Lung nodules in children: video-assisted thoracoscopic surgical resection after computed tomography-guided localization using a microcoil

Background

Lung nodules that develop in children with cancer may represent metastatic disease or other conditions potentially requiring aggressive treatment. Thoracoscopic methods have been used for nodule resection; however, lesions deep in the lung parenchyma can be difficult to visualize. Fluoroscopic-guided thoracoscopic surgical resection after computed tomography (CT)-guided localization using microcoils has been described in the adult literature and has the potential to assist in the resection of deep pulmonary nodules in children.

Methods

Six patients (ages 6-15 years) with an undiagnosed pulmonary nodule were treated using a combined CT-guided microcoil localization/fluoroscopic video-assisted thoracoscopic surgical technique. Preoperatively, a platinum-fibered microcoil was deployed with the deep end of the coil placed either through or in the vicinity of the pulmonary nodule and the superficial end coiled on the pleural surface. The nodule and coil were then resected with endoscopic staplers guided by fluoroscopy and video-assisted thoracoscopic surgical.

Results

Computed tomography-guided microcoil localization and fluoroscopic-guided thoracoscopic resection were successful and critically influenced the management of all patients. Three patients were diagnosed with malignancy (2 metastatic diseases and 1 Hodgkin disease). A diagnosis of nonmalignant disease was made in 3 patients (granuloma, eosinophilic granuloma, and aspergilloma).

Conclusion

In the pediatric population, we have successfully applied a previously described adult technique using CT-localized microcoils to direct fluoroscopic-guided thoracoscopic surgical resection of pulmonary nodules.     

The ex utero intrapartum therapy procedure for high-risk fetal lung lesions

Background

Indications for the ex utero intrapartum therapy (EXIT) procedure have expanded to include any fetal anomaly in which resuscitation of the neonate may be compromised.

Methods

We reviewed the medical records of 9 patients after resection of lung lesions during the EXIT procedure.

Results

The mean gestational age at EXIT procedure was 35.4 weeks. All lung masses maintained large sizes late into gestation with mean mass volume/head circumference ratio of 2.5 at presentation and 2.2 at EXIT. Seven of 9 fetuses demonstrated hydropic changes (n = 6) and/or polyhydramnios (n = 5), and underwent prenatal intervention including thoracentesis, thoracoamniotic shunt placement, amnioreduction, and/or betamethasone administration. Overall survival after EXIT for lung mass resection was 89%. The average time on placental bypass was 65 minutes. Postnatal complications included reoperation for air leak (n = 1), reoperation for bleeding (n = 1), and death from sepsis and prematurity (n = 1). Venoarterial extracorporeal membrane oxygenation was used in 4 neonates for persistent pulmonary hypertension. Maternal prenatal complications included polyhydramnios (n = 5), preterm labor (n = 4), and chorioamnionitis (n = 1). One mother required perioperative blood transfusion.

Conclusion

The EXIT procedure allows for controlled resection of large fetal lung lesions at delivery, avoiding acute respiratory decompensation related to mediastinal shift, air trapping, and compression of normal lung.     

A contemporary evaluation of pulmonary function in children undergoing lung resection in infancy

Background/Purpose

The management of asymptomatic congenital lung lesions is controversial. Some centers recommend resection in infancy, and others prefer observation. Our objective was to evaluate the pulmonary function of children who underwent lung resection at 12 months or younger. We hypothesized that these children would not have a significant reduction in pulmonary function when compared with norms for age.

Methods

All patients at 2 tertiary-care children's hospitals who underwent lung resection at 12 months or younger and are currently older than 5 years were identified and prospectively recruited. Pulmonary function testing was standardized in all patients.

Results

Fourteen children were tested prospectively, whereas results were available for another 5 children. Four children were excluded for inability to perform pulmonary function testing (n = 2) or for preexisting pulmonary hypoplasia/syndrome (n = 2). Pulmonary function testing values were considered normal if they were more than 80% of predicted. Forced vital capacity was normal in 14 (93%) of 15 children, and forced expiratory volume in 1 second was normal in 13 (86%) of 15 children. Diffusion capacity and respiratory muscle strength were normal in all children tested.

