Original articleComputed tomography-guided minithoracotomy for the resection of small peripheral pulmonary nodules
Abstract
Small peripheral pulmonary nodules ranging in size from 1 mm to 20 mm were excised in 58 patients. Computed tomography was used to mark the skin overlying the nodules to minimize the surgical exposure needed for operative identification. The nodules were 1 cm or less in maximum diameter in 76% of the patients. Twenty-six patients had single nodules and 32 patients had multiple nodules. The preoperative diagnosis was inaccurate in 67% of the patients. In 61% of the patients in whom malignancy was suspected, no tumor was demonstrated. Conversely, of the 20 patients in whom a malignant nodule was excised, the preoperative diagnosis was correct in only 50%. Thirty-one patients required no further treatment apart from their biopsy and 27 required additional intervention. Small peripheral pulmonary nodules require biopsy for diagnosis. When percutaneous needle aspiration biopsy is unsuccessful, or technically difficult, a computed tomography-guided thoracotomy is an effective and minimally invasive surgical alternative.
References (5)
- BDT Daly et al.
Computed tomography minithoracotomy: a preliminary report of a new approach to open lung biopsy
Radiology
(1983) - BDT Daly
Open lung biopsy
Cited by (19)
Evaluation and Management of Indeterminate Pulmonary Nodules
2012, Radiologic Clinics of North AmericaCitation Excerpt :Thoracotomy remains the most invasive but effective means to obtain a histologic diagnosis. The operative mortality of thoracotomy is 3% to 7% for malignant nodules and less than 1% for benign nodules.131,132 Decreased perioperative mortality and hospital stays have been achieved with the development of video-assisted thoracoscopy.61
Neural networks for the analysis of small pulmonary nodules
1997, Clinical ImagingPurpose: Small pulmonary nodules can be readily detected by computed tomography (CT). The goal of this detection is to diagnose early lung cancer as the five year survival at this early stage is over 70% in contradistinction to the overall 5-year survival of around 10%. Critical to the efficacy of CT for early lung cancer detection is the ability to distinguish between benign and malignant nodules. We explored the usefulness of neural networks (NNs) to help in this differentiation. Methods: CT images of 28 pulmonary nodules, 14 benign and 14 malignant, each having a diameter less than 3 cm were selected. All were sufficiently malignant in appearance to require needle biopsy and surgery. The statistical-multiple object detection and location system (S-MODALS) NN technique developed for automatic target recognition (ATR) was used to differentiate between these benign and malignant nodules. Results: S-MODALS was able to correctly identify all but three benign nodules. S-MODALS classified a nodule as malignant because it looked similar to other malignant nodules. It identified the most similar nodules to display them to the radiologist. The specific features of the nodule that determined its classification were also shown, so that S-MODALS is not simply a “black box” technique but gives insight into the NN diagnostics. Conclusion: This initial evaluation of S-MODALS NNs using pulmonary nodules whose CT features were very suspicious for lung cancer demonstrated the potential to reduce the number of biopsies without missing malignant nodules. S-MODALS performed well, but additional optimization of the techniques specifially for CT images would further enhance its performance.
Lung biopsy in diffuse interstitial disease: Videothoracoscopy versus thoracotomy
1996, Archivos de BronconeumologiaEl objetivo del trabajo es evaluar y comparar los resultados de las biopsias pulmonares realizadas por videotoracoscopia (VTC) y por toracotomía limitada (TL) en la enfermedad intersticial difusa entre los años 1992 y 1994. En este período se han realizado 45 biopsias pulmonares (25 varones y 20 mujeres) con una edad media de 56 años. Treinta y una biopsias se efectuaron por VTC (grupo I) y 14 mediante toracotomía limitada (grupo II). En cada uno de los casos estudiados se determinó el tiempo quirúrgico, los días de estancia postoperatoria, el tiempo de permanencia del drenaje pleural y el volumen de la pieza de biopsia.
Los resultados han mostrado que el diagnóstico se obtuvo en el 100% de los casos. La duración media de la intervención quirúrgica (tiempo quirúrgico) fue de 49,3 minutos para el grupo I y de 58,2 minutos para el grupo II. La estancia media postoperatoria fue de 6,7 días para el grupo I y de 10,1 días para el grupo II. El tiempo medio de permanencia del drenaje pleural fue de 3,8 días para el grupo I y de 5,9 días para el grupo II. El volumen medio de la pieza de biopsia fue de 6,5 cm3 para el grupo I y de 5,18 cm3 para el grupo II. La mortalidad fue de un paciente que pertenecía al grupo I sin relación directa con la técnica quirúrgica. En conclusión, la biopsia pulmonar por VTC es una técnica efectiva y útil para el diagnóstico de las enfermedades intersticiales difusas del pulmón. El material que se obtiene es en todo comparable con el de la biopsia por toracotomía. Disminuye de forma significativa (p < 0,05) la estancia media hospitalaria y el tiempo de permanencia del drenaje postoperatorio.
