Ann Thorac Cardiovasc Surg 2016; 22: 261–263
Case Report
Online October 23, 2015 doi: 10.5761/atcs.cr.15-00212
Usefulness of Intraoperative Computer Tomography-Assisted Thoracoscopic Segmentectomy for Small-Sized Lung Cancer Sung Soo Chang, PhD, Takayuki Nakano, MD, and Taku Okamoto, PhD
We report the case of a patient who had synchronous primary lung cancers in the left upper lobe (S1+2a, S1+2c), and underwent S1+2 segmentectomy. The lesion in S1+2c was non-palpable, and the location was confirmed using intraoperative computed tomography (CT) scan. After A1+2 and B1+2 had been cut, the intersegmental border was marked with clips and intraoperative CT was performed. After confirming the correct anatomical intersegmental border and the resection margin was sufficient, we cut the intersegmental border. The two lesions were both adenocarcinomas. Intraoperative CT was useful for confirming the locations of nonpalpable lesions and anatomical intersegmental borders. Keywords: lung cancer surgery, imaging, segmentectomy, intraoperative CT
Introduction Intraoperative computed tomography (CT) navigation in a hybrid operating room is reportedly useful for the identification of non-palpable microlesions in the lung whereas, there are several methods of detecting intersegmental borders when performing segmentectomy. We describe our experience with a patient with whom we were able to confirm the locations of non-palpable lesions and intersegmental borders, while performing segmentectomy, employing intraoperative CT.
Case Report The patient was 73-year-old man who had undergone right upper lobectomy for lung cancer 5 years prior to the current presentation. A CT scan showed the two gradually Department of General Thoracic Surgery, Kochi Health Sciences Center, Kochi, Kochi, Japan Received: July 7, 2015; Accepted: October 6, 2015 Corresponding author: Sung Soo Chang. Department of General Thoracic Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi 781-8555, Japan Email: [email protected] ©2015 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
enlarging nodular shadows in the left upper lobe. Chest CT findings (Fig. 1) showed a nodular shadow in the left upper lobe (S1+2a), measuring 1.5 cm × 1.2 cm, with spicules. In addition, a nodular shadow measuring 0.6 cm × 0.4 cm, in contact with the bulla wall, was observed in S1+2c. We evaluated both as multiple lung cancer cT1aN0M0 and decided to surgically resect them. Pulmonary function test showed reduced vital capacity (1970 mL: 75%) and reduced forced expiratory volume 1 s (1470 mL: 71.1%). S1+2 segmentectomy was planned, because the patient had previously undergone pulmonary resection and both lesions were less than 2 cm in diameter. After viewing preoperative 3D-CT images reconstructed using Vincent®, we confirmed the two lesions located in the S1+2 segment. Since the lesion in S1+2c was expected to be non-palpable, general anesthesia was started in a hybrid operating room. For intraoperative CT imaging, the left upper limb was placed on the head side using a side panel, while the C-arm was placed at the caudal side of the operative field. A small thoracotomy incision, just 3.5 cm, was made over the fourth rib, and pure thoracoscopic surgery with two ports was then initiated. The lesion in S1+2a was palpable, whereas that in S1+2c was not. Therefore, after the point at which the lesion would have been expected to be present had been marked by clipping (LIGACLIP® MCA; size M), intraoperative CT was performed under two-lung ventilation to confirm
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Chang SS, et al.
Fig. 1 C hest CT findings showed two gradually enlarging nodular shadows: (A) the nodule on the left S1+2a was 1.5 cm × 1.2 cm in size with spicules, (B) and the nodule on the left S1+2c was 0.6 cm × 0.4 cm in size in contact with the bulla wall. CT: computed tomography Fig. 3 3 D images were reconstructed and colorized using Vincent® from intraoperative CT scan data by a medical radiation technologist at the time of surgery. Non-pulpable nodule was located just below and very near the marking (double crip, arrow). The intersegmental border was marked with crips (arrowhead). CT: computed tomography
Fig. 2 T he surface of the pulmonary pleura on the intersegmental border was marked employing the VIO® soft-coagulation system and clips (arrowhead). Non-pulpable nodule was marked by double crips (arrow).
that the lesion was located just below and very near the marking. After A1+2 segment and B1+2 branch were cut with staplers, the intersegmental border was confirmed using the ventilation and collapse method. After the surface of the pulmonary pleura on the intersegmental border had been marked employing the VIO® soft-coagulation system, seven points were marked with clips on the intersegmental border (Fig. 2). We confirmed that a sufficient resection margin had been secured and that the anatomical segmental border was correct, while performing intraoperative CT scan and viewing CT images and 3D reconstructed images using Vincent® (Fig. 3). The intersegmental border was cut with staplers, and the specimen was extracted. We completed the resection after confirming that sufficient surgical margin had been secured in the extracted specimen. Intraoperative CT was performed twice.
