Video-assisted thoracoscopic resection of lung nodules localized with a hydrogel plug

Advances in the localization of pulmonary nodules: a comprehensive review

In recent years, with the widespread use of chest CT, the detection rate of pulmonary nodules has significantly increased (Abtin and Brown, J Clin Oncol 31:1002-8, 2013). Video-assisted thoracoscopic surgery (VATS) is the most commonly used method for suspected malignant nodules. However, for nodules with a diameter less than 1 cm, or located more than 1.5 cm from the pleural edge, especially ground-glass nodules, it is challenging to achieve precise intraoperative localization by manual palpation (Ciriaco et al., Eur J Cardiothorac Surg 25:429-33, 2004). Therefore, preoperative accurate localization of such nodules becomes a necessary condition for precise resection. This article provides a comprehensive review and analysis of the research progress in pulmonary nodule localization, focusing on four major localization techniques: Percutaneous puncture-assisted localization, Bronchoscopic preoperative pulmonary nodule localization, 3D Printing-Assisted Localization, and intraoperative ultrasound-guided pulmonary nodule localization.

Computed tomography-guided localization of pulmonary nodules prior to thoracoscopic surgery

With the increasing awareness of physical examination, the detection rate of pulmonary nodules is gradually increasing. For pulmonary nodules recommended for management by video-assisted thoracic surgery (VATS), preoperative localization of the nodule is required if its location is difficult to determine intraoperatively by palpation. The computed tomography (CT)-guided preoperative localization technique is the most widely used method with low operational difficulty and high efficiency, which can include hook wire, microcoil, medical dye, medical surgical adhesive, combined application, and emerging localization techniques according to the material classification. Each method has its corresponding advantages and disadvantages, but there is still a lack of unified guidelines or standards for the selection of CT-guided preoperative localization methods in clinical practice. This review summarizes the operation precautions, advantages, and shortcomings of the above localization techniques in order to provide references for clinical application.

Easy Intra-Operative Localization of Pulmonary Nodules during Uniportal Video-Assisted Thoracoscopy: Experience with Hydrogel Plugs at Our Institution

Background: The diffusion of lung cancer screening programs has increased the detection of both solid and ground-glass opacity (GGO) sub-centimetric lesions, leading to the necessity for histological diagnoses. A percutaneous CT-guided biopsy may be challenging, thus making surgical excision a valid diagnostic alternative. CT-guided hydrogel plug deployment (BioSentry^®) was recently proposed to simplify intraoperative nodule localization. Here, we report our initial experience. Methods: We evaluated 62 patients with single, small, peripheral, non-subpleural pulmonary GGO that was suspicious for cancer. All lesions were preoperatively marked, using CT-guidance, with a hydrogel plug (BioSentry^®). Then, a uniportal video-assisted thoracoscopy (uniVATS) wedge resection was performed. If cancer was confirmed at the frozen section, a major lung resection was then performed. The study’s end points were the rates of intraoperative localization and of successful resection. Results: The hydrogel plug was correctly placed in 54 of the 62 cases, leading to an effective resection of the target lesion. In the remaining eight cases, the plug was displaced, and so the identification of pleural erosions due to the previous percutaneous procedure guided the resection. The uniVATS resection success rate was 98.3%. Conclusions: CT-guided hydrogel plug placement allowed for the successful detection of lung GGOs and resection with the uniVATS approach. This device allowed us to obtain lung cancer diagnoses and successfully treat 85.4% of cases.

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.

The risk factors for the failure of hook wire localization of ground glass nodules prior to thoracoscopic surgery

Objectives

To retrospectively analyse the potential influencing factors of CT-guided hook wire localization failure prior to thoracoscopic resection surgery of ground glass nodules (GGNs), and determine the main risk elements for localization failure.

Methods

In all, 372 patients were included in this study, with 21 patients showing localization failure. The related parameters of patients, GGNs, and localization were analysed through univariate and multiple logistic regression analysis to determine the risk factors of localization failure.

