Preoperative non-invasive visual localization of synchronous multiple lung cancers using three-dimensional computed tomography lung reconstruction

Intraoperative patient radiation dose from cone-beam computed tomography in thoracic surgery

BACKGROUND

Several methods can be used to intraoperatively identify pulmonary lesion using radiation technology. However, little is known about patient radiation exposure during chest surgery. We aimed to measure patients' radiation exposure from cone-beam computed tomography (CBCT) used in a hybrid operating room.

METHODS

This retrospective study included patients who underwent surgical treatment in a hybrid operating room between April 2019 and December 2023 at the Teikyo University Hospital. All data was obtained prospectively, but the study was approved by the IRB as a retrospective study because of repeated extensions of study period in order to collect more cases. Skin radiation exposure was measured using five wearable dosimeters per patient. The measurements were compared to cumulative Air Kerma. Furthermore, the radiation exposure dose on the surgical side, which cannot be measured, was estimated by computer simulation.

RESULTS

Among 182 patients who underwent surgery in a hybrid operating room, radiation exposure measurements were conducted on 67 patients. The patients' mean age was 60.7 years. The average number of CBCT scans was 2.1 (1-5) and the intraoperative identification rate was 100%, with no marking-related complications. Average patient's skin radiation dose was 3.69 ± 5.48 mGy per dosimeter, and cumulative Air Kerma was 25.4 ± 19.3 mGy. The highest radiation exposure was recorded in the 5th intercostal space whereas the lowest was measured in the supraclavicular or 11th intercostal spaces. Referring to phantom and computer simulation data, the 5th and 8th intercostal spaces were significantly more exposed to radiation at not only measurement side but also the surgical field, particularly when the number of CT scans was four.

CONCLUSION

We found that the patient's 5th to 8th intercostal space was the most radiation exposed area by intraoperative CBCT imaging because the CBCT movement was restricted by the patient's arm, anesthesia machine, and operating table during chest surgery. In future, it is strongly required to research for radiation protection in this area. Furthermore, performing no more than three scans intraoperatively may be preferable in order to protect patients from radiation exposure during CBCT guided thoracic surgery.

Indocyanine green localization for preoperative CT-guided localization of multiple pulmonary nodules

OBJECTIVES

This study assesses the safety and efficacy of using indocyanine green (ICG) for preoperative CT-guided localization of multiple pulmonary nodules.

METHODS

We included patients who underwent CT-guided preoperative ICG localization followed by video-assisted thoracoscopic surgery (VATS). Four primary outcomes were evaluated: technical success, pneumothorax, pulmonary hemorrhage, and postoperative hospital stay (PHS). Patients were classified into single nodule and multiple nodules groups, with further subgroups based on the side of localization including unilateral and bilateral subgroups. Univariate and multivariate analyses were used to evaluate risk factors for PHS and pneumothorax.

RESULTS

A total of 374 patients (54.8 ± 11.4 years, 99 with multiple nodules). The success rate in the multiple nodules group was 98.3%, similar to single nodules. Apart from PHS, no significant differences were observed in outcomes between patients with single and multiple nodules. Longer PHS was observed for patients with multiple nodules (3 [2-4] days vs. 3 [3-4] days, p = 0.022). Multivariable analysis indicated longer stays were associated with pulmonary hemorrhage during localization, surgical blood loss, postoperative complications, and non-segmentectomy procedures. Advanced age emerged as the sole independent risk factor for pneumothorax. The success rate in the unilateral subgroup and the bilateral subgroup was 97.8% and 99%, respectively, with higher pneumothorax rates in the unilateral subgroup (38.3% vs. 20%).

CONCLUSION

CT-guided preoperative ICG localization of multiple pulmonary nodules is safe and effective. It can be applied to both unilateral and bilateral nodules, supporting simultaneous VATS resection.

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.

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.

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.

State of the Art in Lung Nodule Localization

Lung nodule and ground-glass opacity localization for diagnostic and therapeutic purposes is often a challenge for thoracic surgeons. While there are several adjuncts and techniques in the surgeon's armamentarium that can be helpful, accurate localization persists as a problem without a perfect solution. The last several decades have seen tremendous improvement in our ability to perform major operations with minimally invasive procedures and resulting lower morbidity. However, technological advances have not been as widely realized for lung nodule localization to complement minimally invasive surgery. This review describes the latest advances in lung nodule localization technology while also demonstrating that more efforts in this area are needed.