Pulmonary Nodules In Children Research Articles

Interhospital variability in localization techniques for small pulmonary nodules in children: A pediatric surgical oncology research collaborative study

BackgroundPulmonary nodules that are deep within lung parenchyma and/or small in size can be challenging to localize for biopsy. This study describes current trends in performance of image-guided localization techniques for pulmonary nodules in pediatric patients. MethodsA retrospective review was performed on patients < 21 years of age undergoing localization of pulmonary nodules at 15 institutions. Localization and resection success, time in interventional radiology (IR), operating room (OR) and total anesthesia time, complications, and technical problems were compared between techniques. Results225 patients were included with an average of 1.3 lesions (range 1–5). Median nodule size and depth were 4 mm (range 0–30) and 5.4 mm (0–61), respectively. The most common localization techniques were: wire + methylene blue dye (MBD) (28%), MBD only (25%), wire only (14%), technetium-99 only (11%), coil + MBD (7%) and coil only (5%). Localization technique was associated with institution (p < 0.01); technique and institution were significantly associated with mean IR, OR, and anesthesia time (all p < 0.05). Comparing techniques, there was no difference in successful IR localization (range 92–100%, p = 0.75), successful resection (94–100%, p = 0.98), IR technical problems (p = 0.22), or operative complications (p = 0.16). ConclusionsMany IR localization techniques for small pulmonary nodules in children can be successful, but there is wide variability in application by institution and in procedure time. Level of evidenceRetrospective review, Level 3.

Incidental pulmonary nodules in children: characteristic features and clinical course.

There exists insufficient information about the natural course of incidental pulmonary nodules (IPN) determined on tomography in children. The aim was to determine the characteristic features and factors affecting the course of IPN. This retrospective study included patients who presented at the Pediatric Pulmonology, Allergy & Immunology Section of Akdeniz University Hospital between January 2014-2020, and were determined with pulmonary nodules on high-resolution computed tomography (HRCT). The patients were separated into two groups as those with a nodule decreased in size or which had disappeared on the follow-up HRCT (Group 1) and those with a nodule which had remained at the same size (Group 2). These two groups were compared in respect to demographic data, nodule size and characteristics, and accompanying findings on HRCT. A total of 177 nodules were determined in the 66 patients included in the study. A follow-up HRCT was taken within mean 16.29±11.38 months in 27 patients. In these patients, 78 nodules were determined on the initial HRCT. On the follow-up, twelve of the nodules were seen to have shrunk or disappeared compared to the initial images, 66 had remained the same size, and none had grown. The mean age of the patients in Group 1 was statistically significantly lower than that of patients in Group 2 (p < 0.001). The rates of an accompanying mosaic attenuation pattern (p < 0.001) on HRCT and subsolid density (p=0.011) of the nodules in Group 1 were statistically significantly higher compared to Group 2 and the rate of calcification content was statistically significantly lower (p=0.002). No suspicious or confirmed malignancy was observed in any case throughout the mean follow-up period of 38.33±16.5 months after the initial HRCT. The young age of patients, subsolid structure of nodules, calcification content and the presence of an accompanying mosaic attenuation pattern on HRCT, could be useful factors in the estimation of size in the follow-up of nodules.

Imaging features and management strategies of pulmonary nodules in children

Imaging features and management strategies of pulmonary nodules in children

Microcoil localization as an effective adjunct to thoracoscopic resection of pulmonary nodules in children

Background/PurposeThoracoscopic excision of pulmonary nodules is often required for diagnostic or therapeutic purposes, however subpleural and sub-centimeter nodules can be difficult to visualize. Various CT-guided localization techniques have been described, though there is minimal published pediatric data regarding the use of microcoils. We hypothesize that microcoil localization facilitates thoracoscopic resection of pulmonary nodules in children. MethodsA multi-institutional retrospective review of children who underwent preoperative CT-guided localization of lung nodules was conducted from 2012 to 2019. A combination of methylene blue dye (MBD), wires, and microcoils were utilized for CT-guided localization. When microcoils were utilized, fluoroscopy assisted in lesion identification and resection. ResultsEighteen patients (mean age 13 years, range 2–21 years) underwent thoracoscopic resection of 24 preoperatively localized pulmonary nodules. Mean size and depth of the lesions were 5.5 mm and 10 mm, respectively. Microcoil placement was successful 95% of the time and assisted in lesion localization in 88% of cases. Wire localization was not a durable technique, as 3 of 5 wires became dislodged upon lung isolation. ConclusionsPreoperative CT-guided localization with microcoils can assist in fluoroscopic-guided resection of pulmonary nodules in children. This technique avoids the pitfall of wire dislodgement, and provides surgeons an additional technique to localize sub-centimeter, subpleural nodules. Type of StudyRetrospective Review. Level of EvidenceLevel III.

