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Ann Thorac Surg 2005;79:313-316
© 2005 The Society of Thoracic Surgeons

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New technology

Video-Assisted Thoracoscopic Surgery for Pulmonary Nodules After Computed Tomography-Guided Marking With a Spiral Wire

^a Clinic for Abdominal, Transplant, Vascular and Thoracic Surgery, Leipzig University, Leipzig, Germany
^b Department of Diagnostic Radiology, Leipzig University, Leipzig, Germany

Accepted for publication October 20, 2003.

^* Address reprint requests to Dr Eichfeld, Universität Leipzig, Chirurg Klinik II, Liebigstr 20a, 04103 Leipzig, Germany
eichu{at}medizin.uni-leipzig.de

	Abstract

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PURPOSE: Peripheral pulmonary nodules are preferably removed by minimally invasive techniques, such as video-assisted thoracoscopic (VATS) surgery. These nodules should be marked preoperatively for better intraoperative detection and removal.

DESCRIPTION: Twenty-two cases with a single pulmonary nodule requiring surgical removal for histologic examination were included in a prospective study. Guided by computed tomography, nodules were marked preoperatively using a laser marker system and fixed with a spiral wire. The marked nodules were removed by VATS surgery immediately after the marking.

EVALUATION: The marking wire was placed in all 22 patients without any complications. The marked nodule was completely removed by VATS surgery in 19 patients. Conversion to thoracotomy was necessary in 3 patients, twice because of thoracoscopy-related problems and once because of a marking failure. The average times for the marking procedure and operation were 24 minutes and 32 minutes, respectively.

CONCLUSIONS: This new method of computed tomography-guided nodule marking with a spiral wire and subsequent VATS surgery is very efficient in terms of localization and stable fixation of subpleural pulmonary nodules.

	Introduction

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Pulmonary nodules are defined as intraparenchymal lung masses smaller than 3 cm in size, not associated with atelectasis or adenopathy. Frequently, these nodules are detected incidentally when patients are examined for another medical reason. More sensitive methods such as thin-slice helical computed tomography (CT) make smaller nodules visible. Hoffmann and colleagues [1] stated that approximately 50% of all of these nodules are linked to malignancy. Therefore, an urgent invasive clarification of the pathology of these nodules is strongly recommended owing to that high rate. The method of choice for clarification should be minimally invasive procedures such as transthoracic and transbronchial biopsy, depending on the size and location of the nodule. These interventional procedures have a low complication rate. However, a higher diagnostic value can be obtained by surgical removal of the entire nodule with subsequent histologic examination.

In thoracic surgery of peripheral pulmonary lesions video-assisted thoracoscopic (VATS) surgery has gained widespread acceptance, because it provides increased comfort for the patient and lowers morbidity compared with standard thoracotomy. However, the disadvantage of minimally invasive procedures is the difficulty in detecting subpleural nodules, which are frequently neither visible nor palpable. Different techniques were established to detect such subpleural nodules. Partrick and associates [2] and Neuwirth and colleagues [3] described the use of methylene blue to mark nodules.

Nomori and colleagues [4] used Lipiodol, and radionuclides were used by Chella and colleagues [5] and Boni and colleagues [6]. Gruppioni and associates [7] utilized intraoperative ultrasound scans, and Lizza and colleagues [8] used fluoroscopy after coil labeling. Paci and colleagues [9] and Poretti and colleagues [10] favored percutaneous needles or a hook wire. All of these CT-guided techniques have certain advantages and disadvantages. Most authorities favor CT-guided marking irrespective of the marking agent. The main disadvantage of simple wire marking is the risk of dislocation when the lung collapses during surgery.

In this study, we present our first clinical results and experience using a spiral wire to mark subpleural pulmonary nodules. We used a laser marking system as described previously by Kloeppel and colleagues [11] for the CT-guided placement of the spiral wire. The main advantage of using the spiral wire is the stabile fixation and its capability to pull the fixed tissue toward the thoracic wall.