262
Histopathological diagnosis of the tumor in S1+2a was an acinar predominant mixed-type adenocarcinoma 15 mm × 9 mm in size and the tumor in S1+2c was a papillary predominant mixed-type adenocarcinoma 7 mm × 5 mm in size. Both tumors were free of pleural and vascular infiltrations and were pT1aN0M0 stage IA. The patient currently remains alive without recurrence 6 months after surgery.
Discussion In recent years, the frequency of video-assisted thoracoscopic surgery has been increasing, making it more difficult to examine lesions with sufficient palpation. Various methods have been attempted to identify locations of microlesions in the lung, which are difficult to palpate during surgery. Although CT-guided marking has long been used, air embolism has been recognized as a serious complication in recent years,1,2) and a marking method without lung puncture has thus been sought. Coil placement and the dye-injection method are available for transbronchial marking, whereas the lipiodol and tapping methods have been applied for lung surface marking.3,4) However, these techniques are difficult and have not gained widespread popularity. Since the introduction of a hybrid operating room in our hospital we have used Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
Intraoperative CT-Assisted Segmentectomy
intraoperative CT to identify microlesions in the lung, an approach which has been very useful for identifying lesion locations in all patients. Meanwhile, although the classical ventilation and collapse method has been used for the identification of intersegmental borders during segmentectomy, it is sometimes difficult to clearly identify these borders in patients with underlying lung diseases such as pulmonary emphysema. The transbronchial dye-injection method and the jet ventilation method5) have also been advocated, but are technically difficult to perform. Misaki et al. reported an intersegmental border identification method based on the blood flow at the lung surface using infrared thoracoscopy with indocyanine green.6) Although this approach is also considered to be useful in patients with underlying lung diseases, the intersegmental border visualization time is rather short. Intraoperative CT is anticipated to facilitate confirmation of correct anatomical intersegmental borders. Intraoperative CT is also considered to be useful for obtaining the margins of lesions to be resected. 3Dreconstructed intraoperative CT images allow precise visualization of the position and distance between the intersegmental border and lesions to be resected. This information facilitates the securement of enough surgical margin. In cases undergoing segmentectomy for microlesions in the central area of the lung, such as those with metastatic lung tumors or small-sized lung cancers, it is often difficult to confirm whether there actually is a lesion at the resection site. In such cases, intraoperative CT would be very useful. As this procedure is very straightforward, no preoperative preparation or intraoperative technical method is necessary, allowing it to be used readily and repeatedly. There is no data about the radiation exposure level with intraoperative chest CT. At the field of neurosurgery or orthopedic surgery, the exposed dose was approximately half or less of that of a routine CT scan.7,8)
Conclusion In summary, the following three points can easily be ascertained with intraoperative CT scan: (1) identification
Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
of the locations of non-palpable lesions; (2) identification and confirmation of anatomical intersegmental borders; and (3) securing the resection margin from a non-palpable lesion.
Disclosure Statement All authors have no conflict of interest related to the manuscript.
References 1) Higashino T, Noma S, Nishimoto Y, et al. Cerebral air embolism as a complication of computed tomographyguided marking of the lung: depiction of air inflow route from a pulmonary vein to the left atrium. J Thorac Imaging 2011; 26: 26-9. 2) Tomiyama N, Yasuhara Y, Nakajima Y, et al. CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan. Eur J Radiol 2006; 59: 60-4. 3) Okumura T, Kondo H, Suzuki K, et al. Fluoroscopyassisted thoracoscopic surgery after computed tomography-guided bronchoscopic barium marking. Ann Thorac Surg 2001; 71: 439-42. 4) Kawada M, Okubo T, Poudel S, et al. A new marking technique for peripheral lung nodules avoiding pleural puncture: the intrathoracic stamping method. Interact Cardiovasc Thorac Surg 2013; 16: 381-3. 5) Okada M, Mimura T, Ikegaki J, et al. A novel videoassisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting. J Thorac Cardiovasc Surg 2007; 133: 753-8. 6) Misaki N, Chang SS, Igai H, et al. New clinically applicable method for visualizing adjacent lung segments using an infrared thoracoscopy system. J Thorac Cardiovasc Surg 2010; 140: 752-6. 7) Van de Kelft E, Costa F, Van der Planken D, et al. A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation Navigation. Spine 2012; 37: 1580-7. 8) Seguchi S, Saijou T, Ishikawa Y, et al. Radiation dose evaluation in 3D rotation angiography and conebeam computed tomography with a flat panel detector. Nihon Hoshasen Gijutsu Gakkai Zasshi 2014; 70: 646-52. (in Japanese)
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Case Report
Online October 23, 2015 doi: 10.5761/atcs.cr.15-00212
Usefulness of Intraoperative Computer Tomography-Assisted Thoracoscopic Segmentectomy for Small-Sized Lung Cancer Sung Soo Chang, PhD, Takayuki Nakano, MD, and Taku Okamoto, PhD
We report the case of a patient who had synchronous primary lung cancers in the left upper lobe (S1+2a, S1+2c), and underwent S1+2 segmentectomy. The lesion in S1+2c was non-palpable, and the location was confirmed using intraoperative computed tomography (CT) scan. After A1+2 and B1+2 had been cut, the intersegmental border was marked with clips and intraoperative CT was performed. After confirming the correct anatomical intersegmental border and the resection margin was sufficient, we cut the intersegmental border. The two lesions were both adenocarcinomas. Intraoperative CT was useful for confirming the locations of nonpalpable lesions and anatomical intersegmental borders. Keywords: lung cancer surgery, imaging, segmentectomy, intraoperative CT
Introduction Intraoperative computed tomography (CT) navigation in a hybrid operating room is reportedly useful for the identification of non-palpable microlesions in the lung whereas, there are several methods of detecting intersegmental borders when performing segmentectomy. We describe our experience with a patient with whom we were able to confirm the locations of non-palpable lesions and intersegmental borders, while performing segmentectomy, employing intraoperative CT.
