Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1069_Библиотеки_им_академика_М_И_Перельмана
.pdf
Radioguided Surgery of Small
https://t.me/med1917
Pulmonary Nodules
Amelia W. Maiga and Eric L. Grogan
2 1
Contents
21.1 Background 336
21.1.1 Need for Surgical Localization Adjuncts
for Small Pulmonary Nodules 336
21.2 Radioguided Surgery: Percutaneous
Delivery Techniques 337
21.2.1 Percutaneous Transthoracic Injection of
Technetium-99m 337
21.2.2 Technique in Detail 338
21.2.3 Co-localization with Radiotracer and
Another Modality 339
Dr. Maiga is supported by the Offi ce of Academic
Affi liations, Department of Veterans Affairs (VA)
National Quality Scholars Program. Dr. Grogan is a recipient of the Department of Veterans Affairs, Veterans
Health Administration, Health Services Research and
Development Service Career Development Award (10–
024). The views expressed in this chapter are those of the
authors and do not necessarily represent the views of the
Department of Veterans Affairs.
A. W. Maiga , MD, MPH
Department of Surgery, Vanderbilt University
Medical Center , Nashville , TN , USA
Department of Surgery, Veterans Affairs Tennessee
Valley Healthcare System , Nashville , TN , USA
E. L. Grogan , MD, MPH, FACS ()
Department of Thoracic Surgery, Veterans Affairs
Tennessee Valley Healthcare System ,
Nashville , TN , USA
Department of Thoracic Surgery , Vanderbilt
University Medical Center ,
609 Oxford House, 1313 21st Ave. South ,
Nashville , TN 37232 , USA
eric.grogan@vanderbilt.edu
e-mail:
21.2.4 Iodine-125 (I-125) Seeds 341
21.3 Radioguided Surgery: Intravenous
Delivery Techniques 341
21.3.1 Radioimmunoguided Surgery 341
18
21.3.2
21.3.3 Bleomycin Derivatives 342
21.3.4 DOTATATE 342
21.4 Alternatives to Radioguidance 343
21.4.1 CT-Guided Hookwire 343
21.4.2 CT-Guided Coil or Marker Placement 343
21.4.3 Radiopaque Dyes 345
21.4.4 Methylene Blue 345
21.4.5 Ultrasound 346
21.4.6 Experimental Techniques 346
21.5 Summary 346
References 347
F-FDG-Guided Surgery 341
Abstract
The incidence of pulmonary nodules discovered by imaging is increasing. These pulmonary nodules may be discovered incidentally
or through a computed tomography (CT) scan
screening program. Small lesions suspicious
for lung cancer may require tissue, and surgical resection may be necessary to rule out
malignancy. Due to the small size of these
lesions, intraoperative localization with minimally invasive surgical techniques may be
challenging and require lesion localization
prior to resection. Radioguided surgery using
a radiotracer and a handheld gamma probe
technology facilitates real-time pulmonary
© Springer International Publishing Switzerland 2016
K. Herrmann et al. (eds.), Radioguided Surgery: Current Applications and Innovative
Directions in Clinical Practice, DOI 10.1007/978-3-319-26051-8_21
335
336
https://t.me/med1917
A.W. Maiga and E.L. Grogan
nodule localization and surgical resection.
Most commonly, this involves two steps. First,
a radiotracer (usually injectable technetium99m) is preoperatively and percutaneously
delivered into or immediately deep to the pulmonary nodule under CT guidance. Second, a
handheld gamma probe is used to localize the
pulmonary nodule for thoracoscopic resection. Alternatively, a radiotracer can be given
intravenously, such as radiolabeled monoclonal antibodies, 18 F-fl uorodeoxyglucose
(FDG), bleomycin derivatives, or DOTATATE
(i.e., a highly selective somatostatin analog).
These other techniques remain experimental.
