电视胸腔镜手术在肺部孤立性结节诊治中的应用

目的评价电视胸腔镜手术（VATS）在肺部孤立性结节（SPN）诊治中的应用。方法回顾性分析55例SPN患者行VATS手术的临床资料,术中对SPN进行探查定位,然后行肺叶楔形切除并送快速冰冻病理检查。若为良性,则缝闭结束手术,若为恶性,则VATS辅助小切口行肺叶切除加纵隔淋巴结清扫术。结果全组55例SPN患者中31例为良性病变,24例为恶性病变;30例行VATS下肺楔形切除,25例行VATS辅助小切口肺叶切除加纵隔淋巴结清扫。全组患者无围手术期死亡,无严重手术并发症发生。结论 VATS对SPN患者具有诊断准确和治疗规范的突出优势,应做为SPN主要或标准的诊治手段加以明确。     

Positron emission tomography (PET)-computed tomography (CT) suggesting small intestinal metastasis from lung cancer; report of a case

A 75-year-old man admitted to our hospital due to an abnormal X-ray shadow detected during an annual health check-up. Chest computed tomography (CT) revealed 3.0 cm solid nodules with chest wall invasion in the left lung. We could not get a definitive diagnosis by transbronchial lung biopsy or CT-guided needle biopsy. Positron emission tomography (PET)-CT revealed positive findings in the tumor, aortopulmonary window lymph node and splenic flexure. Under a diagnosis of suspected lung cancer, thoracotomy was performed. As intraoperative diagnosis revealed a moderately differentiated squamous cell carcinoma, the patient underwent a left upper lobectomy, mediastinal lymph node dissection, and combined chest wall resection. Pathological stage was T3N2M0, stage IIIA. Ten days after surgery, the patient suffered from ileus and emergent surgery was performed. Subsequent pathological examination revealed lung cancer metastasis in the small intestine.     

Folded lung: a masquerader of malignancy.

Four cases of folded lung were observed over an 8-year period up to 1990. Because of suspected malignancy, three patients underwent exploratory thoracotomy, without subsequent morbidity or mortality, but the fourth patient declined surgery. Although folded lung may have characteristic computed tomographic features, these may be mimicked by carcinoma. If the patient is fit enough, exploratory thoracotomy is advisable in order to establish the diagnosis and permit resection of the lesion, if indicated, while avoiding the risks entailed by false negative CT scan and needle biopsy.     

胸腔镜辅助小切口手术诊治肺周围型结节

目的探讨胸腔镜辅助小切口手术在诊断和治疗肺周围型结节病变中的临床应用价值。方法胸腔镜辅助小切口手术诊治肺周围型结节55例，其中单发结节54例，多发结节1例。肺楔形切除术23例；肺叶切除联合淋巴结清扫治疗原发性肺癌32例，采用常规开胸手术器械及胸腔镜用器械切除肺叶，自制淋巴结摘除钳完成淋巴结清扫。结果55例均在胸腔镜下完成手术。手术时间35～180min，平均109min，术中出血量50～400ml，平均122min。均未输血，1例术后漏气术后32d出院，1例切口延迟愈合，术后19d出院，余53例术后住院4～11d，平均8．3d。无严重并发症。术后病理：良性病变15例，原发性肺癌38例，非典型性腺瘤样增生1例，转移性肺癌1例。良性病变行肺楔形切除术，32例原发性肺癌行解剖学肺叶切除联合淋巴结清扫，4例肺癌胸膜广泛播散未手术处理，2例肺癌因肺功能差行姑息性肺楔形切除。结论胸腔镜辅助小切口手术有助于明确诊断肺周围型结节病变，治疗临床早期原发性肺癌的长期疗效有待随访观察。     

Video-assisted thoracoscopic surgery for diagnosis, staging, and management of lung cancer with suspected mediastinal lymphadenopathy

The aim of this report was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) in staging, diagnosis, and treatment of lung cancer. Fifty-two patients were scheduled for mediastinal lymph node VATS biopsy at the Oncologic Thoracic Surgery Department of the National Cancer Institute in Milan. Fifty patients underwent lymph nodal thoracoscopic biopsy (96%), whereas for the other 2 patients, histologic diagnosis was done by pleural metastatic nodule thoracoscopic biopsy (4%). We performed 17 lymph nodal biopsies in level 5 (33%), 14 in level 6 (27%), 12 in level 7 (23%), and 7 in level 8 (13%). No postoperative complications were observed, and 19 subjects (36%) underwent open lung resection. The histologic diagnosis was adenocarcinoma in 25 cases (48%), epidermoid carcinoma in 14 (27%), microcytoma in 9 (17%), and giant-cell lung carcinoma in 4 (8%); 10 patients were at stage I (19%), 9 at stage II (17%), 31 at stage III (60%), and 2 at stage IV (4%). The use of VATS allowed diagnosis of the suspected involved mediastinal lymph nodes in lung cancer patients and obviated the need for painful thoracotomy, enabling accurate staging and thus selection of the optimal treatment.     

