A novel hybrid technique for localization of subcentimeter lung nodules

Hybrid operating room with ceiling mounted imaging system assisted pre-operative and intra-operative lung nodule localization for thoracoscopic resections: a 5-year case series

BACKGROUND

Video-assisted thoracoscopic (VATS) lung resections are increasingly popular and localization techniques are necessary to aid resection. We describe our experience with hybrid operating room (OR) cone-beam computed tomography (CT) assisted pre-operative and intra-operative lesion localization of lung nodules for VATS wedge resections, including our novel workflow using the hybrid OR cone-beam CT to re-evaluate patients who have undergone pre-operative localization for those who are unsuitable for intra-operative localization.

METHODS

Retrospective analysis of all consecutive patients with small (≤ 20 mm), deep (≥ 10 mm distance from pleura) and/or predominantly ground-glass nodules selected for lesion localization in the Interventional Radiology suite followed by re-evaluation with cone-beam CT in the hybrid OR (pre-operative), or in the hybrid OR alone (intra-operative), prior to intentional VATS wedge performed by a single surgeon at our centre from January 2017 to December 2021.

RESULTS

30 patients with 36 nodules underwent localization. All nodules were successfully resected with a VATS wedge resection, although 10% of localizations had hookwire or coil dislodgement. The median effective radiation dose in the pre-operative group was 10.4 mSV including a median additional radiation exposure of 0.9 mSV in the hybrid OR for reconfirmation of hookwire or coil position prior to surgery (p = 0.87). The median effective radiation dose in the intra-operative group was 3.2 mSV with a higher mean rank than the intra-operative group, suggesting a higher radiation dose (p = 0.01).

CONCLUSIONS

We demonstrate that our multidisciplinary approach utilizing the hybrid OR is safe and effective. Intra-operative localization is associated with lower radiation doses. Routine use of cone-beam CT to confirm the position of the physical marker prior to surgery in the hybrid OR helps mitigate consequences of localization failure with only a modest increase in radiation exposure.

Implications of Preoperative Transbronchial Lung Biopsy for Non-small Cell Lung Cancer Less than 3-cm

BACKGROUND/AIM

Transbronchial lung biopsy (TBLB) has been recommended for patients with suspected lung cancer. However, its diagnostic value is limited to small lesions, and some studies have indicated that biopsy might be related to metastasis and/or dissemination. This study aimed to evaluate the outcomes after preoperative TBLB for non-small cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Data were reviewed from 371 patients with resected pN0 NSCLC less than 3-cm. Patients were divided into two groups: TBLB and Non-TBLB. Recurrence-free survival (RFS) curves were plotted using the Kaplan-Meier method. Cox regression analyses were used to evaluate the hazard ratio (HR) with the endpoint RFS.

RESULTS

The 5-year RFS rates were 75.5% in the TBLB group and 91.4% in the Non-TBLB group (p<0.001). Poor RFS was independently associated with TBLB (HR=2.491, 95%CI=1.337-4.640; p=0.004).

CONCLUSION

Preoperative TBLB may adversely affect RFS among NSCLC patients with small size tumours.

CT-Guided Microcoil Localization of Small Peripheral Pulmonary Nodules to Direct Video-Assisted Thoracoscopic Resection without the Aid of Intraoperative Fluoroscopy

OBJECTIVE

To evaluate the feasibility, safety, and effectiveness of CT-guided microcoil localization of solitary pulmonary nodules (SPNs) for guiding video-assisted thoracoscopic surgery (VATS).

MATERIALS AND METHODS

Between June 2016 and October 2019, 454 consecutive patients with 501 SPNs who received CT-guided microcoil localization before VATS in our institution were enrolled. The diameter of the nodules was 0.93 ± 0.49 cm, and the shortest distance from the nodules to the pleura was 1.41 ± 0.95 cm. The distal end of the microcoil was placed less than 1 cm away from the nodule, and the proximal end was placed outside the visceral pleura. VATS was performed under the guidance of implanted microcoils without the aid of intraoperative fluoroscopy.