Conclusions

Most children undergoing lung resection in infancy will have normal pulmonary function tests, supporting our philosophy of early, elective resection of congenital lung lesions.     

The value of surgery in directing therapy for patients with Wilms' tumor with pulmonary disease. A report from the National Wilms' Tumor Study Group (National Wilms' Tumor Study 5)

Background/Purpose

Computed tomography (CT) of the chest with its increased sensitivity frequently identifies lesions not visible on chest radiograph. Treatment of such lesions is controversial. A recent review suggests that patients with Wilms' tumor with pulmonary lesions detected only by CT, who were treated with dactinomycin and vincristine, have an inferior outcome compared with those who also received pulmonary radiation therapy (RT) and doxorubicin. It is important to determine if these small lesions seen only on CT represent metastatic disease and whether patients with these lesions require RT and/or doxorubicin for optimal outcome.

Methods

Patients with Wilms' tumor with lung metastasis, registered on National Wilms' Tumor Study 5, were reviewed, and those with CT-only lesions who had a radiology and surgical checklist submitted were identified. The treatment regimens of these patients and the histological findings of the pulmonary lesions are presented. We analyzed the pathological findings by whether the patients had single or multiple lesions.

Results

Of 2498 patients registered on National Wilms' Tumor Study 5, 252 had pulmonary metastases. Of these patients, 129 (5.2%) had CT-only lesions (<1 cm). Forty-two of these patients (20 boys and 22 girls) underwent lung biopsy at the discretion of the attending physicians. The local tumor stages in these patients were stage I (7%), II (34%), and III (59%). The treatment stages in these patients were stage I (n = 3, 2 drugs), II (n = 3, 2 drugs), III (n = 12, 3 drugs); and IV (n = 24, 3 drugs + RT). There were 16 patients with isolated lung lesions and 26 with multiple lesions, average size 5.8 ± 0.5 mm. Of 16 isolated lesions, 13 patients (82%) and 69% (18/26) with multiple lesions had tumor on biopsy. Of the 24 who received RT, 8 had a negative biopsy and, thus, may not have needed the RT. Five of 6 treated with just 2 drugs may have been undertreated. Nine of 12 treated with 3 drugs had tumor on biopsy.

Conclusions

Computed tomography-only pulmonary lesions are not invariably tumor, demonstrating the need for histopathological confirmation. Biopsy remains critical until radiographic techniques allow differentiation between benign and malignant lesions to optimally direct therapy.     

Quantitation of lung sealing in the survival swine model

Purpose

Small intercostal spaces and limited pleural space significantly limits the use of 12-mm stapling devices in pediatric thoracoscopic surgery. The goal of this study was to compare sealing of lung tissue by the 5-mm Ligasure (Valley Lab, Boulder, CO) device to a standard 12-mm Endo-GIA stapler (US Surgical, Norwalk, CT).

Methods

Institutional Animal Care and Use Committee (IACUC) approval was obtained (#A3-02). Sixteen 10-kg female swine were divided between 2 survival surgical groups. Lung biopsy sections of the lingula were taken by 2 methods: group A, left anterolateral thoracotomy employing a 12-mm Endo-GIA stapler and group B, left thoracoscopy employing the Ligasure 5-mm instrument. After a 7-day survival period, lung burst pressures were measured by flow-controlled insufflation into the trachea.

Results

Burst pressure measurement reflects the first air leak. By Student’s t test analysis there were no statistically significant differences between the burst pressures, biopsy weights, or operating times. Fifty percent (4 of 8) of the animals in group A (Endo-GIA), and 50% (4 of 8) of the animals in group B (Ligasure) developed the first air leak in the nonoperative lung. Two animals, one from each group, had evidence of intrapleural infections at the time of necropsy. These were asymptomatic and did not appear to affect burst pressure measurement.

Conclusions

After 7 days of healing, lung biopsy sites created with both the Ligasure and the Endo-GIA stapler have burst strengths equal to or greater than that of normal lung tissue in the swine survival model.     

Thoracoscopic versus open resection of congenital lung lesions: a case-matched study

Purpose

The purpose of the study was to compare the outcomes in children undergoing thoracoscopic versus open resection of congenital lung lesions.