Unsuspected lung cancer accompanied by catamenial pneumothorax.

A 45-year-old nonsmoking woman with repeated coughing and dyspnea on effort was admitted to our hospital diagnosed with right-sided pneumothorax on chest X-ray. Chest computed tomography showed neither bullae nor nodules. Chest drainage failed to completely reexpand the lung, necessitating video-assisted thoracic surgery. Thoracoscopy showed pleural thickening in the apical segment without bullae or air leakage, dark-brown pigmentation of the diaphragm, and an unsuspected small nodule about 5 mm in diameter on the diaphragmatic surface of the right lower lobe. Pneumothorax was treated by mechanical abrasion of parietal pleura and upper lobe wedge resection. The lower lobe and nodule were wedge-resected using staplers. The nodule was bronchioloalveolar carcinoma of Noguchi's type B. To improve curability and check for diaphragmatic lesions, right posterolateral thoracotomy was conducted on post-video-assisted thoracic surgery day 28. Aggressive intraoperative lymph node exploration yielded no remarkable histological findings. Nonanatomical lower lobe wedge resection was done and the diaphragm with pinhole-like perforations was partially resected. The resected lung showed no cancerous tissue. Endometrial tissue was histologically confirmed in the resected diaphragm. The patient has remained asymptomatic in 14-month follow-up. This is, to our knowledge, the first lung cancer accompanied by catamenial pneumothorax.     

Minute localized malignant pleural mesothelioma coexisting with multiple adenocarcinomas

We report an extremely rare case of minute localized malignant pleural mesothelioma (LMPM) coexisting with multiple lung adenocarcinomas in a 64-year-old woman without a history of smoking or asbestos exposure. A computed tomography scan of the chest displayed total five ground-glass opacities in the lung. Transbronchial lung biopsy from a ground-glass opacity in the posterior segment revealed a bronchioloalveolar carcinoma. With a diagnosis of primary lung cancer, right upper lobectomy and wedge resection of the right lower lobe with systematic lymph node dissection was performed using video-assisted thoracoscopic surgery. Incidentally, a minute gray-white nodule measuring 6 mm was detected on the visceral pleural surface of the right upper lobe. The postoperative histological diagnosis was minute LMPM coexisting with multiple adenocarcinomas.     

Intraoperative ultrasound during thoracoscopic procedures for solitary pulmonary nodules.

BACKGROUND: Traditional nonoperative diagnostic approaches to the solitary pulmonary nodule (bronchoscopy and percutaneous needle biopsy) can be inconclusive. Video-assisted thoracic surgery (VATS) provides a minimally invasive way to diagnose and treat these nodules. We evaluated the use of a dedicated intraoperative ultrasound probe as an aid in localization of small pulmonary nodules during VATS. METHODS: An intraoperative ultrasound examination during a thoracoscopic procedure was performed on 18 patients to localize deep pulmonary nodules less than 20 mm in diameter without a definitive diagnosis by preoperative imaging techniques. RESULTS: In the 18 patients, all nodules were successfully identified by intraoperative ultrasound. A definitive pathologic diagnosis was obtained from thoracoscopic biopsy or resection. The final diagnoses were primary lung cancer in 5 patients, metastatic lesions in 4 patients, hamartoma or chondroma in 4, granuloma in 3, and interstitial fibrosis in 2 patients. CONCLUSIONS: In our experience, intraoperative ultrasound can safely and effectively localize invisible or nonpalpable pulmonary nodules at the time of thoracoscopy. This may help surgeons perform minimally invasive lung resections with clear surgical margins.     