Pulmonary metastases in children: are we operating unnecessarily?

to determine, in pediatric patients with malignant neoplasms, the characteristics of pulmonary nodules identified on computed tomography, as well as the possibility of differentiating benign lesions from metastases. we conducted a retrospective study of patients submitted to pulmonary resections of nodules diagnosed as metastases in a period of seven years. We compared computed tomography and surgery findings, as well as results of anatomopathological examinations. we studied nine patients submitted to 11 surgical interventions. Among the studied variables, only nodule size greater than 12.5mm proved to be statistically significant to predict malignancy. among the tomographic characteristics of pulmonary nodules in children with malignant neoplasms, only the size of the lesion was a predictor of malignancy.

The impact of reconstruction techniques on observer performance for the detection and characterization of small pulmonary nodules in chest CT of children under 13 years

ObjectiveTo compare three different reconstruction techniques of CT data for the detection of pulmonary nodules in children under 13 years. Secondly to assess the prevalence of perifissural nodular opacities. Materials and methodsThe study consisted of chest CTs of 31 children (median age 6.9 years, range 2.1–12.7), of whom 17 had known extra-thoracic malignancies. Four observers assessed three techniques for the presence of nodules: axial 5 mm maximum intensity projections (MIPs) used in conjunction with 1 mm slices (mode A), 1 mm slices alone (mode B) and 3 mm slices (mode C). All modes were available in 3D. Per mode sensitivities were determined above a certain threshold of reader agreement. Confidence level and reader agreement for identification of an opacity as nodule served as surrogate for quality of nodule characterization. Results103 nodules (median size 2.0 mm) were detected. Mode A yielded the highest interreader agreement (κ 0.336) and a superior sensitivity (71%, p = 0.003) compared to mode B and C (κ 0.218, sensitivity 57% and κ 0.247, sensitivity 56%, respectively). Mode B provided the highest confidence level and interreader agreement with respect to nodule identification (mean 4.3/5, κw 0.508). Double reading improved and evened interreader agreement for all modes (κ 0.450), mode A maintained the highest sensitivity (89.1%, p = 0.05–0.08). A median of 1 intrapulmonary lymph node/patient was seen in children with and without malignancy. ConclusionMIP improves the detection of pulmonary nodules in chest CTs of children, but overall interreader agreement is only fair. Double reading represents a powerful tool to increase diagnostic reliability in chest CTs of children with a malignancy. Nodule characterization is best with 1 mm slices. Intrapulmonary lymph nodes occur in children with and without malignancy.

Frequency and characteristics of pulmonary nodules in children at computed tomography

BackgroundNormative data on pulmonary nodules in children without malignancy are limited. Knowledge of the frequency and characteristics of pulmonary nodules in healthy children can influence care decisions in children with malignant disease.ObjectiveTo provide normative data concerning the frequency and characteristics of pulmonary nodules on computed tomography (CT) in young children.Materials and methodsAll children ages 1 year–12 years who underwent chest CT after high-energy trauma were retrospectively investigated. Exclusion criteria were a history of malignancy, thick image slices, motion artefacts and extensive post-traumatic pulmonary changes. Two radiologists were asked to independently identify all nodules and to characterize each nodule with respect to location, size, perifissural location and calcification. Discrepancies were adjudicated by a third reader, who set the reference standard in this study. Interobserver agreement in detection and characterization was assessed using the kappa coefficient (κ).ResultsIdentified were 120 patients, of whom 72 (75% male; median age: 8.0 years [interquartile range: 4–11]) were included. A total of 59 pulmonary nodules were present in 27 patients (38%; 95% confidence interval: 26–49%; range: 1–5 nodules per patient, with a mean diameter of 3.2 mm [standard deviation: 0.9 mm]). For nodule detection, the per-patient interobserver agreement was substantial (κ=0.78) and per-lobe agreement was moderate (κ=0.40). For characterization, there was fair to substantial agreement (κ=0.36–0.74).ConclusionSmall pulmonary nodules on chest CT are a common finding in otherwise healthy children, but detection and characterization have only moderate interobserver agreement.

