Bronchioloalveolar carcinoma in small pulmonary nodules: clinical relevance

Increased use of chest computed tomography (CT) as well as improvements in CT resolution has led to increased detection of subcentimeter pulmonary nodules. Although the majority of these nodules are benign in etiology, a subset will harbor bronchioloalveolar carcinoma. The diagnosis of malignancy in this setting can be challenging to radiologists, surgeons, and occasionally pathologists as well. The challenge is compounded by a lack of knowledge about the natural course of these lesions--specifically, whether they represent life-threatening aggressive malignancies or indolent lesions of little or no consequence. Given the relative infrequency of these abnormalities, it will be essential to establish a sufficiently large database, to organize multi-institutional registries, and to collaborate on correlative studies. Only in this way will we be able to determine the clinical and molecular characteristics of these lesions and thus hopefully gain insight into their clinical relevance.     

肺部小结节的外科策略

肺部小结节(SPN)是临床上常见的现象,早期临床难以判断其性质。恶性SPN发病较隐匿,如果不进行临床干预,其病程发展迅速、恶性程度高、预后差。如能在早期就对恶性病灶行手术切除,会明显改善患者的预后。目前对肺小结节的处理指南更新频繁,但各大指南尚未达成统一共识。文章通过收集国内外各大中心针对SPN处理的临床研究,明确SPN的定义,并对其诊断标准和手术指征进行了系统归纳,对不同类型SPN的外科处理策略进行了总结分析,以达到指导临床诊治的目的。     

Needle localization of small pulmonary nodules: Lessons learned

Background

Lung nodules that are small and deep within lung parenchyma, and have semisolid characteristics are often challenging to localize with video-assisted thoracoscopic surgery (VATS). We describe our cumulative experience using needle localization of small nodules before surgical resection. We report procedural tips, operative results, and lessons learned over time.

Localization of small pulmonary nodules for videothoracoscopic surgery

The aim of this study is to discuss and summarize the localization of small pulmonary nodules for video-thoracoscopic surgery. Thirty-eight patients were selected, 22 men and 16 women, and they underwent video-assisted thoracoscopic surgery resection for small pulmonary nodules: 28 patients for small solitary pulmonary nodules and 10 patients for multiple small pulmonary nodules. In all cases, resection of the nodules was successful. Localization methods included: (i) computed tomography (CT)-guided methylene blue labelling for preoperative localization; (ii) a high-quality chest CT scan for preoperative localization; (iii) visual exploration, digital palpation and 'instrumental' palpation to locate the nodule; and (iv) endosonographic inspections of intraoperative localization. Using a combination of CT scan, digital palpation, methylene blue labelling and endosonographic inspections, all nodules were successfully localized and resected without significant complications. Video-assisted thoracoscopic surgery is an effective approach but the small lung nodules (especially those less than 1.0 cm in diameter) localized at thoracoscopic resection must be treated carefully. Combined imaging and thoracoscopic techniques may help identify small nodules.     

A strategy for thoracoscopic resection of small pulmonary nodules

BACKGROUND: Preoperative procedures are often necessary to localize pulmonary nodules during thoracoscopic resection in order to reduce the necessity of resorting to thoracotomy. The aim of this report is to describe the strategy we developed to limit preoperative techniques without reducing the thoracoscopic success rate of localization.METHODS: Between January 2000 and December 2003, 183 patients underwent video thoracoscopic resection of small pulmonary nodules. The patients were divided into two groups on the basis of the radiological features of the nodule. The subjects in group 1 were operated on directly, and endothoracic ultrasonography was performed when necessary. The subjects in group 2 underwent preoperative radionuclide labeling of the nodule. RESULTS: In group 1, 112 out of 119 nodules (94%) were localized. Twenty-five out of 32 lesions, neither visible nor palpable, were found by endothoracic ultrasonography. In group 2, we localized 62 out of 64 nodules (97%). CONCLUSIONS: Currently, we cannot completely avoid preoperative labeling techniques for thoracoscopic resection of small pulmonary nodules. However, correct patient selection may limit this necessity, without an increased conversion rate to thoracotomy, if endothoracic ultrasonography is available.     

Diagnostic accuracy of fine-needle aspiration biopsy versus frozen section in solitary thyroid nodules

Fine-needle aspiration biopsy is widely used in the diagnosis and management of the solitary thyroid nodule. It is the most accurate tool available and decreases the need for ultrasonography and thyroid scanning. In those patients who are selected for surgical treatment by fine-needle aspiration biopsy, it has been advocated as a guide to determining the extent of operation. Frozen section, which usually serves as the surgeon's guide, and fine-needle aspiration biopsy both have varying accuracy rates. Few direct comparisons have been made. We studied 198 aspirates in 198 patients who presented with a solitary nodule and had surgical excision. Fine-needle aspiration biopsy (198 cases) and frozen section (182 cases) were compared with the final histologic diagnosis. Accuracy rates for fine-needle aspiration biopsy and frozen section were 90 percent and 95 percent, respectively. Fine-needle aspiration biopsy detected 43 percent of the cancers and frozen section, 64 percent. There were no false-positive diagnoses with frozen section, but three cases with fine-needle aspiration biopsy. The false-negative diagnosis rate was 5 percent for frozen section and 8.5 percent for fine-needle aspiration biopsy. When the "other" diagnosis category was grouped with the "positive" diagnosis category and a single expert cytopathologist was used to read the cytology report, the sensitivity was increased to 80 percent whereas the accuracy was maintained at 83 percent. We believe that since there were no false-positive diagnosis using frozen section, it can reliably be used as a guide when it reveals malignancy. When the fine-needle aspiration biopsy diagnosis is "positive" or "other," it can guide operation, but only after carefully assessing the wording of the cytology report and the clinical situation. Each modality can provide information missed by the other. We continue to use them as complementary tools in the diagnosis and management of solitary thyroid nodules.     