肺部微小结节的微创伤诊治

目的 确定肺部微小病灶的微创诊治方法。方法 对ＣＴ和Ｘ线胸片发现肺部病灶在１．３ｃｍ以下的２６例病人,利用胸部微创伤外科技术将之楔形切出,肿物完整送作快速连续多层病理冲冻切片以确诊,恶性者作进一步肺叶切除加淋巴清扫。淋巴结各组病理切片均未发现转移。术后１４例未作化疗和疗效,５例化疗１～２疗程。结果 １９例最后诊断为恶性,占７３％,全部为Ⅰ期;６例为良性,占２７％。术后病理诊断与术前ＣＴ定性诊断相符     

New forceps for thoracoscopic needle biopsy

INTRODUCTION: When the diagnosis cannot be established preoperatively but malignant lung tumor is suspected, we frequently perform thoracoscopic wedge resection in order to perform rapid histodiagnosis on the specimen. If the diagnosis is malignancy, we extend the surgery to lobectomy for complete resection in many cases. However, cartridges of linear endoscopic staplers used for wedge resection are useless in such cases. This economic loss is expensive. Thoracoscopic needle biopsy is economic, but the technique is difficult and there is a risk of damage to important blood vessels when the needle penetrates deeper than is needed. Therefore, we developed forceps for thoracoscopic needle biopsy. METHOD: We changed the tip shape of endoscopic grasping forceps, fixed a guide for inserting a biopsy needle and prevented the biopsy needle from going through the grasping extension for safety. We made 3 types of forceps, small, middle, and large sized forceps that could adapt the various sizes of tumors. RESULT: We used the small forceps for 23 cases: the middle forceps for 13 cases; the large forceps for 7 cases; for a total of 43 cases, and succeeded in diagnosing 35 cases. The reason for failure in 6 cases using the small forceps was the exceeding softness of the lesion in 1 case, failure of rapid histodiagnosis in 1 case, and mal-adaptation between the forceps and tumor size in the remaining cases. The reason for failure in 2 cases using middle forceps was failure of rapid histodiagnosis in both cases. There was no complication due to biopsy. All bleeding after the puncture was quickly stopped. There was no dissemination or recurrence in the thoracic lumen. CONCLUSION: During surgery for palpable visible lung tumors with an uncertain histological diagnosis, thoracoscopic needle biopsy is very easy and economic. It is also useful for avoiding unnecessary lung lobectomy, and is a minimally invasive method, contributing to medical economy.     

Prospective study on video-assisted thoracoscopic surgery in the resection of pulmonary nodules: 209 cases from the Spanish Video-Assisted Thoracic Surgery Study Group.

OBJECTIVE: The diagnosis of pulmonary nodules has become one of the main indications of video-assisted thoracoscopic surgery (VATS), especially for small nodules not accessible by bronchoscopy or by percutaneous transthoracic needle aspiration. In this study we evaluate the indications, diagnostic safety, complications, and technical difficulty of VATS in the diagnosis of pulmonary nodules in Spain. MATERIALS AND METHODS: We conducted a prospective study of 209 patients with one or more pulmonary nodules from a group of Spanish thoracic surgery divisions (The Spanish Video-assisted Thoracic Surgery Study Group). Data was collected and evaluated on variables contained on a questionnaire including demographic information, characteristics of the nodules, identification methods, surgical technique, morbidity and mortality rates, and diagnostic yield. RESULTS: The mean size of the nodules was 1.9 cm (range 0.3-5 cm). A total of 93.3% were peripheral. A diagnosis was established in 100% of the cases. In this study, 51.1% of lesions were benign and 48.8% were malignant. In 16.3% of cases, a conversion to thoracotomy was needed. The morbidity was 9.6% and the mortality 0.5%. We found a relationship between the size of a nodule and a diagnosis of malignancy (P=0.019) and between a central location and a need to convert to thoracotomy (P=0.002). Patients with nodules >2 cm had a greater risk of complications (P=0.0001). CONCLUSIONS: In the diagnosis of pulmonary nodules, VATS has a specificity of 100% and a low mortality rate. The probability of developing complications is higher when the nodule is >2 cm.     

Use of India Ink During Preoperative Computed Tomography Localization of Small Peripheral Undiagnosed Pulmonary Nodules for Thoracoscopic Resection

Background  Computed tomography (CT) scans of the chest permit us to identify a large number of small peripheral, undefined pulmonary lesions that require a diagnosis. Broncoscopy results are generally negative in these cases, and needle aspiration results are often inconclusive owing to poor cytology and false-negative cases. Thoracoscopy is an ideal tool but allows us only to localize lesions that retract the visceral pleura. Our aim in this study was to establish a marking procedure for excising nodules of unknown etiology by injecting India ink on the surface of the lung. Methods  Since January 2008, eight patients (six men, two women) who had been diagnosed as having a peripheral small pulmonary nodule of unknown etiology were selected for preoperative tattooing under CT guidance to facilitate thoracoscopic wedge resection. Results  In six cases, thoracoscopy allowed diagnosis and definitive treatment of two benign peripheral nodules and four single metastases from colon carcinoma. In two patients who had been diagnosed to have a primitive non-small-cell lung cancer on frozen section following thoracoscopy, the surgical treatment was concluded with limited lateral thoracotomy and lobectomy with ilomediastinal node dissection. Conclusions  Our experience suggests that this CT technique, which includes using India ink to label and localize peripheral small pulmonary nodules, is a safe, valid option for marking the lung, thereby facilitating subsequent thoracoscopic resection.     

