minimally invasive techniques

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1 minimally invasive techniques Needle Localization of Peripheral Lung Nodules for Video-assisted Thoracoscopic Surgery* jo-anne 0. Shepard, M.D.; Douglas]. Mathisen, M.D., F.C.C.P.; Victorine V. Muse, M.D.; fmeenakshi Bhalla, M.D.; and Theresa C. McLoud, M.D. 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 em (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 subl to 2- cm deep the. A 20-gauge Greene biopsy needle was used as an introducer for a 3xm-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=l), benign metastasizing leiomyoma (n=l), 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. (Chest 1994; 105:1559-&) OR=operating room; PNAB=percutaneous needle aspiration biopsy; VATS=video-assisted thoracoscopic surgery V ideo-assisted thoracoscopic surgery (VATS) is a new technique that has been used to examine and resect portions of the lung and without performing a traditional thoracotomy. The advancement of video technology coupled with conventional endoscopic methods in the chest provides superior endoscopic images of the lung and. With the improved optics and instrumentation that are now available, lung resection for peripheral pulmonary nodules can be performed by VA TS. 1 Locating the nodule may be a limiting factor. If the nodule is small ( <2 em) and/ or deep to the l surface, it may not be visible on inspection of the lung surface. Because the lung is collapsed during the thoracoscopy and the chest wall incisions for the instruments are small, it may not be possible to *From the Departments of Radiology (Drs. Shepard, Muse, Shalla, and McLoud) and General Thoracic Surgery (Dr. Mathisen), Massachusetts General Hospital and Harvard Medical School, Boston. fcurrently at Department of Radiology, New England Medical Center, Boston. Presented at the Meeting of the Radiological Society of North America, Chicago, December 4, Reprint requests: Dr. Shepard, Department of Radiology, Massachusetts General Hospital, Boston locate the nodule by palpation. In this article, we present our experience with a technique for localizing small peripheral pulmonary nodules for VATS that incorporates conventional mammographic localization techniques and PNAB techniques in the lung. MATERIALS AND METHODS Between October 1991 and June 1993, ten patients were referred by the general thoracic surgical service for needle localization of peripheral lung nodules. The indications for needle localization included the following: (1) small nodules inaccessible to percutaneous needle aspiration biopsy (PNAB) because of subcostal or paracardiac location (n=3); (2) nodules considered too small for PNAB, less than 1 em in size (n=2); (3) previous nondiagnostic PNAB (n=4); and (4) planned resection of a known small peripheral tumor (n=1). The patients ranged in age from 45 to 72 years and included seven women and three men. The nodules measured 2 to 15 mm in diameter and were located immediately subl to 2-cm deep to the l surface. The location of the nodules included right upper lobe (n=5), right middle lobe (n=1), right lower lobe (n=2), and left lower lobe (n=2). All patients had had prior chest computed tomography (CT) according to routine protocol. The shortest and most direct intercostal approach was selected, including posterior (n=4), posterolateral (n=2), anterior (n=3), and anterolateral (n=1). An approach was selected to avoid CHEST /105/5/ MAY,

2 j :Z: j I J I J I J I J I J I J : J I i I i I - 4 I I ~ FIGURE 1. Localization needle and wire. A 15-cm-long 20-gauge Greene aspirating needle (A) with a stylet (B) was used as an introducer for a 35-cm-long Kopans breast localization wire (C). A burnish mark (arrow) was present on the wire to indicate a point 15 em from the tip of the wire, corresponding to the length of the introducer needle. entering scapular muscles that may move with patient positioning and thus dislodge the wire or crossing fissures that may lead to pneumothorax. Localization Technique The patients were positioned on a Cf scanner (General Electric 9800, GE Medical Systems, Milwaukee) in the appropriate position. They were instructed not to talk, cough, or move during the procedure. Preliminary scans were obtained through the nodule with 5-mm collimation and the nodule was localized using a grid and light beam. The skin was prepared, draped, and anesthetized with 1 percent lidocaine. A nick was made in the skin with a No. 11 blade. A 