perioperative period.

CONCLUSION

The new method of preoperative surface positioning and intraoperative lung positioning through puncture has a high success rate, good positioning accuracy, and good safety, which is worthy of clinical application.

Intraoperative Transbronchial Metallic Coil Marking for Small Peripheral Pulmonary Lesions in a Hybrid Operation Room

Background/Objectives: Computed tomography (CT)-guided transbronchial metallic coil marking is useful for identifying the locations of small peripheral pulmonary lesions. Even deeply located lesions may be accurately identified and resected with adequate margins. This method is also applicable to multiple lesions. The present study examined the efficacy of our marking method using cone-beam CT (CBCT) under general anesthesia in a hybrid operation room. Methods: In the hybrid operation room, an ultrathin bronchoscope was inserted into the objective bronchus under virtual bronchoscopic navigation, and a metallic coil was installed under CBCT guidance. The lesion was then resected with wedge resection by single- or 3-port video-assisted thoracoscopic surgery under fluorescence guidance. Eighty-seven patients with 90 lesions were treated between October 2016 and December 2022. The median lesion size was 11 mm and the median distance from the pleural surface was 8.7 mm. Lesions comprised 19 pure ground-glass nodule (GGN), 35 partly solid, and 36 solid types. Results: All lesions were visualized by CBCT, and metallic coils were installed into the objective bronchi. The median distance from lesions to coils was 3.6 mm, and the median marking time was 23.5 min. All lesions were resected with sufficient margins. In total, 57 lesions were diagnosed as primary lung cancer, 26 as metastatic lung tumors, 3 as nodular lymphoid hyperplasia, and 4 as others. There were no complications associated with the marking procedure. Conclusions: CBCT represents an alternative modality for identifying peripheral lung lesions due to its ability to visualize even small GGNs. It is a minimally invasive technique because the treatment sequence is completed under general anesthesia with the same quality as previous methods performed in a CT-equipped interventional radiology suite.

Effects of pregabalin combined with tramadol/paracetamol on acute pain in patients with CT-guided puncture localization of pulmonary nodules

OBJECTIVE

To investigate the effects of pregabalin combined with tramadol/paracetamol on acute pain in patients with CT-guided puncture localization of pulmonary nodules.

MATERIALS AND METHODS

In this randomized, placebo-controlled and single-center study, 120 patients were allocated randomly to four groups: the control group (Group P), the pregabalin-placebo group (Group BP), the tramadol/paracetamol-placebo group (Group AP), and the pregabalin-tramadol/paracetamol group (Group AB). The primary outcome was the NRS (Numerical Rating Scale) score. Other outcomes included systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), pulse oxygen saturation (SpO2), the incidence of moderate to severe pain, the analgesia recovery ratio, the incidence of adverse drug reactions and patients' satisfaction.

RESULTS

No significant interaction was detected between the interventions (P = 0.752). The NRS score of the Taking pregabalin group and the Taking tramadol/paracetamol group were significantly lower than those of the Not-taking pregabalin group and the Not-taking tramadol/paracetamol group respectively (P < 0.05). There was significant difference in the NRS scores among the four groups (P < 0.001). The NRS score of Group AB was significantly lower than that of Group P (P < 0.001), Group BP (P < 0.001) and Group AP (P = 0.001). At the same time, the NRS scores of Group BP (P < 0.001) and Group AP (P < 0.001) were significantly lower than those of Group P, but there was no significant difference between Group BP and Group AP (P = 1.000). The SBP, DBP, HR, the incidence of moderate to severe pain and the analgesia recovery ratio of Group AB were significantly lower than those of Group P (P < 0.05), while the SpO2 and the number of people who were very satisfied were significantly higher than those of Group P (P < 0.05). There was no significant difference in the incidence of adverse drug reactions among the four groups (P = 0.272).

CONCLUSIONS

The combination or single use of pregabalin and tramadol/paracetamol can effectively relieve the acute pain after localization. Pregabalin combined with tramadol/paracetamol has the best analgesic effect and significantly reduces the hemodynamic fluctuations, with high safety and low incidence of adverse drug reactions, which has a certain clinical popularization and application value.