	Patients and Methods

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In a prospective study starting in May 2000, we included 21 patients with 22 suspicious pulmonary nodules requiring removal and histologic classification. All patients had a single subpleural nodule, with the exception of 1 patient who had a single pulmonary lesion on both sides. This patient underwent marking and surgery on the right side and the same procedure on the left side 5 weeks later. Only subpleural nodules with a size as large as 30 mm in diameter and a maximum distance to the pleural surface of 30 mm were included (Fig 1). All patients underwent CT-guided marking with a spiral wire and immediate surgery afterward. The average age of the patients was 60.4 years (range, 40 to 73); there were 14 men (aged 40 to 71 years) and 8 women (aged 51 to 73 years).

View larger version (6K): [in this window] [in a new window]   Fig 1. Indication for spiral wire marking and video-assisted thoracoscopic surgery. Subpleural nodule (A) with a maximum diameter of 3 cm and a maximum distance (B) from the pleura of 3 cm.

CT-Guided Marking
All patients underwent preoperative CT-guided marking of the nodule using a laser marker system (LAP, Lüneburg, Germany) and a special marking system for pulmonary nodules (Somatex, Berlin, Germany). The complete procedure has been described by Kloeppel and colleagues [11]. The main steps are listed below. The laser light target system, a flexible target system fixed on a rail, was mounted onto the gantry of a Somatom plus 4 CT (Siemens Medical Solutions, Germany). Steps before placement of the spiral wire, first, a CT scan with an external radiopaque marker in the zero position of the laser marker system was performed; second, the location of the nodule was exactly defined in relation to the marker. The measurements for the intervention were determined from the inside to the outside (optimal approach, length and angle of the needle, location and marking of needle injection in relation to the zero position of the laser system). Data were then transferred to the laser marking system. Finally, the intervention was carried out under local anesthesia. The laser was always visible on the back of the needle during insertion. The needle was inserted for the calculated length, preferably passing through the nodule.

The wire with a preformed helix was inserted through the needle. After removal of the needle, the wire was fixed and covered under sterile conditions. We always confirmed the final position of the spiral wire by CT scan (Fig 2). The wires were easily moved backward when placed too deep in the lung tissue simply by rotating the wire counter-clockwise. The patient was then transferred to the operating room immediately after the marking. For proper and adequate marking, the most important factor was to keep the same breath position in all procedures, from the initial CT to the insertion of the spiral wire.

View larger version (136K): [in this window] [in a new window]   Fig 2. Computed tomography scan after marking of a pulmonary nodule with the spiral wire (right top: preformed helix of the spiral wire).

View larger version (127K): [in this window] [in a new window]   Fig 3. Thoracic space: the spiral wire (open arrow) fixed nodule (closed arrow) is pulled toward the thoracic wall.

	Results

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Nonthoracoscopic Surgical Procedures
Nineteen of the 22 thoracoscopic resections were successfully carried out with complete thoracoscopic removal of the nodule. For these patients, the mean duration of surgery was 32 minutes (range, 16 to 70). In the remaining 3 patients, it was necessary to convert to open surgery because of impossible collapse of the lung due to intubation problems with the double-lumen tube, severe pleural adhesions, and a dislocated spiral wire after collapse of the lung. In 1 more case, the wire dislocated while pulling the nodule toward the thoracic wall for removal; however, we were able to identify the nodule by a still-visible tiny injury and air lack at the previous insertion site of the wire at the pulmonary surface.

The suction tubes were removed within 2 to 3 days postoperatively. All patients had an uncomplicated postoperative course and were discharged on postoperative day 4 on average (range, 3 to 7 days). Histologic examination of the nodules showed 12 (specific or nonspecific) inflammatory tumors, 6 malignancies (3 metastases, 3 primary lung carcinomas), and 4 hamartomas. All patients with malignancy were converted to open surgery, according to oncological standards at the same procedure. In cases of primary lung carcinoma, we performed a lobectomy and systematic lymphadenectomy; in cases of metastases, we manually palpated the remaining lung tissue to detect further nodules (there were no further nodules in all 3 cases), and we performed lymph node sampling.

	Comment

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The method of VATS surgery is widely accepted to clarify the pathology of pulmonary nodules histologically. These nodules are more easily identified and removed when associated with the pleura. Nodules in subpleural location are frequently not visible or palpable, and often result in costly and time-consuming surgical procedures. Therefore, to mark these nodules, a variety of methods has been developed [2–11].