Three primary cancers of pulmonary cancer, malignant melanoma and esophageal cancer; report of a case

A 61-year-old man, who had medical history of hepatitis type C, surgery for malignant melanoma of the lower limb, endoscopic mucosal resection for esophageal cancer, was pointed out a pulmonary nodule in the right middle lobe by surveillance computed tomography after 5 years of surgery for melanoma. Pathology of esophageal cancer was squamous cell carcinoma limited in mucosa without lymphatic nor venous invasion. The nodule gradually enlarged and respiratory endoscopic examination could not establish pathological diagnosis. Thoracoscopy-assisted pulmonary biopsy revealed squamous cell carcinoma, and right middle lobectomy with mediastinal node dissection was performed. Histological examination showed moderately differentiated squamous cell carcinoma without lymph node involvement. The stage of lung cancer was T1N0M0, stage IA. Although 9 months have passed since surgery for lung cancer, recurrence of each malignancy has not been detected.     

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.

Analysis of 945 cases of pulmonary metastatic melanoma.

From 1970 to 1990, 7564 patients with melanoma were seen at Duke University Cancer Center. Complete follow-up data were available in all patients. The estimated probability of a pulmonary metastasis developing 5, 10, or 20 years after initial diagnosis was 0.13, 0.19, and 0.30, respectively. Pulmonary metastases were documented in 945 patients (12%), these having 1-, 3-, and 5-year survival rates of 30%, 9%, and 4%, respectively. The methods of diagnosis were chest radiograph (n = 544), computed tomography (n = 157), transthoracic needle biopsy (n = 121), bronchoscopy (n = 14), thoracotomy (n = 112), and autopsy (n = 7). Evidence of advanced pulmonic spread included bilateral disease in 543 and more than two nodules in 595. Univariate predictors for early formation of pulmonary metastases (p less than 0.001) were male sex, black race, increased primary thickness (millimeters), higher Clark's level, nodular or acral lentiginous histology, location on trunk or head and neck, and regional lymph nodes positive for metastasis. Multivariate predictors of improved survival (p less than 0.001) in order of importance were complete resection of pulmonary disease, longer time for formation of metastases, treatment with chemotherapy, one or two pulmonary nodules, lymph nodes negative for metastasis lymph nodes (p less than 0.005), and histologic type (p less than 0.04). Additionally, survival in patients with one nodule and resection (n = 84) was better than in those with similar disease and no resection (n = 142 months, p less than 0.001). These data comprise the largest series to date and emphasize the importance of long-term follow-up, as well as supporting the selective use of resection for isolated pulmonary metastases, increasing the 5-year survival rate from 4% to 20%.     

CT differentiation of benign and malignant lung nodules in children.

The superiority of computed tomography (CT) for detection of lung nodules has been documented and attempts have been made to distinguish benign from malignant lesions in adults. We attempted to characterize lung nodules in 12 children with solid malignant tumors (aged 8 months to 17 years) in an effort to differentiate benign from metastatic disease. All scans were performed at 10-mm contiguous intervals on a GE 9800 CT scanner. The scans were retrospectively viewed by two pediatric radiologists independently and without knowledge of the pathological findings. All biopsies were done via open thoracotomy. The CT findings were correlated with pathology results. Twelve children had 13 nodules biopsied. Six of these showed malignancy, two showed inflammatory changes, and two had a reactive subpleural lymph node. In three children, no abnormality was found and a biopsy was not obtained. One child had a metastatic nodule in one lung, and a simultaneous inflammatory nodule in the other. The radiologists agreed with each other on the CT interpretation in 11 of 13 surgically explored areas. They correctly predicted malignancy in four cases and correctly excluded it in two cases. However, they were simultaneously incorrect in five instances. Our conclusion is that, contrary to reports in adults, a tiny nodule may be either benign or malignant. Malignancy cannot be separated from benign disease by CT established criteria.     