Radioguidance with transthoracic technetium99m injection and intraoperative gamma
probe detection offers several advantages over
CT-guided hookwires or markers, locally
administered radiopaque contrast and blue
dyes, and thoracoscopic ultrasound. These
techniques may be employed alone or in combination with radioguidance. Precise localization of small pulmonary nodules will become
more pressing as national lung cancer CT
screening guidelines are implemented.
bronchoscopy or CT-guided fi ne needle aspiration (FNA), surgical biopsy of such pulmonary
nodules is often necessary for defi nitive diagnosis, to be followed by an immediate or staged
formal resection in the event malignancy is confi rmed. The success rates of nonoperative diagnostic modalities are inversely related to
pulmonary nodule size, resulting in unacceptably high false-negative rates [
lar, subcentimeter pulmonary nodules cannot be
reliably biopsied percutaneously [ 6 , 7 ]. Positron
emission tomography (PET) also has low sensitivity in screening for subcentimeter lesions,
particularly those 7 mm or smaller [ 8 , 9 ]. For
this reason, both the American College of Chest
Physicians (ACCP) and the American
Association of Thoracic Surgery (AATS) recommend obtaining a tissue diagnosis via surgical
excision of subcentimeter pulmonary nodules
with suspicious changes in size and appearance
[ 10 , 11 ].
4 , 5 ]. In particu-
21.1.1 Need for Surgical Localization
Adjuncts for Small Pulmonary
Nodules
21.1 Background
In 2011, the National Lung Screening Trial
(NLST) reported a 20 % reduction in lung cancerspecifi c mortality with low-dose chest CT screening in a population at high risk, namely, older
male smokers [
Preventive Service Task Force (USPSTF) began
recommending annual screening for lung cancer
with low-dose CT scans in adults aged 55–80
years with a recent 30 pack-year smoking history
[ 2 ]. In light of these recommendations and the
eight million Americans at risk, more than three
million lung abnormalities are projected to be
identifi ed in the fi rst three years of a national CT
screening program [ 3 ]. This will create an
unprecedented number of pulmonary nodules to
manage appropriately.
Whereas some pulmonary nodules can be
sampled noninvasively, most commonly with
1 ]. In December 2013, the US
Unfortunately, small indeterminate pulmonary
nodules identifi ed on high-resolution CT images
as candidates for excisional biopsy can be challenging to identify thoracoscopically via the traditional combination of direct visualization,
instrument palpation, and digital palpation [
This is particularly true with pulmonary nodules
located deep in the lung parenchyma and with socalled ground glass pulmonary nodules that are
less solid to the touch and diffi cult to palpate thoracoscopically. Preoperative marking for subcentimeter pulmonary nodules has been
recommended to facilitate a successful minimally
invasive approach [ 13 ]. Various perioperative
adjuncts have been developed to facilitate videoassisted thoracoscopic surgery (VATS) excision
of small pulmonary nodules and thereby avoid
the morbidity of a thoracotomy. These include
radioguided surgery and its alternatives, which
will be reviewed below.
12 ].
21 Radioguided Surgery of Small Pulmonary Nodules
https://t.me/med1917
337
21.2 Radioguided Surgery:
Percutaneous Delivery
Techniques
A radioguided surgical approach to pulmonary
nodules involves either percutaneous transthoracic or intravenous delivery of a radiotracer, followed by intraoperative gamma detection,
typically with a handheld gamma probe.
Percutaneous transthoracic delivery of the radiotracer is by far the most common, typically relying on CT guidance for precise placement of the
radiotracer into or deep to the pulmonary nodule
of interest. Advantages of this approach include
better differential uptake of the radiotracer in the
relevant area and the resultant superior spatial
resolution and selectivity. Disadvantages include
those inherent to introducing a needle into the
pleural space and lung parenchyma, namely,
pneumothorax, hemothorax, and parenchymal
bleeding, as well as the additional time and coordination of services needed between radiology,
surgery, and operating room staff. Bronchoscopic
delivery of a radiotracer, still experimental and
highly specialized with a steep learning curve,
may avoid some of the disadvantages of the percutaneous transthoracic route while maintaining
the advantages of a localized approach.
21.2.1 Percutaneous Transthoracic
Injection of Technetium-99m
Most of the published experience with CT-guided
injection of a radiotracer for pulmonary nodule
localization and excisional biopsy has relied on
technetium-99m (Tc-99m), a commonly used
medical radioisotope. This approach dates back
to 2000, when Chella et al. fi rst described
CT-guided percutaneous transthoracic injection
of Tc-99m-labeled human serum microspheres
into or near a target pulmonary nodule to guide
subsequent thoracoscopic excisional biopsy [ 14 ].
