Müller Joachim, Putora Paul Martin, Schneider Tino, Zeisel Christoph, Brutsche Martin, Baty Florent, Markus Alexander, Kick Jochen
Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
Interact Cardiovasc Thorac Surg. 2016 Sep;23(3):345-50. doi: 10.1093/icvts/ivw136. Epub 2016 May 20.
Radioactive marking can be a valuable extension to minimally invasive surgery. The technique has been clinically applied in procedures involving sentinel lymph nodes, parathyroidectomy as well as interventions in thoracic surgery. Improvements in equipment and techniques allow one to improve the limits. Pulmonary nodules are frequently surgically removed for diagnostic or therapeutic reasons; here video-assisted thoracoscopic surgery (VATS) is the preferred technique. VATS might be impossible with nodules that are small or located deep in the lung. In this study, we examined the clinical application and safety of employing the newly developed handheld single photon emission tomography (handheld SPECT) device in combination with CT-guided radioactive marking of pulmonary nodules.
In this pilot study, 10 subjects requiring surgical resection of a pulmonary nodule were included. The technique involved CT-guided marking of the target nodule with a 20-G needle, with subsequent injection of 25-30 MBq (effective: 7-14 MBq) Tc-99m MAA (Macro Albumin Aggregate). Quality control was made with conventional SPECT-CT to confirm the correct localization and exclude possible complications related to the puncture procedure. VATS was subsequently carried out using the handheld SPECT to localize the radioactivity intraoperatively and therefore the target nodule. A 3D virtual image was superimposed on the intraoperative visual image for surgical guidance.
In 9 of the 10 subjects, the radioactive application was successfully placed directly in or in the immediate vicinity of the target nodule. The average size of the involved nodules was 9 mm (range 4-15). All successfully marked nodules were subsequently completely excised (R0) using VATS. The procedure was well tolerated. An asymptomatic clinically insignificant pneumothorax occurred in 5 subjects. Two subjects were found to have non-significant discrete haemorrhage in the infiltration canal of the needle. In a single subject, the radioactive marking was unsuccessful because the radioactivity spread into the pleural space.
In our series of 10 patients, it was demonstrated that using handheld SPECT in conjunction with VATS to remove radioactively marked pulmonary nodules is feasible. The combination of proven surgical techniques with a novel localization device (handheld SPECT) allowed successful VATS excision of pulmonary nodules which, due to their localization and small size, would typically have required thoracotomy.
ClinicalTrials.gov, NCT02050724, Public 01/29/214, Joachim Müller.
放射性标记可成为微创手术的一项重要补充技术。该技术已在涉及前哨淋巴结、甲状旁腺切除术以及胸外科手术等操作中得到临床应用。设备和技术的改进使得人们能够突破相关限制。肺结节常因诊断或治疗原因而进行手术切除；在此，电视辅助胸腔镜手术（VATS）是首选技术。对于小的或位于肺深部的结节，VATS可能无法实施。在本研究中，我们考察了新开发的手持式单光子发射断层扫描（手持式SPECT）设备联合CT引导下肺结节放射性标记的临床应用及安全性。
在这项前瞻性研究中，纳入了10例需要手术切除肺结节的受试者。该技术包括用20G穿刺针在CT引导下对目标结节进行标记，随后注射25 - 30MBq（有效剂量：7 - 14MBq）的Tc - 99m MAA（大颗粒白蛋白聚集物）。采用传统SPECT - CT进行质量控制，以确认定位正确并排除与穿刺操作相关的可能并发症。随后使用手持式SPECT进行VATS手术，以在术中定位放射性从而确定目标结节。将三维虚拟图像叠加在术中视觉图像上以辅助手术。
10例受试者中有9例放射性物质成功直接放置在目标结节内或其紧邻区域。所涉及结节的平均大小为9mm（范围4 - 15mm）。所有成功标记的结节随后均通过VATS完全切除（R0切除）。该操作耐受性良好。5例受试者出现无症状且临床上无显著意义的气胸。2例受试者在穿刺针进针通道发现不显著的散在出血。1例受试者放射性标记未成功，因为放射性物质扩散至胸膜腔。
在我们的10例患者系列中，证明了使用手持式SPECT联合VATS切除放射性标记的肺结节是可行的。成熟的手术技术与新型定位设备（手持式SPECT）相结合，使得成功通过VATS切除因位置和大小原因通常需要开胸手术的肺结节成为可能。
ClinicalTrials.gov，NCT02050724，公开于2014年1月29日，Joachim Müller
