Use of methylene blue and a spring microcoil in the preoperative localization of small pulmonary nodules under CT guidance: a meta-analysis.

OBJECTIVE: Methylene blue (MB) and spring microcoils are used for the preoperative localization of small pulmonary nodules (SPNs). We aimed to compare the efficacy and safety of these methods using published data. METHODS: We identified randomized controlled trials and observational studies that assessed preoperative SPN localization using MB or spring microcoil and compared these using a meta-analysis. RESULTS: Seven studies of 933 patients were identified, in whom 1081 SPNs were located. Four hundred twenty-four SPNs were located using MB (n = 359 participants), and 657 SPNs were located using the spring microcoil method (n = 574 participants). The prevalence of technical success of SPN localization was higher using MB (mean deviation [MD]: 0.43; 95% confidence interval [CI]: 0.20, 0.93); the incidence of postoperative complications was lower (MD: 1.70; 95% CI: 1.09, 2.65); and the time taken for removal was longer (MD: -12.37; 95% CI: -22.60, -2.13). There were no differences with respect to the successful wedge resection rate, the time taken for localization, the duration of the procedure, or the mean hospital stay. CONCLUSIONS: Both methods can detect SPNs; however, MB is associated with a higher success rate and fewer postoperative complications, while spring microcoil localization is associated with more rapid removal.

A novel localization device for small pulmonary nodules in thoracoscopic wedge resection with adequate margin distance: a retrospective study.

Background: Thoracoscopic wedge resection of small pulmonary nodules (SPNs) is a common surgical procedure. Adequate surgical margin distance is challenging and key to successful resection for malignant nodules. The aim of this study was to evaluate the feasibility of a novel localization needle in wedge resection for SPNs with adequate margin distance. Methods: A retrospective review of needle localization cases from November 2021 to August 2022 was performed, in which 58 patients who underwent modified computed tomography (CT)-guided needle localization following thoracoscopic wedge resection were enrolled. Nodules were localized by placing a novel device characterized by a 4-hook anchor and a tricolored suture with a scale. The clinical characteristics were collected to evaluate the feasibility of the procedure in obtaining a sufficient margin distance. Results: A total of 68 SPNs were collected, and the median size of SPNs was 10.0 mm with a median depth of 18.9 mm. Needle localization was successful in 65 nodules (95.6%), and all nodules were completely removed. The median resection margin distance was 14 mm (range, 8-26 mm). There were 62 (91.2%) SPNs with a margin distance to tumor size ratio ≥1, 38 (92.7%) SPNs with a depth <20 mm, and 24 (88.9%) SPNs with a depth ≥20 mm, respectively. Regardless of the nodule depth, the median resection margin distances were both 14 mm. Conclusions: This study indicated that modified preoperative CT-guided 4-hook needle with scaled suture localization is a safe, efficient strategy for the wedge resection of SPNs via thoracoscopic surgery. Furthermore, it was considerably advantageous for obtaining adequate margins distance, especially for deep nodules.

Cryobiopsy and dye marking guided by electromagnetic navigation bronchoscopy before resection of pulmonary nodule.

BACKGROUND: Our aims were to explore the feasibility, safety, and efficacy of peroperative transbronchial lung cryobiopsy (TBLC) guided by electromagnetic navigation bronchoscopy (ENB) and ENB-guided methylene blue marking of presumably non-palpable pulmonary nodules, and to assess its impact on video-assisted thoracoscopic surgery (VATS) and postoperative lung function. METHODS: This approach was applied to 16 consecutive patients (Group A, mean age 64 years) who were compared retrospectively to a historical group of 49 patients (Group B, mean age 62 years) with similar nodules resected without guidance. The usefulness of dye marking was graded. The success rates of both ENB-guided TBLC and nodule localization through dye marking were computed. The type of resection, volume of resected parenchyma, duration of procedures, and postoperative lung function were compared between groups. Unpaired t-test, chi-square test, unpaired Wilcoxon test, and exact Fisher test were used when appropriate. RESULTS: Malignancy was pathologically proven in all patients. TBLC revealed malignancy in 9 patients in Group A. The success rate of ENB-guided dye marking was 94%. Lobectomy was less frequently performed in Group A than in Group B (p = 0.022). Forced expiratory volume in 1 s and total lung capacity were significantly less reduced in Group A than in Group B (p = 0.006 and p = 0.019, respectively). Combined procedure was longer than surgery alone (p<0.001), but its surgical part was shorter than VATS without guidance (p < 0.001). CONCLUSION: Peroperative ENB-guided TBLC with methylene blue marking of non-palpable lung nodules is feasible. A sparing lung parenchyma procedure could be achieved thanks to the ENB-guided dye marking before VATS.

