Hook-wire localization versus lipiodol localization for patients with pulmonary lesions having ground-glass opacity

Preoperative pulmonary nodule localization: A comparison of hook wire and Lung-pro-guided surgical markers

In minimally invasive thoracoscopic surgery, for solitary pulmonary nodules (SPNs) far from the pleura, it is difficult to resected by only relying on imaging data, and effective preoperative localization can significantly improve the success rate of surgery. Therefore, preoperative localization is particularly important for accurate resection. Here, we compare the value of a novel Lung-pro-guided localization technique with Hook-wire localization in video-assisted thoracoscopic surgery.

METHOD

In this study, 70 patients who underwent CT-guided Hook-wire localization and Lung-pro guided surgical marker localization before VATS-based SPNs resection between May 2020 and March 2021 were analyzed, and the clinical efficacy and complication rate of the two groups were compared.

RESULT

Thirty-five patients underwent Lung-pro guided surgical marker localization, and 35 patients underwent CT-guided Hook-wire localization. The localization success rates were 94.3% and 88.6%, respectively (p = 0.673). Compared with the puncture group, the locating time in the Lung-pro group was significantly shorter (p = 0.000), and the wedge resection time was slightly shorter than that in the puncture group (P = 0.035). There were no significant differences in the success rate of localization, localization complications, intraoperative blood loss, postoperative hospital stay, and the number of staplers used.

CONCLUSION

The above studies show that the Lung-pro guided surgical marker localization and the CT-guided Hook-wire localization have shown good safety and effectiveness. However, the Lung-pro guided surgical marker localization may show more safety than the Hook-wire and can improve the patient's perioperative experience.

A novel preoperative image-guided localization for small pulmonary nodule resection using a claw-suture device

Video-assisted thoracoscopic surgery (VATS) provides better option concerning pathological diagnosis and curative intention of small pulmonary nodules (SPNs) that are sometimes challenging to localize. We assess the safety and feasibility of a new localization technique for SPNs, and report experience accumulated over time. A retrospective review of the new claw-suture localization cases between February 2018 and May 2023 was performed. Nodules were localized by a novel system that has an anchor claw and a tri-colored suture, guided by computed tomography (CT). Localization and operative procedure outcomes were then assessed. A total of 590 SPNs were localized from 568 patients before operation. The median nodule size was 0.70 cm (range, 0.3-2.0 cm). The claw-suture localization was successful without dislodgment or device fracture in 574 of 590 lesions (97.3%). Failures included not meeting target distance between claw and lesion (n = 13 [2.2%]), and device displacement (n = 3 [0.5%]). Complications requiring no further medical intervention included asymptomatic pneumothorax (n = 68 [11.5%]), parenchymal hemorrhage (n = 51 [8.6%]), and hemothorax (n = 1 [0.2%]) with the exception of pleural reaction observed in 2 cases (0.3%). Additionally, the depth of pulmonary nodules was significantly associated with the occurrence of pneumothorax (P = 0.036) and parenchymal hemorrhage (P = 0.000). The median duration of the localization was 12 min (range, 7-25 min). No patient complained of remarkable pain during the entire procedure. Retrieve of device after operation was 100%. The new localization technique is a safe, feasible, and well-tolerated method to localize SPNs for VATS resection.

Advances in Surgical Techniques for Lung Cancer

Thoracic surgery for non-small cell lung cancer has evolved tremendously in the past two decades. Improvements have come on multiples fronts and include a transition to minimally invasive techniques, an incorporation of neoadjuvant treatment, and a greater utilization of sublobar resection. These advances have reduced the morbidity of thoracic surgery, while maintaining or improving long-term survival. This review highlights major advances in the surgical techniques of lung cancer and the keys to optimizing outcomes from a surgical perspective.

Three-Dimensional Near-Infrared Specimen Mapping Can Identify the Distance from the Tumor to the Surgical Margin During Resection of Pulmonary Ground Glass Opacities

BACKGROUND

Lung cancers can recur locally due to inadequate resection margins. Achieving adequate margin distances is challenging in pulmonary ground glass opacities (GGOs) because they are not easily palpable. To improve margin assessment during resection of GGOs, we propose a novel technique, three-dimensional near-infrared specimen mapping (3D-NSM).

METHODS

Twenty patients with a cT1 GGO were enrolled and received a fluorescent tracer preoperatively. After resection, specimens underwent 3D-NSM in the operating room. Margins were graded as positive or negative based upon fluorescence at the staple line. Images were analyzed using ImageJ to quantify the distance from the tumor edge to the nearest staple line. This margin distance calculated by 3D-NSM was compared to the margin distance reported on final pathology several days postoperatively.