RESULTS

All 501 nodules were marked with microcoils. The time required for microcoil localization was 12.8 ± 5.2 minutes. Microcoil localization-related complications occurred in 179 cases (39.4%). None of the complications required treatment. A total of 463 nodules were successfully resected under the guidance of implanted microcoils. VATS revealed 38 patients with dislocated microcoils, of which 28 underwent wedge resection (21 cases under the guidance of the bleeding points of pleural puncture, 7 cases through palpation), 5 underwent direct lobectomy, and the remaining 5 underwent a conversion to thoracotomy. In 4 cases, a portion of the microcoil remained in the lung parenchyma.

CONCLUSION

CT-guided microcoil localization of SPNs is safe and reliable. Marking the nodule and pleura simultaneously with microcoils can effectively guide the resection of SPNs using VATS without the aid of intraoperative fluoroscopy.

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.

Computed tomography criteria for the use of advanced localization techniques in minimally invasive thoracoscopic lung resection

Background

The significant improvement of patient outcomes from minimally invasive lung surgery has led to the development of advanced lung nodule localization techniques to help manage patients with small suspicious lung nodules or to help resect patients with small pulmonary metastases. However, there are no clear computed tomography (CT) criteria to guide the use of advanced localization techniques for this group of patients.

Methods

We conducted a retrospective chart review of patients who had undergone initial wedge resection of single or multiple lung nodules. We collected demographics, surgical information and surgical outcomes as well as CT scan features. Multiple logistic regression was performed to determine which factors were most predictive of the need for advanced localization techniques.

Results

A total of 45 patients (73%) were resected by direct identification alone while 17 patients (27%) required advanced localization techniques. Of those requiring advanced localization, 11 patients had cone beam CT, 3 patients had transbronchial localization using electromagnetic navigation and 3 patients had preoperative CT guided wire localization. Patients requiring advanced localization had significantly smaller lung nodules at 0.8 cm compared to 1.4 cm (P=0.01), nodules that were further away from the pleura at 1.3 cm compared 0.1 cm (P<0.001) and were more likely to have ground glass nodules (P=0.01) compared to patients who were resected by direct identification alone. Multiple logistic regression confirmed that nodule size, distance to pleura and ground glass attenuation were predictive factors for requiring advanced localizing techniques. Every patient was treated with minimally invasive lung resection. A 1.3-cm or greater solitary pulmonary nodule less than 5 mm from the pleura can be removed without advanced techniques with a 96% success rate.

Conclusions

Overall, in patients undergoing resection of a suspicious primary or metastatic lung nodule, advanced localization techniques should be considered in those with small non-solid nodules, which are not near the pleural surface on CT scan.

High-resolution computed tomography features and CT-guided microcoil localization of subcentimeter pulmonary ground-glass opacities: radiological processing prior to video-assisted thoracoscopic surgery

Background

With the rapid development of high-resolution computed tomography (HRCT), low-dose CT scanning and video-assisted thoracoscopic surgery (VATS), smaller pulmonary nodules can be detected. Subcentimeter ground-glass opacities (GGOs) are extremely difficult to diagnose and accurately locate during VATS and in surgically resected specimens.

Methods

From September 2013 to September 2017, 42 subcentimeter GGO lesions (≤1 cm) in 31 patients who underwent CT-guided microcoil insertion followed by VATS resection were included. All HRCT images were assessed by two experienced radiologists, and CT-guided microcoil localization procedures were performed by two experienced interventional radiologists.

Results

A total of 42 subcentimeter GGOs included 28 malignancies (66.7%) and 14 benign lesions (33.3%). The diameter of malignant GGOs (8.52±1.46 mm) was significantly larger than that of benign lesions (7.04±1.52 mm) (P<0.05). Seven patients had more than one GGO nodule. There were no significant differences in the location, composition, shape, margins, presence of air bronchograms, presence of the pleural indentation sign and presence of the vascular convergence sign between benign and malignant GGOs (P>0.05). All the localization procedures were performed successfully. A small pneumothorax occurred in 9 patients (21.4%), and minor hemorrhage in the lung parenchyma occurred in 8 patients (19.0%). All GGOs were easily identified during VATS and were definitively diagnosed.

Conclusions

Common HRCT features cannot be used as criteria for the differential diagnosis of subcentimeter benign and malignant pulmonary GGOs. CT-guided microcoil marking of these lesions prior to VATS is a feasible, safe, and effective procedure for the localization of subcentimeter pulmonary GGOs.