Use of radiotracer labeling of pulmonary nodules to facilitate excisional biopsy and metastasectomy in children with solid tumors

PurposeExcision of suspected pulmonary metastases in children is challenging in the setting of multiple nodules or nodules that are small, deep, or soft. This study describes preoperative technetium macro-aggregated albumin (Tc 99m MAA) localization of pulmonary lesions to aid in intraoperative identification and resection. MethodsPatients with past or present pediatric solid tumors who underwent resection of pulmonary nodules following CT-guided Tc 99m MAA labeling were identified. The primary outcomes were successful preoperative localization and subsequent resection. ResultsMetastasectomy following Tc 99m MAA localization was performed 15 times in 11 patients from 2014 to 2016. Mean age was 13years; the most common diagnosis was osteosarcoma (33%). Tc 99m MAA labeling was attempted in 24 nodules with mean nodule diameter 6±5mm and mean depth from the pleural surface of 12±17mm; localization was successful in 23 nodules (96%). Subsequent resection was performed by thoracotomy in 12 cases and thoracoscopy in 3. All labeled nodules were identified intraoperatively; two were not resected and 17 of the 21 nodules resected demonstrated metastatic disease on pathology. ConclusionTc 99m MAA labeling of pulmonary nodules in children is effective in facilitating resection of sub-centimeter intraparenchymal metastases identified on preoperative imaging. Furthermore, this technique allows for thoracoscopic metastasectomy in select patients. Type of study/level of evidenceCase Series/Level IV.

Insights into Development and Treatment of Multi-Drug Resistant Tuberculosis (Mdr-Tb)

Chest magnetic resonance imaging (MRI) has emerged as a radiation-free alternative to computed tomography (CT) for the evaluation of thoracic abnormalities, including pulmonary nodules; particularly those measuring one centimeter or greater, the size for which magnetic resonance has demonstrated 100% sensitivity. We describe the case of a 9-year-old girl presenting with necrobiotic pulmonary nodules secondary to Crohn’s disease in which MRI was successfully utilized to monitor treatment response. This case demonstrates that chest MRI may be an effective and practical imaging modality that can be used for the surveillance of actionable pulmonary nodules in children.

Prevalence and configuration of pulmonary nodules on multi-row CT in children without malignant diseases.

To assess the prevalence and morphologic characterization of pulmonary nodules in children on a chest computed tomography (CT). Two hundred and fifty-nine trauma chest CTs in children aged 0-18 years were retrospectively reviewed by two radiologists, each with more than 10 years of experience. Images were acquired on a 64-row CT. Pulmonary lobes with trauma affections such as contusion or haemorrhage were excluded. All pulmonary nodules were evaluated for distance from the pleural surface, location, calcification and size on axial slices. A total of 1,190/1,295 (92%) pulmonary lobes without traumatic injury were included in this study. In 86 of 259 (33%) patients, 131 pulmonary nodules were detected. Number of nodules per patient ranged from 1 to 4. Calcifications were seen in 19% (25) of all nodules. Diameters ranged from 1 to 5 mm. 59% (77) were located in the lower lobes, 9% (12) in the middle lobe and 32% (42) in the upper lobes. 84% of the non-calcified nodules >2 mm showed a slightly angular or triangular (mostly pleural nodes) shape. Pulmonary nodules smaller than 5 mm can be detected frequently in children without malignant disease and are predominantly located in the lower lobes. • Pulmonary nodules in children with trauma CTs were retrospectively analysed • Pulmonary nodules seen on CT are frequent in children without malignant disease • Nodules in this group are more frequent in the lower lobes • No age dependency for the number of pulmonary nodules in children was observed.