The aim of this work was to evaluate and compare the results of lung biopsies performed by videothoracoscopy (VT) and minithoracotomy (MT) in diffuse interstitial disease between 1992 and 1994. during which period 45 lung biopsies were performed on patients (20 women) with a mean age of 56 years. Thirty-one biopsies were performed by VT (group I) and 14 by MT (group II). For all patients we recorded duration of procedure, days to discharge after surgery, total time with a pleural drain in place, and volume of tissue sample.
Diagnosis was possible in all cases. Mean duration of surgery was 49.3 minutes for group I and 58.2 minutes for group II. Mean time to discharge was 6.7 days for group I and 10.1 for group II. Mean time of pleural drainage was 3.8 days for group I and 5.9 days for group II. Mean volume of tissue sample was 6.5 cm3 for group I and 5.18 cm3 for group II. One patient died in group I from causes unrelated to surgical technique. In conclusion, lung biopsy with VT is effective and useful for diagnosing diffuse interstitial lung diseases. The sample obtained is in every way comparable to that obtained by thoracotomy. Mean hospital stay and mean time of postoperative drainage decreases significantly (p < 0.05) with VT.
Radiographic screening for cancer proposed paradigm for requisite research
1994, Clinical ImagingComputed tomography (CT) imaging as an excellent approach to the detection and characterization of small solitary pulmonary nodules (SSPN) raises three questions: (1) How often does CT imaging lead to detection of SSPN? (2) How often is such an SSPN malignant? (3) If malignant, how curable is it? The first question pertains to decisions about screening use of CT (clinical or mass screening), the second to decisions about screening for SSPN and diagnosis of malignancy given SSPN, and the third-in the context of known curability at ordinary clinical diagnosis-to decisions about screening for SSPN, diagnosis given SSPN and intervention given malignant SSPN. We present a three component study design that addresses these questions. The first is directed primarily to the first question. Some 1000 persons at high risk for lung cancer will be screened for SSPN using screening-type CT The primary aim is to determine the prevalence of CT detectable SSPN as a joint function of risk-relevant aspects of the person. The second component addresses the prevalence of malignancy among the detected cases of SSPN. To develop the prevalence function, a larger series of CT-detected SSPN will be obtained by developing a multi-center SSPN “egistry”. A subsequent, third component will focus on the registered cases of malignant SSPN screening incidentally detected and address their curability on the basis of long-term follow-up. This design, in lieu of a randomized trial, may represent a new paradigm for applied research on radiologic technologies in cancer screening, given its advantages in terms of research efficiency and implications to decisions about diagnostic workup and therapeutic intervention.
Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery
1994, Journal of Thoracic and Cardiovascular SurgeryThe prevalence and severity of chronic pain after video-assisted thoracic surgery for pulmonary resection remains to be defined. Three hundred forty-three of 391 consecutive patients 3 to 31 months after pulmonary resection by lateral thoracotomy (n =165) or video-assisted thoracic surgery (n =178) responded to a questionnaire aimed at comparing the relative occurrence of chronic postoperative pain after video-assisted thoracic surgery and lateral thoracotomy approaches for pulmonary resection. Patients less than 1 year after operation (video-assisted thoracic surgery =142; thoracotomy = 97) and more than 1 year after operation (video-assisted thoracic surgery = 36; thoracotomy = 68) were analyzed as individual cohorts. Chronic pain was assessed by questioning patients about the presence and the intensity of discomfort on the side of the operation (using a visual analog scale) and their need for analgesic medication and the presence of ongoing limitations in shoulder function. Patients who underwent video-assisted thoracic surgery (less than 1 year from operation) had less pain and subjective shoulder dysfunction although their pain medication requirements were similar to those of thoracotomy patients less than 1 year from operation. After 1 year, there was no significant difference in these “pain related” morbidity parameters between the two surgical approach groups (video-assisted thoracic surgery or thoracotomy).
Video-assisted thoracoscopic surgery provides an alternative to conventional thoracotomy for resection of peripheral lung nodules. To localize small peripheral lung nodules that may not be visible or palpable by the surgeon, we have placed a Kopans hook wire percutaneously into the lung as a guide. The indications for localization included previous nondiagnostic percutaneous needle aspiration biopsy (PNAB) (n=4), nodules too small for PNAB (n=2), nodules inaccessible to PNAB (n=3), and planned resection of a known peripheral tumor less than 1 cm (n=1). The localization procedure was performed with computed tomographic guidance in all patients. The nodules ranged in size from 2 to 15 mm and were located immediately subpleural to 2-cm deep the pleura. A 20-gauge Greene biopsy needle was used as an introducer for a 35-cm-long Kopans hook wire. Patients were sent directly to the operating room in a dependent position. All ten nodules were successfully resected, including hamartoma (n=1), carcinoid tumors (n=2), granulomas (n=3), adenocarcinoma (n=1), fibrosis (n=1), benign metastasizing leiomyoma (n=1), and lymphoma (n=1). In two patients, the wire slipped out of the lung. Small focal pneumothoraces developed in five patients. There were no major complications. This procedure can safely and effectively localize nonvisible or nonpalpable pulmonary nodules for thoracoscopic surgery for diagnostic purposes or for resection of small peripheral tumors in patients who cannot tolerate a lobectomy or pneumonectomy.