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Ann Thorac Surg 1995;59:868-870
© 1995 The Society of Thoracic Surgeons

Videothoracoscopy Versus Thoracotomy for the Diagnosis of the Indeterminate Solitary Pulmonary Nodule

Division of General and Thoracic Surgery, University of Milan, Milan, Italy

Accepted for publication October 27, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The solitary pulmonary nodule often presents a diagnostic challenge to the specialist because the nature of the nodule is often indeterminate at the end of the usual diagnostic process, and operation frequently is required before a definite diagnosis can be made. We have conducted a randomized, prospective trial to evaluate the diagnostic efficacy of video-assisted thoracic surgery versus muscle-sparing lateral thoracotomy. Between January 1991 and May 1994, 44 patients suffering from solitary pulmonary nodule were divided at random into two groups: the nodule was removed in 22 cases by video-assisted thoracic surgery and in 22 cases by lateral thoracotomy. Nineteen wedge resections, 1 segmentectomy, and 2 lobectomies were performed in the first group and 13 wedge resections, 8 segmentectomies, and 1 lobectomy in the second group. An ``access'' thoracotomy had to be performed in 5 patients in the video-assisted thoracic surgery group. The operating room time was 97.2 +/- 32.9 minutes in the video-assisted thoracic surgery group and 130.5 +/- 14 minutes in the lateral thoracotomy group (p > 0.05). In both groups a final diagnosis was made in 100% of cases. The postoperative hospital stay was 4.6 +/- 1.08 days in the video-assisted thoracic surgery group and 7.8 +/- 0.89 days in the lateral thoracotomy group (p < 0.01). Pain was evaluated on a visual analogue scale; the scores were 26.5 +/- 11.6 in the video-assisted thoracic surgery group and 48.3 +/- 12.8 in the lateral thoracotomy group (p < 0.05). On the basis of the results obtained in this trial, video-assisted thoracic surgery seems to be as effective as lateral thoracotomy in the diagnosis of solitary pulmonary nodule, but causes less discomfort to the patients and requires a shorter period of hospitalization.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 870.

The solitary pulmonary nodule (SPN) appears in the standard chest roentgenogram as a well-defined opacity not associated with atelectasis or hilar lymphadenopathy [1]. The maximum dimensions reported in the literature are fairly dissimilar, reaching up to 6 cm [2]; in our trial we examined SPNs with a maximum diameter of 2.5 cm.

The diagnostic process is well codified, but the final diagnosis of the nature of the nodule is often highly complex; up to 80 different diagnostic possibilities have been formulated [3], and it should be borne in mind that some 30% of SPNs are malignant [4].

The spiky radiographic appearance of the SPN (``radiating crown'') can be considered a sign of malignancy in 90% of cases [5]. Conversely, the presence in the nodule of calcium [6] or adipose tissue [7], demonstrated by thin-layer (1.5 mm) computed tomography (CT), can be considered a sign of benignancy. Solitary pulmonary nodules that do not present these characteristics usefully can be investigated by CT density analysis compared with a reference nodule at 185 Hounsfield units, in accordance with the technique described by Zerhuoni and associates [8]; approximately 30% of nodules can be classified in this way as benign, whereas the rest are considered indeterminate [9].

As bronchoscopy is of no assistance in diagnosing this disorder [10], patients with indeterminate SPNs can be subjected to CT-guided thin-needle biopsy. In expert hands this technique enables a diagnosis of malignancy to be made in 95% to 98% of cases, and a diagnosis of benignancy in 88% to 96% of cases [6, 11]. Patients who still present an indeterminate SPN after these tests usually undergo thoracotomy [12, 13].

We have conducted a randomized, prospective trial to ascertain whether video-assisted thoracic surgery (VATS) is as sensitive and specific in the diagnosis of indeterminate SPNs as lateral thoracotomy (LT), and whether the endoscopic technique presents any advantages for the patient or the hospital.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The criteria for admission to the trial were as follows: patient with SPN, maximum nodule size of 2.5 cm, location in peripheral third of lung, nodule classified as ``indeterminate'' after a suitable diagnostic process, low risk of primary lung cancer, and absence of intrabronchial vegetation. The diagnostic procedure involved standard chest roentgenography, CT, bronchoscopy, and fine-needle biopsy if the nodule was more than 1 cm in diameter. The pathologist recorded a nonsignificant or doubtful finding in the case of the 25 patients who previously had undergone at least three attempts at fine-needle biopsy.