They successfully localized and excised pulmonary nodules with a mean size of 8.3 mm in 39 of
39 patients, with surgery performed 2 h after
intralesional injection. The specifi c radiotracer
they used is unavailable in the United States
(US). A variety of radiotracers have subsequently
been used for this indication. Burdine et al. used
Tc-99m sulfur colloid, the standard tracer in melanoma and breast cancer sentinel lymph node
dissections, for a similar radiotracer localization
technique in 17 patients [
cessfully resected all lesions, one caveat they
identifi ed was the radiotracer’s rapid diffusion
away from the pulmonary nodule. Sugi et al. used
Tc-99m tin colloid and Tc-99m phytate in Japan
and also reported good success with locating and
resecting 25 pulmonary nodules averaging
13.8 mm in size [ 16 ]. Neither of these radiola-
beled Tc-99m compounds is available in the US,
however, and both require special handling due to
radioactivity.
The radiotracer now most commonly
employed for pulmonary nodule radioguided surgery in the US is Tc-99m macroaggregated albumin (MAA). This radiotracer was fi rst developed
for this purpose by a group at the University of
Virginia [ 17 ]. Daniel et al. tested a variety of
Tc-99m solutions in an animal model, including
Tc-99m sulfur colloid, Tc-99m MAA, and
Tc-99m pertechnetate (TcO4). They determined
that Tc-99m MAA provided the most precise and
sustained localization, up to 8 h, likely due to its
larger particle size, thus preventing diffusion
away from the pulmonary nodule through the
lung parenchyma. They then successfully piloted
the Tc-99m MAA radiotracer injection in lesions
in 13 of 13 humans with thoracoscopic biopsy
[
12 , 17 , 18 ].
On the basis of this work, in 2008, the same
group at the University of Virginia published
their results of the successful identifi cation and
excision of 77 of 81 indeterminate pulmonary
nodules (95 %), with 71 of the 77 (92 %) removed
thoracoscopically [ 19 ]. The mean size of the pul-
monary nodules was 9.8 mm. Under CT guidance
on the day of surgery, these 81 pulmonary nodules were injected with 0.1 mL Tc-99m MAA
(approximately 0.3 mCi) just deep to the lesion to
ensure adequate incorporation of the lesion. The
corresponding pulmonary nodule was then identifi ed and confi rmed as frequently as needed
intraoperatively using a special angled gamma
detection probe. Of note, the four patients in
15 ]. Although they suc-
338
https://t.me/med1917
A.W. Maiga and E.L. Grogan
whom the lesion was not identifi ed and successfully excised had accidental spillage of the radiotracer, either into the pleural space or the soft
tissues of the chest wall. This occurred early in
the series. The team subsequently modifi ed their
protocol to include an immediate preoperative
scintigraphy, in order to confi rm an intraparenchymal location of the injected radiotracer for the
remaining patients, and with 100 % success with
localization and excision thereafter (77 of 77).
This additional step adds 10–15 min to the procedure. An unknown number of patients required a
second CT-guided radiotracer injection based on
the fi ndings of preoperative scintigraphy.
The radiotracer injection itself was performed
under conscious sedation and was well tolerated.
A total 8 of 81 patients (10 %) developed pneumothoraces requiring pigtail catheter placement
into the intrathoracic pleural space in the radiology suite. This is comparable to the 6 patients
with asymptomatic pneumothoraces of the 39
(15 %) in the original series by Chella et al. [ 14 ].
Most patients underwent surgery the same day as
radiotracer injection, but the team also successfully performed excision the following morning
with an increased radiotracer dose (0.3–0.4 mL
of Tc-99m MAA rather than the standard
0.1 mL). This in vivo radiotracer longevity facilitates practical incorporation of this technology
given the often unpredictable nature of surgical
schedules and operating room case start times.
This technique is described in detail below. The
University of Virginia provides some additional
educational information at the following website:
http://www.med-ed.virginia.edu/courses/rad/
rsnanucs/.
