To aggressively cure early stage nonsmall cell lung cancer (NSCLC), minimally invasive video-assisted thoracic surgery (VATS) can be applied simultaneously for diagnosis and therapy of indeterminate pumonary nodules. Multiple, often cumbersome, techniques have been described to faciliate VATS, avoiding thoracotomy, in small nodules. We describe a simplified technique.
Small and/or deep pulmonary nodules, with a high probablity of malignancy and judged by the managing thoracic surgeon as unlikely to be identifiable at VATS, were considered for the techique. All patients underwent oncologic evalution, demonstrating no other sites of disease (probable NSCLC or metastasis), and physiologic competence for potentially curative surgery. All cases were presented at a weekly Multidisciplinary Thoracic Oncology Conference with interventional radiology (IR) participation. IR performed CT guided localization of nodules by percutanously delivering intravascular wire coils medial to the nodule. The patient was transported to the operating room where antero-posterior fluoroscopy (fluoro) was used to localize the coil and VATS excisional biopsy was performed. Pathologic examination directed the next step: benign-close; NSCLC: lobectomy and lymphadenctomy; metastasis: lymphadenectomy.
Over 48 months, 2119 thoracic operations included 444 lobectomies, 43 pneumonectomies and 341 wedge resections. 20 patients underwent CT-guided wire coil localization with fluoro-assisted VATS excision. Patients: Av age-65.5 yrs; Right 65%; Av CT size 11 mm; Av distance to pleura 19 mm. Procedure: Av time to loc: 30 min; Success: 95%; Av time to surgery: 133 min; VATS bx success: 95%; Conversion: 15%; Diagnosis: NSCLC 55% (all pStage 1A), benign 30%, metastatic 15%; Additional therapeutic surgery: VATS lobectomy/MLND 8, open lobectomy/MLND 1, VATS wedge/MLND 2, open wedge/MLND 1, VATS MLND 1; Av PO LOS 4.2 days.
CT-guided wire coil localization of a small pulmonary nodule followed by fluoro-assisted VATS excisional biopsy is straightforward and safe with a high success rate.
This technique allows appropriate immediate therapeutic surgery. With multidisciplinary management, a high proportion of malignancy is identified including curative-intent resection of early stage lung cancer.
John Handy, No Financial Disclosure Information; No Product/Research Disclosure Information