Asian Cardiovasc Thorac Ann 2006;14:e48-e49
© 2006 Asia Publishing EXchange Ltd
Transbronchial Localization of Small Pulmonary Lesions for Thoracoscopic Resection
Tohru Mawatari, MD,
Atsushi Watanabe, MD,
Hisayoshi Ohsawa, MD,
Tomio Abe, MD,
Gen Yamada, MD1
Department of Thoracic and Cardiovascular Surgery
1 Third Department of Internal Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
For reprint information contact: Tohru Mawatari, MD Tel: 81 13 843 2000 Fax: 81 13 843 4434 Email: t-mawatari{at}hospital.hakodate.hokkaido.jp, Thoracic & Cardiovascular Surgery, Hakodate Municipal Hospital, Minato Cho 1chome 10-1, Hakodate, Japan.
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ABSTRACT
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The localization of small lung masses at thoracoscopic operation is very difficult. A 67-year-old female with tiny pulmonary metastases of renal cell carcinoma primary was successfully treated by pulmonary thoracoscopic resection after transbronchial localization using a dye.
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INTRODUCTION
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The localization of tiny lung masses is often very difficult, much operative time is wasted performing resections, and large areas of lung around the lesion are unnecessarily excised. Preoperative marking aids the resection of such lung lesions. We describe a case in which tiny lung lesions were easily located and successfully resected after preoperative marking transbronchially with a dye.
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CASE REPORT
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A 67-year-old female with renal cell carcinoma underwent a left nephrectomy in December 2001. A computed tomography (CT) scan of the lung was performed during routine postoperative evaluation in February 2003. This showed 3 nodules measuring 3 to 5 mm on the left lung and 3 smaller nodules measuring 2 to 3 mm on the right lung. The patient was admitted to our hospital for resection of these lesions. The primary malignant lesion was found to be controlled, without evidence of recurrence, and all of the lung lesions were on the surface of the lung, so complete resection was scheduled. Resection of the lesions on the left lung was performed first. The surface of the left lung was observed with a thoracoscope and conscientiously palpated using one finger, through a thoracic access port. These 3 lesions were easily located and resected using stapling instruments (Endo-GIA; United States Surgical Corp., Norwalk, CT, USA). Resection of the nodules on the right lung was performed 2 weeks later. Transbronchial localization under CT guidance was carried out before the operation because locating these tiny lesions was expected to be very difficult. The head of a bronchoscope was introduced to a point near the lesion under CT guidance. The head of the needle portion of the catheter (Disposable Injector NM; Olympus Corp., Tokyo, Japan) was cut off, and the catheter head was advanced towards the lesion through the bronchoscope. When the catheter head was positioned 2 mm from the pleura, 0.3 mL of dye (a mixture of indigo carmine and barium 4:1 v/v) was injected near the lesion through a sheath catheter using a bronchoscope under CT guidance. The position of the target lesion and dyed area were confirmed by CT. (Figure 1
). The operation was performed 2 hours later. The surface of the right lung was carefully observed with a thoracoscope, and the dye-marked portion was clearly observed (Figure 2). The surface of the marked region was palpated with one finger, and the lesions were located comparatively easily. The lesions were resected using a stapling instrument. Subsequently, CT of the chest showed that all of the lesions had been completely resected. Pathological examination demonstrated that all 6 of these lesions were metastases of renal cell carcinoma origin.
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Figure 1. Computed tomographic scan immediately after transbronchial localization; the arrow head indicates a tiny metastatic lesion; the arrow indicates the area dyed by a mixture of indigo carmine and barium.
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Figure 2. Intraoperative thoracoscopic findings. The area marked by the blue dye is distinguished well enough to detect the lesion.
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DISCUSSION
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Localization of lung lesions is generally either via a transthoracic or transbronchial approach. In the former, locating the lesions is easily achieved intraoperatively if the localization is performed appropriately. Pneumothorax is occasionally caused if a needle punctures the lung lesion through the chest wall. Once pneumothorax occurs, needle localization is difficult; therefore, this method is unsuitable for pleural localization. Moreover, the apical, mediastinal, diaphragmatic sides of the lung, and lung below the scapula are difficult areas for needle insertion. Cerebral arterial air embolism following needle localization of lung lesions has been reported, so the use of needle localization is currently being re-examined.1,2 However, there are complications such as pneumothorax, bleeding, and air embolism associated with transbronchial localization. In transbronchial localization, locating the target lesion is very difficult if the dyed visceral pleuras are faint or large.
Several injection materials for transbronchial localization have been described, but we consider the mixture of barium and indigo carmine used in this case to be superior as the dye stays in the lung for a few days.3–5 Barium is insoluble, but in our experience, the barium shadow on the chest radiograph gradually vanishes. Pulmonary marking is useful for small lesions, but conclusive detection by digital palpitation is needed at resection. Hematomas and other marked portions of the lung are soft, whereas genuine nodules are comparatively hard when touched.
The number of operable cases with tiny lung lesions has recently increased with the development and widespread application of better diagnostic techniques; however, the detection of tiny lung lesions is often very difficult during the operation. Localization of the lesions beforehand is useful to shorten the operation time and avoid unnecessary resection of large areas of lung. The transbronchial localization performed in this case is superior to the transthoracic approach with respect to complications (pneumothorax, cerebral arterial air embolism), and the contrast between the dyed and other lung areas was very clear at the time of operation. We recommend this transbronchial localization method for tiny lung lesions.
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REFERENCES
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- Kamiyoshihara M, Sakata K, Ishikawa S, Morishita Y. Cerebral arterial air embolism following CT-guided lung needle marking. Report of a case. J Cardiovasc Surg (Torino) 2001;42:699–700.[Medline]
- Horan TA, Pinheiro PM, Araujo LM, Santiago FF, Rodrigues MR. Massive gas embolism during pulmonary nodule hook wire localization. Ann Thorac Surg 2002;73:1647–9.[Abstract/Free Full Text]
- Nomori H, Horio H, Naruke T, Suemasu K. Fluoroscopy-assisted thoracoscopic resection of lung nodules marked with lipiodol. Ann Thorac Surg 2002;74:170–3.[Abstract/Free Full Text]
- Okumura T, Kondo H, Suzuki K, Asamura H, Kobayashi T, Kaneko M, et al. Fluoroscopy–assisted thoracoscopic surgery after computed tomography-guided bronchoscopic barium marking. Ann Thorac Surg 2001;71:439–42.[Abstract/Free Full Text]
- Sakamoto T, Takada Y, Endoh M, Matsuoka H, Tsubota N. Bronchoscopic dye injection for localization of small pulmonary nodules in thoracoscopic surgery. Ann Thorac Surg 2001;72:296–7.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