Methods

Retrospective review of 12 consecutive children (<3 years of age) undergoing thoracoscopic resection of a congenital lung lesion between 2004 and 2005 was performed. Intraoperative and early postoperative results were compared with randomly selected age- and sex-matched (2:1) patients undergoing thoracotomy between 2000 and 2005.

Results

Twelve children underwent thoracoscopic resection and were compared with 24 that underwent thoracotomy. Seventy five percent of the lesions in both groups were congenital cystic adenomatoid malformations. There were no major intraoperative complications. Two thoracoscopic procedures were converted to a thoracotomy. Perioperative outcomes including operative time, length of stay, duration and volume of chest tube drainage, and dose and duration of intravenous opioids were similar for the procedures. However, children undergoing thoracoscopic procedures were less likely (odds ratio = 0.07) to have received adjunctive regional anesthesia. Overall morbidity was 33% thoracoscopic and 25% open (P = .70).

Conclusion

Thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions. Examination of long-term advantages of the thoracoscopic approach such as decreased risk of chest wall deformity and scoliosis and improved cosmesis will require longer follow-up.     

Tissue diagnosis of new lung nodules in patients with a known malignancy

Background

New lung nodules in patients with known malignancy often represent metastatic disease. However, a lack of pathological confirmation can lead to inappropriate treatment.

Methods

A retrospective review was performed of patients with malignancy undergoing tissue diagnosis of a lung nodule between January 2006 and January 2008.

Results

Ninety-five cancer patients were identified with new lung nodules. Percutaneous biopsy was the first diagnostic procedure in 64 patients, showing metastatic disease in 37 patients and an alternative specific diagnosis in 9 patients. Eighteen biopsies were nondiagnostic. Surgical resection was the first diagnostic procedure in 31 patients. This confirmed cancer in 16 patients and benign disease in 15 patients. Overall, tissue diagnosis changed management in 31% of patients.

Conclusions

Pathological confirmation of metastatic disease is vital before treatment, especially in regions with endemic pulmonary fungal diseases, because a number of lung nodules will represent benign processes despite a history of cancer.     

Radionuclide imaging study of long-term pulmonary function after lobectomy in children with congenital cystic lung disease

Purpose

We evaluated the long-term pulmonary function after lobectomy for congenital cystic lung disease, in both infants and children, using radionuclide imaging (RI).

Methods

We performed a retrospective review of 93 patients who underwent resection of cystic lung lesions between 1974 and 2001. The results of postoperative lung volume/perfusion scintigraphy at 1 (n = 64), 5 (n = 32), and 10 years (n = 18) after surgery (V1, 5, 10/Q1, 5, 10) and mean transit time (MTT—a marker for air-trapping) at 1, 5, and 10 years after surgery (MTT1, 5, 10) were compared with respect to age at operation, preoperative infection, underlying disease, and type of surgery.

Results

Patients who were younger than 1 year at the time of surgery showed a significantly lower MTT5 (1.09 ± 0.08) and MTT10 (1.15 ± 0.11) than patients who were older than 1 year at the time of surgery (MTT5, 1.49 ± 0.67; MTT10, 1.54 ± 0.33). The noninfected group had significantly higher Q10 and lower MTT10 values (P < .05) compared to the infected group. No significant differences were observed between patients with single lobe vs multiple lobe resection.

Conclusions

The optimal age for surgery in patients with congenital cystic lung disease appears to be less than 1 year.     

Thoracoscopic resection of intra- and extralobar pulmonary sequestration in the first 3 months of life

Background

Thoracoscopic techniques have gained increasing acceptance in pediatric surgery, but experience with newborns and small children is limited. To our knowledge, a series of minimally invasive resection of pulmonary sequestration in newborns has not yet been reported in the literature. We report on 5 patients with pulmonary sequestration thoracoscopically.

Methods

From November 2000 to November 2002, 5 patients underwent thoracoscopic resection of pulmonary sequestration. Ages ranged from 4 to 91 days. Two patients had postnatal pulmonary symptoms. Preoperative diagnosis was dubious in 4 children. There were 4 extralobar and 1 intralobar pulmonary sequestrations.

