Thoracoscopic Wedge Resection Research Articles

Lung Biopsy after Localization of Pulmonary Nodules with Hook Wire

Background: A chest computed-tomography has become more prevalent so that it is more common to detect small sized pulmonary nodules that have not been found in previous simple chest x-ray. If those detected nodules are undersized or located in pulmonary parenchyma, it is difficult to accomplish a biopsy since it is vulnerable to explore them either grossly or digitally. Thus, in our hospital, a thoracoscopic pulmonary wedge resection was performed after locating a lesion by means of hook wire with CT-guided. Material and Method: 31 patients (17 males and 14 female patients) from December in 2006 to June in 2010 became our subjects; their 34 pulmonary nodules were subjected to the thoracoscopic pulmonary wedge resection after locating a lesion by means of hook wire with CT-guided. Also we analyzed a possibility of hook wire dislocation, a frequency of conversion to open thoracotomy, time consumed to operation after location of a lesion, operation time, post operation complication, and histological diagnosis of the lesion. Result: 12 of 34 cases were ground glass lesion, whereas 22 cases of them were solitary pulmonary lesion. The median value of the lesion was 8㎜ in size (range: 3 to 23 ㎜), while the median value was 12.5 ㎜ in depth (range: 1 to 34 ㎜). The median value of time consumed from location of the lesion to anesthetic induction was 86.5 minutes (41~473 minutes); furthermore the mean value of operation time was 103 minutes (25~345 minutes). Intrathoracic wire dislocation was found in one case, but a target lesion was successfully excised. Open thoracotomy was performed in four cases due to pleural adhesion. However, there was no case of conversion to open thoracotomy due to failure to detect a target lesion. In histological diagnosis, metastatic cancer were found in 15 cases, which were the most common, primary lung cancer were in 9 cases, non-specific inflammation were in 3 cases, tuberculosis inflammation were in 2 cases, lymph nodes were in 2 cases, active tuberculosis were in 1 case, atypical adenomatous hyperplasia was in 1 case and normal lung parenchymal finding was in 1 case, respectively. Conclusion: In our hospital, in order to accomplish a precise histological diagnosis of ground-glass lesion and pulmonary nodules in lung parenchyma, location of pulmonary nodules were exactly located with hook wire under chest computed-tomography, which was followed by lung biopsy. We concluded that this was an accurate, minimally invasive and valuable method to minimize the complications and increase of cost of medical service provided.

Solitary pulmonary metastasis from prostate sarcomatoid cancer

BackgroundPulmonary metastasis from prostate cancer is considered to be a late event, and patients can be treated with chemotherapy or hormonal manipulation. However, there has been only a few reports on surgical resection for pulmonary metastasis from prostate cancer.Case PresentationWe present a surgical case of solitary pulmonary metastasis from prostate cancer. A 73-year-old man underwent pelvic evisceration for prostate cancer. Histopathological examination revealed a poorly differentiated adenocarcinoma with a sarcomatoid carcinoma component. During postoperative follow-up, chest computed tomography showed a nodular shadow in the lung, and thoracoscopic wedge resection of the lung was performed. Histopathological examination revealed a histological appearance similar to that of the prostate sarcomatoid carcinoma. This is the first reported case of solitary pulmonary metastasis from prostate sarcomatoid cancer.ConclusionIsolated pulmonary metastasis from prostate sarcomatoid cancer is extremely rare, but surgery could be the treatment of choice.

Electromagnetic Navigation Bronchoscopy-Guided Thoracoscopic Wedge Resection of Small Pulmonary Nodules