Identification of factors affecting the surgical margin in wedge resection using preoperative lipiodol marking.

BACKGROUND: The factors affecting the surgical margin distance in resection of small lung lesions after preoperative marking are still unclear. The purpose of this study was to identify these factors in wedge lung resection using a localization technique. METHODS: The subjects were 45 patients with small pulmonary nodules who underwent preoperative computed tomography-guided lipiodol marking followed by video-assisted thoracoscopic surgery between April 2017 and December 2019. Data were obtained for nodule size, depth from the pleural surface, imaging features, and procedure-related factors that could affect the surgical margin. Subjects were divided into groups with margin distances <10 and ≥10 mm. Logistic regression analysis was used to identify factors associated with the margin distance. RESULTS: Preoperative marking was performed using lipiodol prior to resection of 52 nodules (median size, 10.1 mm; range, 6.75-12.3 mm) in 45 patients (23 men, 22 women; median age, 65.4 years). The mean distance from the pleural surface to the pulmonary lesion was 13.8 mm (range, 5.44-22.2 mm). The 3D deviation of the radio-opaque nodule (lipiodol spot) from the lesion was the only significant difference in nodule- and procedure-related factors between the two groups. Multivariate analysis also showed that this 3D deviation was the most significant factor affecting the margin distance (odds ratio, 0.26; 95% CI, 0.08-0.81; P=0.02). CONCLUSIONS: The findings in this study may help to ensure a sufficient surgical margin after preoperative lipiodol marking, through recognition that the 3D deviation of the radio-opaque nodule from the target lesion has a particularly important influence on the margin distance.

The value of circulating tumor cells with positive centromere probe 8 in the diagnosis of small pulmonary nodules.

Circulating cancer cells (CTCs) can serve as a non-invasive liquid biopsy and provide opportunities for early cancer diagnosis and evaluation. However, the value of CTCs for diagnosis or prognosis of small pulmonary nodules (SPNs) is unclear. Fifty-three patients diagnosed with SPNs with a diameter less than 30 mm by CT examination were enrolled in the study. The CTC numbers, CT examination features, serum tumor marker concentrations, and histopathological characteristics were analyzed. Centromere probe 8 (CEP8) was used as a marker for CTC identification. The CTC numbers were significantly different in patients with malignant and benign SPNs and with early (0/Ⅰa) and advanced (Ⅰb/Ⅱ/Ⅲ) lung cancer stages. ROC analysis showed that the CTC numbers was effective on malignant SNP diagnosis. The combined use of CTCs and the density features of the nodules determined by CT further improved the overall screening, the diagnostic effectiveness for malignant SNPs, and determination of the pTNM (≤Ia vs.>Ia) stage. The CT morphology revealed that large, single, and solid SPNs were associated with significant CTC numbers and the CTC numbers were correlated with malignant histopathology. Using CEP8 as a marker resulted in detection of more CTC numbers in 22 patient samples triple stained for CEP8, EpCAM, and CKs. The CTCs determined by CEP8-positive staining could serve as potential screening and diagnostic markers for malignant SPNs.

False positive reduction in pulmonary nodule classification using 3D texture and edge feature in CT images.