Results

Thoracoscopy was performed with 3-mm instruments and 3 to 5 ports. All procedures were completed successfully. The median duration of the operation was 95 minutes (range, 63-117 minutes), and visualization was excellent. Anomalous blood vessels were clipped and/or ligated. Four patients were extubated immediately after the operation, 1, the day after. The postoperative course was uneventful in all children. At follow-up after 14 months (mean; range, 10-19 months), all patients were free of symptoms and had normal chest x-rays.

Conclusion

Thoracoscopy is feasible for resection of intra- and extralobar pulmonary sequestrations during the first 3 months of life.     

Comparison of extracellular-type-Kyoto solution and Perfadex as a preservation solution in a pig ex vivo lung perfusion model: impact of potassium level

Background

The ex vivo lung perfusion (EVLP) system has been used successfully to assess donor lungs. Perfadex (PX) is usually the flush and preservation solution in EVLP systems. We have used the extracellular-type-Kyoto (ET-K) solution containing 44 mEq/L potassium for clinical lung transplantation, investigating whether it rather than PX affects the EVLP system.

Methods

We used domestic slaughterhouse pigs to analyze the EVLP system. After 20-minute warm ischemia and 6-hour cold ischemia, EVLP was performed for 2 hours. Pig heart-lung blocks were divided into the PX (n = 5) and ET-K (n = 5) groups depending on the flush/cold preservation solution. At the beginning, we discarded the first 100 mL of effluent in the PX group and the first 200 mL in the ET-K group. We measured pulmonary physiological data and potassium levels.

Results

In both groups, perfusion for 2 hours showed no differences between the 2 groups with respect to the final flow, pulmonary arterial pressure, pulmonary vascular resistance, PaO₂/FiO₂, and shunt fraction. The potassium level in the perfusate was 4.4 mEq/L for the PX and 5.4 mEq/L for the ET-K group.

Conclusion

The pig EVLP system was not affected when ET-K was used instead of PX as the flush/preservation solution. The initial 200 mL of effluent should be discarded when using the ET-K to ensure that the potassium level does not increase.     

Laparoscopy-assisted surgery for prenatally diagnosed small bowel atresia: simple, safe, and virtually scar free

Purpose

The aim of this study was to describe a new technique for the surgical management of prenatally diagnosed small bowel atresia.

Methods

Under general anesthesia, a 5-mm trocar was inserted using an open technique through an intraumbilical incision. The proximal atretic bowel end was identified using laparoscopy and mobilized toward the umbilicus using an additional 3-mm trocar inserted in the left lower quadrant. The umbilical trocar then was removed, and a ring retractor was inserted into the trocar site and used to expand the wound to deliver both atretic bowel ends. The bowel was repaired and returned to the abdomen through the umbilical wound. The umbilical fascia and skin were closed conventionally.

Results

Three patients were reviewed. Two had minimal abdominal distension, and the atretic bowel ends could be identified easily; laparoscopy-assisted surgery was successful. The third case had significant dilatation, and laparotomy was required. Postoperatively, there was minimal abdominal scarring, and the umbilicus was normal in appearance.

Conclusions

Although this experience is limited to 3 patients, this technique is simple, safe, and virtually scar free and can be applied for the treatment of neonates with prenatally diagnosed small bowel atresia, especially if there is minimal abdominal distension at birth.     

Accuracy of helical CT in the detection of pulmonary metastases: is intraoperative palpation still necessary?

Background

Pulmonary metastasectomy is well accepted in patients with isolated metastases from an extrathoracic malignancy. The standard approach involves careful intraoperative palpation of the lungs because more metastases are frequently found than were seen by preoperative conventional computed tomography (CT). Helical CT detects more nodules than conventional CT, raising the question of whether palpation of the lungs is still necessary if helical CT is used.

Methods

Retrospective review was done of medical records of patients undergoing metastasectomy with curative intent at the University of North Carolina (UNC) from 1999 to 2003. During this time at UNC, helical CT was routinely performed using a standardized technique, and all metastasectomy patients underwent manual lung palpation. The primary outcome measure of this study was whether malignant nodules (palpated, resected, and proven histologically) were reliably detected preoperatively by helical CT.