RESULTS

3D-NSM identified 20/20 GGOs with no false positive or false negative diagnoses. Mean fluorescence intensity for lesions was 110.92 arbitrary units (A.U.) (IQR: 77.77-122.03 A.U.) compared to 23.68 A.U. (IQR: 19.60-27.06 A.U.) for background lung parenchyma (p < 0.0001). There were 4 tumor-positive or close margins in the study cohort, and all 4 (100%) were identified by 3D-NSM. 3D-NSM margin distances were nearly identical to margin distances reported on final pathology (R2 = 0.9362). 3D-NSM slightly under-predicted margin distance, and the median difference in margins was 1.9 mm (IQR 0.5-4.3 mm).

CONCLUSIONS

3D-NSM rapidly localizes GGOs by fluorescence and detects tumor-positive or close surgical margins. 3D-NSM can accurately quantify the resection margin distance as compared to formal pathology, which allows surgeons to rapidly determine whether sublobar resection margin distances are adequate.

Using the robotic platform in the therapy of multifocal ground glass opacities

Due to their association with invasive adenocarcinoma, ground glass opacities that reach 3 cm in size, develop a solid component ≥2 mm on mediastinal windows, or exhibit ≥25% annual growth warrant operative resection. Minimally invasive techniques are preferred given that approximately one third of patients will present with multifocal focal disease and may require additional operations. A robotic-assisted thoracoscopic surgical approach can be used with percutaneous or bronchoscopic localization techniques and are compatible with developing intraoperative molecular targeting techniques.

CT-guided placement of microcoil end in the pleural cavity for video-assisted thoracic surgical resection of ground-glass opacity: a retrospective study

BACKGROUND

The aim of the study was to investigate and summarize the effectiveness and safety of CT-guided microcoil localization before video-assisted thoracic surgery (VATS) for the removal of ground-glass opacity (GGO).

METHODS

A total of 147 patients with GGO who were treated at our hospital between January 2019 and February 2021 were retrospectively analyzed. They were divided into two groups according to the final position at the end of the microcoil: intracavity (n = 78) and extracavity (n = 69), which were compared based on puncture complications and influence of the coil end position on VATS.

RESULTS

The proportions of supine and prone positions in the intracavity group were significantly higher than those in the extracavity group (82.1% vs. 66.7%, P < 0.05). The incidence of intrapulmonary hemorrhage, chest pain, and coil displacement in the intracavity group was significantly lower than that in the extracavity group (28.2% vs. 46.4%, 19.2% vs. 39.1%, 1.3% vs. 11.6%, P < 0.05, respectively); however, the incidence of pneumothorax was not significantly different (P > 0.05). The time of VATS and the rate of conversion to thoracotomy in the intracavity group were significantly lower than those in the extracavity group (103.4 ± 21.0 min vs. 112.2 ± 17.3 min, 0% vs. 5.8%, P < 0.05, respectively).

CONCLUSION

CT-guided placement of the microcoil is a practical, simple, and convenient localization method before VATS, with a high success rate and few complications. Furthermore, it is a better alternative method to place the end of the coil in the pleural cavity because of the lower complication rate, shorter VATS time, and lower rate of thoracotomy conversion.

Identification of factors affecting the surgical margin in wedge resection using preoperative lipiodol marking

Background

The factors affecting the surgical margin distance in resection of small lung lesions after preoperative marking are still unclear. The purpose of this study was to identify these factors in wedge lung resection using a localization technique.

Methods

The subjects were 45 patients with small pulmonary nodules who underwent preoperative computed tomography-guided lipiodol marking followed by video-assisted thoracoscopic surgery between April 2017 and December 2019. Data were obtained for nodule size, depth from the pleural surface, imaging features, and procedure-related factors that could affect the surgical margin. Subjects were divided into groups with margin distances <10 and ≥10 mm. Logistic regression analysis was used to identify factors associated with the margin distance.

Results

Preoperative marking was performed using lipiodol prior to resection of 52 nodules (median size, 10.1 mm; range, 6.75-12.3 mm) in 45 patients (23 men, 22 women; median age, 65.4 years). The mean distance from the pleural surface to the pulmonary lesion was 13.8 mm (range, 5.44-22.2 mm). The 3D deviation of the radio-opaque nodule (lipiodol spot) from the lesion was the only significant difference in nodule- and procedure-related factors between the two groups. Multivariate analysis also showed that this 3D deviation was the most significant factor affecting the margin distance (odds ratio, 0.26; 95% CI, 0.08-0.81; P=0.02).