BACKGROUND: Pulmonary nodule detection can significantly influence the early diagnosis of lung cancer while is confused by false positives. OBJECTIVE: In this study, we focus on the false positive reduction and present a method for accurate and rapid detection of pulmonary nodule from suspective regions with 3D texture and edge feature. METHODS: This work mainly consists of four modules. Firstly, small pulmonary nodule candidates are preprocessed by a reconstruction approach for enhancing 3D image feature. Secondly, a texture feature descriptor is proposed, named cross-scale local binary patterns (CS-LBP), to extract spatial texture information. Thirdly, we design a 3D edge feature descriptor named orthogonal edge orientation histogram (ORT-EOH) to obtain spatial edge information. Finally, hierarchical support vector machines (H-SVMs) is used to classify suspective regions as either nodules or non-nodules with joint CS-LBP and ORT-EOH feature vector. RESULTS: For the solitary solid nodule, ground-glass opacity, juxta-vascular nodule and juxta-pleural nodule, average sensitivity, average specificity and average accuracy of our method are 95.69%, 96.95% and 96.04%, respectively. The elapsed time in training and testing stage are 321.76 s and 5.69 s. CONCLUSIONS: Our proposed method has the best performance compared with other state-of-the-art methods and is shown the improved precision of pulmonary nodule detection with computationaly low cost.

Safety and reliability of computed tomography-guided lipiodol marking for undetectable pulmonary lesions.

OBJECTIVES: This study aimed to evaluate the safety and reliability of percutaneous computed tomography (CT)-guided lipiodol marking for undetectable pulmonary lesions before video-assisted thoracic surgery (VATS). METHODS: We retrospectively analysed the cases of CT-guided lipiodol marking followed by VATS in 9 institutes from May 2006 to March 2018. Lipiodol (0.2-0.5 ml) was percutaneously injected closely adjacent to undetectable pulmonary lesions with computed-tomography guidance. Lipiodol spots were identified using C-arm-shaped fluoroscopy during VATS. We grasped the lipiodol spots, including the target lesions, with ring-shaped forceps and resected them. RESULTS: Of 1182 lesions, 1181 (99.9%) were successfully marked. In 1 case, the injected lipiodol diffused, and no spot was created. Of the 1181 lesions, 1179 (99.8%) were successfully resected with intraoperative fluoroscopy. Two lipiodol spots were not detected because of the lipiodol distribution during the division of pleural adhesions. The mean lesion size was 9.1 mm (range 1-48 mm). The mean distance from the pleural surface was 10.2 mm (range 0-43 mm). Lipiodol marking-induced pneumothorax occurred in 495 (57.1%) of 867 cases. Of these, chest drainage was required in 59 patients (6.8%). The other complications were 19 (2.2%) cases of bloody sputum, 3 (0.35%) cases of intravascular air, 1 (0.12%) case of pneumonia and 1 (0.12%) case of cerebral infarction. There were no lipiodol marking-induced deaths or sequelae. CONCLUSIONS: Preoperative CT-guided lipiodol marking followed by VATS resection was shown to be a safe and reliable procedure with a high success rate and acceptably low severe complication rate.

Multicenter, prospective, observational study of a novel technique for preoperative pulmonary nodule localization.

OBJECTIVES: Minimally invasive surgery provides an ideal method for pathologic diagnosis and curative intent of small pulmonary nodules (SPNs); however, the main problem with thoracoscopic resection is the difficulty in locating the nodules. The goal of this study was to determine the safety and feasibility of a new localization technique tailored for SPNs. METHODS: A computed tomography (CT)-guided technique, which has a tri-colored suture and claw with 4 fishhook-shaped hooks, was designed to localize SPN preoperatively. Then a multicenter, prospective study was conducted to evaluate the safety and feasibility of this device. The primary endpoints included safety (asymptomatic/symptomatic pneumothorax or parenchymal hemorrhage, and unanticipated adverse effects) and success rate (precise placement and device fracture, displacement, or dislodgement). The secondary endpoints included feasibility (duration of the localization procedure and device fracture or fault) and patient comfort (pain). RESULTS: A total of 90 SPNs were localized from 80 patients. Overall, no symptomatic complications requiring medical intervention, with the exception of asymptomatic pneumothorax (n = 7 [7.8%]) and lung hemorrhages (n = 5 [5.6%]), were observed. The device was successfully placed without dislodgment or movement in 87 of 90 lesions (96.7%). The median nodule size was 0.70 cm (range, 0.30-1.0 cm). The median duration of the procedure was 15 minutes (range, 7-36 minutes). No patient complained of notable pain during or after the procedure. CONCLUSIONS: This new device for SPNs is safe, and has a high success rate, feasibility and good tolerance.

