Interactive Cardiovascular and Thoracic Surgery 3:104-106(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Work in progress report - Thoracic general |
Immediate localization using ultrasound-guided hookwire marking of peripheral lung tumors in the operating room
Noboru Nakanoa,*,
Katsutoshi Miyauchib,
Hiroshi Imagawab and
Kanji Kawachib
a Department of Respiratory Surgery, Kinan General Hospital, 510, Minato, Tanabe-city, Wakayama 646-8588, Japan
b Department of Surgery II, Ehime University School of Medicine, 454, Shitsukawa, Shigenobu-cho, Onnsenn-gunn, Ehime 791-0295, Japan
* Corresponding author. Tel.: +81-739-22-5000; fax: +81-739-22-0925
nnakano{at}kinan-hp.or.jp
Received June 12, 2003;
received in revised form September 6, 2003;
accepted September 23, 2003
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Abstract
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A new method of marking peripheral lung tumors using an ultrasound-guided hookwire has been developed. The procedure was done for nine tumors taking 15–20 min for each method in the operating room; all of them had no complications. In eight cases (89%), the wire tips were shown to be located within the tumor itself or within 5 mm from the targets, close enough to support appropriate surgery. Ultrasound-guided hookwire marking of peripheral tumors can provide appropriate guidance and prove effective in immediately facilitating subsequent thoracoscopic resection.
Key Words: Lung nodule; Preoperative localization; Ultrasound-guide; Thoracoscopy
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1. Introduction
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The incidence of lung tumor detection has increased substantially due to the improvement in CT sensitivity.
The anchor-wire marking methods, guided by CT, were developed in order to facilitate surgical resection of a lung tumor as much as possible [1–3]. These techniques require both CT scan and operating room to be simultaneously available because of anticipated complications [4].
There has been no published report to utilize both ultrasound and hookwires together to localize a lung tumor. The aim of our study was to test the effectiveness of ultrasound-guided hookwire to locate peripheral lung tumors in the operating room.
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2. Technique
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Nine subpleural or pleural lung tumors (45%) were chosen from among 20 with lung tumors detected by CT, their histology was unknown but their CT results were highly suspected of malignancy. These tumors were selected for this study after an ultrasound examination revealed that they were adjacent to the chest wall. Informed consent was obtained from all patients.
Prior to the procedure itself, the precise position, surrounding anatomical structures, dimension, and depth of the lesion from the skin surface were determined by ultrasound using a 3.5-MHz linear scanner. The tip of the hookwire set [3] consisted of an introducer, a pusher system, an inner hookwire and a 30-cm-long nylon suture system. In the operating room after local anesthesia, the tip was directed toward the lung tumor using ultrasound guidance (Fig. 1). The pusher was fully advanced to eject the hookwire, and then shaped as a hook. At the end, the outer introducer and pusher system were removed and the nylon suture was fixed at skin level.
Immediately following the procedure, the patient was referred to the thoracoscopic resection. The nylon suture itself was used as a guide to the lesion at thoracoscopic resection (Fig. 2).
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Fig. 2 Thoracoscopic image reveals intrathoracic suture (arrow) from lung surface to chest wall. Lung tumor surface has pleural color change and indentation.
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3. Location, size, visualization and pleural adhesion of target tumors
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The diameters of the marked tumors ranged from 10 to 35 mm (median 20.3 mm). Six of the nine tumors (67%) were less than or equal to 20 mm in diameter. Their depth below skin surface level was between 18 and 28 mm (median 20.0 mm): Pleural color changes or indentations were visible in four of the nine lung tumors (44%) at thoracoscopic resection. Eight of the patients with lung tumors (89%) had no pleural adhesions.
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4. Ultrasound-guided hookwire marking
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The ultrasound-guided hookwire marking procedure was completed in 15–20 min and was well tolerated by all patients with the use of local anesthesia. In four cases (44%), the wire tips proved to be located precisely within the tumor lesion; in another four cases (44%), the wire tips were located within 5-mm distance and thus were close enough to support appropriate surgery. In one case (11%), the patient could not hold his breath at the marking and the wire tip missed the lung tumor by 15 mm. Nevertheless, the surgeon enlarged the incision and managed to locate the lesion with palpation and removed it. Neither pneumothoraces nor other complications were observed in our small series.
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5. Histological findings
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Frozen section diagnoses revealed that six of the lung tumors were primary lung cancer. Two lesions proved to be metastases and one tumor diagnosed as benign.
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6. Comment
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The small lung tumors will be diagnostic in 89.5% of malignant lesions and in 47% of benign nodules by CT-guided transthoracic needle biopsy [5]. Using US-guided transthoracic cutting biopsy, the diagnostic accuracy for malignant peripheral thoracic lesion was 92% and that for benign lesion was 65% [6]. In a case of no diagnostic results or highly suspected malignancy, the definite diagnosis should be made by thoracoscopic surgery.
Peripheral lung tumors often can not be found at thoracoscopic surgery. From 22 to 54% of the patients in thoracoscopic surgery needed conversion to thoracotomy, mainly because of the failure to localize the lesion [7,8]. To localize these lesions, several techniques have been proposed, such as CT guided anchor-wire marking [1–3], dye injection [4], thoracoscopic ultrasonography [9,10] and manual palpation [7]. These methods have several problems. During the anchor-wire marking methods guided by CT, about 5–50% of patients developed small to moderate pneumothoraces [1–3]. We believed that the cause of pneumothoraces might possibly lie between the time from the marking and the operation. Therefore, patients must be transported to the operation room immediately after or on the same day of the procedure [4]. Injection of dye has three major problems: the possible risk of shock after dye injection, the difficulty of recognition on patients with extensive anthracotic pigmentation and the dye diffusion across the lung surface [3]. Ultrasound has some limitations that a sufficient surgical margin could not be ensured because the margins were ill-defined in half of the malignant cases [9,10].
To allow direct palpation with a finger, surgeon needs an access thoracotomy incision (6–10 cm in length) [4]. Even if to detect the lesion of pleural surface, the probability of failure to detect the lesion using palpation is 9–21% [7].
Despite the fact that the 44% of lung tumors were visible at the thoracoscopy, there is no way to diagnose before surgery if a tumor may be visible or invisible. For that reason, we developed ultrasound-hookwire marking of peripheral lung tumors to be used in the operating room in order to provide appropriate guidance and decrease the incidence of complications.
In conclusion, ultrasound-guided hookwire marking of peripheral lung tumors facilitates appropriate localization and right away subsequent thoracoscopic removal in eight out of nine tumors (89%) in the operating room.
doi:10.1016/S1569-9293(03)00222-6
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Abstract
1. Introduction