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ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 671-675

Preoperative computed tomographic-guided percutaneous coil localization of pulmonary nodules: 184 Cases in Single-center


1 Department of Medical Intervention, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University; Department of Medical Intervention, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
2 Department of Medical Intervention, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
3 Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
4 Department of Radiology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University; Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China

Date of Submission02-Dec-2020
Date of Decision20-Jan-2021
Date of Acceptance08-Mar-2021
Date of Web Publication9-Jul-2021

Correspondence Address:
Ximing Wang
Department of Radiology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250021; Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1736_20

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 > Abstract 


Objectives: The aim of this study was to evaluate the feasibility, accuracy, and safety of computed tomographic (CT)-guided coil localization before video-assisted thoracoscopic surgery.
Methods: One hundred and eighty-four consecutive patients with 200 pulmonary nodules who underwent CT-guided percutaneous coil localization before thoracoscopic surgery were retrospectively analyzed in this study. Success rate for localization, complication rates, CT findings, and pathological results of the lesions, as well as the data related to surgery were all recorded and analyzed.
Results: All 184 patients with 200 lesions completed localization and resection. The success rate of the coil localization on lesion baseline was 99.0% (198/200) and 98.9% (182/184) on patient baseline. The number of wedge resection, segmental resection, and lobectomy were 179 (89.5%), 19 (9.5%), and 2 (1.0%), respectively. The malignancy rates in a lesion-based analysis were 83.5% (91.1% in ground-glass nodules, 91.4% in part-solid nodules, and 37.9% in solid nodules). No serious complications occurred in all localization procedures.
Conclusion: Preoperative CT-guided percutaneous coil localization is a safe and effective method to facilitate high success rates for both wedge and segmental resection for peripheral pulmonary nodules.

Keywords: Coil, computed tomographic-guided, localization, pulmonary nodule, video-assisted thoracoscopic surgery


How to cite this article:
Han X, Li Z, Gu H, Shi H, Dou W, Wang X. Preoperative computed tomographic-guided percutaneous coil localization of pulmonary nodules: 184 Cases in Single-center. J Can Res Ther 2021;17:671-5

How to cite this URL:
Han X, Li Z, Gu H, Shi H, Dou W, Wang X. Preoperative computed tomographic-guided percutaneous coil localization of pulmonary nodules: 184 Cases in Single-center. J Can Res Ther [serial online] 2021 [cited 2021 Aug 5];17:671-5. Available from: https://www.cancerjournal.net/text.asp?2021/17/3/671/321019




 > Introduction Top


Lung cancer is the leading cause of cancer death worldwide.[1] Approximately 70% of patients have advanced disease at the time of diagnosis. Correspondingly, only 15% in all lung cancer patients survive more than 5 years.[2] In 2011, the National Lung Screening Trial (NLST) in U.S. reported that three annual computed tomographic (CT) screenings resulted in 20.0% lower mortality from lung cancer than screening with the use of chest radiography at high risk for lung cancer and the trial recently confirmed that reduction in lung cancer deaths was sustained. The detection rate of pulmonary nodules in healthy people has recently increased due to the widespread use of low-dose computed tomography.[3],[4],[5] The prevalence of noncalcified lung nodules in screening study population has been reported as 33% (range: 17%–53%) and 13% (range: 2%–24%) represents an incidental finding. However, the prevalence of malignancy was similar (around 1.5%) in two groups.[6] Researchers have reported a ground-glass nodule (GGN) malignancy rate of 59%–73%.[7] Video-assisted thoracoscopic wedge or segmental resection is the best diagnostic or therapeutic method for pulmonary nodules and provides less discomfort and reduced postoperative complications compared to standard thoracotomy.[8],[9],[10],[11] Meanwhile, surgical resection may provide nearly 100% disease-free survival for patients with subsolid lung nodules.[12] However, accurate localization and resection of small lesions, especially nonsolid nodules, are a challenge in thoracoscopic surgery or open thoracotomy. Therefore, it is necessary to provide a safe and effective preoperative localization technique. Current relevant reports tended to study the application of preoperative localization in wedge resection. Meanwhile, we find that some deep lesions requiring segmentectomy also need preoperative localization to determine the lesion location. In the past year, our interventional therapy team has performed 184 preoperative localization of pulmonary nodules by coils. Relevant case reports and experience are summarized as follows.