Clinical application of CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization in thoracoscopic lung nodule resection: a single-centre retrospective study

BACKGROUND

Today, the detection rate of lung nodules is increasing. Some of these nodules may become malignant. Thus, timely resection of potentially malignant nodules is essential. However, Identifying the location of nonsurface or soft-textured nodules during surgery is challenging. Various localization techniques have been developed to accurately identify lung nodules. Common methods include preoperative CT-guided percutaneous placement of hook wires and microcoils. Nonetheless, these procedures may cause complications such as pneumothorax and haemothorax. Other methods regarding localization of pulmonary nodules have their own drawbacks. We conducted a clinical study which was retrospective to identify a safe, accurate and suitable method for determining lung nodule localization. To evaluate the clinical value of CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization in thoracoscopic lung nodule resection.

METHODS

We retrospectively collected the clinical data of 120 patients who underwent lung nodule localization and resection surgery at the Department of Thoracic Surgery, First Affiliated Hospital of Bengbu Medical College, from January 2020 to January 2022. Among them, 30 patients underwent CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization, 30 patients underwent only CT-assisted body surface localization, 30 patients underwent only intraoperative stereotactic anatomical localization, and 30 patients underwent CT-guided percutaneous microcoil localization. The success rates, complication rates, and localization times of the four lung nodule localization methods were statistically analysed.

RESULTS

The success rates of CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization and CT-guided percutaneous microcoil localization were both 96.7%, which were significantly higher than the 70.0% success rate in the CT-assisted body surface localization group (P < 0.05). The complication rate in the combined group was 0%, which was significantly lower than the 60% in the microcoil localization group (P < 0.05). The localization time for the combined group was 17.73 ± 2.52 min, which was significantly less than that (27.27 ± 7.61 min) for the microcoil localization group (P < 0.05).

CONCLUSIONS

CT-assisted body surface localization combined with intraoperative stereotactic anatomical localization is a safe, painless, accurate, and reliable method for lung nodule localization.

Comparative Study of Indocyanine Green Fluorescence Imaging in Lung Cancer with Near-Infrared-I/II Windows

BACKGROUND

We compare the application of intravenous indocyanine green (ICG) fluorescence imaging in lung cancer with near-infrared-I (NIR-I) and near-infrared-II (NIR-II) windows.

METHODS

From March to December 2022, we enrolled patients who received an intravenous injection of ICG (5 mg/kg) 1 day before the planned lung cancer surgery. The lung cancer nodules were imaged by NIR-I/II fluorescence imaging systems, and the tumor-to-normal-tissue ratio (TNR) was calculated. In addition, the fluorescence intensity and signal-to-background ratio (SBR) of capillary glass tubes containing ICG covered with different thicknesses of lung tissue were measured by NIR-I/II fluorescence imaging systems.

RESULTS

In this study, 102 patients were enrolled, and the mean age was 59.9 ± 9.2 years. A total of 96 (94.1%) and 98 (96.1%) lung nodules were successfully imaged with NIR-I and NIR-II fluorescence, and the TNR of NIR-II was significantly higher than that of NIR-I (3.9 ± 1.3 versus 2.4 ± 0.6, P < 0.001). In multiple linear regression, solid nodules (P < 0.001) and squamous cell carcinoma (P < 0.001) were independent predictors of a higher TNR of NIR-I/II. When capillary glass tubes were covered with lung tissue whose thickness was more than 2 mm, the fluorescence intensity and the SBR of NIR-II were significantly higher than those of NIR-I.

CONCLUSIONS

We verified the feasibility of NIR-II fluorescence imaging in intravenous ICG lung cancer imaging for the first time. NIR-II fluorescence can improve the TNR and penetration depth of lung cancer with promising clinical prospects.

Saving Lives in Thoracic Surgery: Balancing Oncological Radicality and Functional Preservation, Transitioning from Standard Pneumonectomy to Targeted Sublobar Resection

This review chronicles the evolution of thoracic surgical interventions, from the standardized pneumonectomy to the precise approach of sublobar resections. It discusses the emergence and acceptance of minimally invasive and robot-assisted surgical techniques, highlighting their impact on improving outcomes beyond cancer and their influence on the surgical management of early-stage lung cancer. Evaluating historical developments alongside present methodologies, this review underscores the critical need for meticulous surgical planning and execution to optimize both oncological radicality and functional preservation. This evolution portrayed not only technical advancements but also a shift in the clinical approach towards tailored, organ-preserving methodologies, culminating in a contemporary framework promoting sublobar resections as the standard for specific patient profiles, signifying a new era of precision in thoracic surgery.

