PURPOSE: VATS success in diagnosing indeterminant pulmonary nodules is limited by the ability to visualize and palpate the nodule. There is a 46% conversion from VATS to thoracotomy due to failure to localize nodules ≤;10mm in size or ≥5mm from the pleural surface. Therefore, preoperative marking is advantageous. We report a new therapeutic strategy for small nodules that minimizes thoracotomies by utilizing a combined modality approach of electromagnetic navigational bronchoscopy(EMNB) with a dye marker.
METHODS: During the planning phase, two target points were labeled: the nodule, and the adjacent pleural surface. Precise localization of the nodule was achieved using a steerable locatable guide(LG) within an extended working channel(EWC) during EMNB. After localization of the nodule, the LG was advanced towards the pleural surface, subsequently removed and replaced with a 25g sclerotherapy catheter through which 1mL of indigo carmine was injected at the pleural surface. The needle was withdrawn in 5mm increments with repeat injection of 0.5mL until reaching the nodule. The following day, patients underwent VATS.
RESULTS: Five patients (2 males and 3 females with an age range 46-78 years) had EMNB with staining followed by VATS for nodules ranging 7mm-30mm. Staining was easily visible and outlined the area for excisional biopsy. No procedure related complications were noted. Four patients were diagnosed with adenocarcinoma, and one with histoplasmosis. Three patients had wedge resections only, and one a complete lobectomy. In one patient, extensive adhesions from prior surgery necessitated conversion to a thoracotomy. Three patients were discharged within 24 hours, one on post-operative day 3, and the patient with a thoracotomy on post-operative day 6.
CONCLUSION: EMNB with dye staining enabled “tattooing” of pulmonary nodules for precise locatability and directing the depth of resection. Without staining, the visceral pleura was otherwise unremarkable and the location of the nodule impossible, likely necessitating conversion to thoracotomy for identification prior to excision.
CLINICAL IMPLICATIONS: Preoperative dye staining with EMNB is feasible, safe, and can minimize VATS conversions to thoracotomies by enabling visualization of the target.
DISCLOSURE: Sonali Sethi, No Financial Disclosure Information; No Product/Research Disclosure Information