VATS (video-assisted thoracic surgery) of undefined pulmonary nodules. Preoperative evaluation of videoendoscopic resectability

Successful thoracoscopic resection of pulmonary metastasis less than 1 cm in size utilizing preoperative CT-guided wire localization

Preoperative computer tomography (CT) guidance localization utilizing a percutaneous guidewire before thoracoscopic resection is safe and beneficial in children with pulmonary nodules less than 1 cm in size or located deep in the pleural surface. This paper describes a successful thoracoscopic resection of a little subpleural pulmonary metastasis of a Wilm's tumor in a 5-year-old child utilizing preoperative CT-guided wire localization of the lesion. The thoracoscopic procedure was performed with the use of two ports, the nodule was easily localized,and the pulmonary wedge resection was made by the use of an endo-GIA linear stapling device after guidewire removal. The operating time was 45 minutes and the chest tube was removed after 48 hours. The postoperative course was uneventful, and the child was discharged on postoperative day 5. This technique allows the surgeon to resect little pulmonary nodules, avoiding the need of more invasive procedures as standard thoracotomy without adjunctive morbidity and with good cosmetic results.

Intrathoracoscopic localization techniques

BACKGROUND

Several techniques for localizing pulmonary nodules have been described, but the advantages and disadvantages of each method remain unclear. We reviewed ultrasound, endofinger, finger palpation and wait and watch, radioguided, vital dye, fluoroscopic, agar marking, and needle wire methods for localizing pulmonary nodules.

METHODS

Original, peer-reviewed, and full-length articles in English were searched with PubMed and ISI Web of Sciences. Case reports and case series with less than 10 patients were excluded.

RESULTS

All localization techniques showed good reliability, but some carry a high rate of major or minor complications and drawbacks.

CONCLUSION

No ideal localization technique is available; thus, the choice still depends on surgeon's preference and local availability of both specialists and instruments.

Ultrasonographic localization of occult pulmonary nodules during video-assisted thoracic surgery

The aim of our study was to evaluate the role of ultrasonography in the localization of pulmonary nodules during video-assisted thoracic surgery (VATS). Ultrasonography was performed in 35 patients for the localization of pulmonary nodules during VATS. Indication for VATS was excisional biopsy of undetermined nodules in 22 patients, single or multiple metastasectomy in 12 patients and resection of primitive pulmonary cancer in 1 patient with reduced pulmonary reserve. A laparoscopic probe with flexible head and multi-frequency transducer (5-7.5 MHz) was used. Intraoperative ultrasonography localized 37 of 40 nodules preoperatively detected by CT and/or by positron emission tomography in 35 patients. Furthermore, ultrasonography localized two nodules not visualized at spiral CT. Eighteen nodules were not visible or palpable at thoracoscopic examination and were found by intraoperative sonography only. In 6 patients in whom thoracotomy was performed, manual palpation did not reveal more lesions than ultrasonography. In our experience, ultrasonography was very helpful when lesions were not visible or palpable during thoracoscopy, showing high sensitivity (92.5%) in finding pulmonary nodules. Since it is not possible to determine preoperatively whether a localization technique will be necessary during the operation or not, and ultrasonography is a non-invasive technique, we think that, at present, this technique can be considered as the first-instance localization technique during thoracoscopic resection of pulmonary nodules.

Successful thoracoscopic lung biopsy in children utilizing preoperative CT-guided localization

BACKGROUND/PURPOSE

Although thoracoscopy in children is a well-accepted technique, there are limitations to this approach. Small lung nodules or those not located on the pleural surface often require an open thoracotomy. The purpose of this report is to evaluate the utility of computed tomography (CT) guided needle localization of lung nodules in children followed by thoracoscopic resection.

METHODS

From 1997 to 2000, 13 thoracoscopic procedures were performed on 12 children who presented with small pulmonary nodules (<1 cm) or nodules deep to the pleural surface. Preoperative needle localization was performed by injecting methylene blue under CT guidance. Patients then were taken directly to the operating room for thoracoscopic resection.

RESULTS

All 13 procedures were completed successfully thoracoscopically. Twelve yielded diagnostic pathologic findings as well as therapeutic resections in 7. All patients underwent extubation in the operating room, and chest tubes were removed within 36 hours. No thoracotomies were performed, and there were no complications.

CONCLUSIONS

Preoperative localization utilizing CT guidance is safe and beneficial in children with pulmonary nodules less than 1 cm in size and those located deep to the pleural surface. This technique allows the surgeon to perform thoracoscopy for diagnosis and therapeutic resection of these lesions rather than submitting patients to the morbidity of a thoracotomy.

Differentiation of malignant from benign solitary pulmonary lesions using chest radiography, spiral CT and HRCT

OBJECTIVE

The aim of this prospective study was to summarize all of the qualitative and quantitative imaging criteria for the differentiation of solitary pulmonary lesions (SPLs) as malignant (MSPLs) or benign (BSPLs) described in the literature and to critically analyze the different characteristics in order to evaluate their clinical importance and usefulness as criteria for a discrimination during the primary diagnostic assessment of SPLs using chest radiography, spiral computed tomography (SCT) and high-resolution computed tomography (HRCT).

MATERIALS AND METHODS

SPLs were examined, evaluated and then completely removed by surgery in 104 consecutive patients (MSPLs n=81, BSPLs n=23). No SPL was excluded by size. Chest radiography was performed with frontal and lateral views, SCT was carried out with a slice thickness of 8 mm and HRCT with a slice thickness of 1 mm and a 12-cm field of view.