Video assisted thoracoscopic (VATS) wedge resection of a small non-palpable and non-visible pulmonary nodule (PN) is a commonly encountered clinical challenge. A variety of techniques have been described to mark the pleural surface in the vicinity of a small PN and guide thoracoscopic resection: computerized tomography-guided percutaneous placement of wires, coils, or radio-opaque dye; intraoperative ultrasonography; and electromagnetic navigation bronchoscopy (ENB)-guided dye injection ( 1 Hänninen E.L. Langrehr J. Raakow R.R. et al. Computed tomography-guided pulmonary nodule localization before thoracoscopic resection. Acta Radiol. 2004; 45: 284-288 Crossref PubMed Scopus (16) Google Scholar , 2 Kang D. Kim H.K. Kim Y.K. et al. Needlescopy-assisted resection of pulmonary nodule after dual localization. Eur Respir J. 2010; (Epub ahead of print) Google Scholar , 3 Mayo J.R. Clifton J.C. Powell T.I. et al. Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection. Radiology. 2009; 250: 576-585 Crossref PubMed Scopus (145) Google Scholar , 4 Kawanaka K. Nomori H. Mori T. et al. Marking of small pulmonary nodules before thoracoscopic resection: Injection of lipiodol under CT-fluoroscopic guidance. Acta Radiol. 2009; 16: 39-45 Scopus (42) Google Scholar , 5 Grogan E.L. Jones D.R. Kozower B.D. et al. Identification of small lung nodules: Technique of radiotracer-guided thoracoscopic biopsy. Ann Thorac Surg. 2008; 85: S772-S777 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar , 6 Santambrogio R. Montorsi M. Bianchi P. et al. Intraoperative ultrasound during thoracoscopic procedures for solitary pulmonary nodules. Ann Thorac Surg. 1999; 68: 218-222 Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar ). However, each of these techniques has practical limitations. We propose a technique that may circumvent the logistical problems of previously described approaches.

Immunoglobulin G4-related inflammatory pseudotumor of the lung

An 82-year-old man presented with a nodule in the right S(2)a of the lung as seen by chest computed tomography (CT). He had undergone treatment for chronic obstructive lung disease. He had a 53-year history of smoking 20 cigarettes a day. Subsequent to the appearance of the nodule in the right S(2)a, the CT images revealed consolidations in the right S(2)b, right S(3), and left S(5). The nodule in the right S(2)a was diagnosed as squamous cell carcinoma after performing video-assisted thoracoscopic wedge resection of the lung. After 4 months, the size of the consolidation in the right S(2)b increased. Recurrence of lung cancer was suspected. Using transbronchial lung biopsy, the consolidation in the left S(5) was diagnosed as organizing pneumonia; therefore, right upper lobectomy was performed. The consolidations in the right S(2)b and right S(3) were diagnosed as inflammatory pseudotumors with infiltrations of immunoglobulin G4-positive plasma cells.

Primary Acinic Cell Carcinoma of the Lung: A Case Report

Primary acinic cell carcinoma (ACC) of the lung is very rare and this tumor is thought to arise from pluripotent cells of the submucosal glands of the tracheobronchial tree. We report here on a case of primary ACC of the lung in a 68-year-old man who had a solitary pulmonary nodule in the left lower lobe. The patient was symptomless and the lesion was found on a chest X-ray taken during a regular health checkup. The video assisted thoracoscopic surgery wedge resection revealed an ovoid yellow tan solid mass that was 1.8 cm at the largest diameter. Microscopically, the neoplastic cells grew in solid sheets of round cells with eccentric nuclei and abundant basophilic granular cytoplasm. There were no mitotic figures or areas of pleomorphic or anaplastic cells. Immunohistochemical staining for cytokeratin (AE1/AE3) was positive, but the staining for chromogranin A and CD56 was negative. Ultrastructural examination revealed polyhedral cells with many zymogen granules of varying electron density. The patient is well 4 months postoperatively.

Electromagnetic navigation guided bronchoscopy.

This review describes the technique and applications of an emerging bronchoscopic approach utilizing three-dimensional reconstructions of chest computed tomography scans to facilitate electromagnetic guidance to peripheral lung nodules. This approach, electromagnetic navigation bronchoscopy, is useful for biopsy, placement of fiducial markers, or dye marking of overlying pleura prior to thoracoscopic wedge resection. This technique offers some potential advantages over other forms of biopsy. The design, application, relative advantages and pitfalls of this system are the subject of this review.

Systemic air embolism during preoperative pulmonary marking with a short hook wire and suture system under CT fluoroscopy guidance

We encountered a case of systemic air embolism during preoperative pulmonary marking with a short hook wire and suture system under CT fluoroscopy guidance. The pulmonary tumor was present in the right S3, and the procedural position was supine. The patient experienced cardiac symptoms, and systemic air embolism was confirmed on CT images. With the patient in the Trendelenburg position, 100% oxygen was immediately administered as therapy for the embolism. Subsequently, the symptoms and systemic air embolism were resolved. The patient underwent video-assisted thoracoscopic wedge resection after 5 days and was then discharged without any sequelae.