15-cm-long 20-gauge Greene aspiration needle with a stylet (Cook, Bloomington, Ind) (Fig 1, A and B) was placed into the chest wall. One patient required a 20-cm-long needle due to a thick chest wall. Once the needle was properly aligned, the was punctured during suspended respiration. The needle was then positioned approximately 0.5- to 1-cm deep to the nodule. Whenever possible, the needle was placed through the nodule and deep to it. If for technical reasons this was not possible, the needle was placed adjacent to the nodule. Sequential CT scanning was performed to ascertain the needle position following each manipulation of the needle. Once the introducer needle was properly placed, the patient was instructed to suspend respiration, the stylet was removed, and the introducer needle was filled with saline solution to prevent potential air embolus. A 35-cm-long Kopans hook wire (Cook, Bloomington, Ind) (Fig 1, C) was then introduced through the 20-gauge needle and inserted beyond the tip of the needle to engage the hook in the lung. A burnish mark (arrow) is present on the wire at 15 em to indicate when the hook wire extends beyond the tip of the needle. The introducer needle was then removed and the position of the hook wire relative to the nodule was determined by Cf scanning. The external portion of the wire was loosely coiled and taped to the skin with sterile strips and dressed with gauze. The patients were then instructed to roll onto a stretcher and to lie in a dependent position on the wire. They were then brought directly to the operating room (OR) with a copy of the Cf scan demonstrating the hook wire within the lung. Although the localization procedure takes 45 to 60 min, the time from actual placement of the wire to surgical resection may be 1 to 3 h. Thoracoscopy Technique Once in the OR, the patient was placed in the usual thoracotomy position and prepared and draped as if for a standard thoracotomy, should one become necessary, either to achieve better exposure or manage a complication. General anesthesia was administered and the patients were intubated with a double-lumen tube. The lung was then collapsed and the thoracoscope, forceps, and stapler were inserted into the l space through three small 1580 intercostal incisions. The localization wire was visible as a guide to the nodule and could be used to tent up the lung if it was firmly engaged in the nodule (Fig 2). A wedge resection was then performed with the endoscopic stapler. The resected specimen was then examined by frozen section to obtain a diagnosis and determine whether adequate margins were obtained. The instruments were removed, a chest tube left in place, and the chest wall incisions were closed. RESULTS The results are summarized in Table l. Needle localization and wire placement was performed in ten patients under CT guidance with successful placement of the wire in eight patients. In two patients, the wire slipped out of the lung into the l space shortly after placement. Both of these patients developed small pneumothoraces at the time of needle localization. In one case, the patient coughed when the introducer needle punctured the and in the other case, the needle inadvertently crossed the major fissure. In one of the two patients in whom the wire slipped out of the lung, the hook rested against the parietal causing pleuritic chest pain. In an additional three cases, small, 1- to 15-mm, focal pneumothoraces developed after wire placement without dislodgement of the wire. Chest tube treatment for pneumothorax was not necessary in any patient. There was no evidence for hemorrhage in the lung or hemoptysis. All ten nodules were successfully resected by thoracoscopic wedge resection. In the two cases in which the wire became dislodged, the surgeon was able to identify the nodule by inspection. The resected nodules included hamartoma (n=1), granulomas (n=3), fibrosis (n=1), adenocarcinoma (n= 1), carcinoid tumors (n=2), benign metastasizing leiomyoma (n=1), and malignant lymphoma (n=1). DISCUSSION Imaged thoracoscopic surgery is a new procedure used to operate on intrathoracic organs without a thoracotomy incision. The thoracoscopic instruments, which include a thoracoscope, forceps, and an auto- Needle Localization of Peripheral Llllg Nodules (Shepard et sj)

