A simple and efficient method to perform preoperative pulmonary nodule localization: CT-guided patent blue dye injection

Diagnosis and treatment of high-risk bilateral lung ground-glass opacity nodules

In recent years, there has been a significant increase in the detection rate of Ground Glass Opacity (GGO) nodules through high-resolution computed tomography (HRCT). GGO is an imaging finding that encompasses various pathological types, some of which exhibit indolent growth, while others may represent early lung cancer or remain relatively stable, not significantly impacting the surgical treatment outcome. In clinical practice, patients often experience psychological anxiety when multiple pulmonary GGO nodules are present, and they may request simultaneous resection. However, there is currently no standardized criterion for determining when multiple GGO nodules should be resected. As personalized medicine continues to advance, the treatment approach for multiple pulmonary GGO nodules needs to prioritize accuracy. High-risk factors associated with multiple pulmonary GGO nodules may necessitate surgical intervention along with mediastinal lymph node dissection or sampling. This article provides a review of the characteristics, treatment methods, and clinical experiences related to multiple pulmonary GGO nodules, offering practical insights and guidance for healthcare professionals.

Application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection

PURPOSE

To explore the application value of CT-guided localization using a coil in combination with medical adhesive in sublobar resection.

METHODS

The clinical data of 90 patients who had small pulmonary nodules and received thoracoscopic sublobar resection during the period from September 2021 to October 2022 in the Department of Thoracic Surgery, Juxian People's Hospital, Shandong Province, were retrospectively analyzed.

RESULTS

The diameters of 95 pulmonary nodules in the 90 patients in the whole group ranged from 0.40 to 1.24 cm, and their distances from the visceral pleura ranged from 0.51 to 2.15 cm. In these patients, percutaneous lung puncture was successfully performed under local anesthesia, through which coils were implanted in the nodules and medical adhesive was injected around the nodules, with a success rate of localization of 100%. Localization complications included 10 cases of asymptomatic pneumothorax, 9 cases of intrapulmonary hemorrhage, 5 cases of severe pain, and 1 case of pleural reaction, all of which required no special treatment. After preoperative localization, the success rate of resection of pulmonary nodules was 100%, and sufficient surgical margins were obtained.

CONCLUSION

CT-guided localization using a coil in combination with medical adhesive is a safe, effective, and simple localization method that can meet the requirements of thoracic surgeons for intraoperative localization; for small pulmonary nodules, especially those small-sized and deep-located ground-glass nodules containing few solid mass, this method has important clinical application value, which is a preoperative localization technique worthy of wide application in clinical practice.

Preoperative small pulmonary nodule localisation using hookwires or coils: strategy selection in adverse events

OBJECTIVE

This is a retrospective study of adverse events associated with preoperative computed tomography (CT)-guided hookwire or coil localisation. We analysed the experience and process flaws in resecting ground-glass nodules (GGNs) through video-assisted thoracoscopic surgery (VATS) and determined the remedial strategy.

METHODS

Adverse events were evaluated in 40 patients with 45 GGNs who underwent CT-guided hookwire or coil localisation before VATS. For lesions not successfully marked or detected, palpation, resection of the highly suspected area, segmentectomy or lobectomy was performed.

RESULTS

Among all adverse events, 15 were dislodgement of the marking materials, 5 were breakaway of the marking materials, 7 were > 2 cm distance between the lesions and the tips, 3 was marking material across the two adjacent lobes, 15 were pneumothorax and 2 were certain parts of marking materials stuck into the chest wall. All GGNs were resected successfully. 20 lesions were detected by palpation. 9 GGNs were discovered after the resection of highly suspected areas. Segmentectomies and lobectomies were performed directly on 7 and 9 GGNs, respectively.

CONCLUSIONS

When adverse events occur, a second intraoperative localisation, by resecting the highly suspected area either through non-anatomical resection (wedge resection) or anatomical resection (segmentectomy or lobectomy) using the VATS should be considered the alternatives for GGNs localization.

Image-guided intratumoral immunotherapy: Developing a clinically practical technology

Immunotherapy has revolutionized the contemporary oncology landscape, with durable responses possible across a range of cancer types. However, the majority of cancer patients do not respond to immunotherapy due to numerous immunosuppressive barriers. Efforts to overcome these barriers and increase systemic immunotherapy efficacy have sparked interest in the local intratumoral delivery of immune stimulants to activate the local immune response and subsequently drive systemic tumor immunity. While clinical evaluation of many therapeutic candidates is ongoing, development is hindered by a lack of imaging confirmation of local delivery, insufficient intratumoral drug distribution, and a need for repeated injections. The use of polymeric drug delivery systems, which have been widely used as platforms for both image guidance and controlled drug release, holds promise for delivery of intratumoral immunoadjuvants and the development of an in situ cancer vaccine for patients with metastatic cancer. In this review, we explore the current state of the field for intratumoral delivery and methods for optimizing controlled drug release, as well as practical considerations for drug delivery design to be optimized for clinical image guided delivery particularly by CT and ultrasound.