21.2.2 Technique in Detail
21.2.2.1 CT-Guided Radiotracer
Injection
On the morning of or day prior to the operation,
the patient undergoes placement of the radiotracer as follows (Fig. 21.1 ). Conscious sedation
is administered. A limited CT scan confi rms the
nodule’s position. The surgeon and interventional
radiologist agree on the optimal approach angle,
avoiding the pleural surface of major fi ssures.
Local anesthesia is administered. The radiologist
positions a 20-gauge coaxial needle along the
intended track with the tip ending just proximal
to the pleural cavity. Under CT fl uoroscopy, a
22-gauge needle is then advanced through this
needle into or just deep to the pulmonary nodule.
Between 0.1 and 0.3 mL (~0.3–0.9 mCi) of
Tc-99m MAA is injected. An immediate postprocedural scintigram confi rms intraparenchymal location of radiotracer. If unsuccessful, the
procedure is repeated as needed.
21.2.2.2 Radioguided VATS Surgery
Later that day or the following morning, the
patient is brought to the operating room
(Fig. 21.2 ). General anesthesia with single-lung
ventilation is induced. The patient is placed in
the left lateral decubitus position and prepped
and draped in the standard fashion. A sterile
handheld angled gamma detection probe is used
to identify the area of maximum signal on the
external chest wall. Three standard VATS incisions are made, one 5-mm port for the thoracoscopic grasper and two 10-mm ports for the
thoracoscope and the gamma detection probe
alternating with the endostapler, respectively.
Inside the chest cavity, the gamma detection
probe is again used to identify the site of maximum counts per second signal on the surface of
the lung parenchyma.
The area of interest is grasped and elevated
with an endoscopic grasper. The lung parenchyma is scanned with the angled probe to confi rm the signal from multiple angles and to
determine the depth of the lesion. The lesion is
then wedged out with one or more fi res of an
endostapler, taking care to incorporate the entire
lesion distal to the staple line. The specimen is
removed in an Endobag. After excision, the specimen is probed ex vivo with the gamma detection
probe to confi rm the presence of radiotracer
activity within the excised specimen and then
opened on the operative fi eld and/or sent directly
to pathology for frozen sectioning. The gamma
detection probe is then reintroduced into the thoracic cavity to scan the adjacent lung parenchyma
and ensure removal of all areas of radiotracer
21 Radioguided Surgery of Small Pulmonary Nodules
https://t.me/med1917
a
339
b
c
Fig. 21.1 CT-guided injection of Tc-99m. ( a ) A 77-year-
old smoker was referred to the thoracic surgery service
with a 0.7 × 0.9 cm right lower lobe nodule, greater than
2 cm from the pleura. The pulmonary nodule was noted
incidentally 6 months prior and had increased in size from
0.5 × 0.6 cm at that time. His preoperative FEV1 was
activity. As needed, additional lung parenchyma
is removed and the process repeated. Based on
frozen section results, a formal lung resection
may or may not be required.
21.2.3 Co-localization
with Radiotracer
and Another Modality
A number of researchers have also combined
Tc-99m radiotracer localization with other common localization adjuncts, including radiopaque
d
49 %. ( b ) Under CT guidance, the interventional radiolo-
gist positions the needle with the tip just deep to the pulmonary nodule. ( c ) The radiologist injects 0.1–0.3 mL of
technetium-99m-labeled albumin at the site of interest.
( d ) Post-procedural scintigram confi rms precise intrapa-
renchymal radiotracer uptake
contrast injection, hookwire placement, and
methylene blue injection. Radiopaque contrast
media has been the most common adjunct
reported in the literature [ 20 – 22 ]. For example,
Bellomi et al. used Tc-99m MAA mixed with
nonionic iodinated contrast medium to successfully localize and resect 47 indeterminate pulmonary nodules (mean 11 mm size and 11 mm
depth) in 44 patients [ 20 ]. A post-procedural CT
scan was performed to defi ne the distribution of
the contrast media and rule out an iatrogenic
pneumothorax, followed by a confi rmatory scintigram and then surgery within 24 h, typically on
340
https://t.me/med1917
a
b
A.W. Maiga and E.L. Grogan
c
Fig. 21.2 Localization of lung nodule using gamma
probe during VATS excisional biopsy. ( a ) A sterile gamma
radioprobe is introduced into one of the thoracoscopic
port sites. ( b ) The lung parenchyma is scanned with the
radioprobe to identify the area of maximum radioactive
signal, rotating to confi rm the depth of the pulmonary
the following day. Thirteen patients (30 %) had
asymptomatic pneumothoraces on CT imaging,
none requiring drainage. Similarly, Bertolaccini
et al. used Tc-99m MAA diluted with iodized
contrast medium in a prospective series of 19
patients with pulmonary nodules <15 mm located
20–40 mm from the pleural surface and also
reported good success with minimal complications [
21 ]. In the largest series, Ambrogi et al., a
group from Italy, reported success in 208 of 211
cases (99 %), again with the Tc-99m MAA/contrast co-localization method [ 22 ]. A total of
10.4 % developed pneumothoraces, none requiring drainage.
