Preoperative Small Pulmonary Nodule Localisation Using Hookwires or Coils: Strategy Selection in Adverse Events

Objective We conducted a retrospective study of adverse events associated with the preoperative procedure of computed tomography (CT)–guided hookwire or coil localisation. We analysed the experience of and process flaws in resecting ground-glass nodules (GGNs) using video-assisted thoracoscopic surgery (VATS) and determined the remedial strategy. Methods Adverse events were evaluated in 20 patients with 25 GGNs who underwent CT-guided hookwire or coil localisation before VATS. For lesions not successfully marked or detected, palpation, resection of the highly suspected area, segmentectomy or lobectomy was performed. Results Among all adverse events, 10 were dislodgement of the marking materials, 2 were breakaway of the marking materials, 4 were >2-cm distance between the lesions and the tip, one was marking material across the two adjacent lobes, 10 were pneumothorax and two were certain parts of marking materials stuck into the walls. All GGNs were resected successfully. Fifteen lesions were detected by palpation. Three GGNs were discovered after the resection of highly suspected areas. The GGNs were removed by lobectomy. Segmentectomies and lobectomies were performed directly on two and four GGNs, respectively. Conclusions When adverse events occur, a second localisation, intraoperative localisation, resection of a highly suspected area, or a segmentectomy or lobectomy can be successfully attempted using VATS for resection of GGNs.

Pulmonary nodules precision localization techniques

The advent of helical high-resolution CT scanners, the application of screening programs and the follow-up of patient with oncological history, led to an increasing number of diagnosis of small pulmonary nodule (less than 10 mm in maximum diameter), partially solid nodule or completely ground glass ones. Their management is controversial. Excisional biopsy by mean of video-assisted thoracic surgery is often a viable choice but to locate these lesions intraoperatively can be impossible without the aid of preoperative or intraoperative localization techniques. In this brief review we will analyze the benefit of adopting localization techniques prior to pulmonary resection for small pulmonary lesions and face the advantages and problems with the main techniques described in the literatures.

Airways Disease

Pulmonary hamartoma is a benign neoplasm of the lung. It accounts for the majority of benign lung tumors. A hamartoma is composed of a variety of mesenchymal elements that may include cartilage, calcification, fat, epithelial cells, and smooth muscle. While benign, they are considered true neoplasms, and may demonstrate slow growth. Hamartomas are most commonly discovered in the 6th decade of life. Men have a 2-to-3 fold increased incidence compared to women. Most hamartomas are discovered incidentally. However, patients may rarely present with symptoms such as cough, hemoptysis, or recurrent pneumonia due to lesion proximity to the airway. On CT, hamartoma classically manifests as a small pulmonary nodule with intrinsic chondroid calcification and fat. These findings are essentially diagnostic of hamartoma. However, only 60% of hamartomas contain macroscopic fat, and even fewer (15%) exhibit characteristic “popcorn” calcification. Most hamartomas do not require resection, unless they are symptomatic. Other benign lesions also occur in the lung, but are much less common. A chondroma differs from a hamartoma in that is entirely comprised of cartilage. Chondromas are a component of Carney triad, which is also comprised of gastric leiomyosarcomas and extraadrenal paragangliomas. Lipomas and leiomyomas are other rare benign neoplasms, composed of fat and smooth muscle, respectively. Benign neurogenic neoplasms may also occur within the central airways.