 > Methods Top


Patients

One hundred and eighty-four consecutive patients (66 male, age: 53.7 ± 9.3) with 200 pulmonary nodules underwent CT-guided percutaneous coil localization before thoracoscopic surgery from May 2019 to May 2020 were retrospectively analyzed [Table 1]. Single nodule was planned to localize in 171 patients, two nodules in 11 patients, three nodules in 1 patient, and a maximum of four nodules localized in 1 patient. Forty-two targeted nodules were in left upper lobe lung, 33 in left inferior, 65 in right upper, 12 in right middle, and 48 in right inferior. According to the CT manifestations, all target nodules can be classified as GGNs (101), part-solid nodules (70), and solid nodules (29). Inclusion criteria for preoperational localization as follows: (1) the target lesions were all indicated for surgical resection after consultation by thoracic surgeons and imaging physician. All lesions were determined to excise under preoperative localization by multidisciplinary team (MDT), including thoracic surgeon, respiratory physician, radiologist, and pathologist; (2) each nodule size was <3 cm; (3) wedge or segmental resection under the video-assisted thoracoscopic surgery (VATS) is the planned surgical method; and (4) there are no contraindications for thoracic surgery. All patients or clients were informed and signed informed consent before positioning and surgery.
Table 1: Patients' characteristics

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Localization procedure

All patients were scheduled to complete localization within 2–6 h before the thoracoscopic surgery on the same day. According to the location of the nodules and the operability, reasonable position of patients was determined, including supine, lateral, and prone position. The CT guiding equipment adopted a Siemens AS40-slice spiral CT. 10 cm or 15 cm 18G PTC needles (Hakko, Japan) were selected for puncture according to the thickness of chest wall and the depth of lesions. The localization marker adopted 18S-8–4 tower-type coil (Cook, USA). All procedures were performed under local anesthesia. First, 18G puncture needle was advanced nearby the target nodule and confirmed by CT scan. Second, 1/2–3/4 of the coil was inserted into the lung tissue through the 18G needle so that the head of the coil was curled at the lesion and kept the residual segment of the coil remaining in the trocar of the 18G needle. Third, pulled out the puncture needle trocar slowly and made sure that 2–3 cm of the end of the coil was dragged out of the pleura. Fourth, after the coil was placed, the CT scan was performed again to confirm the presence of complications and the CT images were sent to the surgeon to inform the relevant parameters of the coil [Figure 1]. Finally, the patient returned to the ward to wait surgery.
Figure 1: (a) 18G needle (blue arrow) was advanced nearby the target nodule. (b) Part of the coil was inserted into the lung tissue through the 18G needle. The head of the coil curled up into a knot (red arrow). The end of the coil remained in the needle and outside the pleura (yellow arrow). (c) Pulled out the puncture needle and the localization was finished

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Surgery procedure

The patient underwent thoracoscopic surgery under general anesthesia on the day of localization. Under the VATS, the coil could be seen hanging on the chest wall or entrenched on the visceral pleural surface [Figure 2]. Wedge resection or segmentectomy was performed according to the CT image and relevant parameters of the coil. After resection, the lesions were immediately sent to rapid pathological examination. Based on preoperative planning and rapid pathologic findings, the surgeon determines whether further lobectomy is necessary to performed. Untouchable lesions, such as deep, soft, or small lesions, should be resected with the localizable coils together to find the lesions along the coils in the excised tissue.
Figure 2: (a) The head of the coil was embedded in lung tissue and the tail was suspended from the chest wall. (b) The tension at the head of the coil was stronger than at the tail. The coil is retained stably in the lung tissue. (c) Severe pleural adhesion. The coil was found by blunt separation

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Statistical analysis

The software of statistical analysis was used by SPSS v21.0 (SPSS Inc., Chicago, IL, US). Descriptive statistics for continuous variables were presented as mean ± standard deviation or median. Pearson's Chi-square test was used to analyze the results and compare wedge resection and segmentectomy. Statistical significance was defined as P < 0.05.


 > Results Top


All 184 patients with 200 nodules completed preoperative puncture coil localization and VATS. 198 lesions in 182 patients were accurately resected, assisted by coil localization. Two lesions in 2 patients were not accurately localized by the coil and resected by lobectomy alternatively. The success rate of the coil localization on lesion baseline was 99.0% (198/200) and 98.9% (182/184) on patient baseline. According to the preoperative plans, 163 patients with 179 lesions underwent wedge resection and segmentectomy was performed in the other 19 patients. Thirty-seven patients in wedge resection group and two patients in segmentectomy group suffered additional lobectomy in term of the risk assessment by surgical teams based on rapid pathological findings.

Common complications after localization included local pain, pneumothorax, and hemorrhage, all of which did not affect the original thoracoscopic surgical plan. Eight patients (4.3%, 8/184) were administrated nonsteroidal analgesics due to intolerant pain. Pneumothorax occurred in 11 patients (6.0% 11/184), and each volume of pneumothorax was <15 of single thoracic cavity. No one with pneumothorax required closed thoracic drainage. A small amount of hemoptysis occurred after localization in 3 patients (1.6%, 3/184). Intrathoracic hemorrhage was found in two patients (1.1%, 2/184) during the thoracoscopic surgery, and the bleeding volume was <10 ml. Other serious complications did not occur.

