Image-guided localization for video-assisted thoracic surgery.

Video-assisted thoracic surgery (VATS) has become a useful diagnostic and therapeutic tool in the management of lung, pleural, and mediatstinal disease. Preoperative image-guided localization is performed to aid the surgeon in the thoracoscopic resection of small lung lesions that would otherwise be difficult to resect. This article describes the techniques of localization and reviews our experience with this procedure. While the majority of localization procedures are performed during an immediately preoperative computed tomography (CT), the use of intraoperative lesion localization using an endosonographic probe has been reported. The need for localization before resection is dependent on the skill and experience of the thoracoscopist and the characteristics of the lung lesions.

Incidental pulmonary emboli detected at helical CT: effect on patient care.

PURPOSE: To evaluate incidental pulmonary emboli detected at helical computed tomography (CT) and the effect on patient care. MATERIALS AND METHODS: A computer search of reports from 1,879 consecutive contrast material-enhanced helical CT scans identified 28 cases in which pulmonary emboli were suggested. These 28 scans were rereviewed by three radiologists to confirm intraluminal defects. Six cases were excluded (three because of tumor invasion, two arterial stump thrombi after pneumonectomy, one artifact). In four cases, pulmonary emboli were clinically suspected or diagnosed prior to CT. Pulmonary embolus was not suspected at CT in the remaining 18 patients who constituted the study group. The medical records were reviewed for predisposing factors, suspicion of pulmonary embolism, adjuvant studies, and resultant therapy. RESULTS: All 18 patients in the study group had predisposition for thromboembolic disease. Seven of these patients underwent confirmatory or correlative studies (angiography, radionuclide studies, or autopsy), and four patients had supportive studies documenting deep venous thrombosis. Eleven patients received anticoagulants or caval filter placement as a result of CT findings. CONCLUSION: Incidental pulmonary emboli were detected in approximately 1% of patients who underwent contrast-enhanced CT of the chest. All of these patients were at high risk for emboli. Therapeutic intervention was undertaken in 61% of these patients. While ultimate patient outcome is uncertain, the incidental CT diagnosis of pulmonary emboli appears accurate and affects patient care.

The relationship of thoracic lymphadenopathy to pulmonary interstitial disease in diffuse and limited systemic sclerosis: CT findings.

OBJECTIVE: Mediastinal lymphadenopathy is frequently associated with interstitial lung disease (ILD) in patients with systemic sclerosis (SSc). This study compared the extent of lymphadenopathy in diffuse and limited SSc with the presence and type of ILD found on CT scans. SUBJECTS AND METHODS: Seventy-three patients with diffuse and limited SSc underwent thoracic CT. The presence of lymphadenopathy was correlated with the frequency and type of ILD. RESULTS: Fifty-eight percent (18/31) of patients with diffuse cutaneous SSc and 40% (17/42) of patients with limited cutaneous SSc had lymphadenopathy. A significant relationship was found between lymphadenopathy and the presence of interstitial disease (p = .0002). Seventy-two percent (18/25) of patients with a ground-glass parenchymal pattern of interstitial disease and 74% (14/19) of patients with a honeycomb pattern had lymphadenopathy. CONCLUSION: Lymphadenopathy is prevalent in patients with SSc and ILD regardless of clinical subtype or interstitial pattern. Lymphadenopathy appears to increase as a function of the profusion rather than the morphology of ILD.

Lung involvement in systemic sclerosis (scleroderma): relation to classification based on extent of skin involvement or autoantibody status.

Lung involvement accounts for significant morbidity and is a leading cause of mortality in patients with systemic sclerosis (SSc). It has been shown that different patterns of pulmonary involvement are seen in different subtypes of SSc. This paper reports a retrospective review of 72 patients with SSc to determine whether disease classification according to the extent of skin involvement alone (diffuse vs. limited) or autoantibody status was predictive of pulmonary parenchymal involvement. The diagnosis of interstitial lung disease was based on pulmonary function tests and chest radiographs. Restrictive lung disease was common in both limited SSc (lSSc) and diffuse SSc (dSSc), occurring in 30% and 50% of these patients respectively (P = 0.16). Radiographic evidence of significant interstitial disease was also comparable between the groups [nine of 32 lSSc patients (28%) vs. six of 17 dSSc patients (32%), P = n.s.]. No significant difference in mean lung function was found between patients with anti-Scl 70 antibody (n = 12) compared to those without (n = 60) (TLC 79.0 +/- SE 5.1% predicted vs. 82.8 +/- 2.2, P = n.s.; DLCO 63.0 +/- 5.1 vs. 59.7 +/- 2.5, P = n.s.). By contrast, statistically significant differences in mean lung function were found between patients with anticentromere antibody (ACA) (n = 24) and those without ACA (n = 48) (TLC 98.6 +/- SE 3.9% predicted vs. 79.7 +/- 3.1%, P < 0.001); and less frequent radiographic evidence of severe interstitial disease (0 of 17 with significant interstitial changes on chest radiograph vs. 15 of 32 (47%), P = 0.002). It is concluded that classification of SSc patients on the basis of the distribution of skin involvement poorly predicts the occurrence of interstitial lung disease. On the other hand, ACA is highly associated with the absence of interstitial lung disease.

Role of thoracoscopy and preoperative localization procedures in the diagnosis and management of pulmonary pathology.