Mediastinal lymph nodes and pulmonary nodules in children: MDCT findings in a cohort of healthy subjects.

Existing data are very limited on incidentally detected pulmonary nodules or mediastinal lymph nodes in healthy children who undergo chest MDCT. We aimed to evaluate the prevalence, distribution, and average dimensions of these occasional findings in a cohort of otherwise healthy patients. Two radiologists reviewed in consensus the scans of patients referred for chest MDCT during the preoperative workup for pectus carinatum or pectus excavatum treatments. Exclusion criteria included the presence of any documented malignancy (by date of MDCT or during the 2 years after the examination), history of recent infections, or trauma. Patients' records were assessed after 2 years for the development of any malignancy. A total of 99 individuals (63 boys, 36 girls; mean age, 13.5 years; range, 4-18 years) who fulfilled the study criteria were evaluated. The presence of at least one pulmonary nodule was observed in 75% of the patients, with a mean diameter of 2.8 mm. Of a total number of 225 pulmonary nodules, only 24 (10.7%) were calcified. Mediastinal lymph nodes were also identified in 81% of the cases, with a maximum diameter of 7 mm (smallest axis). The presence of pulmonary nodules or mediastinal lymph nodes on the basis of preoperative chest MDCT scans in healthy children is frequent. Given that 95% of the nodules and 100% of the lymph nodes measured less than 6 mm and 7 mm, respectively, we conclude that incidental findings under these limits are very unlikely to be pathologic.

Natural history of incidental pulmonary nodules in children.

As there are no evidence based guidelines for the diagnosis and/or management of pulmonary nodules in children, there is an over reliance on the adult based algorithms when dealing with pulmonary nodules in children. We present our experience of pediatric patients evaluated for incidentally found pulmonary nodules. Retrospective chart review of patients diagnosed with a pulmonary nodule and evaluated at Goryeb Children's Hospital between January 2000 and December 2012. change in the size of the pulmonary nodule between the initial and follow-up imaging. Thirty six patients with pulmonary nodule (21 male/15 female; Median [range] age 15 [5-20] years.) were included in the study. Chest CT was obtained for respiratory symptoms and/or abnormal chest radiograph in 19 (52%). Nine pulmonary nodules (25%) were identified on abdominal CT obtained for abdominal symptoms. A total of 46 nodules were identified in 36 patients. Nine of the pulmonary nodules (9 patients) were ≤4 mm in size, 37 of the pulmonary nodules (27 patients) were >4 mm in size. Twenty-two of the 27 (81%) patients with nodule size >4 mm had follow-up CT: 14 nodules (54%) remained unchanged in size, 5 nodules (19%) decreased in size, and 7 nodules (27%) were not detected. Our review of 36 patients with pulmonary nodules shows no obvious growth of the nodules over the study period, suggesting low risk of malignancy. Routine follow-up chest computer tomography using ACCP/Fleischner Society guidelines may not apply in children without known malignancy.

The Role of PET/CT in Assessing Pulmonary Nodules in Children With Solid Malignancies

OBJECTIVE. The purpose of this article is to assess the feasibility and utility of PET/CT in distinguishing benign from malignant pulmonary nodules in patients with solid childhood malignancies. SUBJECTS AND METHODS. This prospective study was conducted between March 2008 and August 2010. We enrolled 25 subjects 21 years old or younger with solid childhood malignancies and at least one pulmonary nodule measuring 0.5-3.0 cm. PET/CT was performed within 3 weeks of diagnostic chest CT. Three panels of three reviewers each reviewed diagnostic CT only (panel 1), PET/CT only (panel 2), or diagnostic CT and PET/CT concurrently (panel 3) and predicted each nodule's histologic diagnosis as benign, malignant, or indeterminate. Interreviewer agreement was assessed with the kappa statistic. Using nodule biopsy or clinical follow-up as reference standards, the sensitivity, specificity, and accuracy for each panel was assessed. Logistic regression was used to assess the nodule's maximum standardized uptake value (SUVmax) association with its histologic diagnosis. RESULTS. There were 75 nodules with a median size of 0.74 cm (range, 0.18-2.38 cm); 48 nodules were malignant. Sensitivity was 85% (41/48) for panel 1, 60% (29/48) for panel 2, and 67% (32/48) for panel 3. All panels had poor specificities. Interreviewer agreement was moderate for panel 1 (0.43) and poor for panels 2 (0.22) and 3 (0.33). SUVmax was a significant predictor of histologic diagnosis (p = 0.004). CONCLUSION. PET/CT assessment of pulmonary nodules is feasible in children with solid malignancies but may not reliably improve our ability to predict a nodule's histologic diagnosis. The SUVmax may improve the performance of PET/CT in this setting.