Results

Univariate logistic regression analysis indicated that trans-fissure (odds ratio [OR] 4.896, 95% confidence interval [CI] 1.489–13.939); trans-emphysema (OR 3.538, 95% CI 1.343–8.827); localization time (OR 0.956, 95% CI 0.898–1.019); multi-nodule localization (OR 2.597, 95% CI 1.050–6.361); and pneumothorax (OR 10.326, 95% CI 3.414–44.684) were risk factors for localization failure, and the p-values of these factors were < 0.05. However, according to the results of multivariate analysis, pneumothorax (OR 5.998, 95% CI 1.680–28.342) was an exclusive risk factor for the failure of preoperative localization of GGNs.

Conclusion

CT-guided hook wire localization of GGNs prior to thoracoscopic surgery is often known to fail; however, the incidence is low. Pneumothorax is an independent risk factor for failure in the localization process.

A localization-independent approach for invisible and impalpable ground-glass opacity nodules detection in an in vitro lung specimen: two case reports

A growing number of ground-glass opacity (GGO) nodules are screened out in lungs. Small GGOs are frequently neither visible nor palpable, thus undetectable during operation. Various nodule localization techniques have been developed to facilitate the intraoperative detection of GGO nodules; however, general localization techniques are infeasible or inappropriate in some cases. The detection of small GGO is a great challenge, even within a surgical specimen in the absence of preoperative localization. A localization-independent approach for GGO detection is urgently needed. Herein, we report two cases with invisible and impalpable small GGO which were not appropriate for preoperative localization. The lesions were anatomically resected under the guidance of three-dimensional (3D) reconstruction and got an adequate margin distance. A vessel (artery, vein, or bronchus) which had advanced into or immediately adjacent to the nodule was assigned as a reference vessel. By dissecting and tracing the reference vessel from proximal to distal, the GGO lesions were successfully detected in the surgical specimens, to the eventual obtainment of an accurate pathological diagnosis. Via the two case reports, we introduced an easily handled approach, namely dissecting and tracing a reference vessel, for GGO detection. The novel approach was first described. Combined with precise anatomical segmentectomy guided by 3D reconstruction, it provides an alternative scheme for GGO resection with no need for preoperative localization.

Perioperative identifications of non-palpable pulmonary nodules: a narrative review

Early detection of lung cancer is the key to improving treatment and prognosis of this disease, and the advent of advances in computed tomography (CT) imaging and national screening programs have improved the detection rate of very small pulmonary lesions. As such, the management of this sub-centimetric and often sub-solid lesions has become quite challenging for clinicians, especially for choosing the most suitable diagnostic method. In clinical practice, to fulfill this diagnostic yield, transthoracic needle biopsy (TTNB) is often the first choice especially for peripheral nodules. For lesions for which TTNB could present technical difficulties or failed, other diagnostic strategies are needed. In this case, video-assisted thoracic surgery (VATS) is the gold standard to reach the diagnosis of lung nodules suspect of being malignant. Nonetheless it’s often not easy the identification of such lesions during VATS because of their little dimensions, non-firm consistency, deep localization. In literature various marking techniques have been described, in order to improve intraoperative nodules detection and to reduce conversion rate to thoracotomy: CT-guided hookwire positioning, methylene blue staining, intra-operative ultrasound and electromagnetic navigation bronchoscopy are the most used. The scientific evidence on this matter is weak because there are no randomized clinical trials but only case series on single techniques with no comparison on efficacy, so there are no guidelines to refer. From this standing, in this article we conducted a narrative review of the existing literature on the subject, with the aim of outlining a framework as complete as possible. We analyzed strengths and weaknesses of the main techniques reported, so as to allow the clinician to orient himself with greater ease.

