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Intrathorascopic US: Usefulness in Localization of Solitary Pulmonary Nodules [letter]

Department of Surgical, Anaesthesiological and Radiological Sciences, University of Ferrara, C.so Giovecca 203, Ferrara 44100, Italy. e-mail: sors@libero.it

Editor:

We would like to express our opinion about indications for preoperative localization techniques during thoracoscopic procedures (1). The localization of small pulmonary nodules remains an unsolved problem in thoracoscopic surgery.

First, we congratulate Dr Dendo and colleagues for the results obtained in their study, which appeared in the November 2002 issue of Radiology (1).

We know that for small and deep pulmonary nodules, localization techniques are necessary, and in 1999 (2), Suzuki et al established dimensions and depth of nodules for which a localization technique is necessary. We believe that preoperative localization techniques have some negative aspects. First, the use of a needle wire can provoke (1,5) pneumothorax, hemorrhage in the lung, parenchymal damage, or perinodular inflammation in a high number of patients. We are sure that in most cases these complications are nonsymptomatic, but they can negatively influence the health of the patient and the surgical approach; for example, perinodular inflammation can influence the margins at resection.

Second, on the basis of the international literature, use of needle wire and other preoperative techniques (vital stain and radio-guided techniques) do not have a high rate of localization. We never perform preoperative localization, such as with use of a needle wire—we prefer intrathoracoscopic ultrasonography (US) (3,4). For us, US is the most effective method for localization of pulmonary nodules and does not cause side effects. Intrathoracoscopic US is useful and has a 100% localization record in our experience with thirteen cases (4) and in others (3). With intrathoracoscopic US, we can study the structures surrounding the nodule, such as vessels, bronchi, and lymph nodes, and intrathoracoscopic US enables us to choose resection margins. Finally, intrathoracoscopic US can provide a histologic finding of a nodule, thanks to the different US patterns of pulmonary nodules (3,4).

In experienced hands, localization with intrathoracoscopic US is quick (12 minutes in our case records) and without risk and side effects. Another positive aspect of US is the possibility of acquiring an intraoperative scan of the lung to find other nodules that do not appear at thoracic computed tomography (CT). Visualization of pulmonary lesions at US does not require complete collapse of the lung. Moreover, US is applicable in patients with more than one nodule, while it is difficult to position two or three needles. Finally, we believe that intrathoracoscopic US is better than other techniques, such as finger palpation and indirect palpation, because it provides an objective means of localization, while direct or indirect palpation can provide a subjective means of localization.

REFERENCES

1. Dendo S, Kanazawa S, Ando A, et al. Preoperative localization of small pulmonary lesions with a short hook wire and suture system: experience with 168 procedures. Radiology 2002; 225:511-518.[Abstract/Free Full Text]
2. Suzuki K, Nagai K, Yoshida J, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indication for preoperative marking. Chest 1999; 115:563-568.[Abstract/Free Full Text]
3. Santabrogio R, Montorsi M, Bianchi P, Mantovani A, Ghelma F, Mezzetti M. Intraoperative ultrasound during thoracoscopic procedures for solitary pulmonary nodules. Ann Thorac Surg 1999; 68:218-222.[Abstract/Free Full Text]
4. Sortini A, Carrella G, Sortini D, Pozza E. Single pulmonary nodules: localization with intrathoracoscopic ultrasound—a prospective study. Eur J Cardiothorac Surg 2002; 22:440-442.[Abstract/Free Full Text]
5. Sortini A, Sortini D, Carrella G. Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery. J Thorac Cardiovasc Surg. (in press).

Drs Dendo and Kanazawa respond:

Department of Radiology, Okayama University Medical School, 2-5-1 Shikatacho, Okayama 7008558, Japan. e-mail: susumu@cc.okayama-u.ac.jp

We thank Dr Sortini and colleagues for their interest and comments regarding our article (1). We agree with the utility of intrathoracoscopic US for localization of small pulmonary lesions, as they described in their letter and article (2). As described in their article, intrathoracoscopic US is a safe, risk-free, and inexpensive method for the localization of pulmonary nodules (2). We believe there are several disadvantages with this method, however, whereas our localization method has several advantages.