Local injection of simple blue dyes, typically
methylene blue, is a long-standing localization
adjunct for small pulmonary nodules. Wang et al.
reported using both Tc-99m sulfur colloid and
d
TM
nodule. Note the Navigator
counts per second. ( c ) After wedge excision, the lesion is
examined ex vivo with the gamma detection probe to confi rm focal radioactivity. ( d ) The staple line and adjacent
lung parenchyma are scanned to ensure there is no signifi cant residual radioactivity
displaying the radioactivity
methylene blue to locate and resect pulmonary
nodules in a small case series of three patients
23 ]. They deposited both the Tc-99m and blue
[
dye in two locations, one in the subcutaneous fat
in line with the target and then within or just deep
to the lesion, hypothesizing that this would better
highlight the “linear projecting tract” for intraoperative localization and ex vivo confi rmation.
The hookwire localization technique is
described in the “Alternatives to Radioguidance”
section later in this chapter. One group has
reported a dual-localization technique using both
a percutaneous transthoracic hookwire and Tc
99m phytate for 36 pulmonary nodules in 34
patients [
24 ]. Of note, 7 hookwires (19 %) dis-
lodged prior to surgery, although these pulmonary nodules were all successfully excised
secondary to detection of the radiotracer.
21 Radioguided Surgery of Small Pulmonary Nodules
https://t.me/med1917
341
21.2.4 Iodine-125 (I-125) Seeds
Whereas Tc-99m is the most commonly used
radiotracer, iodine-125 (I-125) seeds have been
employed in radioguided surgery for pulmonary
nodules in a limited fashion. In 2013, Gobardhan
et al. from the Netherlands reported using
CT-guided percutaneous transthoracic placement
of I-125 seeds, one per pulmonary nodule, for 28
patients with suspicious pulmonary nodules, followed by VATS wedge resection guided by a
handheld gamma probe [ 25 ]. Downsides of this
technique include the possibility for I-125 seed
dislodgement with subpleural placement (occurring in 5 of 28 patients in this study), the need to
ensure removal of the radioactive seeds in accordance with local and national guidelines, and the
increased risk of hematoma and pneumothorax
given the larger 18-gauge needle that is required
to implant I-125 seeds. There have been no subsequent reports in the literature of using I-125
seed placement in pulmonary nodule surgery.
However, in contrast to using the I-125 seed
localization approach for radioguided surgery for
pulmonary nodules, the I-125 seed localization
approach is much more commonplace for
radioguided surgery for non-palpable breast
lesions (see Chap. 8 ).
21.3 Radioguided Surgery:
Intravenous Delivery
Techniques
The intravenous administration of a radiotracer to
guide resection of pulmonary nodules remains
experimental. Nevertheless, the attraction of the
intravenous route is clear. Intravenous injection
avoids the innate morbidity and mortality of any
percutaneous transthoracic procedure and obviates the need to coordinate services between radiology and surgery during the perioperative time
frame [ 26 ]. The primary challenge remains
ensuring adequate radiotracer uptake at the site of
interest to allow for suffi cient contrast to that of
the background lung parenchyma.
21.3.1 Radioimmunoguided Surgery
Limited work has been published on the application of radioimmunoguided surgery (RIGS) to the
identifi cation and resection of pulmonary nodules
[ 27 – 29 ]. In 1998, Grazia et al. described intrave-
nously injecting 10 patients with I-125- labeled
monoclonal antibodies at an average of 20 days
prior to surgery and then employed a handheld
gamma probe for intraoperative detection [ 27 ].