Das alveoläre Adenom als Differenzialdiagnose zum Bronchialkarzinom: Fallvorstellung und Literaturreview

This report describes the case of a 58-year-old man presenting with haemoptysis. Chest X-ray and CT scans showed a solitary pulmonary mass in the right lower lobe without radiographic signs of malignancy. Definitive histology following thoracoscopic wedge resection showed the distinctive findings of an alveolar adenoma, a very rare benign tumour of the lung of unknown histogenesis. Its existence was first described in 1986 with less than 30 cases published to this day. Alveolar adenoma usually presents as a peripheral solitary lesion in asymptomatic, older patients. Its histological features, the benign proliferation of alveolar epithelium and septal mesenchyme, allow for its distinction from other benign lesions of the lung. Complete excision is considered curative on the basis of current knowledge.

Long-term prognosis of video-assisted limited surgery for early lung cancer☆

The present intervention study was conducted to prospectively evaluate the long-term prognosis for video-assisted limited surgery, such as wedge resection and segmentectomy, for clinically early lung cancers depending on findings in high-resolution computed tomography (HRCT). Patients were enrolled in the study between 2001 and 2004, and followed up for five subsequent years. Of these patients, those with a clinical stage IA lung cancer mainly comprising a ground glass-opacity (GGO) less than 1.5 cm across underwent thoracoscopic wedge resection of the lung (Group A). Patients with a tumour less than 2.0 cm in diameter, not classified in Group A, underwent video-assisted segmentectomy and hilar lymph node dissection with lobe-specific mediastinal nodes sampling (Group B). For patients with a tumour less than 3.0 cm in diameter, not classified in to any of the foregoing two groups, underwent video-assisted lobectomy and hilar and mediastinal lymph node dissection (Group C). During the case registration period, 159 patients were registered for enrollment in the study (21 for Group A, 43 for Group B and 95 for Group C). Of the patients in Groups A and B, 28% were shifted to a surgical procedure involving a larger volume resected; 6% of the entire study population were shifted to thoracotomy. All patients completed the 5-year follow-up. The recurrence-free survival rate was 100% for Group A, 90.5% for Group B and 94.5% for Group C, with no significant difference among the groups. The total recurrence rate was 11.9% with localised recurrences observed in 6.3% of the patients and remote recurrences in 5.7%. The localised recurrences observed included stump recurrence in one case of Group B, and malignant pleural effusions/pleural dissemination in two cases of Group B and one case of Group C. Intrathoracic lymph node recurrences were observed in one case of Group B and five cases of Group C. The present intervention study showed that thoracoscopic-limited surgery for clinically early lung cancers depending on findings in preoperative HRCT is feasible and appropriate from the viewpoint of oncology.

Use of India Ink During Preoperative Computed Tomography Localization of Small Peripheral Undiagnosed Pulmonary Nodules for Thoracoscopic Resection

Computed tomography (CT) scans of the chest permit us to identify a large number of small peripheral, undefined pulmonary lesions that require a diagnosis. Broncoscopy results are generally negative in these cases, and needle aspiration results are often inconclusive owing to poor cytology and false-negative cases. Thoracoscopy is an ideal tool but allows us only to localize lesions that retract the visceral pleura. Our aim in this study was to establish a marking procedure for excising nodules of unknown etiology by injecting India ink on the surface of the lung. Since January 2008, eight patients (six men, two women) who had been diagnosed as having a peripheral small pulmonary nodule of unknown etiology were selected for preoperative tattooing under CT guidance to facilitate thoracoscopic wedge resection. In six cases, thoracoscopy allowed diagnosis and definitive treatment of two benign peripheral nodules and four single metastases from colon carcinoma. In two patients who had been diagnosed to have a primitive non-small-cell lung cancer on frozen section following thoracoscopy, the surgical treatment was concluded with limited lateral thoracotomy and lobectomy with ilomediastinal node dissection. Our experience suggests that this CT technique, which includes using India ink to label and localize peripheral small pulmonary nodules, is a safe, valid option for marking the lung, thereby facilitating subsequent thoracoscopic resection.