A computed tomography-based nomogram to predict pneumothorax caused by preoperative localization of ground glass nodules using hook wire

OBJECTIVE

To develop and validate a CT-based nomogram to predict the occurrence of loculated pneumothorax due to hook wire placement.

METHODS

Patients (n = 177) were divided into pneumothorax (n = 72) and non-pneumothorax (n = 105) groups. Multivariable logistic regression analysis was applied to build a clinical prediction model using significant predictors identified by univariate analysis of imaging features and clinical factors. Receiver operating characteristic (ROC) was applied to evaluate the discrimination of the nomogram, which was calibrated using calibration curve.

RESULTS

Based on the results of multivariable regression analysis, transfissure approach [odds ratio (OR): 757.94; 95% confidence interval CI (21.20-27099.30) p < 0.0001], transemphysema [OR: 116.73; 95% CI (12.34-1104.04) p < 0.0001], localization of multiple nodules [OR: 8.04; 95% CI (2.09-30.89) p = 0.002], and depth of nodule [OR: 0.77; 95% CI (0.71-0.85) p < 0.0001] were independent risk factors for pneumothorax and were included in the predictive model (p < 0.05). The area under the ROC curve value for the nomogram was 0.95 [95% CI (0.92-0.98)] and the calibration curve indicated good consistency between risk predicted using the model and actual risk.

CONCLUSION

A CT-based nomogram combining imaging features and clinical factors can predict the probability of pneumothorax before localization of ground-glass nodules. The nomogram is a decision-making tool to prevent pneumothorax and determine whether to proceed with further treatment.

ADVANCES IN KNOWLEDGE

A nomogram composed of transfissure, transemphysema, multiple nodule localization, and depth of nodule has been developed to predict the probability of pneumothorax before localization of GGNs.

Image-localized body surface marking for the intraoperative localization of pulmonary ground-glass nodules

Background

The method of locating pulmonary nodules before operation plays a crucial role in the surgery of pulmonary ground-glass nodules (GGNs). However, the methodologies surrounding intraoperative localization remains limited, with the majority procedures requiring specific additional equipment. We report a new approach in locating pulmonary GGNs by image-localized body surface marking intraoperative (IBMI) localization.

Methods

A retrospective review of the medical records of 76 patients with pulmonary GGNs was performed. All patients underwent IBMI localization between January 2018 and March 2019. Twenty-six patients underwent CT-guided hook wire localization before IBMI localization during surgery. IBMI localization was undertaken directly without pre-treatment in the remaining patients. The efficacy and complications of this approach were analyzed and compared with other pre- or intraoperative localization methods in the current literature.

Results

The intraoperative localizations were performed successfully in 72 of all 76 patients pulmonary GGNs within a mean duration of 5.3±1.8 (range, 2.0 to 9.6) minutes. The GGNs in four cases were found to have a significant deviation (>1.5 cm) from the positioning points. All GGNs were successfully resected. Except for five cases of active chest wall bleeding (6.5%), no other intra- or postoperative complications occurred.

Conclusions

The IBMI localization approach is a safe and short-duration procedure with high success rates and fewer complications. We used it for the first time for intraoperative localization of peripheral GGNs with excellent results.

Comparison of CT-guided localization using hook wire or coil before thoracoscopic surgery for ground glass nodules

OBJECTIVE

To compare two kinds of metal markers for preoperative localization of ground glass nodules (GGNs).

METHODS

We retrospectively investigated data from 198 cases of GGN localization and compared the success rate and complications of both approaches.

RESULTS

In the hook wire and coil groups, the success rates of CT-guided localization for GGNs were 99.2 and 98.7%, respectively (p = 1.000). The success rates of video-assisted thoracoscopic surgery in both groups were 100% without transthoracic surgery. The post-localization complication rates in the hook wire group and coil group were 36.9 and 32.9% (p = 0.568), and the postoperative complication rates in the hook wire and coil groups were 13.9 and 11.8%, respectively (p = 0.672).