Despite the higher background radioactivity in the
thorax, specifi c binding (i.e., RIGS positivity) to
histologically confi rmed sites of adenocarcinoma
in the lung parenchyma was confi rmed in 9 of 10
cases, with the one RIGS- negative lesion demonstrating benign histology. Another Italian group
reported less promising results with monoclonal
antibodies (MAb) radiolabeled with either I-125
or Tc-99m, with binding occurring in a minority
of primary non-small cell lung cancers, and no in
situ selective localization of I-125- or Tc-99mtagged MAb within the area of the primary lung
tumor cells during RIGS but in situ selective
localization of Tc-99m- MAb to a small lymph
node metastasis previously unidentifi ed on preoperative imaging [ 28 ]. Resected neoplastic tissue
had an ex vivo 2:1 tumor to background ratio, but
this differential was not suffi cient for in vivo identifi cation. In 2000, Wang et al. reported on a pilot
animal study of a RIGS technique using biotinylated monoclonal antibodies in mice to identify
adenocarcinoma lung micrometastases, with a
reported sensitivity, specifi city, and accuracy of
96 %, 98 %, and 97 %, respectively [
this technique reported by Wang et al. has not
been subsequently replicated in humans.
Therefore, overall, RIGS appears to potentially be
most relevant to pulmonary nodules suspected to
be adenocarcinoma, but for which further clinical
research would be necessary for more conclusive
validation.
29 ]. However,
21.3.2 18 F-FDG-Guided Surgery
When administered intravenously, 18 F-fl uorodeoxyglucose ( 18 F-FDG) accumulates within
342
https://t.me/med1917
A.W. Maiga and E.L. Grogan
pulmonary nodules and thoracic lymph nodes
harboring metastatic cancer, lighting up as hypermetabolic lesions on positron emission tomography (PET) imaging [ 30 ]. Gamma radiation
should also be detectable intraoperatively with a
handheld gamma probe, facilitating the identifi cation and localization of any sites of cancer.
Nwogu et al. describe using intravenous injection
of 18 F-FDG in a series of 10 patients on the day of
surgery to guide resection, specifi cally of intrathoracic lymph nodes with suspected micrometastases [ 31 ]. All resected primary tumor sites
and true-positive lymph nodes were 18 F- FDG
avid when measured ex vivo, but in vivo avidity
was less reliable due to cardiac background activity, despite appropriate shielding. Moffatt-Bruce
et al. also published a single case report of using
radioguided localization of 18 F-FDG-avid tissue
after an intravenous injection of 18 F-FDG approximately 98 min prior to surgery [ 32 ]. Notably,
they relied on a triad of preoperative patient PET/
CT, specimen PET/CT, and postoperative patient
PET/CT, as well as intraoperative gamma probe
detection. This technology is likely most applicable to lymph node “ultrastaging” rather than to
the localization and resection of suspicious pulmonary nodules or primary lung cancers
themselves.
21.3.3 Bleomycin Derivatives
Bleomycin is a chemotherapeutic agent produced
by the Streptomyces bacterium as an antiviral
drug. It is known to localize to the lung and when
given in high doses for systemic chemotherapy
can thus cause pulmonary fi brosis. The fi rst use
of a gamma detection probe in lung cancer actually relied on cobalt-57 ( 57 Co) bleomycin as a
localization compound. In 1984, Woolfenden
et al. reported intravenously injecting 34 patients
with bleomycin and then used a sodium iodine
crystal attached to the tip of a bronchoscope to
attempt to detect and localize tumors [ 33 ].
Although these results were intriguing, the long
physical half-life of the 57 Co radionuclide (i.e.,
271.8 days) renders it impractical for radioguided
surgery.
Although the same lines, in 2003 a Chinese
group described administering an intravenous
injection of peplomycin, a bleomycin derivative,
linked to Tc-99m as a “tumor tracer” to not only
identify pulmonary nodules in 37 patients but
also to differentiate malignant versus benign
lesions intraoperatively as based upon the tumor
radioactivity relative to normal lung parenchyma
as calculated by a handheld gamma detection
34 ]. They reported a sensitivity, specifi c-
probe [
ity, and accuracy of 90 %, 88 %, and 89 %,
respectively. This work remains experimental.
