CT-Guided Microcoil Localization of Small Peripheral Pulmonary Nodules to Direct Video-Assisted Thoracoscopic Resection without the Aid of Intraoperative Fluoroscopy

ObjectiveTo evaluate the feasibility, safety, and effectiveness of CT-guided microcoil localization of solitary pulmonary nodules (SPNs) for guiding video-assisted thoracoscopic surgery (VATS).Materials and MethodsBetween June 2016 and October 2019, 454 consecutive patients with 501 SPNs who received CT-guided microcoil localization before VATS in our institution were enrolled. The diameter of the nodules was 0.93 ± 0.49 cm, and the shortest distance from the nodules to the pleura was 1.41 ± 0.95 cm. The distal end of the microcoil was placed less than 1 cm away from the nodule, and the proximal end was placed outside the visceral pleura. VATS was performed under the guidance of implanted microcoils without the aid of intraoperative fluoroscopy.ResultsAll 501 nodules were marked with microcoils. The time required for microcoil localization was 12.8 ± 5.2 minutes. Microcoil localization-related complications occurred in 179 cases (39.4%). None of the complications required treatment. A total of 463 nodules were successfully resected under the guidance of implanted microcoils. VATS revealed 38 patients with dislocated microcoils, of which 28 underwent wedge resection (21 cases under the guidance of the bleeding points of pleural puncture, 7 cases through palpation), 5 underwent direct lobectomy, and the remaining 5 underwent a conversion to thoracotomy. In 4 cases, a portion of the microcoil remained in the lung parenchyma.ConclusionCT-guided microcoil localization of SPNs is safe and reliable. Marking the nodule and pleura simultaneously with microcoils can effectively guide the resection of SPNs using VATS without the aid of intraoperative fluoroscopy.     

The probability of malignancy in small pulmonary nodules coexisting with potentially operable lung cancer detected by CT

The aim of this study was to assess the probability of malignancy in one or two small nodules 1 cm or less coexisting with potentially operable lung cancer (coexisting small nodules). The preoperative helical CT scans of 223 patients with lung cancer were retrospectively reviewed. The probability of malignancy of coexisting small nodules was evaluated based on nodule size, location, and clinical stage of the primary lung cancers. Seventy-one coexisting small nodules were found on conventional CT in 58 (26%) of 223 patients, and 14 (6%) patients had malignant nodules. Eighteen (25%) of such nodules were malignant. The probability of malignancy was not significantly different between two groups of nodules larger and smaller than 0.5 cm (p=0.1). The probability of malignancy of such nodules within primary tumor lobe was significantly higher than that in the other lobes (p<0.01). Metastatic nodules were significantly fewer in clinical stage-IA patients than in the patients with the other stage (p<0.01); however, four (57%) of seven synchronous lung cancers were located in the non-primary tumor lobes in the clinical stage-I patients. Malignant coexisting small nodules are not infrequent, and such nodules in the non-primary tumor lobes should be carefully diagnosed.     

空气支气管征在CT诊断外周型肺弧立结节中的价值

目的评价空气支气管征鉴别诊断外周型肺孤立结节(直径≤3em)的价值。方法作者回顾分析了经手术或/和纤支镜或/和肺穿刺活检病理证实的190例外周型肺结节的空气支气管征的薄层CT影像。结果100例肺癌CT显示空气支气管征52例(52％),其中腺癌71.9％(22/31)、鳞癌34.1％(14/41)、腺鳞癌4/5、小细胞癌7/14、低分化癌5/9。50例炎性假瘤CT显示空气支气管征29例(58％)。32例结核球、5例错构瘤及3例肺囊肿均无肺空气支气管征。结论空气支气管征可见于多种结节性肺病变,它似乎不是外周型小肺癌尤其腺癌的特征。也不能帮助鉴别良恶性肺结节。     

Fleischner Society Guideline Recommendations for Incidentally Detected Pulmonary Nodules and the Probability of Lung Cancer