Postoperative pathological results indicated that 167 nodules were malignant, including 5 lesions of atypical adenomatous hyperplasia, 51 lesions of adenocarcinoma in situ, 62 lesions of minimally invasive adenocarcinoma (IA), 44 lesions of IA, 3 lesions of mucinous adenocarcinoma, 1 lesion of mucosa-associated lymphoid tissue lymphoma, and 1 lesion of carcinoid. The other 33 nodules were benign, of which 23 were chronic inflammation, 4 were hamartoma, 3 were adenoma, 2 were lymph node, and 1 was reactive hyperplasia. The total malignancy rates in a lesion-based analysis was 83.5% (91.1% in GGN, 91.4% in part-solid nodules, and 37.9% in solid nodules, P = 0.000). The pathological diagnoses of all nodules classified as imaging findings are shown in [Table 2].
Table 2: Pathology results

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 > Discussion Top


The decision about the appropriate modality for the surgical management of peripheral pulmonary nodules is dependent on multiple factors, including imaging findings, surgeon preference, and patient's condition, etc., Pulmonary nodules without preoperative localization are difficult to wedge resection or segmentectomy during VATS, which may lead to an increase in thoracotomy up to 46%.[13],[14],[15] Recent studies have shown that preoperative localization is an effective assisted method for wedge resection of pulmonary nodules. For some lesions with small diameter and lack of solid components, it is a challenge to find them in the excised tissue. The coil can help the surgeon find the lesion in the excised tissue rapidly and accurately. In our study, 19 patients suffered preoperative coil localization before segmentectomy and the pathologic results were accurately obtained. Statistical analysis in the two groups of wedge resection and segmentectomy showed that there was no difference in several indicators except for the diameter of nodules [P = 0.003, [Table 3]]. Therefore, it is necessary for small lesions (≤10 mm) requiring preoperative localization before segmental resection.
Table 3: Surgery after percutaneous coil localization

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Multiple preoperative localization methods have been reported, including but not limited to using hook wire, intraoperative ultrasound, injecting medical dye or glue, and injecting.[16],[17],[18],[19],[20],[21] Hook wires are widely used for preoperative localization. However, as a kind of hard localizable material, hook wire can easily cause pan, bleeding, pneumothorax, and displacement from the lung with the patient's respiratory and other necessary movement.[22],[23],[24] Intraoperative ultrasound used for searching intrapulmonary lesions does not add invasive procedures to patients. When the lesion in diameter is <1 cm lesions or air remains in the collapsed lung tissue, it cannot be detected clearly by ultrasonography.[25] Methylene blue, as a common dye, can be used for preoperative localization by local injection, which has the problem of rapid diffusion and unclear label.[26] In addition, injection of medical glue for localization may cause a risk of embolization.[19] The results of this study confirm that the coil localization can overcome the shortcomings of the above methods and provide more wide-range using. The advantages of using coils lie in: (1) accuracy – coils can clearly mark the lesion location, especially for the pleural adhesion. (2) Stability – after imbedded, coils are not easy for displacement under the influence of the patient's breathing or movement. (3) Safety – only a few of patients may suffer pain or oppression in chest due to the pleural reaction, which can be relieve by NSAID. No series complications were recorded. (4) Generality – the length of coils is up to 8 cm, which allows for localizing almost all peripheral pulmonary nodules. (5) Repeatability – in our case, 13 patients with multiple lesions suffered 2–4 localization by coils in one procedure, and all lesions were excised accurately.

A variety of styles of coils are presented, we tend to use tower-type coils (18S-4-8). The self-curling tension in head of the coils is greater than that in the tail. Bending radius of the head part of coils is less than that of the tail part. The head part inserted into lung tissue can be curled into a small knot and the tail part remained outside the pleura is smooth relatively. This asymmetric structure helps to keep the coils stable in the lung and facilitate intraoperative exploration.

Timely communication with the surgeon after localization is also the key to the successful excision of the lesion. As the coils are placed on side of the lesion rather than in the center, the surgeon must clearly know the relative position of the lesion and the coil. Relevant data and images should be provided to the surgeon in time after localization procedures, including puncture position, lesion and coil depths, the correspondence between the lesion and the coil, and potential complications.

This study is a single-center retrospective study and it lacks scientific comparison with other localization methods. However, a large number of sample data proved that the CT-guided coil localization technology was a safe and accurate preoperative assistive method, which effectively guaranteed the accuracy of VATS for peripheral pulmonary nodules resection.


 > Conclusion Top


This study show that preoperative CT-guided percutaneous coil localization is a safe and effective method to facilitate high success rates for both wedge and segmental resection for peripheral pulmonary nodules.

Acknowledgment

The authors thank to the Department of Thoracic Surgery and the Department of Pathology, Shandong Provincial Hospital Affiliated to Shandong First Medical University for their support.

Financial support and sponsorship

This study was supported by a grant from the Taishan Scholars Project (XM. Wang), Project 81871354 and 81571672 supported by NSFC, Academic Promotion Programme of Shandong First Medical University (2019QL023).

Conflicts of interest

There are no conflicts of interest.



 
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