21.3.4 DOTATATE
Somatostatin receptor scintigraphy is a proven
means to visualize many malignancies, including lung cancer [ 35 ]. Investigators have dem-
onstrated the utility of scintigraphy with older
somatostatin analogs, such as depreotide,
in localizing lung neoplasms, other neoplasms,
and infl ammatory nodules such as active granulomas [ 36 – 40 ]. The somatostatin analog, 4,7,
10- tricarboxymethyl- 1,4,7,10-tetraaza-cyclod
odecan- 1-yl-acetyl-D-Phe-Cys-Tyr-D-TrpLys-Thr-Cys- Thr-OH (DOTATATE), is a
highly selective SSTR2 agonist with greater
affi nity for SSTR2 than older somatostatin
analogs [ 41 ]. Some data support DOTATATE
PET/CT in the routine diagnosis of suspected
neuroendocrine tumors [ 42 ]. In particular,
bronchial carcinoids have been shown to have
avid, selective uptake of DOTATATE over that
18
of
F-FDG [ 43 ].
Early experimental data suggest that
DOTATATE, when labeled with indium-111
111
(
In), could serve to localize small pulmonary
nodules not only for imaging but also for intraoperative detection with a handheld gamma probe
and wedge resection. The low normal background uptake of DOTATATE in the lung parenchyma should facilitate localization of lung
lesions with an adequate lesion/background ratio.
Furthermore, the 2.8-day
would also allow intravenous administration 1–2
days prior to surgery. Our research team has
begun preliminary research into this area.
111
In physical half-life
21 Radioguided Surgery of Small Pulmonary Nodules
https://t.me/med1917
343
Ongoing challenges include determining the
optimal injected activity of
the optimal time interval between intravenous
injection and lesion resection in order to maximize the signal to noise ratio for pulmonary nodule detection. Furthermore, improved gamma
detection probe performance or shielding is
needed to reduce background noise and enhance
lesion localization.
111
In-DOTATATE and
21.4 Alternatives
to Radioguidance
In addition to the radioguidance techniques summarized in this chapter, multiple other localization adjuncts are available and have been
described in the literature. These will be reviewed
briefl y in this section of this chapter. A comparison chart of localization techniques for surgical
resection of pulmonary nodules is provided in
Table 21.1 . After a comprehensive review, the
British Thoracic Society concluded in their 2015
guidelines for the investigation and management
of pulmonary nodules that surgeons should “use
localisation techniques depending on local availability and expertise to facilitate limited resection
of pulmonary nodules” [ 44 ].
21.4.1 CT-Guided Hookwire
The use of CT-guided percutaneous transthoracic
placement of hookwires to guide intraoperative
identifi cation and resection of small indeterminate pulmonary nodules has been described by a
number of authors and has perhaps been the most
commonly used preoperative marking strategy
[ 45 – 52 ]. It is greater than 85 % effective but car-
ries a risk of pneumothorax ranging from 3 to
50 %, depending on the series, as well as a risk of
pulmonary hemorrhage upward of 30 %. The
main technical disadvantage of this approach is
the tendency of the hookwire tip to dislodge from
its target over time. To address this problem,
Partik and others have more recently described
using a helical tip wire specially designed to hold
lung parenchyma [ 53 , 54 ]. However, any wire
may cross a fi ssure in transit to the pulmonary
nodule, and intraoperatively it can be diffi cult to
track down from the external wire to the lesion
unless the thoracoscope is in the exact plane as
the wire.
Comparative studies are limited. Gonfi otti
et al. conducted a small prospective, randomized
trial comparing the hookwire technique and
radioguided surgery with Tc-99m human albumin microspheres [
divided into two groups well matched for size
(mean 1.1 cm) and depth (2.5 cm) of pulmonary
lung nodules. Pulmonary nodule localization was
84 % successful (21 of 25) in the hookwire group
compared to 96 % (24 of 25) in the radioguided
group.
