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Ann Thorac Surg 2001;71:986-988
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Thoracoscopic resection of pulmonary nodules after computed tomographic–guided coil labeling

^a Department of Cardiovascular and Thoracic Surgery, Department of Internal Medicine, University of Louvain Medical School at Mont-Godinne University Hospital, B-5530, Yvoir, Belgium
^b Department of Radiology, Department of Internal Medicine, University of Louvain Medical School at Mont-Godinne University Hospital, B-5530, Yvoir, Belgium
^c Chest Medicine Unit, Department of Internal Medicine, University of Louvain Medical School at Mont-Godinne University Hospital, Yvoir, Belgium

Accepted for publication October 18, 2000.

Address reprint requests to Dr Eucher, Cardiovascular and Thoracic Surgery Department, UCL Mont-Godinne, Av Therasse 5, B-5530 Yvoir, Belgium
e-mail: pheucher{at}hotmail.com

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. A limiting factor in performing video-assisted thoracic surgery for resection of peripheral solitary pulmonary nodules has been the recognition of the lesion visually. This study reports our clinical experience of injecting a small metallic marker under computed tomographic scan guidance before the operation, allowing localization of the lesion.

Methods. A series of 14 patients underwent video-assisted thoracic surgery for removal of 15 pulmonary nodules situated in the outer third of the lung. Before operation, a radiopaque microcoil was injected just behind the lesion and then used to locate, under fluoroscopy, the area to be resected during thoracoscopy. The technique was evaluated for accuracy, reliability, and ease of use.

Results. Microcoil labeling of peripheral pulmonary nodules allowed in every case a complete resection and a histologic identification of the lesion. It is more stable and accurate than methylene blue dye marking, and it is as easy to perform as computed tomographic scan–guided biopsy. The incidence of complication was small in spite of our inexperience with the technique.

Conclusions. Our experience with microcoil injection shows that it provides consistent and highly accurate marking of pulmonary nodules for video-assisted thoracic surgery, allowing secure resection with a safe margin.

	Introduction

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The presence of a suspicious solitary pulmonary nodule always necessitates histologic identification. To fulfill this diagnostic imperative, and for peripheral nodules, which are not accessible by bronchoscopy, transthoracic needle biopsy (TTNB) is our first choice. For lesions for which TTNB could present technical difficulties, other diagnostic strategies are needed.

One of the principal indications of video-assisted thoracic surgery is the diagnosis of lung nodules located at or very near the periphery [1], but the difficulty of palpating the nodule during the operation forces us to go back to radiologic labeling techniques [2] to be able to localize the lesion in the operating suite. With this in mind, several methods have been used for identification: methylene blue or barium injection under computed tomography (CT), hook wire localization, ultrasound localization, and so forth. We have resorted to marking nodules by placing a small metallic coil under CT scan guidance, immediately before operation, and herein report results using a technique first described by Asamura and colleagues in 1994 [3].

	Material and methods

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Since 1994 nearly 200 solitary small peripheral pulmonary nodules, inaccessible by bronchoscopy, have been diagnosed at our institution by TTNB. For 15 other lesions, TTNB was considered limited because of the size and the localization of these nodules (too small and deep) or contraindicated in cases of patients with severe respiratory disease. We decided to identify the nodules using thoracoscopic resection after microcoil marking. This group was composed of 14 patients, 7 men and 7 women, aged between 37 and 69 years (average, 53.8 years old), presenting with 15 lesions situated in the outer third of the lung without reaching the pleural surface.

Radiologic technique
The procedure is the same as a CT scan–guided diagnostic biopsy, largely described in the literature [4]. The only preexamination evaluation needed is a coagulation test (prothrombin time and activated prothrombin time).

Access should be as simple as possible, although parietal structures can sometimes be a hindrance. To reduce the risk of creating a pneumothorax, we have improved the technique originally described by Asamura and associates [3] by using a 22-gauge 10-cm-long Chiba needle (William Cook Europe A/S, Bjaeverskov, Denmark) instead of an 18-gauge one. After the needle is placed in position, we inject a 0.018-inch coil (Microcoil Hilal, Cook), 15 mm long and 5 mm in diameter.

Nodules situated just under the pleural surface are the most difficult to label. In any case, to avoid the possibility of the coil slipping into the pleural cavity, the coil must be placed just slightly behind the nodule (Fig 1).

View larger version (152K): [in this window] [in a new window]   Fig 1. Computed tomographic scan showing the metallic coil (A) placed just behind the pulmonary nodule (B).

The resected nodule is extracted in a plastic bag (Lapsac, Cook, Spencer, IN) to avoid neoplastic cell dissemination at the port site.

The sample is split open in the operating room to ensure the presence of the entire nodule and the metallic coil, and then is sent to the anatomicopathologic laboratory for immediate analysis and confirmation of a safe resection margin. At the end of the procedure, we place two pleural drains, using the incision points of the thoracic ports.

	Results

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Radiologic marking
Fifteen procedures have been performed by our team. During one of our first labeling procedures, the coil was not inserted deeply enough into the pulmonary parenchyma; although the chest radiograph that immediately followed showed the coil in place, at the time of perioperative localization, we found the coil at the bottom of the pleural cavity. We were able, however, to locate and resect the nodule after deflation of the lung.

