Computer tomography guided thoracoscopic resection of small pulmonary nodules in the hybrid theatre.

Ioannis Karampinis,Nils Rathmann,Steffen J Diehl,Eric D Roessner,Peter Hohenberger,Michael Kostrzewa,Stefan O Schoenberg,Hyun-Sung Lee

doi:10.1371/journal.pone.0258896

Abstract

Thoracic surgeons are currently asked to resect smaller and deeper lesions which are difficult to detect thoracoscopically. The growing number of those lesions arises both from lung cancer screening programs and from follow-up of extrathoracic malignancies. This study analyzed the routine use of a CT-aided thoracoscopic approach to small pulmonary nodules in the hybrid theatre and the resulting changes in the treatment pathway. 50 patients were retrospectively included. The clinical indication for histological diagnosis was suspected metastasis in 46 patients. Technically, the radiological distance between the periphery of the lesion and the visceral pleura had to exceed the maximum diameter of the lesion for the patient to be included. A spiral wire was placed using intraoperative CT-based laser navigation to guide the thoracoscopic resection. The mean diameter of the lesions was 8.4 mm (SD 4.27 mm). 29.4 minutes (SD 28.5) were required on average for the wire placement and 42.3 minutes (SD 20.1) for the resection of the lesion. Histopathology confirmed the expected diagnosis in 30 of 52 lesions. In the remaining 22 lesions, 9 cases of primary lung cancer were detected while 12 patients showed a benign disease. Computer tomography assisted thoracoscopic surgery (CATS) enabled successful resection in all cases with minimal morbidity. The histological diagnosis led to a treatment change in 42% of the patients. The hybrid-CATS technique provides good access to deeply located small pulmonary nodules and could be particularly valuable in the emerging setting of lung cancer screening.

Highlights

In the remaining 22 lesions, 9 cases of primary lung cancer were detected while 12 patients showed a benign disease
The introduction of lung cancer screening and the implementation of structured follow-up programs for solid malignancies have led to a rapid increase in the number of small pulmonary nodules detected in CT scans [1, 2]
Both the lung cancer screening programs and the guidelines of the Fleischner Society focus on incidentally detected pulmonary nodules and less on lesions diagnosed during follow-up CT scans in cancer patients [4]

Summary

Introduction

The introduction of lung cancer screening and the implementation of structured follow-up programs for solid malignancies have led to a rapid increase in the number of small pulmonary nodules detected in CT scans [1, 2]. The spread of the thoracoscopic surgery has given the medical community access to pulmonary lesions avoiding the morbidity associated with the thoracotomy [3] Both the lung cancer screening programs and the guidelines of the Fleischner Society focus on incidentally detected pulmonary nodules and less on lesions diagnosed during follow-up CT scans in cancer patients [4]. More than two lesions occurring newly in the lung are considered to represent metastases This scenario requires a different treatment approach depending on the primary tumor and on whether a potentially curative or palliative status is assumed. This underlines the dilemma on how to treat a patient with a cured primary tumor who is referred with an unclear pulmonary lesion, especially if previous CT scans are not available for comparison [9]

Objectives

Methods

Conclusion