The incidental pulmonary nodule: an impetus for guidelines

Sir, Every couple of months for the last several years, I find myself in a quandary about what to recommend for solitary and multiple non-calcified pulmonary nodules incidentally found on a pediatric chest CT exam. I am not speaking of those CTs ordered in the setting of pediatric oncology, but the occasional CT ordered by our referring clinicians for the workup of symptoms such as chronic cough. All too often, I find small (less than 1 cm) incidental nodules. Every fiber of my being screams that these are benign and of no clinical significance. However, sticking to the mantra of evidencebased medicine, I dutifully search the literature for articles or guidelines that tell me how these should be followed. I have not found any paper or guideline providing direction. For nearly a decade now, our adult colleagues have had guidelines published by our esteemed thoracic radiology leaders in the Fleischner Society [1]. There are size criteria and recommendations for follow-up imaging for the incidentally detected non-calcified pulmonary nodule. However the society did make one caveat: the guidelines only apply to individuals older than 35 years. In fact, a follow-up study by Feely and Hartman [2] found that the criteria were inappropriately used in 4% of cases for patients younger than 35 years [2]. However, if there is no guidance available in the literature can any of us blame other radiologists in today’s medico-legal environment for using the Fleischner guidelines rather than making up some arbitrary means of follow-up or simply dismissing the findings? Most pediatric radiologists are likely aware that incidental non-calcified pulmonary nodules, in the absence of known malignancy, are almost certainly benign in children. Furthermore what concerns adult imagers and not us (pediatric radiologists) is primary lung malignancy, which is exceedingly rare in those younger than 35, representing less than 1% of all cases. This fact was generally addressed in the Fleischner Society paper, which states that it is reasonable to follow up these incidental nodules with a CT in 6–12 months [1]. Does this suffice? There is no evidence to support or refute it. Also, would a general radiologist who almost certainly interprets more adult CTs than pediatric ones be more likely to use the Fleischner criteria in a child? Again, one cannot be sure. In the end, we will most likely not have studies with sufficient numbers of individuals to prove the benignity of incidental pulmonary nodules in children. For one, most of us likely do not follow them, at least not to the level performed in adults. Second, we have an ethical imperative to keep radiation doses low in our children. A prospective study would be something few of us would like to undertake. Therefore, we are back to what I have searched for over the years, i.e. guidelines. Is it time for us to come together as a society to develop a standard to follow in children? I think the answer is likely yes.

Lung tattooing combined with immediate video-assisted thoracoscopic resection (IVATR) as a single procedure in a hybrid room: our institutional experience in a pediatric population

Analysis of small pulmonary nodules in children poses an important diagnostic and therapeutic challenge for clinicians. To review our experience of lung tattooing with immediate video-assisted thoracoscopic resection (IVATR) performed as a single procedure in a hybrid room for technical difficulties, complications and diagnostic yield of the procedure. Retrospective analysis of 31 children (16 boys, 15 girls) who underwent lung tattooing of various lesions from January 2001 to July 2011. Data were collected from the Interventional Radiology database, Electronic Patient Chart (EPC) and PACS. A total of 34 lesions were treated in 31 children. Tattooing was performed on lung lesions with median size 3mm and median depth 2mm from pleura. Technical success was 91.1% and diagnostic yield was 100%. In seven children, it was combined with other interventional radiologic procedures. The median procedure time for lung tattooing and IVATR was 197min. Lung tattooing with IVATR as a single procedure in a hybrid room is safe and effective in children with several inherent advantages, including avoiding the need to move the child from the interventional radiology suite to the operating room.