Evaluation of pain levels treated by the distal end of the hook-wire positioning needle: A randomized controlled study

BACKGROUND

Severe pain can be expected among adult patients undergoing hook-wire CT-guided localization of pulmonary nodules. We compared varying pain degrees between two different treatment techniques.

METHODS

Data from 100 patients who underwent hook-wire puncture localization under preoperative CT between May 2022 and October 2022 were prospectively reviewed. Using the random number table method, the patients were assigned to an observation and control group in a 1:1 ratio. In the observation group (n = 50), the external part of the hook-wire positioning needle was cut off; in the control group (n = 50), the external portion of the needle was bent. Static pain scores were measured using the visual analog scale (VAS) at 30 min, 1, and 2 h post localization for patients.

RESULTS

No significant differences were present between the two groups in terms of patient age, sex, nodule size, and nodule location. The observation group had lower VAS scores at 30 min (2.57 ± 1.38 vs. 3.51 ± 1.87 p = 0.005), 1 h (2.43 ± 1.14 vs. 3.33 ± 1.76 p = 0.003), and 2 h (2.41 ± 1.12 vs. 3.17 ± 1.74 p = 0.011) after localization. Moreover, the pain level did not gradually worsen in either group. Both groups had a 100% localization success rate. There was no statistically significant difference (p = 0.431) in the localized complication incidences between the two groups.

CONCLUSIONS

We found both approaches for handling the hook-wire extending outside the chest to be safe and effective. However, cutting off the hook-wire extending outside the chest is associated with lesser pain. Moreover, pain severity does not worsen with time after localization.

Preoperative computed tomography-guided transscapular sens-cure needle localization for pulmonary nodule located behind the scapula

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is an approach that is commonly used to resect pulmonary nodules (PNs). However, when these PNs are located behind the scapula, a transscapular access approach is generally required. In this study, the safety, efficacy, and feasibility of preoperative computed tomography (CT)-guided Sens-cure needle (SCN) localization was assessed for PNs located behind the scapula.

METHODS

From January 2020 - June 2022, a total of 122 PN patients in our hospital underwent preoperative CT-guided SCN localization and subsequent VATS resection, of whom 12 (9.8%) exhibited PNs behind the scapula necessitating a transscapular approach for this localization procedure.

RESULTS

This study included 12 patients, each of whom had one PN located behind the scapula. The CT-guided transscapular SCN localization approach was successful in all patients, and no complications near the operative site were observed. The median localization time was 12 min, and 2 (16.7%) and 1 (8.3%) patients respectively developed pneumothorax and pulmonary hemorrhage after the localization procedure was complete. Wedge resection procedures for these PNs achieved technical success in all cases. Four patients were diagnosed with invasive adenocarcinomas and subsequently accepted lobectomy and systematic lymph node dissection. The median VATS duration and the median blood loss was 80 min and 10 mL, respectively. In total, 3, 5, and 4 PNs were respectively diagnosed as benign, mini-invasive adenocarcinomas, and invasive adenocarcinomas.

CONCLUSION

Preoperative CT-guided transscapular SCN localization represents a safe, straightforward, and effective means of localizing PNs present behind the scapula.

Fissureless technique of robotic left lingular segmentectomy for primary lung cancer with incomplete fissure: a case report

BACKGROUND

Pulmonary segmentectomy for a lung with an incomplete interlobar fissure may complicate persistent air leakage. The fissureless technique is often used in lobectomy to prevent persistent air leakage. We herein describe successful use of the fissureless technique for segmentectomy with the aid of a robotic surgical system.

CASE PRESENTATION

A 63-year-old man was clinically diagnosed with early-stage lung cancer for which lingular segmentectomy was indicated. A preoperative image revealed a lung with an incomplete fissure. Based on three-dimensional reconstruction imaging, we planned to divide the hilum structures in the order of the pulmonary vein, bronchus, and pulmonary artery and finally resect the lung parenchyma by dividing the intersegmental plane and interlobar fissure. This fissureless technique was successfully conducted using a robotic surgical system. The patient did not develop persistent air leakage and was alive without recurrence 1 year after segmentectomy.

CONCLUSIONS

The fissureless technique may be a useful option in segmentectomy for a lung with an incomplete interlobar fissure.