3 FIGURE 2. Localization technique. Top, The patient was placed in the prone position. A 1-cm peripheral nodule in the posterior segment of the right-upper lobe was localized by CT. Center, A 20-gauge Greene aspirating needle was inserted through the nodule from a posterior intercostal approach. Bottom, The Kopans hook wire was then inserted through the introducer needle and lodged in the lung beyond the nodule (arrow) and the introducer needle was removed. matic stapler, are placed into the l space through three small intercostal incisions. With the help of video assistance, the surgeon has a panoramic view of the thoracic cavity. The advantages of thoracoscopic surgery include excellent visualization of the entire lung surface, chest wall, and mediastinum, small incisions without the need for rib retractors, less postoperative pain, and earlier return to normal function. Numerous procedures are being performed in this manner, including lung biopsy for diffuse interstitial disease, bullous ablation, treatment for recurrent pneumothorax, and excision of pulmonary nodules. 1 In the case of thoracoscopic resection of pulmonary nodules, localization of the nodule is the limiting factor. Some nodules may cause some puckering of the l surface of the lung or be visible by virtue of a bulge in the lung surface when the lung is deflated. However, small nodules or nodules deep to the l surface may not be visible at thoracoscopy. Additionally, it is not possible to predict on the basis of the CT which small nodules will be visible to the surgeon. Nodules may not be palpable through the small incisions normally made for the thoracoscopic instruments. Likewise, it is not possible to predict which lesions may be visualized or palpated by the surgeon without needle localization as evidenced by the two patients in this series in whom the wires were dislodged prior to surgery. Both of these lesions were located by the surgeon. Conventional mammographic localization techniques traditionally used to locate nonpalpable but mammographically visible breast nodules have been adapted to localize small peripheral lung nodules.2-5 Mack et ap accurately localized nine pulmonary nodules in six different patients. All nine nodules were removed with adequate surgical margins. No complications were reported. Plunkett et al 4 successfully placed a wire within 1 em of 19 of 21 nodules in 18 patients and diagnostic excisional wedge resections of those 19 nodules were obtained. Templeton and Krasna 5 successfully localized nodules less than 1 em in five patients. We achieved successful wire localization in eight of ten patients. In the two patients in whom localization was not successful, the wire slipped out of the lung shortly after placement. Both patients had small pneumothoraces. However, in an additional three patients in whom small pneumothoraces developed, the wire did not become dislodged. We have found that it is best to anchor the hook slightly deeper than the lesion so that if there is traction on the wire, the hook will pull into the lesion and not away from it. Although small pneumothoraces developed in five of ten patients in our series and 50 percent of the patients in the series of Plunkett et al, 4 none of the patients required chest tube treatment. Plunkett et al reported pleuritic chest pain in "several" of their patients and a small extral hematoma was present in one patient. Pleuritic chest pain was present in only one of ten patients in our series. Major complications have not been observed by us CHEST /105/5/ MAY,

4 Patient No./ Age, Yr/Sex I/59/F 2/47/M 3/52/M 4/57/F 5/62/F 6/63/F 7/54/F 8/45/M 9/72/F 10/66/F Table l-resulu of Needle Localization for Thoracoscopic Wedge Resection* Indication New solitary LLL nodule PNAB--+ carcinoid tumor Newly diagnosed LLL nodule located beneath a rib Prior renal cell Ca; new LUL nodule too small for NAB Cluster of nodules RUL too small for PNAB New RUL to nodule; nondiagnostic PNAB RML nodule too close to heart for PN AB Multiple new bilateral pulmonary nodules; nondiagnostic, NAB X3 Cardiac transplant, increasing SPN in RLL; nondiagnostic NAB New LUL nodule PNAB--+ nondiagnostic Incidental new RUL nodule located beneath a rib Size and Location 8-mm nodule, LLL posterior basal segment, 2-cm deep to 1-cm nodule laterobasal segment LLL adjacent to 1-cm nodule, RUL posterior segment, 2-cm deep to Cluster of 2- to 3-mm nodules posterior segment RUL, 1 em deep to 1-cm nodule posterior segment RUL against 12-mm RML nodule medial segment, 0.5 em from anterior 12-mm RLL posterior basal segment against 1.5-cm nodule RLL posterolateral segment against 1.5-cm nodule LUL apical posterior