PurposeThe Fleischner Society aims to limit further evaluations of incidentally detected pulmonary nodules when the probability of lung cancer is <1% and to pursue further evaluations when the probability of lung cancer is ≥1%. To evaluate the internal consistency of guideline goals and recommendations, the authors evaluated stratum-specific recommendations and 2-year probabilities of lung cancer.MethodsA retrospective cohort study (2005-2015) was conducted of individuals enrolled in one of two integrated health systems with solid nodules incidentally detected on CT. The 2017 Fleischner Society guidelines were used to define strata on the basis of smoking status and nodule size and number. Lung cancer diagnoses within 2 years of nodule detection were ascertained using cancer registry data. Confidence interval (CI) inspection was used to determine if stratum-specific probabilities of lung cancer were different than 1%.ResultsAmong 5,444 individuals with incidentally detected lung nodules (median age, 66 years; 54% women; 57% smoked; median nodule size, 5.5 mm; 55% with multiple nodules), 214 (3.9%; 95% CI, 3.4%-4.5%) were diagnosed with lung cancer within 2 years. For 7 of 12 strata (58%), 2,765 patients (51%), and 194 lung cancer cases (91%), there was alignment between Fleischner Society goals and recommendations. Alignment was indeterminate for 5 strata (42%), 2,679 patients (49%), and 20 lung cancer cases (9%) because CIs for the probability of lung cancer spanned 1%.ConclusionsFleischner Society guideline goals and recommendations align at least half the time. It is uncertain whether alignment of guideline goals and recommendations occurs more often.     

Localization of small pulmonary nodules for thoracoscopic resection: Use of a newly developed hookwire system

We developed a stainless steel spring hookwire, 0.28 mm in diameter and 10 mm in length, with a 30-cmlong, 5-0 nylon monofilament suture firmly attached to its funnel-shaped end. A 21-gauge, 10-cm-long cannula was used as an introducer, and a 24-gauge, 10-cm-long blunt-pointed needle as a pusher. The hookwire was successfully placed into the target pulmonary parenchyma under computed tomography guidance in two patients with a small pulmonary nodule. The attached string served as a clear guide at thoracoscopy. Flexibility of the exposed suture through the skin eased wire management after placement. No wire dislodgement occurred     

肺真菌病临床影像学分析

目的：分析肺真菌病的临床影像表现,提高诊断水平。方法：回顾分析21例肺真菌病（穿刺/手术/支纤镜病理证实16例,痰培养及临床证实5例）的X线、CT表现。20例行胸部X线及CT检查,1例仅行胸片检查。结果：肺曲霉菌6例,肺隐球菌8例,肺念珠菌2例,肺毛霉菌3例,肺放线菌2例。左肺6例,右肺6例,双肺多发9例。多发病灶常位于胸膜下,且以两肺中下叶受侵最常见。呈单/多发结节或肿块/空洞10例;呈单/多发斑片影者4例;斑片与结节/空洞影混合者7例。晕征、新月征、洞中球征/滚珠征/悬球征/洞中丝征为本病较为特征性表现。结论：影像学表现典型者可做出诊断,疑似者应及时进一步检查,以免延误诊治。     

Methylene Blue/Collagen Mixture for CT-Guided Presurgical Lung Nodule Marking: High Efficacy and Safety

PurposeTo assess outcomes of computed tomography (CT)-guided methylene blue/collagen marking of preoperative lung nodules before video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS).Materials and MethodsA retrospective cohort study assessing 25 methylene blue/collagen solution CT-guided lung nodule localization procedures on 26 nodules in 25 patients was performed. The procedures were performed by a fellowship-trained radiologist 1–2 hours before scheduled surgery under local anesthesia. Approximately 4–6 ml of methylene blue/collagen solution was injected in a perinodular location under CT guidance with a 19-gauge trocar needle and along the track to the visceral pleural surface. Post-procedural CT images confirmed appropriate lung nodule location marking.ResultsPerinodular CT-guided trocar needle placement was achieved in all marking procedures (n = 26/26). Increased consolidation near the target nodule was also demonstrated in all patients on the post-procedural localized CT scans. One patient with moderate emphysema developed a small to moderate-sized pneumothorax (∼20%–30%), and an 8-Fr thoracentesis catheter was placed under CT guidance before surgery. There was no bleeding or hemoptysis in any patient. Methylene blue/collagen solution was readily visible by the thoracic surgeon in association with all target nodules. One patient required conversion to open procedure due to the proximal portion of the right lower lobe pulmonary artery segmental branch. Of the 26 identified nodules, pathology specimens confirmed the adequacy of nodule resection in all cases.ConclusionsPreoperative CT-guided methylene blue/collagen solution injection offers a safe and highly effective technique for marking subpleural lung nodules undergoing VATS or RATS.     