Video-assisted thoracic surgery is an important component of modern thoracic surgery, providing a safe, less invasive alternative to open thoracotomy in the evaluation of pleural, mediastinal, and parenchymal pathology. Advancements in endoscopic techniques and video-optics have permitted greater visualization of the thoracic cavity and allowed limited pulmonary resections with significantly reduced postoperative morbidity. Thoracoscopy is indicated for diagnosis of intrathoracic pathology when usual methods of diagnosis, including fine-needle aspiration and transbronchial biopsy, are inconclusive. The diagnostic accuracy of video-assisted thoracic surgery approaches 100%. Increasingly, the indications for thoracoscopy include therapeutic resections of pulmonary nodules in cases of limited lung metastases and bronchogenic carcinoma when pulmonary function is poor. Successful diagnostic and therapeutic resection by thoracoscopy requires intraoperative localization of the lesion within the collapsed lung. The indications and methods of thoracoscopic surgery and preoperative localization are discussed.

US-assisted bronchoscopy with use of miniature transducer-containing catheters.

PURPOSE: To demonstrate the value of ultrasound (US) guidance during flexible bronchoscopic procedures in a series of patients with known or suspected pulmonary neoplasms. MATERIALS AND METHODS: US-guided bronchoscopy was carried out as an adjunct to conventional bronchoscopy for the diagnosis of mediastinal, hilar, or parenchymal neoplasms in 25 patients with masses previously detected with chest radiography or computed tomography. Miniature transducer-containing catheters were inserted through the biopsy port of the flexible bronchoscope, and cross-sectional real-time US scans of tumors, lymph nodes, and blood vessels were obtained. RESULTS: Among six cases of peripheral masses and 19 cases of central masses, additional information was provided in 18 cases (72%). This information was used to choose the optimal site for transmural biopsy. CONCLUSION: These preliminary results suggest that this US procedure may become an important diagnostic tool during bronchoscopy, due to the ability to identify structures beyond the lumen of the tracheobronchial tree.

Localization of peripheral pulmonary nodules for thoracoscopic excision: value of CT-guided wire placement.

OBJECTIVE: One of the indications for the rapidly expanding use of thoracoscopic surgery as an alternative to thoracotomy is the excision of peripheral lung nodules. Nodules judged too small or too far from the pleural surface to be seen or palpated during thoracoscopy must be localized beforehand. The purpose of this study was to evaluate the feasibility and effectiveness of percutaneous placement of spring hookwires to localize such nodules before video-assisted thoracoscopy. SUBJECTS AND METHODS: Under CT guidance, 17 nodules in 14 patients were preoperatively localized with the Kopans breast lesion localization system. Three patients who had solitary nodules had thoracoscopic resections for diagnosis because a previous transthoracic needle or transbronchial biopsy had been unsuccessful. Four patients who had lesions less than 8 mm in diameter had thoracoscopic biopsies because transthoracic fine-needle aspiration biopsy was not likely to be diagnostic. Seven patients, who had a total of 10 nodules, had therapeutic wedge resections of either limited metastases or a second bronchogenic carcinoma. Mean nodule diameter was 10 mm (range, 3-20 mm). The mean distance from nodule to costal pleura was 9 mm (range, 0-25 mm). At the end of the procedure, wire placement was confirmed by CT scanning. After thoracoscopy, the surgeons were questioned about the stability and utility of each hookwire localization. RESULTS: In all 17 procedures, a hookwire was placed successfully. In one case, the wire dislodged before thoracoscopy (after a 6-hr preoperative delay and severe bending of the wire during induction of anesthesia). In 16 of the 17 resections, the surgeon thought that thoracoscopic identification of the lesion would not have been possible without hookwire localization. Only one localization, across a major fissure, required placement of a second wire to localize a nodule. Wire-related complications included two instances of serious pain, five cases of clinically insignificant pneumothorax, and one large pneumothorax requiring drainage before a second nodule in the same lung was localized. CT scanning showed presumed local pulmonary hemorrhage in six cases without hemoptysis or hemothorax. CONCLUSION: CT-guided hookwire localization is easily and safely performed and permits thoracoscopic resection of lung nodules, which might otherwise be impossible.

Intrapulmonary lymph nodes. Clinical, radiologic, and pathologic features.

The clinical, radiographic, and pathologic material from ten patients with intrapulmonary lymph nodes was analyzed, along with information from all previously reported cases. In our series the median age was 56 years, and 80 percent (eight) of the patients were men. All patients are or were cigarette smokers. Sixty percent (six) had a history of exposure to either asbestos, nonfibrous silicates, or both. There were no characteristic symptoms attributable to the intrapulmonary lymph nodes. Forty percent (four) had an unexplained pulmonary nodule or nodules on the chest roentgenogram, which prompted further diagnostic studies, including thoracotomy, to rule out a malignant neoplasm. Radiographically, in our cases and in the literature, almost all cases of intrapulmonary lymph nodes are subpleural, inferior to the level of the carina, and less than 2.0 cm in diameter. Thirty-five percent are multiple. Pathologically, in our cases, all intrapulmonary lymph nodes were markedly anthracotic, and 60 percent were additionally silicotic. Although their histogenesis is uncertain, intrapulmonary lymph nodes are probably hyperplastic lymphoid nodules related to inhalation of irritant dusts and attendant distortion of local lymphatic vessels. Precise clinical and radiographic analysis correlated carefully with cytologic and histologic material obtained by percutaneous needle biopsy should obviate exploratory thoracotomy in most instances.

Radiology of the pleura.

Radiologic imaging of the pleura has undergone dramatic changes in the past 5 years. This can be primarily attributed to the availability and better understanding of computed tomography and, to a lesser extent, ultrasonography. When used in the proper clinical-radiologic environment, abnormalities of the pleural space can be quickly identified, localized, and often diagnosed in a rapid efficient manner.