Single-stage augmented fluoroscopic bronchoscopy localization and thoracoscopic resection of small pulmonary nodules in a hybrid operating room

OBJECTIVES

Hybrid operating rooms (HOR) have been increasingly used for image-guided lung surgery, and most surgical teams have used percutaneous localization for small pulmonary nodules. We evaluated the feasibility and safety of augmented fluoroscopic bronchoscopy localization under endotracheal tube intubation general anaesthesia followed by thoracoscopic surgery as a single-stage procedure in ab HOR.

METHODS

We retrospectively reviewed clinical records of patients who underwent single-stage augmented fluoroscopic bronchoscopy localization under general anaesthesia followed by thoracoscopic surgery in an HOR between August 2020 and March 2022.

RESULTS

Single-stage localization and resection were performed for 85 nodules in 74 patients. The median nodule size was 8 mm [interquartile range (IQR), 6-9 mm], and the median distance from the pleural space was 10.9 mm (IQR, 8-20 mm). All nodules were identifiable on cone-beam computed tomography images and marked transbronchially with indigo carmine dye (median markers per lesion: 3); microcoils were placed for deep margins in 16 patients. The median localization time was 30 min (IQR 23-42 min), and the median fluoroscopy duration was 3.3 min (IQR 2.2-5.3 min). The median radiation exposure (expressed as the dose area product) was 4303.6 μGym2 (IQR 2879.5-6268.7 μGym2). All nodules were successfully marked and resected, and the median global operating room time was 178.5 min (IQR 153.5-204 min). There were no localization-related complications, and the median length of postoperative stay was 1 day (IQR, 1-2 days).

CONCLUSIONS

Single-stage augmented fluoroscopic bronchoscopy localization under general anaesthesia followed by thoracoscopic surgery was feasible and safe.

Preoperative computed tomography-guided localization for lung nodules: localization needle versus coil

PURPOSE

To compare the clinical efficacy of computed tomography (CT)-guided localization needle and coil insertion as approaches to preoperative lung nodule (LN) localization.

MATERIAL AND METHODS

Between January 2018 and December 2019, 52 patients awaiting video-assisted thoracoscopic surgery (VATS) resection underwent CT-guided coil insertion to facilitate LN localization. Additionally, 41 patients underwent CT-guided localization needle insertion between January and June 2021.

RESULTS

In total, 62 and 54 LNs were localized in 52 and 41 patients in the coil and localization needle groups, respectively, with respective technical localization success rates of 96.8% and 100% (p = .498). The localization needle group exhibited a significantly shorter duration of localization relative to the coil group (p < .001), whereas comparable rates of pneumothorax (p = .918) and hemorrhage (p = .712) were evident in these groups. VATS-guided LN resection procedures achieved 100% technical success rates in both groups, and there were no significant differences between groups with respect to the type of resection (p = .113) or the mean duration of VATS (p = .778).

CONCLUSION

Coil- and localization needle-based approaches can be successfully used for LN localization prior to VATS resection, with localization needle insertion being associated with a shorter duration of localization.

Hemorrhagic shock caused by preoperative computed tomography-guided microcoil localization of lung nodules: a case report

Background

Video-assisted thoracoscopic surgery (VATS) is an emerging technology in minimally invasive surgery, which has become recognized as standard treatments for early-stage lung cancer. Microcoil localization is considered to be a safe and effective way of preoperative localization, and is essential to facilitate VATS wedge-resection for lung nodules.

Case presentation

Here we report a rare case of a 28-year-old female who developed hemorrhagic shock caused by delayed pneumothorax after preoperative computed tomography (CT)-guided microcoil localization. The thoracic CT revealed hydropneumothorax in the right thoracic cavity at 10 h after microcoil localization, and the patient later had significant decreased hemoglobin level (87 g/L). Emergency thoracoscopic exploration demonstrated that the hemorrhagic shock was induced by delayed pneumothorax, which led to the fracture of an adhesive pleura cord and an aberrant vessel. Electrocoagulation hemostasis was then performed for the fractured vessel and the patient gradually recovered from the hypovolemic shock.

Conclusions

Microcoil localization is a relatively safe and effective way of preoperative localization of lung nodules, however, hemorrhagic shock could be induced by rupture of pleural aberrant vessels subsequent to puncture related pneumothorax. Shorten the time interval between localization and thoracoscopic surgery, extend the monitoring time after localization might help to reduce the risk of these complications.

[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.
.

