To the Editor:
The detection of a small growing pulmonary nodule on chest CT raises the suspicion of
lung cancer, but proof of malignancy must be established by either needle biopsy or
nodule resection.(
11. Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J,
et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic
resection after computed tomography-guided localization using platinum microcoils.
Ann Surg. 2004;240(3):481-8; discussion 488-9.
http://dx.doi.org/10.1097/01.sla.0000137132.01881.57
http://dx.doi.org/10.1097/01.sla.0000137...
) Pulmonary nodules ≤ 10 mm with ground-glass opacity should be considered to
have a high possibility of malignancy.(
22. Yoon HE, Fukuhara K, Michiura T, Takada M, Imakita M, Nonaka K, et
al. Pulmonary nodules 10 mm or less in diameter with ground-glass opacity component
detected by high-resolution computed tomography have a high possibility of
malignancy. Jpn J Thorac Cardiovasc Surg. 2005;53(1):22-8.
http://dx.doi.org/10.1007/s11748-005-1004-8
http://dx.doi.org/10.1007/s11748-005-100...
) Various centers perform the excision of these small growing nodules using
video-assisted thoracoscopic surgery (VATS) in order to minimize postoperative
morbidity, as well as to remove as small a volume of lung tissue as possible. Small
nodules are often visible with the thoracoscope if they lie within 5 mm of the visceral
pleural surface; however, if they are located deeper in the lung, palpation is required
in order to locate them for excision. A previous study found that, in a series of 92
consecutive patients undergoing VATS, 50 (54%) required conversion to
thoracotomy.(
33. Suzuki K, Nagai K, Yoshida J, Ohmatsu H, Takahashi K, Nishimura M, et
al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules:
indications for preoperative marking. Chest. 1999;115(2):563-8.
http://dx.doi.org/10.1378/chest.115.2.563
http://dx.doi.org/10.1378/chest.115.2.56...
) The most common reason for conversion to full thoracotomy was failure to
locate the nodule. Univariate and multivariate analysis of the eleven variables studied
showed that if the distance from the pleural surface to the nodule edge was greater than
5 mm, the probability of failure to detect a nodule was 63%,(
33. Suzuki K, Nagai K, Yoshida J, Ohmatsu H, Takahashi K, Nishimura M, et
al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules:
indications for preoperative marking. Chest. 1999;115(2):563-8.
http://dx.doi.org/10.1378/chest.115.2.563
http://dx.doi.org/10.1378/chest.115.2.56...
) and 40% of those nodules were found to be malignant. Because of the
difficulty in localizing a nodule during surgery and the increasing clinical load due to
the identification of small lung nodules for lung cancer screening using CT, there has
been extensive investigation for improving nodule localization techniques in order to
assist the resection of small nodules during VATS. We would like to report the first use
of a new technique for the intraoperative localization of such nodules in Brazil:
CT-guided placement of platinum coils.
A 72-year-old woman underwent a chest CT for the evaluation of chronic cough. The CT scans demonstrated a 1-cm ground-glass nodule in the central portion of the right upper lobe (Figure 1A). The nodule was later biopsied, and the final pathological examination revealed atypical cells suspected of being adenocarcinoma in situ (formerly known as bronchioalveolar carcinoma). Surgical resection using VATS was planned; however, because of the ground-glass nature of the nodule and its distance from the pleural surface, preoperative wire localization was requested. Using CT guidance, the tip of the loaded Chiba needle was percutaneously placed approximately 5 mm deep into the lung nodule (Figure 1B). The guide wire was introduced up to the first mark, advancing 30 mm of the fiber-coated coil out of the Chiba needle and into the lung parenchyma, where it assumed a tightly coiled helical configuration into the nodule (Figures 1C and 1D). The patient underwent VATS, and the coil was easily localized by lung palpation through a 3-cm minithoracotomy (Figure 1E). The final diagnosis was pulmonary adenocarcinoma.
