Radioguided video-assisted resection of non-palpable solitary pulmonary nodule/ground glass opacity: how to do it.

BACKGROUND

Detection of subcentimeter solitary pulmonary nodules (SPN) and ground glass opacities (GGO) is increased but their small size may make them difficult to be reached by computerized tomography (CT) guided fine needle agobiopsy or transbronchial biopsy. Surgical resection provides the gold standard for obtaining a specimen for histopathologic diagnosis, and video-assisted thoracic surgery (VATS) allows in many cases a minimally invasive technique of resections. The limit of VATS techniques is the need of nodule localization. Often-digital palpation is all needed to identify the appropriate area of resection, but sometimes it may be very difficult to identify and remove small, deep, non-palpable lesions. The criteria for nodule marking are unclear and variety of localization methods have been developed and they are effective but burdened by significant failure rate and complications. To increase the efficacy of thoracoscopic localization/ resection of small pulmonary nodules, we used the radioguided technique.

METHODS

Under CT guidance, the nodule was identified and a needle was inserted to reach lesional or perilesional tissue. A solution of technetium (Tc) macro-aggregates albumin diluted with iodized contrast medium was injected. After injection, CT was performed to confirm precise staining.

RESULTS

At VATS, a gamma detector probe allowed localization of nodules in all patients. Resection was performed, and suture margins were checked with the probe to search for residual hyperabsorption. All specimens underwent frozen section. Frozen section revealed diagnosis in all cases.

CONCLUSIONS

Radioguided surgery is a cost-effective strategy for evaluating suspicious SPN/GGO with a success rate close to 100%, extremely low morbidity, and zero mortality. Radioguided VATS may be useful for preoperative localization of deep, small lung nodules that cannot be digitally localized or for GGO opacities that can be difficult to palpate even with the open technique.