Radio-guided thoracoscopic surgery (RGTS) of small pulmonary nodules

BackgroundThe demand for adequate tissue sampling to determine individual tumor behavior is increasing the number of lung nodule resections, even when the diagnosis is already recognized. Video-assisted thoracic surgery (VATS) is the procedure of choice for diagnosis and treatment of small pulmonary nodules. Difficulties in localizing smaller and deeper nodules have been approached with different techniques. Herein we report our 13-years’ experience with radio-guided thoracoscopic resection.MethodsPatients with pulmonary nodules smaller than 1 cm and/or deeper than 1 cm, below the visceral pleura, underwent computed tomography (CT)-guided injection of a solution, composed of 0.2 ml 99Tc-labeled human serum albumin microspheres and 0.1 ml nonionic contrast, into the nodule. During the VATS procedure, an 11-mm-diameter collimated probe connected to a gamma ray detector was introduced to scan the lung surface. The area of major radioactivity, which matched with the area of the nodule, was resected.ResultsFrom 1997 to 2009, 573 patients underwent thoracoscopic resection of small pulmonary nodules, 211 with the radio-guided technique. There were 159 men and 52 women, with an average age of 60.6 years (range = 12–83). The mean duration of the surgical procedure was 41 min (range = 20–100). The procedure was successful in 208/211 cases. Three patients (0.5%) required conversion to a minithoracotomy. The mean length of pleural drainage and hospital stay was 2.3 and 3.7 days, respectively. Histological examination showed 98 benign lesions and 113 malignant lesions (61 metastases and 52 primary lung cancers).ConclusionThis study confirms that radio-guided localization of small pulmonary nodules is a feasible, safe, and quick procedure, with a high rate of success. The spread of the sentinel lymph node technique has increased the availability of technology required for RGTS.

[1]  S. Mattioli,et al.  Transthoracic endosonography for the intraoperative localization of lung nodules. , 2005, The Annals of thoracic surgery.

[2]  Nishita Kothary,et al.  Computed tomography-guided percutaneous needle biopsy of pulmonary nodules: impact of nodule size on diagnostic accuracy. , 2009, Clinical lung cancer.

[3]  A. Takats,et al.  Monoclonal antibodies in the treatment of lung cancer. , 2006, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[4]  C. Schwarz,et al.  Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with methylene blue. , 1994, AJR. American journal of roentgenology.

[5]  E. Board,et al.  American College of Chest Physicians , 1960, The Grants Register 2022.

[6]  Federico Davini,et al.  Thoracoscopic localization techniques for patients with solitary pulmonary nodule: hookwire versus radio-guided surgery. , 2007, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[7]  Y. Kaneda,et al.  Radioisotope marking under CT guidance and localization using a handheld gamma probe for small or indistinct pulmonary lesions. , 2003, Chest.

[8]  A. Chella,et al.  A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection. , 2000, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[9]  R. Santambrogio,et al.  Intraoperative ultrasound during thoracoscopic procedures for solitary pulmonary nodules. , 1999, The Annals of thoracic surgery.

[10]  M. Graif,et al.  Radioimmunoguided surgery benefits for recurrent colorectal cancer , 1997, Annals of Surgical Oncology.

[11]  D. Libby,et al.  Tumor size predicts survival within stage IA non-small cell lung cancer. , 2003, Chest.

[12]  C. Feo,et al.  Thoracoscopic localization techniques for patients with solitary pulmonary nodule and history of malignancy. , 2005, The Annals of thoracic surgery.

[13]  N. Mitsui,et al.  Role of video-assisted thoracic surgery for the diagnosis of indeterminate pulmonary nodule. , 2006, Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia.

[14]  A. Bernard,et al.  Resection of pulmonary nodules using video-assisted thoracic surgery. The Thorax Group. , 1996, The Annals of thoracic surgery.

[15]  P. Schnyder,et al.  CT-guided localizations of pulmonary nodules with methylene blue injections for thoracoscopic resections. , 1994, Chest.

[16]  H. Ohmatsu,et al.  Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. , 1999, Chest.

[17]  M. Berger,et al.  Percutaneous localization of pulmonary nodules for thoracoscopic lung resection. , 1992, The Annals of thoracic surgery.

[18]  T. Altes,et al.  Clinical experience with radiotracer-guided thoracoscopic biopsy of small, indeterminate lung nodules. , 2006, The Annals of thoracic surgery.

[19]  U. Eichfeld,et al.  Video-assisted thoracoscopic surgery for pulmonary nodules after computed tomography-guided marking with a spiral wire. , 2005, The Annals of thoracic surgery.

[20]  Atul C Mehta,et al.  Evidence-Based Clinical Practice Guidelines Initial Diagnosis of Lung Cancer : ACCP , 2007 .

[21]  David R. Jones,et al.  Identification of small lung nodules: technique of radiotracer-guided thoracoscopic biopsy. , 2008, The Annals of thoracic surgery.

[22]  A. Mussi,et al.  A strategy for thoracoscopic resection of small pulmonary nodules , 2005, Surgical Endoscopy And Other Interventional Techniques.

[23]  R. V. van Klaveren,et al.  Survival after pathological stage IA nonsmall cell lung cancer: tumor size matters. , 2005, The Annals of thoracic surgery.