55 ]. Fifty patients were
21.4.2 CT-Guided Coil or Marker
Placement
Alternatively, Powell and others have described
using platinum microcoil markers for pulmonary
nodule localization [ 56 – 58 ]. This technique is
similar to hookwire implantation, but no external
wire is left in place. Rather than following the
wire down to the pulmonary nodule, surgeons
rely on intraoperative fl uoroscopy to visualize the
implanted marker, adding to operating room time
and introducing awkwardness given the lateral
decubitus positioning of the patient. Other caveats exist. In one study, the coil was displaced in
one of the 12 patients due to atelectasis [
Moon et al. used a similar technique of CT-guided
microcoil placement with fl uoroscopic-guided
VATS resection for 32 pulmonary nodules in 30
patients, with 2 cases of intrathoracic displacement of the coils [ 58 ].
Koyama et al. have also described their experience with a 5-mm point marker with an attached
30-cm-long nylon suture and introducer system,
with low morbidity and good success [ 59 ]. In
theory, this suture obviates the need for fl uoroscopy while avoiding some disadvantages of the
classic hookwire technique. All CT-guided localization procedures employing hooks and wires
carry a risk of pneumothorax, as well as a rare but
catastrophic risk of air embolism [ 47 , 60 ].
56 ].
344
https://t.me/med1917
Table 21.1 Case series reporting localization techniques for surgical resection of pulmonary nodules
Authors/
Reference Localization technique Patient population Effi cacy Complications
Dendo et al.
49 ]
[
Ciriaco et al.
50 ]
[
Saito et al. [
Miyoshi et al.
51 ]
[
Yoshida et al.
52 ]
[
Koyama et al.
59 ]
[
Mayo et al.
57 ]
[
Watanabe et al.
64 ]
[
Kawanaka
84 ]
et al. [
Kim et al. [
Vandoni et al.
67 ]
[
CT-guided hookwire 150 Patients
undergoing
VATS resection
of 168 nodules
CT-guided hookwire 53 patients
undergoing
VATS nodule
resection
46 ] CT-guided hookwire 61 patients
undergoing
VATS nodule
resection
CT-guided hookwire 108 patients
undergoing
VATS nodule
resection
CT-guided hookwire 57 patients
undergoing
VATS nodule
resection
CT-guided point
marker system
CT-guided microcoil
wire
Lipiodol marking 150 patients
Lipiodol marking 65 patients
63 ] Lipiodol marking 67 patients
Methylene blue
marking
52 patients
undergoing
VATS nodule
resection
69 patients
undergoing
VATS resection
of 75 nodules
undergoing
VATS nodule
resection
undergoing
VATS resection
of 107 nodules
undergoing
VATS resection
of 68 nodules
51 patients
undergoing
VATS resection
of 54 nodules
97.6 % hookwire
placed successfully
92.5 % hookwire
remained in situ
facilitating VATS in
58 %
85 % hookwire
facilitated VATS
93.6 % successful
resection
4 % nodule not in
resection specimen,
2.4 % hookwire left
in situ
One hookwire
dislodged by time of
surgery. Successful
surgery for all cases
Successful
placement in 98 %
cases (one
dislodged) and
resection
Successful
placement in all
cases but dislodged
in 3 %. 97 % of
nodules removed
All nodules
successfully resected
All nodules
successfully marked
and resected
Marking successful
in 98 %
Successful
thoracoscopic
resection in 91 % of
patients
A.W. Maiga and E.L. Grogan
32.1 % pneumothorax (chest
tube in 1.2 %)
14.9 % pulmonary
hemorrhage
7.5 % pneumothorax
None reported
3.7 % of patients, chest drain
for pneumothorax
49.1 % pneumothorax (no
chest drain)
29.8 % pulmonary
hemorrhage
7 % pain
19 % asymptomatic
pneumothorax
10 % pulmonary hemorrhage
3 % pneumothorax requiring
drain
1 % asymptomatic
hemothorax
11 % pain requiring
analgesia
17 % pneumothorax (6 %
drain)
0.6 % hemopneumothorax
(emergency operation)
31 % pneumothorax (5 %
drain)
15 % pulmonary hemorrhage
29 % pneumothorax
7 % pulmonary hemorrhage
25.4 % pneumothorax (no
drain)
Соседние файлы в папке Библиотека им академика М.И. Перельмана