Human chorionic gonadotropin production by a benign lung nodule

Ectopic hormone production by a neoplasm is defined as secretion of a hormone by cells not normally a source of that hormone. This relationship is a recognized phenomenon that assists in diagnosis of disease and provides a marker for monitoring treatments. Ectopic human chorionic gonadotropin (hCG) is associated with neoplasms originating in the lungs, gastrointestinal tract, cervix, and bladder. Recent evidence recognizes 3 variants of hCG, with nontrophoblastic tumors producing the free beta-subunit variant. This variant influences cancer cell growth andmay be valuable as a poor prognostic marker [1]. Approximately 15%of lung tumorsdemonstrate detectable hormone [2], and evidence suggests that paraneoplastic lung tumors are often more resistant to treatment, have a poor prognosis, and are rapidly fatal [3]. This report presents an individual with a benign indolent lung nodule secreting beta-hCG. Final pathology revealed an inflammatory myofibroblastic tumor (IMT). This type of tumor is rare, accounting for 0.4%–1.0% of all lung tumors; they are often asymptomatic, but may present with cough, hemoptysis, or dyspnea. IMTs are low-grade tumors, histologically composedof inflammatoryspindle cells thatoftengrowlocallyandslowly [4]. A 42-year-old patient (para 0) presented after a positive homepregnancy test. Medical history was significant for an incidental lung lesion detected in 1989bychestX-ray followingapositivePPD.At that time, evaluation revealed a 2-cm, well-rounded, noncalcified lesion in the right lower lobe with no associated adenopathy. A biopsy (with preoperative evaluation showing negative hCG) was consistent with pseudotumor; no further treatment was advised. Several chest X-rays since 1989 showed a stable lesion. Obstetricgynecology history was noncontributory, with menarche at 13 years, regular periods, and no history of infertility. Upon presentation after positive pregnancy test, the patient reported only fatigue and shortness of breath upon exertion; she denied cough, sputum production, chest pain, fever, chills, or vaginal bleeding. Her last menstrual period was 51/2 weeks prior, and beta-hCG quantitative value (beta-quant) was 8961 mIU/mL. Multiple ultrasounds showed no intrauterine, molar, or ectopic pregnancy. Diagnostic laparoscopy confirmed no ectopic pregnancy; dilation and curettage revealed no gestational trophoblastic disease. The patient was given methotrexate; however, beta-quant continued to rise to 20 648mIU/mL over 5 days, and shewas referred togynecologic oncology.Gynecologic oncologyevaluated and referred her to thoracic surgery for assessment of her lung nodule. Lung exam was normal, and chest CT and positron emission tomography (PET) demonstrated a solitary, round, noncalcified right lower lobe nodule 1.2 cm (Fig. 1) with moderate uptake on PET. The patient underwent fiberoptic bronchoscopy and right thoracoscopic lower lobe wedge resection revealing a solitary, firm, solid lesion within the right lower lobe. Pathology revealed a noninvasive, 1-cm spindle cell lesion consistent with IMT. Postoperative beta-quant decreased steadily reaching zero approximately 3 weeks postoperatively, and the patient resumed regular periods. Beta-hCG secreting lung cancer is too rare to be a useful tumor marker by pulmonologists; however, it is critical that obstetriciangynecologists recognize the wide range of sources of beta-hCG production and refer patients for further evaluation after excluding common obstetric etiologies. The present case demonstrates the importance of considering all lung nodules as a source of ectopic betahCG; however, it is unclearwhether this case signifies a change in nature of the tumor, or a newfindingnot previously clinically evident. Given the recent evidence on multiple variants of hCG, further detailed analysis of hCG may be warranted in determining malignant potential of nontrophoblastic tumors. Physicians should be aware of the malignant nature ofmost beta-hCG secreting tumors and consider the potential for transformation of benign appearing nodules to more aggressive tumors.

