Computed Tomography-Guided Percutaneous Radiotracer Localization and Resection of Indistinct/Small Pulmonary Lesions

doi:10.1016/j.athoracsur.2019.03.102

The Annals of Thoracic Surgery

Volume 108, Issue 3, September 2019, Pages 852-858

Presented at the Sixty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Amelia Island, FL, Nov 7-10, 2018.

https://doi.org/10.1016/j.athoracsur.2019.03.102 Get rights and content

Background

Detection of small pulmonary lesions has increased, and often they are difficult to localize and resect. We present our mature experience with preoperative computer tomography-guided radiotracer localization, followed by resection of these lesions.

Methods

Patients with pulmonary nodule smaller than 1 cm or deep below the visceral pleura underwent computer tomography-guided injection of radiotracer technetium macroaggregates in or close to the lesion. A gamma probe was used to localize the marked area that was resected, and in case of primary lung cancer a lobectomy with nodal dissection was performed.

Results

Between November 2007 and December 2017, 262 patients (196 men; median age 63 years) underwent preoperative radiotracer injection with a successful marking in all patients. Complications included 35 asymptomatic pneumothoraxes (13.4%), 36 parenchymal hemorrhage suffusions (13.7%), and 2 mild allergic reactions to contrast medium (0.7%). In all cases, except for 3, the gamma probe revealed the pulmonary lesion. Mean distance from the pleura was 10 mm (range, 0 to 40 mm). Pulmonary resection was performed by thoracoscopy in 212 cases (80.9%), intentional thoracotomy in 42 (16.0%), and converted thoracoscopy in 8 (3.1%). Mean pathologic nodule size was 9.3 mm (range, 2.5 to 39 mm). One hundred sixty-six nodules (63.4%) were nonsolid, 64 (24.4%) were partially solid, and 32 (12.2%) had a solid morphologic characteristic. Histologic examination showed 16 benign (6.1%) and 246 malignant (93.9%) lesions (218 primary lung cancers).

Conclusions

Preoperative radiotracer localization of small or indistinct pulmonary lesions is simple and feasible with a high rate of success. It may be an effective and attractive alternative in managing lung lesions.

Section snippets

Study Patients

The proposal to place ⁹⁹TC radionuclide to guide subsegment lung resection was approved by our institutional review board. All patients with small pulmonary nodules who were enrolled to receive preoperative CT-guided radiotracer localization, followed by resection, were informed of the procedure's benefits, risks, and limitations and gave their written approval.

Between November 2007 and December 2017, 262 consecutive patients underwent radiotracer injection, followed by thoracoscopic

Characteristics of Patients and Pulmonary Lesions

Between November 2007 and December 2017, 262 patients with ill-defined or not palpable pulmonary lesions underwent CT-guided radiotracer placement, with a successful marking in all the patients, and radio-guided surgical biopsy. The general characteristics of the study participants are given in Table 1. There were 196 male and 66 female patients, with a median age of 63 years (range, 19 to 79 years). The mean nodule size was 9.3 mm (range, 2.5 to 39 mm). Radiologic aspects of the pulmonary

Comment

As the use of CT becomes widespread in clinical practice, the frequency of encountering small or faint lesions on CT is increased.³¹ Low-dose CT greatly increases the likelihood of detection of small nodules, and 51.7% of detected lung cancers found during baseline screening were GGO.³² According to some researchers, these small nodules may be safely followed with serial CT scans to assess for their growth; some of these nodules, particularly those less than 5 mm, are said to be unlikely to be

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These characteristics were not evaluated in previous studies. Previous studies experienced successful nodule localization by performing surgery on the same day or even the next day (but within 24 h) after radiotracer injection.19,20 This is attributed to the 6 hour half-life of technetium-99m and the slow clearance of MAA at the injection site.11
CT guided technetium99m-macroaggregated albumin (^99mTc-MAA) injection for lung nodule localization prior to video-assisted thoracoscopic surgery (VATS) is employed at our institution for more than a decade. We retrospectively studied the success rate, factors that affect outcomes, and complications of this procedure.
147 patients with 164 nodules underwent this procedure before VATS. Imaging and procedure characteristics, complications of the procedure, successful intra-operative localization and wedge resection, if there was conversion of primary VATS to open thoracotomy and if so the reason, and histopathological diagnosis for each nodule were reviewed by two radiologists in consensus. In case of unsuccessful wedge resection, reasons for failure were derived from electronic medical record. The impact of nodule and procedure characteristics on successful intra-operative localization was assessed.
Excluding 9 nodules with unsuccessful localization due to non-procedure related reasons, the CT guided procedure was successful in 96.1% for intraoperative localization (149/155). Pleural leak of the radiotracer, split injection within the lobe, injection into a wrong nodule and gamma probe malfunction were primary reasons for failure. Nodule size, depth from pleura, and time between radiotracer injection and surgical incision did not impact success of the procedure. Among the 6 cases with procedure related failure, only 1 required conversion to open thoracotomy.
CT guided ^99mTc-MAA injection for intra-operative lung nodule localization is a feasible procedure with a high success rate and low complication rate. Attention to technique can potentially avoid procedure failure.
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Original articleGeneral thoracicComputed Tomography-Guided Percutaneous Radiotracer Localization and Resection of Indistinct/Small Pulmonary Lesions

Background

Methods

Results

Conclusions

Section snippets

Study Patients

Characteristics of Patients and Pulmonary Lesions

Comment

Chest

Am J Med

Ann Thorac Surg

Chest

Clin Lung Cancer

Chest

J Thorac Cardiovasc Surg

J Formos Med Assoc

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Lancet

Ann Thorac Surg

Ann Thorac Surg

Original article
General thoracic
Computed Tomography-Guided Percutaneous Radiotracer Localization and Resection of Indistinct/Small Pulmonary Lesions