Comparison of cyanoacrylate and hookwire for localizing small pulmonary nodules: A propensity-matched cohort study.

BACKGROUND: Localizing small pulmonary nodules (SPNs) is a challenge during thoracoscopic resection, but preoperative computed tomography (CT)-guided localization using either cyanoacrylate or hookwire can be helpful. This study compared the safety, efficiency, and operability of the two techniques. METHODS: From September 2013 to November 2018, 269 patients (269 SPNs) who underwent preoperative CT-guided SPN localization were enrolled. A propensity-matched analysis, incorporating 13 variables, was performed to control potential selection bias. RESULTS: All the patients were divided into two groups: CT-guided cyanoacrylate localization group (Group C, n = 149) and CT-guided hookwire localization group (Group H, n = 120). Eighty-six patients were propensity-matched in each group. All SPNs were successfully removed thoracoscopically, and no conversion was required. Localization-related complications in the two groups were similar, including intrapulmonary focal hemorrhage (p = 0.823), pneumothorax (p = 1.000), or hemoptysis (p = 0.121). For pain assessment and management, the cyanoacrylate localization saw a lower pain score (p < 0.001) and less morphine use (p < 0.001). In Group H, the localization took a significantly longer time (p < 0.001). Covering only the patients in Group C, the sub-analysis found that cyanoacrylate localization on the day before surgery did not compromise the accuracy of intraoperative targeting or increase the incidence of complications, compared with the localization on the day of surgery (all p > 0.05). CONCLUSION: Compared to hookwire localization, CT-guided cyanoacrylate localization decreased pain and morphine use and allowed flexible surgical schedules, suggestive of its preferability for the resection of SPNs.

Computed tomography-guided preoperative semi-rigid hook-wire localization of small pulmonary nodules: 74 cases report.

OBJECTIVES: The study aimed to retrospectively evaluate the success rate, utility, practicality and results of pre-operative CT (computed tomography)-guided semi-rigid single hook-wire placement and the pathology results of small pulmonary nodules (SPN). MATERIALS AND METHODS: Seventy-four patients with 81 small pulmonary nodules underwent CT-guided semi-rigid single hook wire localization consecutively between 2016 and 2017 were reviewed. VATS (video-assisted thoracoscopic surgery) resection of lung tissue containing each pulmonary nodule and were performed in the direction of hook wire. The success rate and utility of the localization, hook wire related complications, the histopathology of SPN are analyzed. RESULTS: The semi-rigid hook wire was performed successfully in all 81 small pulmonary nodules within mean time of 10 min (8-13 min, SD: 1.58 min). Compared with solid nodules, GGOs (ground-glass opacity) were more frequently malignant (p < 0.05), with an OR (odds ratio) 8.59 (95%CI, 0.967, 412.845). Of the pure GGOs, 9 (25%) nodules were classified as AIS, 10 (27.8%) nodules were classified as MIA and 22 (57.9%) of the mGGOs were lung cancer. According to multivariate analysis, the malignant hazard was as high as 6.533-fold higher in nodules with a size larger than 10 mm compared with those smaller than 10 mm. GGOs with tiny blood vessels showed a statistically significant correlation with malignancy. Surprisingly, no statistically significant difference in the incidence of lung cancer in age. No major complication occurred. CONCLUSIONS: Preoperative localization of small pulmonary nodules using semi-rigid single hook wire was found to be practical and safe, which allows for proper diagnosis. Incidental small pulmonary nodule, especially GGO larger than 10 mm needs to be taken seriously.