Ten-year experience of totally laparoscopic liver resection in a single institution

Recent developments in liver surgery include the introduction of laparoscopic liver resection. The aim of the present study was to review a single institution's 10-year experience of totally laparoscopic liver resection (TLLR). Between May 1997 and April 2008, 82 patients underwent TLLR for hepatocellular carcinoma (HCC) (37 patients), liver metastases (39) and benign liver lesions (six). Operations included 69 laparoscopic wedge resections, 11 laparoscopic left lateral sectionectomies and two thoracoscopic wedge resections. Nine patients underwent simultaneous laparoscopic resection of colorectal primary cancer and synchronous liver metastases. Median operating time was 177 (range 70-430) min and blood loss 64 (range 1-917) ml. Median tumour size and surgical margin were 25 (range 15-85) and 6 (range 0-40) mm respectively. One procedure was converted to a laparoscopically assisted hepatectomy. Three patients developed complications. Median postoperative stay was 9 (range 3-37) days. The overall 5-year survival rate after surgery for HCC and colorectal metastases was 53 and 64 per cent respectively. TLLR can be performed safely for a variety of primary and secondary liver tumours, and seems to offer at least short-term benefits in selected patients.

Resection of Pulmonary Metastases From Sarcoma: Can Some Patients Benefit From a Less Invasive Approach?

Although video-assisted metastasectomy has been proposed for some solitary metastases, its value has not been investigated in patients with pulmonary metastases from sarcoma for which open resection remains the usual approach. In all, 113 consecutive patients underwent curatively intended lung resection for metastases from sarcomas. Of these 113 patients, 31 were selected for a thoracoscopic wedge resection (group TS). These patients were compared with 29 patients operated on by thoracotomy but whose features could have made them possible candidates for a thoracoscopic resection (group TT). Follow-up was complete for all patients (mean follow-up, 34 months). No mortality occurred. No morbidity was observed in group TT, and 1 complication occurred in group TS. The mean postoperative hospital stay was 3.7 days for group TS and 6.2 days for group TT (p < 0.0001). Overall survival rates at 1, 3, and 5 years were, respectively, 87.4%, 70.9%, and 52.5% in group TS, and 82.3%, 63.6%, and 34% in group TT (p = 0.20). Disease-free survival rates at 1 and 3 years were, respectively, 50.5% and 26.4% in group TS and 60% and 24.8% in group TT (p = 0.74). Local recurrence occurred in 1 patient in each group. Survival without a homolateral recurrence (i.e., in the operated lung) at 1 and 3 years was 66.7% and 44.4% in group TS and 83.5% and 45% in group TT, respectively (p = 0.54). In selected patients with a maximum of two pulmonary nodules, thoracoscopic resections yield survival rates similar to open resections while being less invasive and preserving the patient's ability to undergo possible repeat operations.

Dual Localization Technique for Thoracoscopic Resection of Lung Lesions in Children

Thoracoscopic wedge resection has gained widespread acceptance as a method of resecting pulmonary metastases in pediatric cancer patients. This is most successful for lesions on the pleural surface that can be identified without palpation. Deeper lesions can be marked by preoperative computed tomography (CT)-guided techniques, but neither needle localization nor dye injection alone is foolproof. In this paper, we present our experience with a dual localization technique. Under CT guidance, a 20-G needle is advanced to within 1 cm of the lesion and 0.1 mL of methylene blue: Low osmolar contrast (4:1 ratio) is injected. A Kopans breast biopsy hook wire is then introduced through the needle and its tip placed within the lesion. Its tail is cut flush with the chest wall. The patient is transferred to the operating room, and a wedge resection around the hook wire is performed thoracoscopically. Six deep pulmonary metastatic lesions were preoperatively localized in 4 pediatric patients (ages, 6-17).Median localization time was 30 minutes. All lesions were successfully marked and identified at operation.Margin-free resection of the lesion was successful in all cases. Thoracoscopic resection of metastatic pulmonary lesions in children, using preoperative localization with both wire localization and methylene blue/contrast injection, is safe and effective. This method allows the successful localization of lesions, even in the event of either dislodgement of the wire or over infusion of the methylene blue dye.

Pulmonary embolism and cerebral venous thrombosis after thoracoscopic surgery for benign pulmonary disease

A-76-year-old woman consulted for open biopsy for a pulmonary mass. Thoracoscopic wedge resection was performed. The lesion was histologically diagnosed as nonspecific inflammation. On the first postoperative day (POD1), the patient lost consciousness transiently. Eleven hours after the first stroke, the patient experienced a second stroke together with hypoxia. Pulmonary perfusion scan on POD2 showed multiple perfusion defects, and the patient was diagnosed with pulmonary embolism (PE). Thrombolitic therapy was started. Neurological symptoms didn't improve, and cerebral angiography on POD3 showed delayed perfusion in superficial veins. The patient was diagnosed with cerebral venous thrombosis (CVT). Thrombolytic and anticoagulant therapy had been continued, and the patient was found to have hemorrhagic cerebral infarction on POD11. After persistent therapy, the patient was discharged on POD120. Although both PE and CVT are rare complications after thoracic surgery, we must consider these complications in patients undergoing thoracic operations including thoracoscopic surgery.