拟诊肺癌患者肺额外结节切除术前介入定位

目的 探讨CT引导微弹簧圈定位电视辅助胸腔镜手术(VATS)切除拟诊肺癌患者肺部额外小结节病灶的价值.方法 对11例拟诊肺癌患者的肺部额外小结节行CT引导下微弹簧圈术前定位.微弹簧圈前端位于靶病灶旁,尾部留置于胸膜表面.之后24 h内行VATS切除,进行肺部主要病灶与额外靶病灶的手术及病理综合评估,选择合适的手术方式进行切除.结果 VATS成功切除术前定位的11个肺小结节病灶(直径4~15 mm),9个病灶的定位用微弹簧圈留尾于肺脏层胸膜表面.定位操作均无严重并发症出现.手术另外切除包含11个肺部主要病灶的16个肺内病灶,获得肺内病灶全面的手术及病理评估结果.结论 微弹簧圈术前定位方法为VATS完成切除并评估拟诊肺癌患者肺内多发病灶提供新的思路.     

A simple and efficient method to perform preoperative pulmonary nodule localization: CT-guided patent blue dye injection

ObjectiveTo assess the efficacy of computed tomography (CT)-guided localization with the injection of a low dose of patent blue dye (PBD) for the thoracoscopic resection of pulmonary nodules.Materials and methodsOverall, 125 consecutive patients underwent CT-guided localization with injection of a lower dose of PBD between June 2015 and June 2016. The total injection dose relative to the distance between nodules and the visceral pleura was recorded. The clinical and radiological characteristics, technical details, pathological results and procedure-related complications were reviewed.ResultsA total of 137 indeterminate pulmonary nodules were identified. The mean nodule size was 9.5 (3.0–22.0) mm. The mean injection dose of PBD relative to the distance between nodules and the visceral pleura was classified as follows: 0.07 ml: <1 cm, 0.1 ml: 1–2 cm and 0.18 ml: >2 cm. The mean time of CT-guided localization was 16.5 (10–50) min. The mean time interval from localization to surgery was 188 (24–1440) min. Pneumothorax developed in 50 patients (40%), and focal parenchymal hemorrhage occurred in 16 patients (12.8%) after localization. No patient required chest tube placement or emergent resuscitation. The success rate of dye marking was 98.5% (135/137). Malignancies, including 82 lung cancers, were diagnosed in 97 nodules (70.8%).ConclusionThe injection of a lower dose PBD based on the distance to the visceral pleura can be successful with nodular localization and may facilitate thoracoscopic surgery, even in cases with a long interval from localization to surgery.     

孤立性肺结节影像特征和误诊分析

目的 探讨误诊的孤立性肺结节CT的影像特征,与病理结果对照,并分析误诊原因.方法 选取CT诊断错误的30例孤立性肺结节病例,回顾性分析病灶的位置,大小,形状,内部密度,强化特点及影像学特征,以此分析其发生误诊的原因.CT误诊为恶性肿瘤为假阳性组,反之为假阴性组.结果 1)结节分布:假阳性组病灶位于右肺上叶3例,右肺下叶...     

细针穿刺肝脏孤立性坏死结节的临床病理特征

目的研究B超下穿刺肝孤立性坏死结节的临床及病理学特点。方法收集32例肝孤立性坏死结节的临床资料,并在光镜下观察其细针穿刺组织病理形态,同时复习相关文献。结果本组男性21例,女性11例,平均年龄46.8岁,结节直径0.8~4.0 cm,临床及影像学缺少特异表现,光镜下结节中央为凝固性坏死,坏死外周围绕着一层弹力纤维及胶原组织,伴少数炎细胞浸润,结节周围的肝细胞基本正常。结论肝孤立性坏死结节是一种少见的非肿瘤性结节状病变,对B超引导下穿刺标本进行组织病理学观察能够准确诊断。     

Sonographically guided fine-needle biopsy of thyroid nodules: the effects of nodule characteristics, sampling technique, and needle size on the adequacy of cytological material

AIM: To evaluate the effects of sonographic characteristics of thyroid nodules, the diameter of needle used for sampling, and sampling technique on obtaining sufficient cytological material (SCM). MATERIALS AND METHODS: We performed sonography-guided fine-needle biopsy (FNB) in 232 solid thyroid nodules. Size-, echogenicity, vascularity, and localization of all nodules were evaluated by Doppler sonography before the biopsy. Needles of size 20, 22, and 24 G were used for biopsy. The biopsy specimen was acquired using two different methods after localisation. In first method, the needle tip was advanced into the nodule in various positions using a to-and-fro motion whilst in the nodule, along with concurrent aspiration. In the second method, the needle was advanced vigorously using a to-and-fro motion within the nodule whilst being rotated on its axis (capillary-action technique). RESULTS: The mean nodule size was 2.1+/-1.3 cm (range 0.4-7.2 cm). SCM was acquired from 154 (66.4%) nodules by sonography-guided FNB. In 78 (33.6%) nodules, SCM could not be collected. There was no significant difference between nodules with different echogenicity and vascularity for SCM. Regarding the needle size, the lowest rate of SCM was obtained using 20 G needles (56.6%) and the highest rate of adequate material was obtained using 24 G needles (82.5%; p=0.001). The SCM rate was 76.9% with the capillary-action technique versus 49.4% with the aspiration technique (p<0.001). CONCLUSION: Selecting finer needles (24-25 G) for sonography-guided FNB of thyroid nodules and using the capillary-action technique decreased the rate of inadequate material in cytological examination.     