Results

Thirty-four patients were identified who underwent 41 cases of pulmonary metastasectomy with lung palpation. Our analysis revealed that in 22% (9/41), more malignant nodules were found intraoperatively than were detected by helical CT. Of 88 malignant intraparenchymal nodules, 69 were detected by helical CT (sensitivity 78%). Subset analyses of tumor histology, disease-free interval, the presence of a single lesion versus multiple lesions, the interval between the CT and metastasectomy, and the size of the largest lesion were unable to identify a cohort in which lung palpation was no longer needed after preoperative helical CT.

Conclusions

Despite the advent of helical CT, palpation of the lung is necessary if the goal is to resect all detectable disease.     

Long-term outcome in patients with prenatally diagnosed cystic lung disease: special reference to ventilation and perfusion scan in the affected lung

Background/Purpose

The natural history of cystic lung disease (CLD) such as congenital cystic adenomatoid malformation (CCAM) and pulmonary sequestration has been altered by the advent of prenatal diagnosis. Although recent advances including fetal therapy have gradually improved outcome, the long-term course and the function of the residual lung have not been well clarified.

Methods

Twenty-two patients with CLD who had been prenatally diagnosed and treated between 1990 and 2004 were reviewed. The clinical outcome and growth measurements were established, and, where possible, all infants underwent ventilation and perfusion lung scan.

Results

Mediastinal shift was present in 14 fetuses. Fetal hydrops was present in 5 fetuses. Antenatal intervention was performed for hydrops in 2 fetuses (cyst-amniotic shunt and aspiration). Twenty-one infants underwent appropriate excisional surgery. Final diagnosis included CCAM (n = 12) and pulmonary sequestration (n = 7). No late death was observed. Common complications were failure to thrive (n = 5), frequent respiratory tract infection (n = 4), and asthmatic attack (n = 4). A significant decrease in lung ventilation and perfusion on the affected side was observed in patients with hydrops, lobectomy, and CCAM.

Conclusion

Long-term follow-up including respiratory care and growth assessment should be performed in prenatally diagnosed patients with CLD, especially those who present with hydrops.     

Establishment of a Porcine Model for Lobar Lung Auto-Transplantation

Objective

The aim of this study was to develop a porcine model of left single lung auto-transplantation.

Methods

Eighteen 50-kg male domestic pigs underwent left pneumonectomy and lobar lung auto-transplantation (left lower lobe). Each animal was allocated to a perfusion protocol during surgery: group I, cold saline (n = 6); group II, cold heparin (n = 6); and group III, cold Euro-Collins (n = 6). We measured changes of partial pressure of oxygen in pulmonary vein blood (PvO₂), partial pressure of carbon dioxide in pulmonary vein blood (PvCO₂), lung compliance, and mean pulmonary artery pressure.

Results

The postoperative survival rate was 100%. PvO₂, PvCO₂, mean pulmonary artery pressure, and lung compliance of the left lower lobe showed a significant difference between the saline and the heparin groups or the Euro-Collins group (P < .05), whereas there was no significant difference between the heparin and the Euro-Collins groups.

Conclusion

Compared with other species, humans and pigs show remarkable anatomical and physiological similarity. It is useful experimental animal model to evaluate pulmonary function and grafting protocols following lobar lung transplantation.     

Safety and efficacy of a quinolone-based regimen for treatment of tuberculosis in renal transplant recipients

Background

Rifampin (RFP) is a first-line antituberculosis drug, but it increases the risk of acute rejection (AR) in transplant recipients. This study evaluated whether quinolone (QNL) can replace RFP in renal transplant recipients with tuberculosis.

Methods

One hundred nine patients with active tuberculosis were included. Patients consisted of RFP (n = 91) and QNL (n = 18) groups based on the initial treatment regimen. Patients with RFP-associated adverse effects were subdivided into RFP-maintenance (RFP-M; n = 18) and QNL-conversion (QNL-C; n = 8) groups. Clinical outcomes were compared between groups.