Additional mechanical pleurodesis after thoracoscopic wedge resection and covering procedure for primary spontaneous pneumothorax

Additional mechanical pleurodesis for the treatment of primary spontaneous pneumothorax (PSP) is believed to reduce the recurrence of PSP, and a covering procedure with absorbable mesh also shows comparable results. This study was conducted to determine whether additional mechanical pleurodesis would be effective in reducing recurrence after thoracoscopic wedge resection and covering procedure. Between May 2003 and August 2005, 99 patients underwent thoracoscopic bullectomy with staple line covering with absorbable cellulose mesh and fibrin glue followed by an additional mechanical pleurodesis. These patients were compared with 98 patients who underwent thoracoscopic bullectomy with staple line coverage alone. The additional mechanical pleurodesis group had findings comparable to those of the coverage group for duration of postoperative chest drainage, length of hospital stay, and complication rate. After median follow-up of 29.2 months, postoperative recurrence occurred in four patients (4.0%). Additional mechanical pleurodesis after covering procedure is also effective in decreasing postoperative recurrence of PSP.

Radiotracer-Guided Thoracoscopic Resection is a Cost-Effective Technique for the Evaluation of Subcentimeter Pulmonary Nodules

Excisional biopsy of small subcentimeter pulmonary nodules can be difficult using standard thoracoscopic techniques and may require thoracotomy. Radiotracer-guided thoracoscopic resection (RGTR) was developed to facilitate resection of intraparenchymal subcentimeter pulmonary nodules. Decision analysis, used to model cost and effectiveness, is useful to compare treatment options. We hypothesize that RGTR strategy is more cost-effective compared with thoracotomy for subcentimeter pulmonary nodules. The cost-effectiveness of RGTR versus thoracotomy for evaluating highly suspicious subcentimeter pulmonary nodules was examined with a decision analysis model (Fig 1). A 40-patient institutional cohort who underwent RGTR was used to estimate probabilities and costs of the two treatment options within the model. Effectiveness was estimated using 5-year, stage-specific cancer survival and population survival curves. The Society of Thoracic Surgeons General Thoracic Database was queried obtaining mortality estimates for thoracotomy and thoracoscopic wedge resections. These were used to adjust the 5-year survival estimates of patients with benign disease. Sensitivity analyses determined model robustness and the thresholds at which the most cost-effective strategy changed. Radiotracer-guided thoracoscopic resection was 95% successful with no mortality. The average cost-to-effectiveness ratio of RGTR strategy was $27,887 versus $32,271 for thoracotomy. Sensitivity analyses demonstrated that the thoracotomy strategy was more cost-effective if the estimated cost of RGTR increased by 33% or the estimated cost-effectiveness of thoracotomy decreased by 14% or more. Radiotracer-guided thoracoscopic resection was more cost-effective as long as the probability of success was greater than 44%. Decision analysis is a useful tool to evaluate treatment options for thoracic surgeons, and RGTR is a more cost-effective strategy than thoracotomy for subcentimeter pulmonary nodules.

CT-guided Hook Wire Localization of Subpleural Lung Lesions for Video-assisted Thoracoscopic Surgery (VATS)