Augmented reality-assisted localization of solitary pulmonary nodules for precise sublobar lung resection: a preliminary study using an animal model

Background

Accurate localization of early lung cancer, manifested as solitary pulmonary nodules (SPNs) on computed tomography (CT), is critical in sublobar lung resection. The AR-assisted localization of SPNs was evaluated using a pig animal model.

Methods

A Microsoft HoloLens AR system was used. First, a plastic thoracic model was used for the pilot study. Three female 12 months 45 kg Danish Landrace Pigs were then used for the animal study. Thirty natural pulmonary structures, such as lymphonodus and bifurcated bronchioles or bronchial vessels, were chosen as simulated SPNs. The average angle between the actual puncturing needle and the expected path, the average distance between the puncture point and the plan point, and the difference between the actual puncturing depth and expected depth were recorded, and the accuracy rate was calculated.

Results

The point selected in the plastic thoracic model could be hit accurately with the assistance from the AR system in the pilot study. Moreover, the average angle between the actual puncturing needle and the expected path was 14.52°±6.04°. Meanwhile, the average distance between the puncture point and the expected point was 8.74±5.07 mm, and the difference between the actual and expected depths was 9.42±7.95 mm. Puncturing within a 1 cm³ area around the SPN using a hook-wire was considered a successful hit. The puncture accuracy was calculated. The average hit rate within a spherical area with a diameter of 1 cm range was 76.67%, and within a diameter of 2 cm range was 100%.

Conclusions

The HoloLens AR-assisted localization of SPNs may become a promising technique to improve the surgical treatment of early-stage lung cancer. Here, we evaluated its feasibility in an animal model. Nevertheless, its safety and effectiveness require further investigation in clinical trials.

Three-Dimensional Computed Tomography Bronchography and Angiography-Guided Thoracoscopic Segmentectomy for Pulmonary Nodules

BACKGROUND

Three-dimensional computed tomography bronchography and angiography (3D-CTBA) provides detailed imaging information for pulmonary segmentectomy. This study was performed to verify the feasibility of 3D-CTBA-guided thoracoscopic segmentectomy for the treatment of pulmonary nodules.

METHODS

A retrospective analysis was performed on all patients who underwent 3D-CTBA-guided uniport thoracoscopic segmentectomies or subsegmentectomies for pulmonary nodules in the period from May 2019 to May 2020. All of the information related to perioperative management and surgical operations was retrieved from the medical records and operating notes for detailed analysis.

RESULTS

A total of 104 eligible operations involving the resection of 110 nodules with diameters in the range of 5-20 mm were included. Under 3D-CTBA guidance, the pulmonary nodules were located with an accuracy of 100% (110/110) and the median resection margin was 24.3 mm (17-33 mm). Additionally, the segmental (subsegmental) bronchi, arteries, and veins were identified with accuracy rates of 100% (104/104), 96.2% (100/104), and 94.2% (98/104), respectively. The postoperative complications consisted of 3 cases of pulmonary infection (2.9%), 6 cases of arrhythmia (5.8%), 2 cases of hemoptysis (1.9%), 4 cases of air leak (3.8%), and 2 cases of subcutaneous emphysema (1.9%). No perioperative death occurred.

CONCLUSION

3D-CTBA-guided thoracoscopic segmentectomy is an effective surgical approach for the management of pulmonary nodules.

A novel localization technique for peripheral ground glass opacity using geometric parameters measured on CT images

Background

Currently no optimal localization technique has been established for localization of ground glass opacity (GGO). We aimed to introduce a localization technique using geometric localization for peripheral GGO.

Methods

We delineated the location of pulmonary GGO using geometric method which was similar with localization of a point in a spatial coordinate system. The localization technique was based on the anatomical landmarkers (ribs or intercostal spaces, capitulum costae and sternocostal joints). The geometric parameters were measured on preoperative CT images and the targeted GGO could be identified intraoperatively according to the parameters. We retrospectively collected the data of the patients with peripheral GGOs which were localized using this method and were wedge resected between June 2019 and July 2020. The efficacy and feasibility of the localization technique were assessed.

Results

There were 93 patients (male 34, median = 55 years) with 108 peripheral GGOs in the study. All the targeted GGOs were successfully wedge resected in the operative field with negative surgical margin at the first attempt. For each GGO, the localization parameters could be measured in 2–4 min (median = 3 min) on CT images before operation, and surgical resection could be completed in 5–10 min (median = 7 min). A total of 106 (98.15%) GGOs achieved sufficient resection margin. No complications and deaths occurred related to the localization and surgical procedure.