Interventions guided by CT, supported by laser marking systems, were used for different indications to punctuate or mark these nodules with tissue specific wires. An accurate and sufficient fixation of these wires is necessary to avoid dislocation.

Partrick and associates [2]. and Neuwirth and colleagues [3] described the use of methylene blue injections to mark pulmonary nodules. However, the colored substances frequently spread into the surrounding normal tissues. Computed tomography fluoroscopy after coil labeling, as described by Lizza and colleagues [8], is another feasible method, but requires further investigation.

The method described in this study of CT-guided marking of subpleural nodules using a laser marking system and a spiral wire is novel and shows promising results. This laser localization system allows a more expeditious and accurate marking of the nodule, especially in nodules with a size of less than 1 cm, as described by Kloeppel [11]. Oncological concerns, such as the risk of seeding tumor cells by spiral wire marking, are not justified in our limited experience, because this risk seems comparable with that of other CT-guided biopsies.

In our study, the insertion of the spiral wire was successful in all cases without complications. The wire was placed either directly into the nodule or nearby in all cases, and confirmed by CT at the end of the marking procedure. In 1 patient, however, the wire was detected outside the lung during VATS surgery. It could not be definitely clarified whether this wire was misplaced in the first place or dislocated during VATS surgery. Exept for 2 cases, the fixation of the nodule was stable. In contrast, Poretti and colleagues [10] reported a wire dislocation in 4 of 19 patients, using a hook-wire for localization. The spiral wire, as used in this study, is fixed with even more stability and also allows manipulation along the wire.

In our series, the duration of the marking procedure was short and became even shorter after having peformed more procedures. In addition, the operative technique itself also improved with the increasing number of patients. An advantage of the spiral wire fixation is that one can pull the marked nodule toward the thoracic wall before resection, thereby allowing exact placement of the linear stapler.

In addition, the wire marking procedure and VATS surgery can be repeated within a relatively short period of time, as both methods are comfortable for the patient and are minimally invasive. Utilizing this method in this study, we treated only a small number of patients thus far. Based on our experience, however, the main advantages of this method include low complication rate, short duration, and safe and stabile fixation of the nodule, allowing complete resection. In conclusion, given all these advantages, we recommend this combination of CT-guided spiral wire marking and VATS surgery to remove subpleural pulmonary nodules.

	Disclosures and Freedom of Investigation

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This study was performed with funds from our institution without any external financial support. The tested technology (spiral wires) was purchased. The authors had full control of the design of the study, methods used, outcome parameters, analysis of data, and production of the written report.

	Footnotes

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The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.

	References

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1. Hoffmann H, Dienemann H. Der pulmonale Rundherd, Prinzipien der Diagnostik. Deutsches Aerzteblatt. 2000;97:907–912
2. Partrick DA, Bensard DD, Teitelbaum DH, Geiger JD, Strouse P, Harned RK. Successful thoracoscopic lung biopsy in children utilizing preoperative CT-guided localization. J Pediatr Surg. 2002;37:970–973[Medline]
3. Neuwirth J, Fanta J, Vojtisek O. Percutaneous localization and marking of small solitary pulmonary nodules in CT imaging before video thoracoscopy surgery. Cas Lek Cesk. 1999;138:666–668[Medline]
4. Nomori H, Horio H, Naruke T, Suemasu K. Fluoroscopy-assisted thoracoscopic resection of lung nodules marked with Lipiodol. Ann Thorac Surg. 2002;74:170–173[Abstract/Free Full Text]
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7. Gruppioni F, Piolanti M, Coppola F, et al. Intraoperative echography in the localization of pulmonary nodules during video-assisted thoracic surgery. Radiol Med (Torino). 2000;100:223–228
8. Lizza N, Eucher P, Haxhe JP, De Wispelaere JF, Johnson PM, Delaunois L. Thoracoscopic resection of pulmonary nodules after computed tomographic-guided coil labeling. Ann Thorac Surg. 2001;71:986–988[Abstract/Free Full Text]
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