Histologic diagnosis of suspicious small subpleural lung lesions is difficult and often impossible using existing image-guided needle biopsy techniques including video-assisted thoracoscopic wedge resection. Preoperative lung lesion localization provides a more obvious target to facilitate intraoperative resection. This study reviewed the indications, results and complications of CT-guided hook wire localization for subpleural lung lesions in video-assisted thoracoscopic surgery (VATS). Between February 2001 and January 2007, 41 patients (20 males, 21 females; mean age, 52.5 +/- 5.1 years) with 43 subpleural pulmonary lesions underwent preoperative CT-guided double-thorn hook wire localization prior to video-assisted thoracoscopic wedge resection. Nodule diameters ranged from 2 mm to 26 mm (mean, 9.7 +/- 1.6 mm). The distance of the lung lesions from the nearest pleural surfaces ranged from 2 mm to 30 mm (mean, 9.6 +/- 2.0 mm). Patients then received VATS within 5 hours. The efficacy of preoperative localization was evaluated in terms of procedure time, VATS success rate and associated complications of localization. Forty-three wedge resections of the lungs containing 43 subpleural lung lesions as guided or assisted by the inserted hook wires were successfully performed in 41 VATS procedures (41 of 43 procedures, 95.3%). The mean procedure time for preoperative CT-guided hook wire localization was 30.4 +/- 2.8 minutes. Eight patients had asymptomatic minimal pneumothoraces (18.6%); six patients had minimal needle tract parenchymal hemorrhages (13.9%) and one patient (2.3%) had an estimated 100 mL of hemothorax due to a small intercostal artery bleed that was cauterized during operation. The mean procedure time for VATS was 103 +/- 9.7 minutes (range, 44-198 minutes). Pathologic examination revealed seven primary lung cancers, 11 metastases, one hemangioma, 19 definite non-neoplastic pathologies, two nonspecific chronic inflammation, and three metallic foreign bodies. Diagnostic yield was 95%. No major complications related to the preoperative hook wire localization and VATS were noted. CT-guided hook wire fixation is useful, helps in precise lesion localization in VATS wedge resection, and has a low rate of minor complications.

Thoracoscopic localization techniques for patients with solitary pulmonary nodule: hookwire versus radio-guided surgery☆

Our aim was to evaluate the best intrathoracoscopic localization technique between hookwire and radio-guided surgery, in patients with pulmonary nodule. From January 2000 to January 2005 we enrolled in this study 50 patients with a solitary pulmonary nodule, prospective randomized in two groups, well matched for diameter and depth of the pulmonary lesion. In 25 patients we performed the hookwire technique (Group A), whereas in the other 25 patients radio-guided localization was adopted (Group B). In both groups the localization technique was compared with finger palpation. In Group A, 9 lesions were in the left and 16 in the right lung; in Group B, 14 nodules were in the left lung and 11 in the right one. In both groups, the distance of the nodule from the pleural surface with lung inflated was 2.5 cm (1.5-2.5 cm in 12 patients, and >2.5 cm for the remaining 13). The mean size of the nodules in both groups was 1.1, range 0.6-1.9 (<or=1 cm n=18 patients, and >1 cm n=7 patients). All patients underwent thoracoscopic wedge resection, and 23 patients with a primary pulmonary lesion underwent thoracotomy for lobectomy and radical mediastinal lymphadenectomy. In Group A the hookwire technique localized the nodule in 21 of 25 patients (84%) whereas finger palpation localized it in 7 of 25 patients (28%). In Group B, radio-guided surgery localized the nodule in 24 of 25 patients (96%) whereas finger palpation localized it in 6 of 25 (24%). In Group A we registered 6 cases of pneumothorax compared to 1 case observed in the radio-guided group. Postoperative hospital stay required an average of 4 days in both groups. In our experience radio-guided surgery has therefore been proven efficacious in the diagnosis of solitary pulmonary nodule and video-assisted thoracoscopic surgery allows the removal of pulmonary nodules without complications. Hookwire was also shown to be efficacious but demonstrated complications linked primarily to external technical factors.

The Role of VATS for Staging and Diagnosis in Patients with Non-Small Cell Lung Cancer

Video-assisted thoracoscopic surgery is an effective and versatile tool for the diagnosis and staging of patients with lung cancer. Despite advances in imaging technology, including integrated positron emission tomography/computed tomography scans, the clinical staging of patients with lung cancer remains inaccurate. Tissue confirmation is critical for accurate staging and treatment of patients with lung cancer. Thoracoscopy is an excellent and often preferred approach to the biopsy of inferior mediastinal, anteroposterior window, and para-aortic lymph nodes, and has the added advantage of allowing simultaneous assessment of the pleural space, satellite lung nodules, and T status of the tumor. Thoracoscopic wedge resection is the preferred technique for diagnosing indeterminate solitary pulmonary nodules. In the era of computed tomography screening, most indeterminate lung nodules are less than 1 cm in size and pose unique challenges in determining malignant potential and obtaining a tissue diagnosis. Several techniques have been adopted to allow successful thoracoscopic biopsy of these subcentimeter lung nodules.