segment, 2-cm deep to 1-cm nodule RUL apical segment, 2-cm deep to Approach Posterolateral Anterolateral Posterolateral Complication 5-mm focal PTX 1-mm PTX 1.5-cm PTX ; needle and wire nicked the major fissure; wire fell out of lung Patient coughed with needle on cm PTX; difficulty positioning needle and wire; wire slipped into l space causing chest pain 5-mm post-ptx Diagnosis Carcinoid tumor Caseating granuloma Necrotizing granuloma Necrotizing granuloma Adenocarcinoma arising in scar Fibrosis Benign metastasizing leiomyoma Malignant lymphoma, diffuse large cell immunoblastic plasmacytoid type Carcinoid tumor Hamartoma *Ca=carcinoma; LLL=Ieft lower lobe; LUL=Ieft upper lobe; NAB=needle aspiration biopsy; PTX=pneumothorax; RLL=right lower lobe; RML=right middle lobe; RUL=right upper lobe; SPN=solitary pulmonary nodule. or others following this procedure. To avoid the potential of pulmonary hemorrhage, only patients with normal results of coagulation studies are considered as candidates for needle localization in the lung. Retention of a wire fragment in the lung or l space has not been reported as a complication. However, it is important to note that the entire wire should be removed at the time of thoracoscopy because migration of localization wires to other parts of the body has been reported. 6 Plunkett et al, 4 Mack et al,s and Bret et af have injected methylene blue through the introducer needle before placement of the wire to ensure that 1582 the nodule would be visualized at thoracoscopy if the wire became dislodged from the lung. Because the dye does diffuse with time, we have chosen not to use it. Others have employed skin surface markers as a guide to lung resection, but when the lung is deflated for thoracoscopic surgery, the relationship of the nodule to the chest wall changes.b- 10 Various localization needles and wires have been employed. Plunkett et al 4 used a Hawkins III breast localization system (Medi-tech/Boston Scientific, Watertown, Mass), Mack et ap employed a different system (Sadowsky Breast Marking System, Ramfac Corporation, Avon, Mass). Templeton and Krasna 5 Needle Localization of Peripheral Loog Nodules (Shepard et al)

5 used another system (Homer Mammalok Plus 20- gauge needle/wire breast localization system, Mitek Surgical Products Inc, Namic Angiographic Systems Division, Glen Falls, NY), and we employed a Greene aspirating needle and Kopans localization wire (Cook, Bloomington, Ind) with similar results. An important feature in wire selection is choosing a wire that is long enough to extend from the chest wall to the lesion when the the lung is deflated at the time of surgery. It is also useful to have a burnish mark on the wire corresponding to the length of the needle to ascertain the position of the hook relative to the tip of the needle. We believe that it is also important to occlude the introducer needle with a stylet while positioning the needle in the lung to avoid the potential of an air embolus. REFERENCES Lewis RJ, Caccavale RJ, Sisler GE. Imaged thoracoscopic lung biopsy. Chest 1992; 102: Kopans DB, Swann CA. Preoperative imaging-guided needle placement and localization of clinically occult breast lesions. AJR 1989; 152:1-9 3 Mack MJ, Gordon MJ, Postma TW, Berger MS, Aronoff RJ, Acuff TE, et al. Percutaneous localization of pulmonary nodules for thoracoscopic lung resection. Ann Thorac Surg 1992; 53: Plunkett MB, Peterson MS, Landreneau RJ, Ferson PF, Posner MC. Peripheral pulmonary nodules: preoperative percutaneous needle localization with CT guidance. Radiology 1992; 185: Templeton PA, Krasna M. Localization of pulmonary nodules for thoracoscopic resection: use of needle/ wire breastbiopsy system. AJR 1993; 160: Davis PS, Wechter RJ, Feig SA, March DE. Migration of breast biopsy localization wire. AJR 1988; 150: Bret PM, Shennib H, Atri M. Localization of pulmonary nodules for thoracoscopic lung resection [ a b s t rradiology c t ~ 1992; 185:293 8 Daly BOT, Pugatch RD, Fating LJ, Jung-Legg V, Gale ME, Snider GL. Computed tomography mini-thoracotomy: a preliminary report of a new approach to open lung biopsy. Radiology 1983; 146: Daly BOT, Fating LJ, Diehl JT, Bankoff MS, Gale ME. Computed tomography-guided mini-thoracotomy for the resection of small peripheral pulmonary nodules. Ann Thorac Surg 1991; 51: Jacobson FL, Shaffer K, Mentzer S, Pugatch RD, Stark P. CT-guided tattoo for lesion localization before thoracoscopic surgery. Radiology 1992; 185(P):293 CHEST /105/5/ MAY,