In three cases (20%), a minor pneumothorax developed, but because the patients were asymptomatic and the operation imminent, pleural drainage was not necessary.

Surgical resection
In 14 patients, we successfully resected 15 lesions varying in size between 5 and 20 mm, located at depths of 5 to 30 mm. There was no perioperative and postoperative mortality resulting from the procedure, and no complications arose during the procedure. In one case (6.6%), we were forced to convert to thoracotomy because of adherences, but none of the procedures required an extension of the resected area.

Anatomopathology
Extemporaneous tissue analysis showed that in 8 cases the lesion was benign (2 fibrous scar nodules, 2 anthracosilicosis nodules, 2 granulomatous nodules, 1 histiocytoma, 1 sarcoid nodule). In the other 7 cases, the resected lesion was malignant (5 colonic adenocarcinoma metastases, 1 metastasis of a small cell parotid carcinoma, and a sheet of cells identified as a carcinoid tumor that was next to a granulomatous nodule), but no cases of lung carcinoma were found.

	Comment

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A solitary pulmonary nodule is defined as a noncalcified opacity measuring less than 3 cm in diameter, surrounded by normal pulmonary parenchyma, without accompanying adenopathy or atelectasia [1]. The diagnosis of solitary nodules remains a real challenge, and a precise histologic identification must be obtained when malignancy is suspected.

Bronchoscopy is a first-line diagnostic tool, yet it is not useful for nodules in peripheral parenchyma. For this kind of lesion, TTNB is necessary, and indeed it is becoming more and more a routine procedure with excellent results having been largely described in the literature [5, 6]. Serious complications associated with TTNB must not be forgotten, however, such as pneumothorax, hemoptysis, and air embolism [6, 7]. Although very rare, these complications seem sometimes excessive to us when dealing with a small nodule, and furthermore this technique does not always produce a tissue sample large enough for proper analysis, thus perhaps increasing the risk of false-negative results. In any case, biopsy is contraindicated in patients with respiratory disorders such as emphysema or serious pulmonary hypertension, in which a pneumothorax could be fatal [6].

In these cases, we believe that video-assisted thoracic surgery resection is justified, but even if this technique is less invasive than the conventional thoracotomy, it is hindered by difficulties of localization of the nodule during the procedure, as digital palpation is not possible. Some authors localize lesions visually or by palpation with endoscopic instruments, but perioperative nodule identification can sometimes be impossible and the rate of conversion to thoracotomy with this technique is, in our opinion, too high [8], especially if one considers that this is a diagnostic procedure.

Every pulmonary nodule at a distance from the pleura of more than 10 mm and lesions of 10 mm in diameter or less and at a depth of more than 5 mm need preoperative labeling [8] and several techniques have been described. Marking with methylene blue [9], an inexpensive yet short-lasting method, requires that the procedure takes place within 3 hours [9] to be able to see the marking, which poses the problem of coordination between the radiologic and surgical services. Furthermore, the injection of an excessive amount of dye can result in its diffusion over a large surface of the lung, making localization of the nodule impossible. Some authors have described placing a hook-wire [10], a well-known technique for marking mammary nodules. There are, however, reports that respiratory dynamics favor the movement of the needle toward the pleural cavity [11]. In addition perioperative exsufflation can displace the hook-wire out of the target. Other described techniques include injection of barium contrast transthoracically [12], or during bronchoscopy [13], and using ultrasound guidance during the operation [14]. The latter, although well known, is limited to institutions that have the specific capability for the procedure, and the technique can be difficult if the ultrasound image is disturbed, as can be seen with incomplete pulmonary exsufflation or in emphysematous patients. Other authors describe the use of thoracoscopic palpation instruments [15] or tactile sensors [16].

In 1994, Asamura and colleagues [3] described an original technique for marking thoracic lesions, which we reproduced. This technique offers several advantages: (1) the simplicity of the radiologic procedure is the same as that of CT scan–guided biopsy, (2) any pneumothorax occurring during marking may be treated immediately or subsequently during the surgical procedure, (3) the diagnostic procedure may become therapeutic for metastatic lesions, and (4) a safe resection margin around the lesion can easily be established by stapling several centimeters from the metallic label. In case of a primitive pulmonary lesion, one can complete the nodule resection with a more extensive procedure such as a lobectomy.

In our series, we marked lesions by injection of a metallic microcoil under CT scan guidance, which allowed us to localize and resect all the nodules in the series, as well as have complete histologic identification of the lesions. The use of a smaller gauge needle to inject the coil allowed us to reduce the incidence of pneumothorax; when it occurred, the amount of air was small, and respiration was not affected. The injection of the metallic coil deeper in the parenchyma than the tumor limited the risks of movement of the marker and permitted us to accurately resect the lesions with a sufficiently large margin.

In 6 cases we resected pulmonary metastases, and it has been shown that the removal of this kind of lesion, in the absence of other localizations, prolongs the survival of patients [17]. In one case of resection of a granulomatous lesion, we found sheets of metastatic carcinoid cancer cells around the nodule.

We are currently using this marking technique before thoracoscopic resection, and we believe that it will stay current because of its efficacy and dependability.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
The authors thank Miss Rosana Shaw for her kind collaboration.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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