Lung nodules in children: video-assisted thoracoscopic surgical resection after computed tomography–guided localization using a microcoil

Background Lung nodules that develop in children with cancer may represent metastatic disease or other conditions potentially requiring aggressive treatment. Thoracoscopic methods have been used for nodule resection; however, lesions deep in the lung parenchyma can be difficult to visualize. Fluoroscopic-guided thoracoscopic surgical resection after computed tomography (CT)–guided localization using microcoils has been described in the adult literature and has the potential to assist in the resection of deep pulmonary nodules in children. Methods Six patients (ages 6-15 years) with an undiagnosed pulmonary nodule were treated using a combined CT-guided microcoil localization/fluoroscopic video-assisted thoracoscopic surgical technique. Preoperatively, a platinum-fibered microcoil was deployed with the deep end of the coil placed either through or in the vicinity of the pulmonary nodule and the superficial end coiled on the pleural surface. The nodule and coil were then resected with endoscopic staplers guided by fluoroscopy and video-assisted thoracoscopic surgical. Results Computed tomography–guided microcoil localization and fluoroscopic-guided thoracoscopic resection were successful and critically influenced the management of all patients. Three patients were diagnosed with malignancy (2 metastatic diseases and 1 Hodgkin disease). A diagnosis of nonmalignant disease was made in 3 patients (granuloma, eosinophilic granuloma, and aspergilloma). Conclusion In the pediatric population, we have successfully applied a previously described adult technique using CT-localized microcoils to direct fluoroscopic-guided thoracoscopic surgical resection of pulmonary nodules.

Minimally invasive thoracoscopic ultrasound for localization of pulmonary nodules in children

Purpose Children with cancer may develop lesions in the lung that may represent metastatic disease. Thoracotomy is considered the standard approach for resection of pulmonary nodules. Recently, thoracoscopic techniques have been applied in these situations. However, nodules that are deep in the lung parenchyma may not be visible. A technique has been developed whereby minimally invasive thoracoscopic ultrasound (MITUS) may be used to guide resection of deep pulmonary nodules. Methods We conducted a retrospective review of children undergoing MITUS at our institution. Only patients with single isolated lesions were chosen to have this diagnostic procedure performed. Patients undergo single lung ventilation. Two 5-mm ports are inserted, one for the grasper and the other for the camera. One 12-mm port is inserted for the flexible 10-mm ultrasound probe and the endoscopic stapler. The patient has CO 2 insufflation to create a 5-mm Hg pneumothorax. Twenty mL/kg of normal saline is introduced into the chest cavity for acoustic coupling. The ultrasound probe is used to isolate the nodule(s), guide resection, and check margins. The specimen is removed and placed in a removable specimen bag to reduce the chance of port site recurrence. After the lung has been inspected, irrigation is removed, and a chest tube inserted. Results Eight procedures were performed on 7 patients (5 males, 2 females) with a median age of 15.2 years (range, 4-18 years). Patients had primary diagnoses of osteosarcoma (n = 4), Wilms' (n = 2), and lymphoma (n = 1). The median size of the lesions that were being isolated was 0.6 cm (range, 0.3-2.9 cm). None of the nodules removed were visible on the surface of the lung. Of the 8 procedures, 7 led to the removal of a pulmonary nodule. Of the 7 nodules isolated, 5 were removed thoracoscopically, with two requiring minithoracotomy because of anatomical limitations. The histologic evaluation on these specimens included osteosarcoma (n = 4), abscesses (n = 2), fibrosis (n = 1), and lymph node (n = 1). The median hospitalization was 2.5 days (range, 2-39 days). One patient had a prolonged hospitalization because of air leak and sepsis. Conclusion Minimally invasive thoracoscopic ultrasound is a real time imaging tool that helps isolate small pulmonary lesions that may otherwise be difficult to see intraoperatively. We would advocate this technique for those patients having video-assisted thoracoscopy to assist clarifying whether focal lesions are malignant, thereby guiding therapy.