Conclusions

The findings in this study may help to ensure a sufficient surgical margin after preoperative lipiodol marking, through recognition that the 3D deviation of the radio-opaque nodule from the target lesion has a particularly important influence on the margin distance.

Simultaneous preoperative computed tomography-guided microcoil localizations of multiple pulmonary nodules

OBJECTIVES

To evaluate retrospectively the feasibility and safety of simultaneous multiple microcoil localizations of multiple pulmonary nodules prior to video-assisted thoracoscopic surgery (VATS).

METHODS

This retrospective cohort study enrolled 288 consecutive patients, who underwent computed tomography (CT)-guided microcoil localization and subsequent VATS at our academic hospital between July 2017 and June 2018. Of these patients, 36 with 79 pulmonary nodules undergoing simultaneous multiple microcoil localizations in the ipsilateral lung were designated the multiple localization group; the remaining 252 with 252 pulmonary nodules undergoing single microcoil localization were designated the single localization group. The main outcomes were the technical success and complication rates of the localization procedures. The Student t test and Mann-Whitney U test were used for continuous variables. The chi-squared test and logistic regression analysis were used to assess dichotomous variables.

RESULTS

The localization technical success rates of the multiple and single localization groups were 96.2% (76/79) and 98.0% (247/252), respectively (p = 0.326). The rate of any complication (pneumothorax or pulmonary hemorrhage) was significantly higher in the multiple localization than in the single localization group (55.6% vs 21.8%, respectively; p < 0.001). The incidence of pneumothorax was significantly higher in the multiple localization than in the single localization group (p < 0.001). The difference between the incidence of pulmonary hemorrhage in the 2 groups was not significant (p = 0.385).

CONCLUSIONS

Although preoperative CT-guided simultaneous microcoil localizations of multiple pulmonary nodules produced a significantly higher incidence of pneumothorax, the localizations were clinically feasible and safe.

KEY POINTS

• Simultaneous preoperative CT-guided microcoil localizations of multiple pulmonary nodules are clinically feasible and safe. • Simultaneous microcoil localizations of multiple pulmonary nodules produced a significantly higher incidence of pneumothorax.

The feasibility of navigation bronchoscopy-guided pulmonary microcoil localization of small pulmonary nodules prior to thoracoscopic surgery

Background

Accurate preoperative localization of small pulmonary nodules facilitates the rapid and precise video-assisted thoracoscopic surgery (VATS). This study aims to evaluate the feasibility, safety, and efficacy of navigation bronchoscopy-guided pulmonary microcoil placement for preoperative pulmonary nodule localization.

Methods

Twelve lung lesions were simulated by mixing lipiodol in three porcine models. After 1 week, two microcoils per lesion were deployed under bronchoscopic guidance. Computed tomography scans were then performed 1 day, 1 week, 2 weeks, and 4 weeks after the deployment to assess the position of the microcoils relative to the lesions. Surgical resection of the simulated lesions was performed under fluoroscopy 5 weeks after the deployment and the accuracy, stability, and associated complications of the microcoil localization were evaluated. Following this, an exploratory clinical study was conducted on three patients with pure ground-glass pulmonary nodules.

Results

The mean diameter of the twelve simulated lung lesions was 9.55±2.36 mm, and the mean distance from the pleura to the lesions was 8.29±2.99 mm. Twenty-four pulmonary microcoils were implanted in the bronchi surrounding the lesions. Four weeks later, the mean distance between the microcoils and the center of the lesions was 16.12±8.97 mm and the average migration of the microcoils relative to the baseline position (1 day after implantation) was 3.48±4.56 mm. All microcoils and target lesions were successfully resected in both the animal experiment and clinical study and no complications, such as pneumothorax, were observed during marker implantation or postoperative follow-up.

Conclusions

The preoperative localization of pulmonary nodules by navigation bronchoscopy-guided microcoil placement is a safe, stable, and effective technique with minimal complication risk. This procedure can assist subsequent thoracoscopic resection.

An update on CT screening for lung cancer: the first major targeted cancer screening programme

Screening for lung cancer with low radiation dose CT has been shown to be effective in reducing lung cancer mortality by two major randomised controlled trials. Lung cancer screening is set to become the largest targeted cancer screening programme globally, but the effectiveness of the programme is dependent on many different factors. This article describes the key evidence for lung cancer screening, the key factors important for optimisation and the progress towards implementation.