Conclusions

The localization technique can achieve satisfactory localization success rate and good safety profile. It can provide an easy-to-use alternative to localize peripheral GGO.

The role of virtual-assisted lung mapping 2.0 combining microcoils and dye marks in deep lung resection

OBJECTIVES

Virtual-assisted lung mapping 2.0 is a novel preoperative bronchoscopic lung mapping technique combining the multiple dye marks of conventional virtual-assisted lung mapping with intrabronchial microcoils to navigate thoracoscopic deep lung resection. This study's purpose was to evaluate the feasibility of virtual-assisted lung mapping 2.0 in resecting deeply located pulmonary nodules with adequate margins.

METHODS

A multicenter, prospective single-arm study was performed from 2019 to 2020 in 8 institutions. The selection criteria were barely identifiable nodules requiring sublobar lung resections, nodules requiring resection lines reaching the inner 2/3 of the pulmonary lobe on computed tomography images in wedge resection, or the nodule center located in the inner 2/3 of the pulmonary lobe in wedge resection or segmentectomy. Resection margins larger than 2 cm or the nodule diameter were considered successful resection. Bronchoscopic placement of multiple dye marks and microcoil(s) was conducted 0 to 2 days before surgery.

RESULTS

We analyzed 65 lesions in 64 patients. The diameter and depth of the targeted nodules and the minimum required resection depth reported as median (interquartile range) were 9 (7-13) mm, 11 (5-15) mm, and 30 (25-35) mm, respectively. Among 60 wedge resections and 5 segmentectomies, successful resection was achieved in 64 of 65 resections (98.5%; 95% confidence interval, 91.7-100). Among 75 microcoils placed, 3 showed major displacement after bronchoscopic placement. There were no severe adverse events associated with the virtual-assisted lung mapping procedure.

CONCLUSIONS

This study demonstrated that virtual-assisted lung mapping 2.0 can facilitate successful resections for deep pulmonary nodules, overcoming the limitations of conventional virtual-assisted lung mapping.

Identifying Lung Cancer Patients Suitable for Segmentectomy: A Brief Review

Background: In 1995, a clinical randomized controlled study (RCT) conducted by the Lung Cancer Study Group (LCSG) pointed out that the lobectomy was the gold standard for treating early lung cancer. However, with the development of technology, the results of several retrospective studies have shown that the efficacy of pulmonary segmentectomy is equivalent to that of lobectomy. Currently, it is still controversial whether segmental resection or lobectomy should be performed for early lung cancer. Thus, we aim to summarize the indications of segmentectomy.

Methods: To conduct the review, previous researches involving indications of segmentectomy were collected from the literature using Pubmed. These articles were published and accepted in English in the medical literature from 2013 to 2020. We have focused on segmentectomy and its indications.

Results: A total of 176 articles were retrieved from the Pubmed database, of which 31 articles included indications for segmentectomy. We summarized the relevant content, and the potential and prospect of segmentectomy for the treatment of lung cancer were emphasized.

Conclusions: These findings have a number of important implications for future practice. Pulmonary segmentectomy is a very vital surgical procedure for select patients with lung cancer, which provides a novel approach for the treatment of lung cancer and the survival of lung cancer patients.

Technical Advances in Segmentectomy for Lung Cancer: A Minimally Invasive Strategy for Deep, Small, and Impalpable Tumors

With the increased detection of early-stage lung cancer and the technical advancement of minimally invasive surgery (MIS) in the field of thoracic surgery, lung segmentectomy using MIS, including video- and robot-assisted thoracic surgery, has been widely adopted. However, lung segmentectomy can be technically challenging for thoracic surgeons due to (1) complex segmental and subsegmental anatomy with frequent anomalies, and (2) difficulty in localizing deep, small, and impalpable tumors, leading to difficulty in obtaining adequate margins. In this review, we summarize the published evidence and discuss key issues related to MIS segmentectomy, focusing on preoperative planning/simulation and intraoperative tumor localization. We also demonstrate two of our techniques: (1) three-dimensional computed tomography (3DCT)-based resection planning using a novel 3DCT processing software, and (2) tumor localization using a novel radiofrequency identification technology.