Although Dr Sortini and colleagues describe in their letter that localization with intrathoracoscopic US is quick in experienced hands, Santambrogio et al (3) noted that it is a difficult technique that requires a great deal of experience. That means that this technique can be performed only in institutions that can provide well-trained and experienced surgeons who are accustomed to using intrathoracoscopic US. The other problem is that visualization of pulmonary lesions at US usually requires almost complete collapse of thelung, which is often impossible in patients with obstructive diseases, such as centrilobular emphysema (4). Formless abnormalities may be particularly difficult to visualize. In our series (1), the proportion of nodules with ground-glass opacity is almost 50% of all lesions in groups with 3- and 4-year experiences. Since we could not find any CT images of lesions in articles by Dr Sortini and colleagues (2) or Santambrogio et al (3), we cannot state the possibility of visualization of small pulmonary lesions with ground-glass opacity by means of intrathoracoscopic US. We would like to know if intrathoracoscopic US can depict such lesions with ground-glass opacity as shown in figure 2 of our article (1).

In our series, we experienced no serious complications. No patients complained of pleural pain during or after the procedure, especially with the suture. Although the overall localization success rate was 97.6%, we experienced no wire dislodgement at our institution during the previous 6 years. We could localize lesions with ground-glass opacity, and double or triple wire placement was sometimes performed without any difficulties. We have never encountered comments from pathologists that the wire placement precluded their accurate pathologic diagnosis after video-assisted thoracic surgery. Thus, we believe that our system can be considered standardized.

We appreciate the great percentage of 100% localization by Dr Sortini and colleagues and are very interested in findings of intrathoracoscopic US described in their article (2). We think that their procedure is really promising. If an institution provides surgeons who are accustomed to using intrathoracoscopic US, there may be no need for preoperative localization. However, if an institution provides no experienced surgeons but does provide a CT scanner and interventional radiologists, preoperative localization may be required. If an institution provides no appropriate surgeons or interventional radiologists, video-assisted thoracic surgery should not be performed for treatment of small pulmonary lesions, in our opinion.

REFERENCES

1. Dendo S, Kanazawa S, Ando A, et al. Preoperative localization of small pulmonary lesions with a short hook wire and suture system: experience with 168 procedures. Radiology 2002; 225:511-518.
2. Sortini A, Carrella G, Sortini D, Pozza E. Single pulmonary nodules: localization with intrathoracoscopic ultrasound—a prospective study. Eur J Cardiothorac Surg 2002; 22:440-442.
3. Santambrogio R, Montorsi M, Bianchi P, Mantovani A, Ghelma F, Mezzetti M. Intraoperative ultrasound during thoracoscopic procedures for solitary pulmonary nodules. Ann Thorac Surg 1999; 68:218-222.
4. Kerviler E. Limitation of intraoperative sonography for the localization of pulmonary nodules during thoracoscopy. AJR Am J Roentgenol 1998; 170:214-215.[Medline]

This article has been cited by other articles:

				D. Sortini, C. V. Feo, P. Carcoforo, G. Carrella, E. Pozza, A. Liboni, and A. Sortini Thoracoscopic Localization Techniques for Patients With Solitary Pulmonary Nodule and History of Malignancy Ann. Thorac. Surg., January 1, 2005; 79(1): 258 - 262. [Abstract] [Full Text] [PDF]

				P. Carcoforo, C. Feo, D. Sortini, E. Pozza, G. Carrella, A. Sortini, and K. Sugi Localization of Pulmonary Nodules Chest, February 1, 2004; 125(2): 796 - 797. [Full Text] [PDF]

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