Pulmonary nodules discovered during the initial evaluation of pediatric patients with bone and soft‐tissue sarcoma

Recent technical advances in CT imaging and data processing have improved the ability to detect small pulmonary nodules in children with bone and soft-tissue sarcoma undergoing radiologic imaging of the chest. We retrospectively studied medical records and CT chest scans at initial diagnosis of 210 children and young adults presenting to a single pediatric tertiary care hospital specialized in oncology for evaluation of bone or soft-tissue sarcoma. We correlated clinical features and CT scan findings with patient outcome and histologic results, when available. Pulmonary nodules (diameter </=3 cm) were identified in 66 patients (31.4%). The median size of the largest nodule in each patient was 5 mm (range, 1-20 mm). Of patients who underwent biopsy or resection of a nodule, 41.7% had metastatic pulmonary disease. Having more than three nodules and a bilateral distribution were associated with histology-proven metastasis (P = 0.002 and P = 0.011, respectively) and an increased frequency of recurrent or progressive metastatic disease in the lung (P < 0.001 and P = 0.023, respectively). Greater size of the largest nodule present showed a trend towards biopsy-proven lung metastasis, but did not reach statistical significance (P = 0.06). When biopsy or resection was not performed, increased size was significantly associated with nodules being presumed as malignant (median, 16.8 mm compared to 4.0 mm for biopsied nodules, P < 0.001). Pulmonary nodules were commonly detected during the initial evaluation of pediatric cases of sarcoma. Number and distribution of nodules were significantly associated with metastatic disease and outcome.

Combined Use of Preoperative Methylene Blue Dye and Microcoil Localization Facilitates Thoracoscopic Wedge Resection of Indeterminate Pulmonary Nodules in Children

The ability to biopsy indeterminate pulmonary lesions in children has evolved with advances in minimal access surgery. Recent advances in preoperative localization including image-guided dye injection or wire implantation have expanded the types of lesions that are accessible via minimal access surgery. We present a case of a 13-year-old boy who underwent preoperative localization using both methylene blue dye and microcoil labeling, and a subsequent thoracoscopic pulmonary wedge resection under the same anesthesia. The combined use of both dye and microcoil localization provides the advantage of superior intraoperative visualization of the lesion and the ability to use fluoroscopy to confirm the presence of the nodule in the surgical specimen. We recommend this technique for the biopsy of indeterminate pulmonary lesions that would not otherwise be accessible via a minimally invasive approach.

Image-guided percutaneous approach is superior to the thoracoscopic approach in the diagnosis of pulmonary nodules in children

Background/Purpose: Image-guided, percutaneous techniques are increasingly used in diagnosis of pulmonary disease in children. The aim of this study was to determine the diagnostic accuracy and clinical outcomes of thoracoscopic versus percutaneous lung biopsy in children. Methods: Sixty-three consecutive patients from January 1996 to December 2000 who had a thoracoscopic lung biopsy, a percutaneous ultrasound scan, or computed tomography (CT)-guided lung biopsy for well-defined and ill-defined lesions were analyzed. Results: Twenty-eight patients had a thoracoscopic lung biopsy (TLB), and 35 patients had a percutaneous image-guided lung biopsy (PLB). Age ranged from 6 months to 17 years (median, 8 years). There was no significant difference between groups with regard to age, depth of lung nodule biopsied, or prebiopsy diagnoses. Seventeen patients (60%) of TLB and 23 (65%) of PLB had well-defined pulmonary nodules suspicious for malignancy at the time of biopsy. Adequate tissue for pathologic diagnosis was obtained in 28 (100%) of TLB versus 26 (80%) of PLB patients. However, 8 (28%) thoracoscopic cases needed to be converted to an open procedure. In 3 (8.5%) PLB cases the percutaneous biopsy was insufficient, and a thoracoscopic or open biopsy was required. The median hospital stay was 3 days for TLB and 4 to 6 hours for PLB (P =.023). There were no complications in the PLB group. Five (18%) of TLB patients suffered a persistent air leak treated with continued chest tube drainage, and one patient died of other causes with a persistent air leak. Conclusions: Percutaneous lung biopsy has a significantly shorter hospital stay and a lower complication rate than thoracoscopic lung biopsy. The authors propose that the percutaneous technique should be considered as the initial approach for children with pulmonary nodules. J Pediatr Surg 38:745-748. © 2003 Elsevier Inc. All rights reserved.