Tailored intraoperative localization of non-palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology.

INTRODUCTION: VATS wedge resection can require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (HORs) provide real-time image acquisition capabilities allowing the intraoperative placement of markers to facilitate the removal of non-palpable nodules during VATS. OBJECTIVES: To present our workflow based on the alternative use of two different markers according to the location of the lung lesion and report our initial results. METHODS: All consecutive patients with non-palpable lesions requiring VATS wedge resection underwent localization of the targets in HOR. Lesions were considered non-palpable if they were small (<1 cm), deep (>1 cm from surface), subsolid, or located within a dystrophic area. Anesthetized patients were placed in lateral decubitus. Cone-beam CT (CBCT) was performed, and the needle trajectory was planned using Syngo iGuide Needle Guidance. Metal hook-wire or coil was placed, according to our workflow, close to the lesion and their position was verified by CBCT or fluoroscopy. RESULTS: Eleven VATS wedge resections were performed in 10 patients with 12 non-palpable lesions. The localization was performed with seven hook-wires and four coils in 30 minutes (range 17-56 minutes). The median estimated total effective dose was 11.6 mSv (range 1.9-24.7 mSv). Eleven lesions were removed by VATS, and one deep nodule required a thoracotomy. No complications were observed. CONCLUSIONS: Our experience confirms that HOR is suitable for simultaneous localization and VATS resection of 'difficult' pulmonary lesions. A versatile approach, using different devices, seems advisable for the removal of targets in every clinical scenario, reducing the VATS conversion rate.

Comparison of digital tomosynthesis and computed tomography for lung nodule detection in SOS screening program.

PURPOSE: To compare the lung nodules' detection of digital tomosynthesis (DTS) and computed tomography (CT) in the context of the SOS (Studio OSservazionale) prospective screening program for lung cancer detection. MATERIALS AND METHODS: One hundred and thirty-two of the 1843 subjects enrolled in the SOS study underwent CT because non-calcified nodules with diameters larger than 5 mm and/or multiple nodules were present in DTS. Two expert radiologists reviewed the exams classifying the nodules based on their radiological appearance and their dimension. LUNG-RADS classification was applied to compare receiver operator characteristics curve between CT and DTS with respect to final diagnosis. CT was used as gold standard. RESULTS: DTS and CT detected 208 and 179 nodules in the 132 subjects, respectively. Of these 208 nodules, 189 (91%) were solid, partially solid, and ground glass opacity. CT confirmed 140/189 (74%) of these nodules but found 4 nodules that were not detected by DTS. DTS and CT were concordant in 62% of the cases applying the 5-point LUNG-RADS scale. The concordance rose to 86% on a suspicious/non-suspicious binary scale. The areas under the curve in receiver operator characteristics were 0.89 (95% CI 0.83-0.94) and 0.80 (95% CI 0.72-0.89) for CT and DTS, respectively. The mean effective dose was 0.09 ± 0.04 mSv for DTS and 4.90 ± 1.20 mSv for CT. CONCLUSIONS: The use of a common classification for nodule detection in DTS and CT helps in comparing the two technologies. DTS detected and correctly classified 74% of the nodules seen by CT but lost 4 nodules identified by CT. Concordance between DTS and CT rose to 86% of the nodules when considering LUNG-RADS on a binary scale.

Lung cancer detection with digital chest tomosynthesis: first round results from the SOS observational study.

OBJECTIVE: Baseline results of the Studio OSservazionale (SOS), observational study, a single-arm observational study of digital chest tomosynthesis for lung cancer detection in an at-risk population demonstrated a detection rate of lung cancer comparable to that of studies that used low dose CT scan (LDCT). We present the results of the first round. METHODS: Totally 1,703 out of 1,843 (92%) subjects who had a baseline digital chest tomosynthesis underwent a first round reevaluation after 1 year. RESULTS: At first round chest digital tomosynthesis, 13 (0.7%) subjects had an indeterminate nodule larger than 5 mm and underwent low-dose CT scan for nodule confirmation. PET/CT study was obtained in 10 (0.5%) subjects and 2 subjects had a low-dose CT follow up. Surgery, either video-assisted thoracoscopic or open surgery for indeterminate pulmonary nodules was performed in 10 (0.2%) subjects. A lung cancer was diagnosed and resected in five patients. The lung cancer detection rate at first round was 0.3% (5/1,703). CONCLUSIONS: The detection rate of lung cancer at first round for tomosynthesis is comparable to rates reported for CT. In addition, results of first round digital chest tomosynthesis confirm chest tomosynthesis as a possible first-line lung cancer-screening tool.

Lung cancer detection with digital chest tomosynthesis: baseline results from the observational study SOS.

INTRODUCTION: Observational studies consistently support strategies for early cancer diagnosis and treatment. Owing to its high prevalence, mortality rate, and easily identifiable at-risk population groups, lung cancer seems ideal for early detection programs. We present the baseline results of the SOS study, a single-arm observational study of digital chest tomosynthesis for lung cancer detection in an at-risk population. METHODS: Accrual of study participants started in December 2010 and ended in December 2011. Participants considered eligible were smokers or former smokers aged 45 to 75 years, with a smoking history of at least 20 pack-years, without malignancy in the 5 years before the start of the study. A tomosynthesis examination was performed at baseline and another the year after. RESULTS: Of the 1919 candidates assessed, 1843 (96%) were enrolled into the study: the mean age was 61 years (range, 48-73 years); 1419 (77%) were current smokers. The most prevalent comorbidities were hypertension, chronic obstructive pulmonary disease, and cardiovascular diseases. A total of 1843 tomosynthesis studies were obtained. Pulmonary abnormalities were detected in 268 subjects (14.5%). First-line basal computed tomography (CT) was subsequently carried out in 132 subjects (7.2%), 68 (4.9%) of which were referred for follow-up CT. Positron-emission tomography/CT was performed on 27 individuals (1.46%), and lung cancer was detected in 18 (0.98%) of them. CONCLUSION: The detection rate of noncalcified lung nodules for tomosynthesis was comparable with rates reported for CT. A small subgroup underwent low-dosage CT and entered a follow-up program. Overall, lung cancer was detected in approximately 1% of cases. Digital chest tomosynthesis holds promise as a first-line lung cancer screening tool.

Not palpable? Role of radio-guided video-assisted thoracic surgery for nonpalpable solitary pulmonary nodules.

PURPOSE: This study aimed to evaluate the effectiveness of radio-guided localization for thoracoscopic resection of small nonpalpable lung nodules. METHODS: Nineteen patients with a solitary nodule were enrolled. Inclusion criteria were maximum nodule diameter <15 mm, distance from nearest pleural surface of 20-40 mm, nonsolid or partly solid nodule, and/or posterior location. Under computed tomography (CT) guidance, the nodule was identified and a needle was inserted to reach lesional or perilesional tissue. A solution of (99m)Tc macro-aggregates albumin diluted with iodized contrast medium was injected. After injection, CT and gamma scintigraphy were performed to confirm precise staining. Localization complications were minimal. RESULTS: At thoracoscopy, the gamma detector probe allowed localization of nodules in all patients, with the radioactive signal being converted by the system into audio and visual numeric signals. Resection was performed, and suture margins were checked with the probe to search for residual hyperabsorption. All specimens underwent frozen section. Mean time to detect nodules with the gamma probe was 6 min (range 3-9 min). Frozen section revealed primary pulmonary tumors in eight cases, secondary lesions in four cases, and a benign nodule in the remaining seven cases. CONCLUSION: Radio-guided localization is a simple, safe procedure for localizing nonpalpable solitary pulmonary nodules.