In A, a CT scan demonstrating a 1-cm ground-glass nodule in the central portion of the right upper lobe. In B, volume rendering of a CT scan demonstrating the needle inside the ground-glass nodule in right upper lobe. In C, volume rendering of a CT scan demonstrating the CT-guided placement (arrow) of a platinum microcoil inside the ground-glass nodule. In D, a CT scan taken after the procedure, demonstrating the platinum coil (arrow) inside the ground-glass nodule. In E, a photograph of the surgical specimen showing the coil.
Techniques for the localization of pulmonary nodules have been classified into three
types. (
11. Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J,
et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic
resection after computed tomography-guided localization using platinum microcoils.
Ann Surg. 2004;240(3):481-8; discussion 488-9.
http://dx.doi.org/10.1097/01.sla.0000137132.01881.57
http://dx.doi.org/10.1097/01.sla.0000137...
,
44. Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary
nodules before thoracoscopic surgery: value of percutaneous staining with methylene
blue. AJR Am J Roentgenol. 1994;163(2):297-300.
http://dx.doi.org/10.2214/ajr.163.2.7518642
http://dx.doi.org/10.2214/ajr.163.2.7518...
) The first class uses intraoperative imaging (either ultrasonography or CT).
Localization with intraoperative ultrasound is difficult because the lung must be
completely collapsed in order to allow the visualization of small nodules.(
11. Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J,
et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic
resection after computed tomography-guided localization using platinum microcoils.
Ann Surg. 2004;240(3):481-8; discussion 488-9.
http://dx.doi.org/10.1097/01.sla.0000137132.01881.57
http://dx.doi.org/10.1097/01.sla.0000137...
,
44. Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary
nodules before thoracoscopic surgery: value of percutaneous staining with methylene
blue. AJR Am J Roentgenol. 1994;163(2):297-300.
http://dx.doi.org/10.2214/ajr.163.2.7518642
http://dx.doi.org/10.2214/ajr.163.2.7518...
) This technique lengthens the surgical time, since the complete collapse of
the lung can take 30-150 min and is often contraindicated in patients with extensive
emphysema. Not only is experience with real-time CT-guided thoracoscopic resection
limited, but also artifacts caused by instruments and staples degrade the CT image, and
the limited space within the scanner gantry makes the procedure difficult.(
11. Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J,
et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic
resection after computed tomography-guided localization using platinum microcoils.
Ann Surg. 2004;240(3):481-8; discussion 488-9.
http://dx.doi.org/10.1097/01.sla.0000137132.01881.57
http://dx.doi.org/10.1097/01.sla.0000137...
,
44. Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary
nodules before thoracoscopic surgery: value of percutaneous staining with methylene
blue. AJR Am J Roentgenol. 1994;163(2):297-300.
http://dx.doi.org/10.2214/ajr.163.2.7518642
http://dx.doi.org/10.2214/ajr.163.2.7518...
)
The second class of targeting techniques includes the percutaneous injection of dyes,
contrast media, radionuclides, or colored adhesive agents.(
11. Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J,
et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic
resection after computed tomography-guided localization using platinum microcoils.
Ann Surg. 2004;240(3):481-8; discussion 488-9.
http://dx.doi.org/10.1097/01.sla.0000137132.01881.57
http://dx.doi.org/10.1097/01.sla.0000137...
,
44. Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary
nodules before thoracoscopic surgery: value of percutaneous staining with methylene
blue. AJR Am J Roentgenol. 1994;163(2):297-300.
http://dx.doi.org/10.2214/ajr.163.2.7518642
http://dx.doi.org/10.2214/ajr.163.2.7518...
,
55. Gagliano RA, Reinschmidt JP, Murray SP, Casha LM, Tracy D, Collins
GJ. A novel method of transthoracic lung nodule localization. Curr Surg.
1999;56(7):410-2. http://dx.doi.org/10.1016/S0149-7944(99)00169-5
http://dx.doi.org/10.1016/S0149-7944(99)...
) Diffusion away from the nodule is a limitation of these techniques and
imposes restrictions on the allowable time between the CT localization procedure and the
thoracoscopic resection. This can cause difficulties in the operating room scheduling.
