Pneumonia occurring after injection of Lipiodol to localize pulmonary nodules before fluoroscopy-aided thoracoscopic resection

Bronchoscopic light delivery method for peripheral lung cancer photodynamic therapy

Background

Trans-bronchoscope treatment for early stage small peripheral lung cancer, such as photodynamic therapy (PDT), has been investigated. However, despite the efficacy of PDT, light delivery issues limit its application. A method of administering mineral oil with a high refractive index (RI) was previously proposed to enhance light delivery in branched or bent anatomic structures. Lipiodol has a high RI and an exhaustive history of use as a contrast medium for bronchography. We aimed to determine whether the use of lipiodol, like mineral oil, could enhance the illumination effect and therapeutic range of PDT for peripheral lung tumors.

Methods

We injected lipiodol into a pig lung model, guided by a bronchoscope under fluorescent surveillance, to simulate future treatment in humans, and then illuminated with PDT laser fiber to the lipiodol-infused lung to test the technique feasibility in a pig orally administered 20 mg/kg of 5-aminolevulinicc acid (5-ALA) 2 hours before treatment. We also attempted to determine the maximal tolerable light dose in this pilot study for the future studies in human.

Results

We successfully injected lipiodol into peripheral lungs by this technique. The pig could tolerate up to a total of 40 mL of lipiodol and 800 J of red light, without severe acute fetal injury in a non-cancerous lung.

Conclusions

The technique of injecting lipiodol using bronchoscopy under fluorescent guidance was feasible in a pig model. We can apply the guide sheath through bronchoscopy under fluoroscope inspection. Lipiodol can be used as a light diffuser for the peripheral lung tumor PDT model. No severe lethal acute lung injury was caused by this PDT model under careful manipulation. Additional studies evaluating the dose correlation of the photosensitizer and light are needed.

[Advancement of Common Localization of Solitary Pulmonary Nodules for Video-assisted Thracoscopic Surgery]

最近，伴随着高分辨多层电子计算机断层扫描（computed tomography, CT）的大量普及，肺小结节的诊断也日益增多，尤其是在伴有肺癌高危因素的患者行CT筛查时尤为明显。电视辅助胸腔镜手术对于肺小结节的诊断和治疗提供了一种全新的微创治疗方式，胸腔镜手术后给患者带来的疼痛感减少、住院时间缩短、手术并发症减少等特点，使其推广更为广泛。如何精准定位及标记病灶，以助电视胸腔镜下切除病灶的方法层出不穷。本文综述近年来胸腔镜下肺小结节定位的各种技术手段，并对各种方法的利弊进行总结及分析。

Combined lipiodol marking and video-assisted thoracoscopic surgery in a hybrid operating room

Background

The development of diagnostic technology has led to detection of an increasing number of small pulmonary nodules (SPNs), which can be difficult to locate intraoperatively. Here, we report our experience performing single-stage lipiodol localization and surgical resection in a hybrid operating room (OR).

Methods

Between June 2016 and August 2017, 30 patients with 32 SPNs underwent sliding gantry-based multidetector computed tomography (MDCT)-guided lipiodol marking followed by video-assisted thoracoscopic surgery (VATS) in a hybrid OR. After induction of general anesthesia, all nodules were marked with 0.2 mL lipiodol under MDCT fluoroscopic guidance, followed by immediate VATS.

Results

The mean SPN diameter and distance from the pleural surface were 10.7±4.5 mm (range, 5.0-21.0 mm) and 18.0±9.0 mm (range, 2.8-32.0 mm) respectively. The MDCT-guided localization procedure required 15.8±6.0 min (range, 8.0-32.0 min). All the nodules were marked with lipiodol and detected during fluoroscopy as a clear spot. The median deviation between the radio-opaque nodule and the target nodule was 7.8±3.6 mm (range, 3.0-20.0 mm). In two cases, MDCT scans performed after completion of marking revealed mild pneumothorax, which did not need further intervention. VATS resection was converted to thoracotomy in two patients because of strong pleural adhesions and intraoperative bleeding from the pulmonary vein. No other complications occurred during the combined approach, and there was no intra- or post-operative mortality or morbidity.

