Image-guided video-assisted thoracoscopic surgery (VATS) excision of small peripheral pulmonary nodules (SPPN) in patients with previous extra-thoracic malignancies

• Main Author: Almousa, Omamah H
• Language: English
• Published: University of British Columbia 2015
• Online Access: http://hdl.handle.net/2429/55261

Objective: The purpose of this study is to determine the utility of preoperative CT-guided microcoil localization (CTML) followed by fluoroscopy guided VATS resection in the diagnosis and management of SPPN in patients with extra-thoracic malignancies. Methods: This study was a retrospective analysis of prospectively collected data between August 2003 and September 2013. Fifty patients underwent preoperative localization of undiagnosed SPPN using percutaneously placed CT-guided platinum microcoils (CTML). Coils were placed with the distal end deep to the nodule and the superficial end coiled on the visceral pleural surface. Nodules were removed by VATS wedge excision using endostapler with visualization by intraoperative fluoroscopy and VATS. Results: A total of 50 patients with a cumulative history of 14 different extra-thoracic cancers (57% female, mean age 62 years) had 55 nodules resected (mean size = 12.11mm, depth from visceral pleura = 22.07 mm) using CTML and fluoroscopic guided VATS wedge excision. The previously treated extra-thoracic tumor sites were colorectal (16), breast (9), urogenital (9), sarcoma (5), melanoma (3), lymphoma (3), thyroid (3), gastro esophageal (2), others (3). Nodule histology showed metastasis (25/50 patients), benign (11/50) and (15/50) early stage primary lung cancer. On logistic regression analysis, lung nodules in smokers were found 6 times more likely to represent primary lung cancer than metastasis (p 0.009). CTML procedure was successful in all patients with a mean time of 31.5 minutes and allowed successful diagnostic VATS wedge resection in all cases with no major complications. The mean time of VATS and fluoroscopy were 26.68 minutes and 1.35 minutes, respectively. After a follow up period of 35 months, all patients were alive and none of the patients had local recurrence of disease. Conclusions: Pre-operative localization of small peripheral pulmonary nodules using percutaneous CT-guided microcoil localization followed by fluoroscopic guided VATS resection was effective in achieving early definitive diagnosis, and changed the management and improved the prognosis in 50% of patients with presumed metastasis with minimal morbidity. The 20% of patients with benign disease required no further therapy while the 30% of patients with early stage primary lung cancer underwent curative surgical resection. === Surgery, Department of === Medicine, Faculty of === Graduate