The study started in January 1991 and terminated in May 1994. Forty-four consecutive patients were subjected to restricted randomization in 11 permutation blocks of 4 patients so that at the end of the process two groups of 22 patients were obtained.

A 10- to 15-cm LT was performed on the first group, 17 with total muscle sparing and 5 standard thoracotomies with sparing of the serratus muscle. All patients in this group required a rib retractor.

The second group underwent VATS with three approaches, positioned on the basis of the location of the nodule. A 4-cm lateral ``access'' thoracotomy also was performed in the fourth or fifth intercostal space without muscle section in the case of the VATS group to remove large surgical specimens or to solve technical problems. Rib retractors were not used for these patients; only self-retaining muscle and skin retractors were used.

Both groups received general anesthesia. Table 1 shows clinical details of the two groups in question.

The majority of the operations for both groups were wedge resection, except where extension of the parenchymal sacrifice was required because of the location or nature of the nodule. The surgical specimens removed were subjected to frozen section.

The quantity of analgesic administered parenterally during the postoperative period (ketorolac, 30 mg intravenously) was recorded.

On the sixth day after the operation the patients filled in a form (even if they had already been discharged) containing two visual analogue scales designed to evaluate the pain and anxiety suffered.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The two groups of patients were sufficiently homogenous, as shown in Table 1.

Thirteen wedge resections, 8 segmentectomies, and 1 lobectomy were performed in the LT group, and 19 wedge resections, 1 segmentectomy and 2 lobectomies were performed in the VATS group. Five patients in the VATS group required an ``access'' thoracotomy: in 2 to conclude the lobectomy, in 1 to find the nodule, and in 2 to remove the surgical specimen. The duration of the operation was shorter in the VATS group than in the LT group, although the difference was not statistically significant.

In both groups a final diagnosis was made in 100% of cases (Table 2); all metastatic lesions were discovered in patients with a history of previous tumor.

Table 3 shows the findings relating to the postoperative hospitalization period, estimated pain, and amount of analgesic administered; all these parameters proved significantly less in the VATS group.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Surgical exploration always is preferable, except in the case of nonsmokers less than 35 years of age who have no previous history of extrapulmonary tumors [14], and elderly patients whose general condition suggests that operation is contraindicated. Some authors now propose VATS as a good alternative to LT [15], and our trial seems to bear out this hypothesis.

We studied two groups of patients who proved homogenous in the comparison of clinical details and in terms of the type of operation performed and psychologic profile obtained from the visual analogue scale for anxiety (see Table 3). The operation performed on patients was shorter with VATS, although the difference compared with LT was not significant; however, at the beginning of the trial our experience with VATS was limited, and this probably affected the findings. We believe that in the future the mean duration of the VATS operation should decline further.

The postoperative hospitalization period was significantly shorter in the case of VATS patients; this finding demonstrates the rapid functional recovery achieved with the endoscopic method.

Postoperative pain was significantly less in the case of VATS patients, as was analgesic administration. This finding also is emerging gradually from the experience of other authors [16, 17], thus confirming the impression that videoendoscopy methods are not particularly unpleasant for the patients.

In the VATS group, 2 patients suffered from primary lung cancer and were subjected to VATS lobectomy. Three presented pulmonary metastasis of carcinoma of another organ and were subjected to wedge resection, again using the endoscopic technique. We are aware that the choice of treatment given to these 5 patients still may be considered questionable, and we are conducting further studies to ascertain its appropriateness.

In conclusion, we can confirm that the sensitivity and specificity of VATS and LT are virtually identical in the diagnosis of SPNs, amounting to 100%. However, the former technique causes less discomfort to patients and requires a shorter hospitalization period. We therefore use and recommend VATS when a patient has an indeterminate SPN with a diameter of less than 2.5 cm located in the peripheral third of the lung parenchyma. If the nodule proves malignant, it is best left to the surgeon to decide whether to treat it by performing open thoracotomy.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Nosotti, via Salomone 21, 20138 Milano, Italy.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Luigi Santambrogio Mario Nosotti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Santambrogio, L. Articles by Mezzetti, M. Search for Related Content PubMed PubMed Citation Articles by Santambrogio, L. Articles by Mezzetti, M. Related Collections Related Article