Recurrence in regional pulmonary lymph nodes after surgery for isolated pulmonary metastasis from hepatocellular carcinoma

Hepatocellular carcinoma occasionally metastasizes to extrahepatic organs, rarely to the mediastinal lymph nodes. We present the case of a 64-year-old man who presented with nodules in the upper and right lower lobes of the lung 4 years after undergoing resection of a hepatocellular carcinoma. We performed wedge resection of both lesions. Pathological examination showed that the lesion in the right upper lobe was non-small cell lung cancer and that in the right lower lobe hepatocellular carcinoma. We accordingly performed right upper lobectomy with lymph node dissection. Nine months later, enlarged subcarinal and segmental lymph nodes were detected and mediastinal lymph node metastases from the hepatocellular carcinoma diagnosed by transbronchial needle aspiration.     

术前CT定位在电视胸腔镜手术治疗肺部小结节中的应用

目的探讨术前CT定位、术中染料结扎夹标记肺结节表面胸膜的方法在电视胸腔镜下肺小结节切除术中的应用价值。方法选取2015年8月至2018年5月在本院胸外科治疗的89例患者,98枚肺小结节,术前CT在体表定位肺部小结节,术中在胸腔镜辅助下,以亚甲蓝结扎夹标记肺结节表面胸膜,完成镜下楔形切除术。结果 98枚结节按此方法成功定位85枚(87%),13枚结节因其位于纵隔面无法按此方法完成定位,术中无并发症发生,定位成功后行VATS肺楔形切除术,无中转开胸手术,术中均取得明确病理诊断。结论术前CT定位,染料结扎夹标记肺结节表面胸膜的定位方法,简单有效,准确率高,安全性好,是肺部小结节微创术前理想的定位方法。     

Sentinel node biopsy for nonpalpable breast tumors requires a preoperative diagnosis of invasive breast cancer

A sentinel node biopsy done at the time of initial tumor resection allows for a one-stage surgical procedure. In addition, sentinel node identification may be impaired when done after a previous tumor excision. This study evaluates the sentinel node biopsy in patients with nonpalpable breast cancer and assesses whether a sentinel node biopsy for mammographically suspect breast lesions is justified when preoperative needle biopsy is inconclusive for invasive malignancy. A sentinel node biopsy was done in 67 patients with nonpalpable breast lesions after injection of radioactive tracer (intraparenchymal in 35 and subdermal in 32) and blue dye (para-areolar). A preoperative core needle biopsy was positive for malignancy in 42 patients. Thirteen patients had positive cytology or ductal carcinoma in situ (DCIS). In 12 patients the needle biopsy was nondiagnostic, but the lesions remained highly suggestive of malignancy on mammography. Sentinel node biopsy was successful in 64 patients (96%). In these, the sentinel node was both radioactive and blue in 58 patients (91%). Only 4 of 13 patients with positive cytology or DCIS on preoperative needle biopsy and only 5 of 12 patients without a preoperative diagnosis had an invasive cancer after resection. Sentinel nodes were positive for nodal metastases in 9 of 49 patients (18%) with a successful sentinel node biopsy for invasive malignancy. None of the eight patients with DCIS had nodal metastases. The sentinel node procedure avoids the potential morbidity of an axillary dissection in more than 80% of patients with nonpalpable breast cancer. A sentinel node biopsy for mammographically detected suspect breast lesions is not justified without a preoperative histologic diagnosis of invasive breast cancer.     

Intrathoracic tuberculous lymphadenopathy: clinical and bronchoscopic features in 17 adults without parenchymal lesions.

BACKGROUND: Whilst intrathoracic lymphadenitis is a characteristic sign of primary tuberculosis in children, its presence without parenchymal lesions in adults is unusual and makes the diagnosis using noninvasive techniques difficult. The diagnostic role of bronchoscopy in adults with intrathoracic tuberculous lymphadenitis is reported. METHODS: Seventeen patients with intrathoracic lymphadenopathy seen during 1993 who had all undergone bronchoscopy and had been found to have tuberculosis in the absence of any parenchymal lung lesions were evaluated retrospectively. RESULTS: Right paratracheal lymphadenopathy was observed on the plain chest radiograph in all the patients. Fifteen of the 17 patients had an endobronchial abnormality and samples taken at bronchoscopy gave a definitive diagnosis in nine (53%) of the 17. Four patients had ulcerating endobronchial granuloma and all had biopsy samples positive for tuberculosis. Transbronchial or transcarinal needle aspiration samples were diagnostic in five of 11 patients (45%) subjected to the procedure. Peripheral lymph node biopsy diagnosed tuberculosis in two cases and in the remaining six patients the diagnosis wa achieved by mediastinoscopy or thoracotomy. CONCLUSIONS: Bronchoscopy has an important role in the diagnosis of intrathoracic tuberculous lymphadenopathy in adults and should be considered before other invasive procedures.