Comparison of hook-wire and medical glue for CT-guided preoperative localization of pulmonary nodules

Background

Preoperative localization is challenging due to the small diameter of pulmonary nodules or their deep location in the lung parenchyma during VATS surgery. The purpose of this study was to compare the efficacy and safety of both hook-wire and medical glue for pre-operative localization of pulmonary nodules.

Methods

In the current study, 158 patients were retrospectively analyzed (January 2019 and January 2020). The patients underwent hook-wire or medical glue for pre-operative localization of pulmonary nodules. Among them, 74 patients in the hook-wire group and 84 patients in the medical glue group underwent VATS anatomic segmentectomy or wedge resection after localization of pulmonary nodules. Pre-operative localization data from all patients were compiled. Moreover, the efficacy and safety of the two methods were evaluated according to localization success rates and localization-related complications.

Results

The success rate of localization in the medical glue group was 100% while 97.3% in the hook-wire group. After localization of the pulmonary nodules, the incidence of minor pneumothorax in the medical glue group (11.9%) was lower than that in the hook-wire group (37.8%) (p=0.01). The incidence of mild pulmonary parenchymal hemorrhage in the medical glue group (13.1%) was also lower than that in the hook-wire group (24.3%) (p=0.000). The mean time from the completion of localization to the start of surgery was also longer in the medical glue group than in the hook-wire group (p=0.000). The mean visual analog scale (VAS) scores after localization were higher in the hook-wire group than in the medical glue group (p=0.02). In both groups, parenchymal hemorrhage was significantly associated with the needle length in hook-wire localization and the depth of the medical glue in the lung parenchyma (p = 0.009 and 0.001, respectively).

Conclusion

These two localization methods are safe and effective in pre-operative pulmonary nodule localization. The medical glue localization method had a lower risk of complications, a higher localization success rate, less pain after localization and more flexibility in the arrangement of operation time.

Simultaneous Patent Blue Dye Injections Aid in the Preoperative CT-Guided Localization of Multiple Pulmonary Nodules

Background and Objectives: Clinically, a major challenge of multiple nodule localization is puncture-related pneumothorax, which may hamper the successful localization. This study aims to investigate and compare the efficacy and safety of the simultaneous and sequential patent blue dye (PBD) injections for identifying multiple pulmonary nodules during preoperative CT-guided localization. Materials and Methods: Sixty-one consecutive patients with multiple pulmonary nodules who underwent preoperative CT-guided localization with PBD injections between January 2020 and December 2020 were retrospectively enrolled. Of these patients, 31 patients with 64 nodules who underwent simultaneous injections were designated as the simultaneous group; the remaining 30 patients with 63 nodules who underwent sequential punctures were designated as the sequential group. The clinical and radiological features, technical information, pathological results, and procedure-related variables and complications of the two groups were reviewed and analyzed. Results: The localization success rate of the simultaneous group was higher than that of the sequential group (100% [64/64] vs. 93.7% [59/63], p = 0.041). The incidences of pneumothorax (32.3 vs. 33.3%, p = 0.929) and pulmonary hemorrhage (6.3 vs. 3.0%, p = 1) were not significantly different between the two groups, and all cases were minor, which did not require further intervention. Additionally, a significantly lower radiation dose (2.7 vs. 3.5 mSv, p = 0.001) and a shorter procedure time (20.95 vs. 25.28 min, p = 0.001) were observed in the simultaneous group than in the sequential group. Conclusions: Compared with the sequential method, simultaneous PBD injections may improve the localization success rate with a shorter procedure time and less radiation exposure if the patient with multiple pulmonary nodules can be approached in a single position. Further prospective studies are needed to validate these results.

Clinical value and application of preoperative CT-guided hookwire localization of solitary pulmonary nodules for video-assisted thoracic surgery

BACKGROUND

Video-assisted thoracic surgery (VATS) is a minimally invasive technique for the diagnosis and management of small pulmonary nodular lesions However, the identification of some lung nodules remains difficult.

OBJECTIVE

This research aimed to investigate the clinical value of preoperative computed tomography (CT)-guided hookwire localization of solitary pulmonary nodules (SPNs) for thoracoscopic resection.