Case Report The patient was 73-year-old man who had undergone right upper lobectomy for lung cancer 5 years prior to the current presentation. A CT scan showed the two gradually Department of General Thoracic Surgery, Kochi Health Sciences Center, Kochi, Kochi, Japan Received: July 7, 2015; Accepted: October 6, 2015 Corresponding author: Sung Soo Chang. Department of General Thoracic Surgery, Kochi Health Sciences Center, 2125-1 Ike, Kochi, Kochi 781-8555, Japan Email: [email protected] ©2015 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
enlarging nodular shadows in the left upper lobe. Chest CT findings (Fig. 1) showed a nodular shadow in the left upper lobe (S1+2a), measuring 1.5 cm × 1.2 cm, with spicules. In addition, a nodular shadow measuring 0.6 cm × 0.4 cm, in contact with the bulla wall, was observed in S1+2c. We evaluated both as multiple lung cancer cT1aN0M0 and decided to surgically resect them. Pulmonary function test showed reduced vital capacity (1970 mL: 75%) and reduced forced expiratory volume 1 s (1470 mL: 71.1%). S1+2 segmentectomy was planned, because the patient had previously undergone pulmonary resection and both lesions were less than 2 cm in diameter. After viewing preoperative 3D-CT images reconstructed using Vincent®, we confirmed the two lesions located in the S1+2 segment. Since the lesion in S1+2c was expected to be non-palpable, general anesthesia was started in a hybrid operating room. For intraoperative CT imaging, the left upper limb was placed on the head side using a side panel, while the C-arm was placed at the caudal side of the operative field. A small thoracotomy incision, just 3.5 cm, was made over the fourth rib, and pure thoracoscopic surgery with two ports was then initiated. The lesion in S1+2a was palpable, whereas that in S1+2c was not. Therefore, after the point at which the lesion would have been expected to be present had been marked by clipping (LIGACLIP® MCA; size M), intraoperative CT was performed under two-lung ventilation to confirm
261
Chang SS, et al.
Fig. 1 C hest CT findings showed two gradually enlarging nodular shadows: (A) the nodule on the left S1+2a was 1.5 cm × 1.2 cm in size with spicules, (B) and the nodule on the left S1+2c was 0.6 cm × 0.4 cm in size in contact with the bulla wall. CT: computed tomography Fig. 3 3 D images were reconstructed and colorized using Vincent® from intraoperative CT scan data by a medical radiation technologist at the time of surgery. Non-pulpable nodule was located just below and very near the marking (double crip, arrow). The intersegmental border was marked with crips (arrowhead). CT: computed tomography
Fig. 2 T he surface of the pulmonary pleura on the intersegmental border was marked employing the VIO® soft-coagulation system and clips (arrowhead). Non-pulpable nodule was marked by double crips (arrow).
that the lesion was located just below and very near the marking. After A1+2 segment and B1+2 branch were cut with staplers, the intersegmental border was confirmed using the ventilation and collapse method. After the surface of the pulmonary pleura on the intersegmental border had been marked employing the VIO® soft-coagulation system, seven points were marked with clips on the intersegmental border (Fig. 2). We confirmed that a sufficient resection margin had been secured and that the anatomical segmental border was correct, while performing intraoperative CT scan and viewing CT images and 3D reconstructed images using Vincent® (Fig. 3). The intersegmental border was cut with staplers, and the specimen was extracted. We completed the resection after confirming that sufficient surgical margin had been secured in the extracted specimen. Intraoperative CT was performed twice.
