Novel Surgical Approach for Localization and Excisional Biopsy of Small or Ill-defined Pulmonary Lesions Thomas M. Daniel, M.D. Section of General Thoracic.

Novel Surgical Approach for Localization and Excisional Biopsy of

Small or Ill-defined Pulmonary Lesions

Thomas M. Daniel, M.D.Section of General Thoracic Surgery

University of Virginia School of MedicineCharlottesville, Virginia

Frequency and Mortality of the Most Commonly Diagnosed Cancers

150 200100500

Lung

Number (x103)

Colon

Breast

Prostate

Deaths

New cases

Cure Rate

50%

12%

75%

80%

171,000

158,900

94,700

47,500

176,300

43,700

179,300

37,000

1999 Cancer Facts and Figures, American Cancer Society

Characteristics of 95 nodules seen in 184 patients entered in UVA lung cancer

screening program • Calcified 5%

• < 3 mm 36%

• 3 to 6 mm 43%

• >6 and <10 mm 6%

• = to or >10 mm 10%

52% had nodules. 85% were less than 10mm!

Review of Intraoperative Localization Techniques for Excisional Biopsy of

Small Lung Nodules

• Needle localization

• Ultrasound localization

• Fluoroscopic localization using solid and liquid radio-opaque substances

• Radiotracer localization

Needle Localization Experiments

• attempt to mimic breast biopsy experience

• UVA animal laboratory experiment using four different hook needle designs

• Goal: Test ability of hooks to stay in place near small lung lesions to guide thoracoscopic biopsy

4 hook needle designs Depth gauge

Results of Needle Localization Experiments

• ALL needles failed to remain in place with minimal standardized resistance

• Summary: - needle localization in lung tissue is

ineffective

Solid Marker Localization Experiments

• Neurosurgical coil with ultrasound localization under saline – UVA ex vivo sample

coil

Solid Marker Localization Experiments

•CT fluoroscopy guided injection of cyanoacrylate via 22 gauge needle- Yoshida-Japanese JTCVS 1999; 47: 210-3

• Summary- Hardness of both localization materials with coil and cyanoacrylate made subsequent frozen pathologic evaluation difficult. Both techniques exposed OR team and patient to fluoroscopy.

Liquid Radio-Opaque Nodule Localization Techniques

Okumura-ATS 2001;71:439-42

• CT-guided bronchoscopic barium sulfate markerplaced in or near nodule

• Subsequent fluoroscopy-assisted thoracoscopic excisional biopsy ( FATS-BM )

• 20 patients- all nodules successfully biopsied.Average distance from outer margin of lesion to nearest pleural margin was 6.5mm ( 0-18 mm)

Lung nodule CT fluoroscopy Barium placednear nodule

E= thoracoscopicstapling device

F= endograsperwith nodule

Fluoroscopic view

Liquid Radio-Opaque Techniques-continued

Nomori-ATS 2002;74:170-3

• Percutaneously placed Lipiodol using CTguidance- 21 gauge needle- aspirate first!

• Simultaneous use of colored collagen for pleural localization

• Fluoroscopically-assisted thoracoscopic biopsy

• 66 patients- Average distance from nodule margin to pleurawas 19mm ( 8-30mm). Average nodule size 7mm.

Lung nodule

Percutaneously placedLipiodal

Liquid radio-opaque techniquesLimitations

• preoperative bronchoscopic localization takes time,high level of skill and exposes bronchoscopist andpatient to radiation from fluoroscopy

• Both techniques require intraoperative fluoroscopy which is of limited use with the patient in the lateral decubitus position and exposes patient and staffto radiation from fluoroscopy

Radiotracer Nodule Localization Study

Chella-European JCTS 2000;18:17-21

• Percutaneous injection of Technetium labeledhuman serum albumin microspheres using CT guidance and 22 gauge needle

• Thoracoscopic biopsy 2 hours later using gamma ray detector- 11mm diameter

• 39 patients- all nodules successfully located.Mean nodule size 8.3mm. Mean distance from pleura 13mm ( 6-30mm)

Digital display of gamma ray emissions

Videoscopic view of radiation probe

zero degreeradioprobe

University of Virginia nodule localization study

• First step-laboratory testing of technique using small animal model and three readily-available Technetium radiotracers ( MAA- used in lung perfusion scans, Sulfur colloid- used in breast cancer sentinel node location, and unbound pertechnetate as control)

• Second step- clinical application with IRB approval

University of Virginia nodule localization experience

November 2002-August 2004

• 29 patients age 48-85 19 males 10 females

27 had >20PY smoking history

• average distance from pleural surface to lesion on CT scan- 13.3 mm (1-50)

• average nodule size- 11mm (1-22)

Results• 2 pneumothoraces during needle placement. No surgical complications

• 2 lesions had disappeared and were not present on day-of-surgery CT scans

• 96% of remaining 27 lesions successfully localized and biopsied

• 13 of 27 lesions were malignant 10 primary lung cancers- 9 Stage IA, I Stage IB 3 solitary metastatic lesions in smokers with previous history of malignancy (colon, 2 melanoma)

Tc-99m MAA lung nodule localization

- Requires no special technology.

- Permits predictable localization and thoracoscopic biopsy of small or ill-defined lung nodules

- Remains useful for nodule localization if VATS is converted to open thoracotomy due to location or pleurodesis

- BUT endoscopic stapling technique for excision of small nodules is awkward and often results in excessive lung tissue removal

Laboratory experiment combining radiotracer localization technique with

1318-nm Nd:YAG laser excision• eight pig lungs studied using open thoracotomy

• Tn 99m MAA radiotracer solution injected transpleurally up to 1 cm deep to create a “lesion”

• Gamma radioprobe used to guide 1318-nm Nd:YAG laser excision of radioactive “lesion”

• lung specimens evaluated with combined scintigram/radiogram to determine accuracy of excision

A

B

A – injection of radiotracer to create lesion

B – YAG laser excision guided by radioprobe

C – combined scintigram/radiograph showing complete excision of lesion

Combined technology experiment for nodule localization and excision

C

Ventilated pig lung with saline-filled biopsy site after cautery excison (left) and 1318 YAG excision (right)

Conclusions

• Radiotracer localization allows accurate and predictable localization of small or ill-defined lung lesions in patients at high risk for lung cancer

• Current lung stapling technology limits its use

• 1318-nm Nd:YAG laser technology when adapted to radiotracer-guided thoracoscopic surgery may allow excisional biopsy of small pulmonary lesions without excessive tissue removal

Acknowledgements

Department of Radiology- University of VirginiaTalissa Altes, MDPatrice Rehm, MDMark Williams, PhDAlexander Stolin, MSBijoy Kundu, PhDSpencer Gay, MDJuan Olazagasti, MDMatthew Bassignani, MDJonathan Ciambotti, MD

Fachkrankenhaus Coswig- GermanyDr. Axel Rolle Department of Surgery- University of VirginiaDavid Jones, MDBrendon Stiles, MDKirk BarbieriBrian Trotta, 2nd year UVA Medical Student