RESULTS

All the characteristics which enabled a reliable differentiation of MSPLs from BSPLs were characteristics which were observed significantly more frequently in MSPLs than BSPLs. Useful characteristics for the differentiation of MSPLs from BSPLs (1) using chest radiography were the indistinct edge (P<0.0001) and a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0. 05); (2) using SCT the presence of spicules (P<0.0005), the vessel sign (P<0.0005), necrotic areas (P<0.001), spicules extending to the visceral pleura (P<0.005), circumscribed pleural thickening (P<0. 005), inhomogeneity (P<0.01), a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0.01), the lesion density (P<0.05), pleural retraction (P<0.05) and the bronchus sign (P<0.05); and (3) using HRCT the presence of spicules (P<0.00005), spicules extending to the visceral pleura (P<0.0005), the vessel sign (P<0.0005), pleural retraction (P<0.001), circumscribed pleural thickening (P<0. 001), the bronchus sign (P<0.005), a ground-glass opacity of the lung parenchyma adjacent to the SPL (P<0.01), the lesion density (P<0.05) and the length of spicules (P<0.05). Using any one of the characteristics with a significance level of P<0.01, the identification of MSPLs (1) using chest radiography showed a sensitivity of 64.2% and a specificity of 82.6% (accuracy of 68.3%); (2) using SCT a sensitivity of 88.9% and a specificity of 60.9% (accuracy of 82.7%); and (3) using HRCT a sensitivity of 91.4% and a specificity of 56.5% (accuracy of 83.7%).

CONCLUSIONS

Using chest radiography, SCT and HRCT, a precise morphological assessment of the periphery of the pulmonary lesion and the adjacent visceral pleura is necessary to distinguish MSPLs from BSPLs. In this respect SCT and HRCT are useful in differentiation of MSPLs from BSPLs. However, metastases strongly resembled benign lesions in terms of size and edge type and chronic inflammatory pseudotumors as a group mimic MSPLs.

Management of the solitary pulmonary nodule: role of thoracoscopy in diagnosis and therapy

OBJECTIVES

The solitary pulmonary nodule remains a common clinical problem. The essential question is whether the lesion is malignant or not. This discussion presents the clinical practice and looks at the problem.

DESIGN

Didactic.

SETTING

Academic tertiary-care hospital.

PATIENTS

Prospective thoracic database.

INTERVENTIONS

Minimally invasive technique.

RESULTS

The workup and treatment of the solitary pulmonary nodule is presented with particular emphasis on the role of minimally invasive techniques. A small single-institution series is referenced.

CONCLUSIONS

The approach is safe and highly effective in diagnosing and often in treating solitary pulmonary nodules.

Video-assisted approach for transxiphoid bilateral lung metastasectomy

Radical resection has proved to be the most effective treatment of lung metastases, and manual palpation is considered the most accurate method for detection of occult metastases. To allow bilateral manual palpation during video-assisted metastasectomy, we developed a transxiphoid approach without sternotomy. Twenty-one lesions were successfully resected in 6 patients without mortality or morbidity. This approach allows easy manual palpation of the lungs and facilitates bilateral video-assisted metastasectomy.

Feasibility of mathematical models to predict success in video-assisted thoracic surgery lung nodule excision

BACKGROUND

Pulmonary nodules are occasionally difficult to excise using video-assisted thoracic surgery (VATS).

METHODS

To predict operative success, mathematical models using preoperative computerized tomography (CT) measurements were tested in 50 consecutive patients who underwent attempted or successful thoracoscopic lung biopsy. Unrelated technical problems resulted in the exclusion of 3 patients.

RESULTS

No differences were noted with respect to lobar location, thoracic dimensions, gender, presence of chronic obstructive pulmonary disease, or nodule pathology. The expression S/(D + 1), where S = nodule size (cm) and D = distance (cm) to the nearest visceral pleura, yielded significantly higher values for visible nodules (P < 0.001). Resectable nodules had a higher score using the expression 1/(S + D + 1), (P < 0.001). Simple cases (n = 19) were defined as those in which nodules were both visible and resectable with very basic VATS techniques. All others (n = 28) were considered complex. The derived expression for Simplicity [1/(S(D + 1))] yielded significantly higher values for simple cases (0.8 +/- 0.3 vs. 0.3 +/- 0.2 cm(-2), P < 0.001) and all simple cases had a score > or = 0.4. Logistic regression analysis showed that the formulas for resectability and simplicity were significant independent predictors for resectability and simplicity.

CONCLUSIONS

Equations based on objective CT measurements may be useful for planning VATS nodulectomy or studying the outcome of these minimally invasive operations.

The utility of video-assisted thoracic surgery in the diagnosis of pulmonary metastases from renal cell carcinoma

The definitive diagnosis of pulmonary metastases requires histologic confirmation. Traditional methods of obtaining tissue for histologic review include transbronchial approaches, percutaneous transthoracic needle biopsy, and open lung biopsy. The purpose of this study is to identify the most effective methods of obtaining histologic confirmation of pulmonary metastases. The utility of video-assisted thoracic surgery in diagnosing pulmonary metastases is demonstrated in 2 patients with metastatic renal cell carcinoma. The diagnostic yields and complication rates of transbronchial approaches, percutaneous needle biopsy, open lung biopsy, and video-assisted thoracic surgery are compared. Finally, an algorithm for the evaluation of pulmonary lesions is presented.