In addition, certain dyes, such as methylene blue, carry a possible risk of anaphylactic
reactions following their injection and are often difficult to visualize on the visceral
pleural surface in patients with extensive anthracotic pigmentation of the lungs.
(
11. Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J,
et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic
resection after computed tomography-guided localization using platinum microcoils.
Ann Surg. 2004;240(3):481-8; discussion 488-9.
http://dx.doi.org/10.1097/01.sla.0000137132.01881.57
http://dx.doi.org/10.1097/01.sla.0000137...
,
44. Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary
nodules before thoracoscopic surgery: value of percutaneous staining with methylene
blue. AJR Am J Roentgenol. 1994;163(2):297-300.
http://dx.doi.org/10.2214/ajr.163.2.7518642
http://dx.doi.org/10.2214/ajr.163.2.7518...
,
55. Gagliano RA, Reinschmidt JP, Murray SP, Casha LM, Tracy D, Collins
GJ. A novel method of transthoracic lung nodule localization. Curr Surg.
1999;56(7):410-2. http://dx.doi.org/10.1016/S0149-7944(99)00169-5
http://dx.doi.org/10.1016/S0149-7944(99)...
) Because these materials are not water-soluble, they carry a potential risk
of stroke if they gain access to the pulmonary veins.
The third class of targeting techniques uses coils or microcoils that are soft and
pliable and cause little damage to lung tissue, even when dislodged. A previous study
compared the use of microcoils and hook wires for the localization of nodules in freshly
harvested goat lungs.(
55. Gagliano RA, Reinschmidt JP, Murray SP, Casha LM, Tracy D, Collins
GJ. A novel method of transthoracic lung nodule localization. Curr Surg.
1999;56(7):410-2. http://dx.doi.org/10.1016/S0149-7944(99)00169-5
http://dx.doi.org/10.1016/S0149-7944(99)...
) The authors reported that when a coil was displaced, it would uncoil,
causing minimal tissue damage. In addition, the "fuzzy" fiber coating on these
microcoils induces coagulation and increases the adhesion of the coil to the lung
tissue. The coiled configuration and the fiber coating virtually eliminate the risk of
embolization.
In conclusion, we would like to highlight this new method of nodule localization, which is a safe and effective technique and increases the success rate of nodule excision using VATS, especially for small, ground-glass nodules.
References
-
1Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J, et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic resection after computed tomography-guided localization using platinum microcoils. Ann Surg. 2004;240(3):481-8; discussion 488-9. http://dx.doi.org/10.1097/01.sla.0000137132.01881.57
» http://dx.doi.org/10.1097/01.sla.0000137132.01881.57 -
2Yoon HE, Fukuhara K, Michiura T, Takada M, Imakita M, Nonaka K, et al. Pulmonary nodules 10 mm or less in diameter with ground-glass opacity component detected by high-resolution computed tomography have a high possibility of malignancy. Jpn J Thorac Cardiovasc Surg. 2005;53(1):22-8. http://dx.doi.org/10.1007/s11748-005-1004-8
» http://dx.doi.org/10.1007/s11748-005-1004-8 -
3Suzuki K, Nagai K, Yoshida J, Ohmatsu H, Takahashi K, Nishimura M, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest. 1999;115(2):563-8. http://dx.doi.org/10.1378/chest.115.2.563
» http://dx.doi.org/10.1378/chest.115.2.563 -
4Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with methylene blue. AJR Am J Roentgenol. 1994;163(2):297-300. http://dx.doi.org/10.2214/ajr.163.2.7518642
» http://dx.doi.org/10.2214/ajr.163.2.7518642 -
5Gagliano RA, Reinschmidt JP, Murray SP, Casha LM, Tracy D, Collins GJ. A novel method of transthoracic lung nodule localization. Curr Surg. 1999;56(7):410-2. http://dx.doi.org/10.1016/S0149-7944(99)00169-5
» http://dx.doi.org/10.1016/S0149-7944(99)00169-5
Publication Dates
-
Publication in this collection
Jul-Aug 2014
History
-
Received
08 Feb 2014 -
Accepted
04 Mar 2014