Chest
Volume 122, Issue 4, October 2002, Pages 1467-1470
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Minimally Invasive Techniques
Feasibility and Value of Video-Assisted Thoracoscopic Surgery Wedge Excision of Small Pulmonary Nodules in Patients with Malignancy

https://doi.org/10.1378/chest.122.4.1467Get rights and content

Purpose

Advances in CT scanning have presented physicians with the challenge of diagnosing small (< 10 mm) or deep (> 5 mm) pulmponary nodules (SmPNs) in patients with known malignancies during workup or follow-up. Wedge excision of SmPNs is difficult with video-assisted thoracoscopic surgery (VATS) and often requires the performance of a thoracotomy. The value of the early detection of metastatic disease must be weighed against the morbidity (ie, thoracotomy) that is necessarily involved in obtaining the information. Little is known about the incidence of metastases in this subset of patients. We describe a VATS technique that allows the reliable excisional biopsy of SmPNs and present our findings in this patient population.

Methods

Using CT scan localization, 150 μCi technetium sulfur colloid is injected into the area of the pulmonary nodule. Additional blue dye is injected at the lung surface. During VATS, a sterile gamma probe is used to identify the area of radioactivity and plan placement of staple lines performed by an endostapling instrument. Palpation and the presence of radioactivity in the specimen supported the resection of the correct nodule, and CT scan findings confirmed the procedure. Between March 2000 and January 2001, 17 patients with known malignancies and SmPNs underwent VATS excisional biopsies. Six patients received a new diagnosis of malignancy, and 11 patients were in follow-up of a previously treated malignancy. The malignancies included the following: breast (four patients), head and neck (four patients), pancreas (two patients), lymphoma (two patients), lung (one patient), prostate (one patient), rectal (one patient), seminoma (one patient), and urethral (one patient).

Results

All lesions were successfully resected on the first try. Nodules were removed from 10 segments and all lobes. The mean (ŷ/SD) nodule size was 9.2 ŷ 3.6 mm, and the mean depth was 9.4 ŷ 5.2 mm. Fourteen of 17 nodules (82.4%) could be neither seen nor felt using standard VATS techniques. Diagnoses included metastatic (four patients), new primary lung cancer (one patient), acid-fast bacillus (one patient), granuloma (seven patients), carcinoid (two patients), and inflammatory pseudotumor (two patients). Among these lesions, 29.4% were malignant, and 35.3% of patients received a diagnosis that altered their therapy. Five of 12 SmPNs (41.7%) < 10 mm in size were malignant. The median length of hospital stay was 2 days. Patients returned to full activity within 1 week.

Conclusion

VATS excision of SmPNs after CT scan localization with radiolabeled technetium is reliable, reproducible, and associated with minimal morbidity. The technique prevented thoracotomies in 82.4% of patients. Despite the small size of these lesions, malignancy was found 29.4% of the time. This technique allows the early diagnosis of SmPNs, with low morbidity, in patients with known malignancies.

Clinical implications

The reliability of this technique, the high incidence of malignancy, and the reduction in morbidity from undergoing excisional biopsy procedures will encourage the clinician to strive for earlier and more aggressive diagnoses of SmPNs.

Section snippets

Materials and Methods

Between March 2000 and January 2001, we prospectively studied all patients with known malignancies and SmPNs that had been found on routine spiral chest CT scans. Seventeen patients were identified. Six had received a new diagnosis of malignancy, and their lung lesions were identified during a workup for metastatic disease. Eleven patients had new lung lesions noted on CT scans that were obtained as routine follow-ups of previously diagnosed and treated malignancies. The malignancies included

Results

Nodules were removed from 10 different segments involving all lobes. The mean node size was 9.2 ŷ 3.7 mm (size range, 6 to 20 mm). The mean depth was 9.4 ŷ 5.2 mm (depth range, 1 to 20 mm). The nodule could neither be seen nor palpated using standard VATS techniques in 14 of 17 patients (82.4%). None of the malignant tumors could be seen or palpated using conventional VATS techniques. All lesions were resected on the first attempt. The mean (ŷ/SD) count of the lesions was 3,333 ŷ 2,237. The

Discussion

The accurate and timely diagnosis of pulmonary nodules is essential for the proper management of patients with known malignancies. The introduction of spiral CT scanning has resulted in the detection of increased numbers of pulmonary nodules of decreasing size.1 The implications of metastatic lung lesions, no matter what size, on treatment selection for patients who have received a diagnosis of a malignancy are enormous. However, the small size of these lesions makes diagnosis difficult. The

Conclusion

Excisional VATS biopsy after radiolabeled localization of SmPNs is highly reliable, easy to use, and reproducible. VATS excision can be accomplished with low morbidity. The high incidence of malignant diagnoses confirms the value of accurate and timely diagnoses in patients with known malignancies. The fear of thoracotomy and its associated morbidities should not be a limiting factor in the workup of SmPNs. This should encourage clinicians to aggressively seek the earlier diagnosis of SmPNs in

ACKNOWLEDGMENT

Thanks to Ms. Pegeen Anderson for her help in preparation of this manuscript.

References (13)

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