METHODS

Seventy-one patients with 74 SPNs underwent VATS wedge resection after CT-guided hookwire localization. The mean diameter of the SPNs was 8.50 ± 4.53 mm,,besides, the mean distance from the SPNs to the parietal pleura was 16.81 ± 5.23 mm.

RESULTS

Sixty-nine of the 74 nodules were successfully localized using a CT-guided hookwire. The success rate of CT-guided localization was 93.2%. The average localization time was 15.23 ± 7.21 min per lesion. Seven patients (9.5%) had asymptomatic pneumothorax and 10 (13.5%) had minimal needle tract parenchymal hemorrhages after localization no clinical intervention was required for these patients. The rate of success for VATS wedge resection of the SPNs was 100%. Histological analysis of the SPNs revealed malignant disease in 67.4% of the patients.

CONCLUSIONS

Preoperative CT-guided hookwire localization for thoracoscopic resection is a safe and effective operation for the identification and stable fixation of SPNs.

Optimal margins for early stage peripheral lung adenocarcinoma resection

Background

A pathologically confirmed negative margin is required when performing sublobar resection in patients with early stage peripheral lung adenocarcinoma. However, the optimal margin distance to ensure complete tumor resection while preserving healthy lung tissue remains unknown. We aimed to establish a reliable distance range for negative margins.

Methods

A total of 52 intraoperative para-cancer tissue specimens from patients with peripheral lung adenocarcinoma with pathological tumors ≤2 cm in size were examined. Depending on the distance from the tumor edge (D), the para-cancer tissues were divided into the following five groups: D < 0.5 cm (group I); 0.5 cm ≤ D < 1.0 cm (group II); 1.0 cm ≤ D < 1.5 cm (group III); 1.5 cm ≤ D < 2.0 cm (group IV); and D ≥ 2.0 cm (group V). During pathological examination of the specimens under a microscope, the presence of atypical adenomatous hyperplasia or more severe lesions was considered unsafe, whereas the presence of normal lung tissue or benign hyperplasia was considered safe.

Results

Group V, in which the margin was the farthest from the tumor edge, was the safest. There were significant safety differences in between groups I and V (χ² = 26.217, P < 0.001). Significant safety differences also existed between groups II and V (χ² = 9.420, P < 0.005). There were no significant safety differences between group III or IV and group V (P = 0.207; P = 0.610).

Conclusions

We suggest that when performing sublobar resection in patients with early stage peripheral lung adenocarcinoma with pathological tumor sizes ≤2 cm, the resection margin distance should be ≥1 cm to ensure a negative margin.

Differentiating focal interstitial fibrosis from adenocarcinoma in persistent pulmonary subsolid nodules (> 5 mm and < 20 mm): the role of coronal thin-section CT images

OBJECTIVES

To investigate thin-section computed tomography (CT) features of pulmonary subsolid nodules (SSNs) with sizes between 5 and 20 mm to determine predictive factors for differentiating focal interstitial fibrosis (FIF) from adenocarcinoma.

METHODS

From January 2017 to December 2018, 169 patients who had persistent SSNs 5-20 mm in size and underwent preoperative nodule localization were enrolled. Patient characteristics and thin-section CT features of the SSNs were reviewed and compared between the FIF and adenocarcinoma groups. Univariable and multivariable analyses were used to identify predictive factors of malignancy. Receiver operating characteristic (ROC) curve analysis was used to quantify the performance of these factors.

RESULTS

Among the 169 enrolled SSNs, 103 nodules (60.9%) presented as pure ground-glass opacities (GGOs), and 40 (23.7%) were FIFs. Between the FIF and adenocarcinoma groups, there were significant differences (p< 0.05) in nodule border, shape, thickness, and coronal/axial (C/A) ratio. Multivariable analysis demonstrated that a well-defined border, a nodule thickness >4.2, and a C/A ratio >0.62 were significant independent predictors of malignancy. The performance of a model that incorporated these three predictors in discriminating FIF from adenocarcinoma achieved a high area under the ROC curve (AUC, 0.979) and specificity (97.5%).

CONCLUSIONS

For evaluating persistent SSNs 5-20 mm in size, the combination of a well-defined border, a nodule thickness > 4.2, and a C/A ratio > 0.62 is strongly correlated with malignancy. High accuracy and specificity can be achieved by using this predictive model.

KEY POINTS

• Thin-section coronal images play an important role in differentiating FIF from adenocarcinoma. • The combination of a well-defined border, nodule thickness>4.2 mm, and C/A ratio >0.62 is associated with malignancy. • This predictive model may be helpful for managing persistent SSNs between 5 and 20 mm in size.