CONCLUSIONS

Preoperative localization of GGNs with both hook wire and coil methods proved to be useful and effective. Both methods have acceptable preoperative and postoperative complication rates, but the localization and operation times were shorter for the hook wire group than the coil group.

ADVANCES IN KNOWLEDGE

Most of previous articles studied a single preoperative localization method. Few studies have compared the preoperative and postoperative methods for metal markers. This paper compared two preoperative localization methods for GGNs to provide clinical guidance.

Preoperative computed tomography-guided pulmonary nodule localization augmented by laser angle guide assembly

Background

There is an increasing need for thoracic medicine specialists to master preoperative localizations after high rates of sub-centimeter nodules have been positively screened by low-dose CT. The Laser Angle Guide Assembly^® (LAGA), an innovative angle reference device for CT-guided pulmonary invasive procedures, has been developed to safely and efficiently aid in the performance of preoperative CT-guided localizations (POCTGL).

Methods

The clinical and localization data of patients who received LAGA-assisted POCTGL for pulmonary nodules between May 2015 and June 2018 were collected and analyzed.

Results

One hundred and eighty-seven patients with 266 pulmonary nodules received LAGA-assisted POCTGL. The number of lung nodules localized for one surgery ranged from 1 to 5, with >1 for 22.1% of the surgeries. The median nodule size was 6 mm. A hookwire was inserted in 32 (12%) of the nodules. Most (83.1%) of the localizations were completed with a single puncture. The median angle was 18 degrees. The median and maximum depths of the nodule to pleura were 12 and 60 mm, respectively. The median procedure time was 19 minutes. The successful targeting and field targeting rates were 100% and 98.1%, respectively. Pneumothorax was noted in 17 (6.4%) localizations that did not require chest drainage. The multivariable analyses for pneumothorax showed odds ratios of 2.4 (95% confidence interval, 1.2-4.9) for puncture times/nodule and 10.1 (95% confidence interval, 2.3-41.7) for tumors adjacent to the fissure, respectively. There was no incidence of hookwire migration.

Conclusions

LAGA enhanced the precision of POCTGL by optimizing targeting precision and decreasing repeated punctures, which minimized complications, such as pneumothorax.

Comparison of cyanoacrylate and hookwire for localizing small pulmonary nodules: A propensity-matched cohort study

BACKGROUND

Localizing small pulmonary nodules (SPNs) is a challenge during thoracoscopic resection, but preoperative computed tomography (CT)-guided localization using either cyanoacrylate or hookwire can be helpful. This study compared the safety, efficiency, and operability of the two techniques.

METHODS

From September 2013 to November 2018, 269 patients (269 SPNs) who underwent preoperative CT-guided SPN localization were enrolled. A propensity-matched analysis, incorporating 13 variables, was performed to control potential selection bias.

RESULTS

All the patients were divided into two groups: CT-guided cyanoacrylate localization group (Group C, n = 149) and CT-guided hookwire localization group (Group H, n = 120). Eighty-six patients were propensity-matched in each group. All SPNs were successfully removed thoracoscopically, and no conversion was required. Localization-related complications in the two groups were similar, including intrapulmonary focal hemorrhage (p = 0.823), pneumothorax (p = 1.000), or hemoptysis (p = 0.121). For pain assessment and management, the cyanoacrylate localization saw a lower pain score (p < 0.001) and less morphine use (p < 0.001). In Group H, the localization took a significantly longer time (p < 0.001). Covering only the patients in Group C, the sub-analysis found that cyanoacrylate localization on the day before surgery did not compromise the accuracy of intraoperative targeting or increase the incidence of complications, compared with the localization on the day of surgery (all p > 0.05).

CONCLUSION

Compared to hookwire localization, CT-guided cyanoacrylate localization decreased pain and morphine use and allowed flexible surgical schedules, suggestive of its preferability for the resection of SPNs.