Conclusions

These results suggest that a combined approach using MDCT-guided lipiodol marking followed by VATS is feasible and has acceptable accuracy in resection of SPNs.

CT findings after lipiodol marking performed before video-assisted thoracoscopic surgery for small pulmonary nodules

BACKGROUND

In preoperative lipiodol marking for small pulmonary nodules, lipiodol has a potential risk of distribution in the surrounding lung structure. There are no reports about the detailed accumulation and distribution of lipiodol.

PURPOSE

To evaluate computed tomography (CT) findings after lipiodol marking before thoracoscopic surgery for pulmonary nodules.

MATERIAL AND METHODS

Sixty-four consecutive CT-guided lipiodol markings for 103 nodules were performed in 55 patients. Lipiodol (0.2-0.4 mL) was injected using a 21-gauge needle near the nodule. The appearance of lipiodol spots was classified into the following three types on CT: type 1, dense; type 2, punctate; and type 3, unclear. The distribution of lipiodol was also investigated. Statistical analyses were performed on the accumulation and distribution related to nodule factors. Incidences of complications were also investigated.

RESULTS

A total of 110 markings were performed because of seven additional procedures due to insufficient marking. All nodules were successfully resected on the same day. The appearances of the lipiodol spots were type 1 (82%), type 2 (11%), and type 3 (7.3%). The areas of distribution were lung parenchyma (54%), central bronchus (39%), peripheral bronchovascular bundle (24%), needle tract (20%), pleural space (19%), another segment of ipsilateral lung (5.5%), and contralateral lung (0.9%). Distribution into pleural space and central bronchus was frequently seen in the shallow nodules (P < 0.05). Complications were pneumothorax (61%) and pulmonary hemorrhage (35%). There were no serious symptoms.

CONCLUSION

The appearance of the lipiodol spot was dense in most cases, despite frequent distribution in the surrounding lung structures without serious complications.

Primary pulmonary synovial sarcoma requiring differentiation from pulmonary metastasis of tibial adamantinoma: a case report

Background

Primary pulmonary synovial sarcoma (PPSS) is rare. We describe a case of PPSS complicated by tibial adamantinoma that required differentiation from lung metastasis.

Case presentation

A 39-year-old Japanese woman presented with hemoptysis, dyspnea, and a well-defined tumor measuring 3.0 cm in greatest diameter in the right lower lobe on chest computed tomography (CT). Positron emission tomography/CT with fluorodeoxyglucose (FDG-PET/CT) showed mild uptake of FDG (maximum standardized uptake value of 2.0). Her past history included surgery for adamantinoma of the right tibia at age 25 years. We considered the possibility of pulmonary metastasis from the adamantinoma and performed fluoroscopy-assisted thoracoscopic resection of the tumor after CT-guided Lipiodol marking. Histologically, the tumor was composed mainly of a dense proliferation of spindle cells. Immunohistochemical studies were positive for epithelial membrane antigen, B cell lymphoma 2, and transducing-like enhancer of split 1. They were negative for CD34. The synovial sarcoma, X breakpoint 1 gene-fusion transcript was detected by reverse transcription-polymerase chain reaction. It is diagnostic of PPSS. Resection margins were negative. The patient was well without evidence of recurrence or metastasis of the PPSS or adamantinoma at the 30-month and 15-year follow-ups.

Conclusion

Clinical and radiological manifestations of PPSS overlap with those of other lung tumors. The solitary pulmonary nodule in this case was indistinguishable from pulmonary metastases of the adamantinoma based on clinical symptoms, epidemiology, chest radiography, CT, and FDG-PET/CT. PPSS was diagnosed only after evaluating gross pathology, histology, immunohistochemistry, and cytogenetics. PPSS should be included in the differential diagnosis of a well-defined homogeneous round or oval lung mass. To our knowledge, this is the first report of PPSS complicated by adamantinoma.