Results

The incidence of AR was higher in the RFP group than in the QNL group (24.2% vs 5.6%). The QNL group showed significantly higher 10-year graft survival rates than the RFP group (88.1% vs 66.5%; P = .022). The QNL-C group showed significantly higher 10-year graft survival rates than the RFP-M group (87.5% vs 27.8%; P = .011). The rate of complete functional recovery after AR was higher in the QNL-C group than in the RFP-M group (50% vs 22.2%).

Conclusions

A QNL-based regimen may be safe and effective for treatment of tuberculosis and may lower the risk of graft failure in renal transplant recipients.     

Resection of pulmonary metastases in pediatric patients with Ewing sarcoma improves survival

Background

Ewing sarcoma (ES) is the second most common bone tumor in children, and survival of those with metastatic ES has not improved. Previous studies have shown a survival benefit to whole lung irradiation in patients with pulmonary metastases and may be given either before, after, or instead of surgical pulmonary metastasectomy (PM). The contribution of surgery compared with irradiation in ES has not previously been studied.

Methods

A retrospective review of patients younger than 21 years (median age, 16 years) treated at a single institution (1990-2006) was performed. Kaplan-Meier survival curves were compared using log-rank test and a multivariate Cox proportional hazards model. P ≤ .05 was regarded as significant.

Results

Eighty patients with ES were identified. Of these, 31 (39%) had pulmonary metastases. Nine patients had incomplete details of their full treatment regimen, but the following groups could be defined from the remainder: resection alone (n = 5), radiation alone (n = 3), radiation and resection (n = 3), or chemotherapy alone (n = 11). There were 24 deaths overall, with a median overall survival (OS) of 2.7 (95% confidence interval [CI], 1.7-5.2) years. Patients who had PM had the best OS (80%), whereas those who underwent radiation to the lung without PM compared with chemotherapy only for pulmonary metastasis both had similar OS of 0% at 5 years (P = .002). Patients who had radiation followed by PM for lung metastasis had a 5-year OS of 65%. Patients with PM had a longer OS compared with those without lung resection (P < .0001).

Conclusion

These data suggest a possible benefit for ES patients who undergo surgical resection of lung metastases.     

Frozen section diagnoses of small pulmonary nodules: accuracy and clinical implications

Background

Pulmonary nodules are frequently first diagnosed by frozen section, immediately followed by lobectomy or other procedures. The frozen section diagnosis of pulmonary nodules can be difficult, as inflammatory and fibrotic lesions can be confused for malignancy, creating intraoperative dilemmas for pathologists and thoracic surgeons.

Methods

We reviewed our experience at Cedars-Sinai Medical Center with the frozen section diagnoses of 183 consecutive pulmonary nodules smaller than 1.5 cm in diameter and calculated the sensitivity, specificity, and predictive values of this diagnostic procedure.

Results

One hundred and seventy four nodules were correctly classified by frozen section as neoplastic or nonneoplastic, six lesions were diagnosed equivocally, and two neoplasms were missed owing to sampling errors. The equivocal frozen section diagnoses included two bronchioloalveolar carcinomas (BAC) interpreted as “atypical hyperplasia, favor BAC,” two BAC diagnosed as “alveolar hyperplasia,” and two carcinoid tumors labeled as “atypical carcinoma” and “spindle cell lesion, carcinoid versus sclerosing hemangioma,” respectively. The sensitivities for a diagnosis of neoplasia were 86.9% and 94.1% for nodules smaller than 1.1 cm in diameter and measuring 1.1 to 1.5 cm, respectively. The diagnostic accuracy of frozen sections was significantly better in nodules larger than 1.0 cm in diameter (p = 0.05). There were no false-positive diagnoses of malignancy, resulting in 100% specificity.

Conclusions

Intraoperative consultation with frozen section is a sensitive and specific procedure for the diagnosis of malignancy from small pulmonary nodules. The distinction between BAC and atypical adenomatous hyperplasia, and of small peripheral carcinoid tumors from other lesions, can be difficult by frozen section. Thoracic surgeons need to become aware of these problems and develop appropriate therapeutic strategies.