孤立性肺结节胸腔镜切除术前CT引导下肺结节定位针与微弹簧圈定位的应用比较

目的比较一次性使用肺结节定位针与微弹簧圈在孤立性肺结节胸腔镜术前定位的临床效果。 方法将徐州市中心医院2020年5月至2020年12月收治的60例经肺结节电视辅助胸腔镜手术（VATS）的患者设为对照组,术前采用微弹簧圈定位;将2021年1月至2021年8月收治的60例经肺结节VATS的患者设为观察组,术前采用一次性使用肺结节定位针定位,比较两组患者的定位相关结果和手术资料等方面的数据。 结果观察组定位术成功率100%（60/60）,对照组定位术成功率98.3%（59/60）,差异无统计学意义（P > 0.05）;观察组定位时间（9.4 ± 3.8）min较对照组（16.5 ±6.3）min短,差异有统计学意义（P < 0.05）;观察组并发症发生率（10.0%~11.7%）与对照组的（10.0%~13.3%）差异无统计学意义（P > 0.05）;两组患者胸腔镜手术切除成功率均是100%（60/60）,观察组手术时间（87.3 ± 60.7）min少于对照组（92.9 ± 36.7）min,差异无统计学意义（P > 0.05）。 结论孤立性肺结节VATS前CT引导下一次性使用肺结节定位针与微弹簧圈定位均安全可靠、效果良好,适合临床推广应用;一次性使用肺结节定位针较微弹簧圈定位操作更简单、省时。     

CT Fluoroscopic-Guided Coil Localization of Lung Nodules prior to Video-Assisted Thoracoscopic Surgical Resection Reduces Complications Compared to Hook Wire Localization

Purpose

To compare the safety and efficacy of hook wire versus microcoil localization of pulmonary nodules prior to video-assisted thoracoscopic resection (VATS).

肺炎性结节30例CT分析

目的:探讨肺炎性结节的CT征象与鉴别诊断。方法:回顾性分析经手术及病理证实的肺炎性结节病例30例,其中单发28例,多发2例。共33个结节。结果:①病变部位:结节位于两肺下叶基底段15个,背段8个,上叶后段(尖后段)3个,前段1个;中叶(舌叶)6个,均邻近胸膜。②CT征象:病灶呈类圆形30个,不规则形3个。其中密度均匀26个,支气管充气征5个,空洞2个,边缘光整16例,有粗长毛刺8例,边缘模糊似短毛刺或棘状突起5例,分叶4例,垂直于胸膜的刀切样边缘13例,局部胸膜增厚粘连18例,胸膜尾征16例。结论:全面分析CT征象能提高肺炎性结节的正确诊断率。     

CT-Guided Percutaneous Transthoracic Localization of Pulmonary Nodules Prior to Video-Assisted Thoracoscopic Surgery Using Barium Suspension

Objective

To describe our initial experience with CT-guided percutaneous barium marking for the localization of small pulmonary nodules prior to video-assisted thoracoscopic surgery (VATS).

Materials and Methods

From October 2010 to April 2011, 10 consecutive patients (4 men and 6 women; mean age, 60 years) underwent CT-guided percutaneous barium marking for the localization of 10 small pulmonary nodules (mean size, 7.6 mm; range, 3-14 mm): 6 pure ground-glass nodules, 3 part-solid nodules, and 1 solid nodule. A 140% barium sulfate suspension (mean amount, 0.2 mL; range, 0.15-0.25 mL) was injected around the nodules with a 21-gauge needle. The technical details, surgical findings and pathologic features associated with barium localizations were evaluated.

Results

All nodules were marked within 3 mm (mean distance, 1.1 mm; range, 0-3 mm) from the barium ball (mean diameter, 9.6 mm; range, 8-16 mm) formed by the injected barium suspension. Pneumothorax occurred in two cases, for which one needed aspiration. However, there were no other complications. All barium balls were palpable during VATS and visible on intraoperative fluoroscopy, and were completely resected. Both the whitish barium balls and target nodules were identifiable in the frozen specimens. Pathology revealed one invasive adenocarcinoma, five adenocarcinoma-in-situ, two atypical adenomatous hyperplasias, and two benign lesions. In all cases, there were acute inflammations around the barium balls which did not hamper the histological diagnosis of the nodules.