262
Histopathological diagnosis of the tumor in S1+2a was an acinar predominant mixed-type adenocarcinoma 15 mm × 9 mm in size and the tumor in S1+2c was a papillary predominant mixed-type adenocarcinoma 7 mm × 5 mm in size. Both tumors were free of pleural and vascular infiltrations and were pT1aN0M0 stage IA. The patient currently remains alive without recurrence 6 months after surgery.
Discussion In recent years, the frequency of video-assisted thoracoscopic surgery has been increasing, making it more difficult to examine lesions with sufficient palpation. Various methods have been attempted to identify locations of microlesions in the lung, which are difficult to palpate during surgery. Although CT-guided marking has long been used, air embolism has been recognized as a serious complication in recent years,1,2) and a marking method without lung puncture has thus been sought. Coil placement and the dye-injection method are available for transbronchial marking, whereas the lipiodol and tapping methods have been applied for lung surface marking.3,4) However, these techniques are difficult and have not gained widespread popularity. Since the introduction of a hybrid operating room in our hospital we have used Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
Intraoperative CT-Assisted Segmentectomy
intraoperative CT to identify microlesions in the lung, an approach which has been very useful for identifying lesion locations in all patients. Meanwhile, although the classical ventilation and collapse method has been used for the identification of intersegmental borders during segmentectomy, it is sometimes difficult to clearly identify these borders in patients with underlying lung diseases such as pulmonary emphysema. The transbronchial dye-injection method and the jet ventilation method5) have also been advocated, but are technically difficult to perform. Misaki et al. reported an intersegmental border identification method based on the blood flow at the lung surface using infrared thoracoscopy with indocyanine green.6) Although this approach is also considered to be useful in patients with underlying lung diseases, the intersegmental border visualization time is rather short. Intraoperative CT is anticipated to facilitate confirmation of correct anatomical intersegmental borders. Intraoperative CT is also considered to be useful for obtaining the margins of lesions to be resected. 3Dreconstructed intraoperative CT images allow precise visualization of the position and distance between the intersegmental border and lesions to be resected. This information facilitates the securement of enough surgical margin. In cases undergoing segmentectomy for microlesions in the central area of the lung, such as those with metastatic lung tumors or small-sized lung cancers, it is often difficult to confirm whether there actually is a lesion at the resection site. In such cases, intraoperative CT would be very useful. As this procedure is very straightforward, no preoperative preparation or intraoperative technical method is necessary, allowing it to be used readily and repeatedly. There is no data about the radiation exposure level with intraoperative chest CT. At the field of neurosurgery or orthopedic surgery, the exposed dose was approximately half or less of that of a routine CT scan.7,8)
Conclusion In summary, the following three points can easily be ascertained with intraoperative CT scan: (1) identification
Ann Thorac Cardiovasc Surg Vol. 22, No. 4 (2016)
of the locations of non-palpable lesions; (2) identification and confirmation of anatomical intersegmental borders; and (3) securing the resection margin from a non-palpable lesion.
Disclosure Statement All authors have no conflict of interest related to the manuscript.
References 1) Higashino T, Noma S, Nishimoto Y, et al. Cerebral air embolism as a complication of computed tomographyguided marking of the lung: depiction of air inflow route from a pulmonary vein to the left atrium. J Thorac Imaging 2011; 26: 26-9. 2) Tomiyama N, Yasuhara Y, Nakajima Y, et al. CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan. Eur J Radiol 2006; 59: 60-4. 3) Okumura T, Kondo H, Suzuki K, et al. Fluoroscopyassisted thoracoscopic surgery after computed tomography-guided bronchoscopic barium marking. Ann Thorac Surg 2001; 71: 439-42. 4) Kawada M, Okubo T, Poudel S, et al. A new marking technique for peripheral lung nodules avoiding pleural puncture: the intrathoracic stamping method. Interact Cardiovasc Thorac Surg 2013; 16: 381-3. 5) Okada M, Mimura T, Ikegaki J, et al. A novel videoassisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting. J Thorac Cardiovasc Surg 2007; 133: 753-8. 6) Misaki N, Chang SS, Igai H, et al. New clinically applicable method for visualizing adjacent lung segments using an infrared thoracoscopy system. J Thorac Cardiovasc Surg 2010; 140: 752-6. 7) Van de Kelft E, Costa F, Van der Planken D, et al. A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation Navigation. Spine 2012; 37: 1580-7. 8) Seguchi S, Saijou T, Ishikawa Y, et al. Radiation dose evaluation in 3D rotation angiography and conebeam computed tomography with a flat panel detector. Nihon Hoshasen Gijutsu Gakkai Zasshi 2014; 70: 646-52. (in Japanese)
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