0
Minimally Invasive Techniques |

Feasibility and Value of Video-Assisted Thoracoscopic Surgery Wedge Excision of Small Pulmonary Nodules in Patients With Malignancy*

Jim Burdine, MD; Lyle D. Joyce, MD, FCCP; Michael B. Plunkett, MD; Subbarao Inampudi, MD; Mitchell G. Kaye, MD; Daniel H. Dunn, MD
Author and Funding Information

*From Minnesota Thoracic Associates, PA (Drs. Burdine and Joyce), Minneapolis, MN; Consulting Radiologists, LTD (Drs. Plunkett and Inampudi), Minneapolis, MN; the Minnesota Lung Center, PA (Dr. Kaye), Minneapolis, MN; and General Surgery (Dr. Dunn), Abbott Northwestern Hospital, Minneapolis, MN.

Correspondence to: Jim Burdine, MD, 920 E 28th St, No. 440, Minneapolis, MN 55407; e-mail: jburdine@mnthoracic.com



Chest. 2002;122(4):1467-1470. doi:10.1378/chest.122.4.1467
Text Size: A A A
Published online

Purpose: Advances in CT scanning have presented physicians with the challenge of diagnosing small (< 10 mm) or deep (> 5 mm) pulmponary nodules (SmPNs) in patients with known malignancies during workup or follow-up. Wedge excision of SmPNs is difficult with video-assisted thoracoscopic surgery (VATS) and often requires the performance of a thoracotomy. The value of the early detection of metastatic disease must be weighed against the morbidity (ie, thoracotomy) that is necessarily involved in obtaining the information. Little is known about the incidence of metastases in this subset of patients. We describe a VATS technique that allows the reliable excisional biopsy of SmPNs and present our findings in this patient population.

Methods: Using CT scan localization, 150 μCi technetium sulfur colloid is injected into the area of the pulmonary nodule. Additional blue dye is injected at the lung surface. During VATS, a sterile gamma probe is used to identify the area of radioactivity and plan placement of staple lines performed by an endostapling instrument. Palpation and the presence of radioactivity in the specimen supported the resection of the correct nodule, and CT scan findings confirmed the procedure. Between March 2000 and January 2001, 17 patients with known malignancies and SmPNs underwent VATS excisional biopsies. Six patients received a new diagnosis of malignancy, and 11 patients were in follow-up of a previously treated malignancy. The malignancies included the following: breast (four patients), head and neck (four patients), pancreas (two patients), lymphoma (two patients), lung (one patient), prostate (one patient), rectal (one patient), seminoma (one patient), and urethral (one patient).

Results: All lesions were successfully resected on the first try. Nodules were removed from 10 segments and all lobes. The mean (±/SD) nodule size was 9.2 ± 3.6 mm, and the mean depth was 9.4 ± 5.2 mm. Fourteen of 17 nodules (82.4%) could be neither seen nor felt using standard VATS techniques. Diagnoses included metastatic (four patients), new primary lung cancer (one patient), acid-fast bacillus (one patient), granuloma (seven patients), carcinoid (two patients), and inflammatory pseudotumor (two patients). Among these lesions, 29.4% were malignant, and 35.3% of patients received a diagnosis that altered their therapy. Five of 12 SmPNs (41.7%) < 10 mm in size were malignant. The median length of hospital stay was 2 days. Patients returned to full activity within 1 week.

Conclusion: VATS excision of SmPNs after CT scan localization with radiolabeled technetium is reliable, reproducible, and associated with minimal morbidity. The technique prevented thoracotomies in 82.4% of patients. Despite the small size of these lesions, malignancy was found 29.4% of the time. This technique allows the early diagnosis of SmPNs, with low morbidity, in patients with known malignancies.

Clinical implications: The reliability of this technique, the high incidence of malignancy, and the reduction in morbidity from undergoing excisional biopsy procedures will encourage the clinician to strive for earlier and more aggressive diagnoses of SmPNs.

Figures in this Article

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543