A novel technique for localization and excisional biopsy of small or ill-defined pulmonary lesions

BACKGROUND: The purpose of this study was to develop and evaluate radiotracer-guided localization of small or ill-defined pulmonary nodules for thoracoscopic excisional biopsy. METHODS: This study consisted of two parts: a laboratory study in rats to determine the most suitable radiotracer, and a pilot study in humans to determine the feasibility of radiotracer lung nodule localization. The right lung of 12 rats was injected with a technetium 99m (Tc 99m) based radiotracer solution: 4 each with macroaggregated albumin (MAA), unfiltered sulfur colloid (SC), and pertechnetate (TcO(4)). Serial imaging was performed using a small animal gamma camera for 4 hours following injection. In 13 patients, computed tomographic (CT) guided injection of Tc 99m MAA solution was made into or adjacent to a pulmonary nodule suspicious for primary lung cancer. Gamma probe localization of the nodule was performed during subsequent thoracoscopic surgery. RESULTS: In the animal model, MAA provided more precise localization than SC or TcO(4) and was selected for the human study. In the human series, all 13 patients had successful gamma probe localization of their lesion. There were no radiologic or surgical complications. Seven of 13 nodules were malignant, and five of these nodules were stage IA primary lung carcinomas. CONCLUSIONS: Computed tomographic-guided radiotracer localization of small or ill-defined pulmonary nodules using Tc 99 m MAA before thoracoscopic excisional biopsy is feasible and may make excisional biopsy the preferred management strategy for the management of small pulmonary nodules in patients at high risk for malignancy.     

Radio-guided thoracoscopic surgery (RGTS) of small pulmonary nodules

Background  

The demand for adequate tissue sampling to determine individual tumor behavior is increasing the number of lung nodule resections, even when the diagnosis is already recognized. Video-assisted thoracic surgery (VATS) is the procedure of choice for diagnosis and treatment of small pulmonary nodules. Difficulties in localizing smaller and deeper nodules have been approached with different techniques. Herein we report our 13-years’ experience with radio-guided thoracoscopic resection.     

对比医用胶与Hook-wire在肺小结节胸腔镜下肺组织切除术前定位中的应用

目的对比医用胶与Hook-wire在肺小结节(最大径≤30mm)胸腔镜下肺组织切除术前定位中的应用价值。方法回顾性分析107例接受胸腔镜下肺楔形切除、肺段或肺叶切除术的肺小结节患者的资料。按术前定位方法分为医用胶组(88例,共90个结节)及Hook-wire组(19例,共19个结节),比较2组病灶位置、结节大小、结节与胸膜的距离、结节良恶性、胸腔镜手术方式及并发症(包括气胸、肺出血、局部疼痛、咳嗽)的差异,并对并发症的相关危险因素进行二元Logistic回归分析。结果 2组病灶位置、结节大小、结节与胸膜的距离、结节良恶性及胸腔镜手术方式差异均无统计学意义(P均0.05),术前定位成功率均为100%。医用胶组总体并发症发生率及肺出血发生率均明显低于Hook-wire组(P均0.01)。定位方法为总体并发症、肺出血、局部疼痛的独立危险因子,结节到胸膜的距离为肺出血的独立危险因子。结论医用胶可用于肺小结节胸腔镜下肺组织切除术前定位,且相对于Hook-wire定位并发症发生率更低。     

Frozen section detection of lymph node metastases in prostatic carcinoma: accuracy in grossly uninvolved pelvic lymphadenectomy specimens

We reviewed our frozen section experience with 310 pelvic lymphadenectomy specimens during the last 5 years. A total of 40 patients (12.9 per cent) had positive lymph nodes on permanent section. In 6 of these patients the lymph nodes were involved grossly and in 34 there were only microscopic metastases. Intraoperative assessment of lymph node involvement classified correctly 299 patients (96.5 per cent of the total number). Whereas previous studies have demonstrated a failure on frozen section to detect all but a few microscopic metastases, we were able by frozen section to identify metastases in 23 of 34 patients (67.6 per cent) with grossly uninvolved lymph nodes. Of the positive frozen sections 16 were in patients with unilateral metastases only, and in 13 of these cases frozen section identified the only positive node present. The average diameter of the metastases found on frozen section was 2.4 mm. In 11 of the 34 patients frozen section did not disclose any of the metastases present on permanent sections (average 1.4 mm.) (false negative rate 3.5 per cent of all patients, 27.5 per cent of those with positive nodes and 32.3 per cent of those with microscopic involvement of lymph nodes only). Ten patients had unilateral metastases and 1 had bilateral involvement. The ability to identify the majority of microscopic metastases, given their adverse effect on prognosis, supports the usefulness of routine frozen section on grossly uninvolved pelvic lymph nodes as a staging procedure before radical prostatectomy.