Conclusion

CT-guided percutaneous barium marking can be an effective, convenient and safe pre-operative localization procedure prior to VATS, enabling accurate resection and diagnosis of small or faint pulmonary nodules.     

肺癌伴肺内单发小结节的良恶性研究

目的:探讨原发性肺癌的临床分期、原发灶与肺内单发小结节的位置关系对诊断结节良恶性的价值。方法:回顾性分析113例原发性肺癌伴肺内单发结节患者的CT资料,分析肺癌的临床分期,观察肺内单发结节与肺癌原发灶的位置关系,并分析良恶性结节的特点。结果:113个结节中38个恶性,Ⅰ期肺癌肺内结节恶性可能性较其它期低(P=0.032)。与原发灶位于同侧肺的结节较对侧肺结节为恶性的可能性大(P=0.012),且为恶性转移结节的可能性大(P<0.001);与原发灶位于同一肺叶的结节也较其它肺叶为恶性的可能性大(P=0.018),其中与原发灶距离≤2cm的结节较>2cm者为恶性的可能性大(P=0.033),且均为转移性结节;同叶内距离原发灶>2cm且<5cm者较≥5cm者为恶性的可能性大(P=0.026)。结论:肺癌患者的临床分期、肺内单发结节位置、原发灶同一叶内的结节距原发灶的距离远近与结节性质均有一定关系,距原发灶2cm以内的小结节高度提示为恶性。     

常规剂量下影响CT检出肺结节的因素

目的：复习文献，并进一步讨论常规剂量下影响CT检出肺结节的因素。方法：选择肺转移瘤20例，分别在不同层厚、重建问隔以及螺距情况下扫描，统计在每一扫描条件下检出的肺结节的大小、数量、部位，讨论扫描条件、结节大小、结节部位与肺结节检出率之问的关系。结果：扫描层厚薄、重建问隔小、螺距值小、检出的肺结节数越多，更多的是提高了微结节的检出；与肺血管影、肺门影、心旁纵隔影、横膈影重叠的肺结节容易漏检。结论：常规剂量扫描条件下，扫描层厚、重建间隔、螺距、结节大小、结节位置均可影响结节的检出。     

开放式MRI导航系统导引行肺病变穿刺活检137例

目的 探讨MRI导引下肺穿刺活检术的可行性、准确性及其临床应用价值.方法 应用配备iPath 200光学追踪系统的低场开放式MR仪,对137例肺内结节或肿物患者行穿刺活检术,其中肺内孤立性结节或肿物103例,肺内多发病灶34例;病灶最大径≥3.5 cm的57例、1.5～3.4 cm的71例、≤1.4 cm的9例.结果 病灶最大径≥3.5 cm组、1.5～3.4 cm组、≤1.4 cm组及总的穿刺成功率分别为100.0%(57/57)、98.6%(70/71)、77.8%(7/9)、97.8%(134/137);穿刺组织病理检查诊断恶性肿瘤98例,良性39例;MRI导引肺穿刺活检的敏感度为94.2%(98/104),特异度为100.0%(33/33),准确性为95.6%(131/137),阳性预测值为100.0%(98/98),阴性预测值为84.6%(33/39).结论 开放式MRI导引肺穿刺活检术具有较高的安全性、准确性和有效性,值得在临床进一步推广和应用.     

孤立结节周围型肺癌的多层螺旋CT诊断

目的：探讨多层螺旋CT对孤立结节周围型肺癌的诊断价值。方法回顾分析我院2009年2月至2014年4月46例经手术、穿刺活检病理证实,直径≤3 cm的肺内孤立结节周围型肺癌的多层螺旋CT征象进行分析和总结。结果46例肺内孤立结节周围型肺癌中,腺癌25例,鳞癌11例,小细胞癌9例,未分型癌1例。多层螺旋CT征象：分叶征36例（78％）;毛刺征28例（61％）,短毛刺21例,长毛刺7例;棘状突起13例（28．3％）;空泡征9例（20％）;胸膜凹陷征16例（35％）;血管集束征12例（26％）。增强扫描11例,增强幅度42-65 Hu。结论多层螺旋CT三维重组,可以发现更多有诊断价值的CT征象,对孤立结节周围型肺癌的诊断与鉴别诊断具有较高的临床价值。