No ideal localization technique is available; thus, the choice still depends on surgeon's preference and local availability of both specialists and instruments.

Background: Several techniques for localizing pulmonary nodules have been described, but the advantages and disadvantages of each method remain unclear. We reviewed ultrasound, endofinger, finger palpation and wait and watch, radioguided, vital dye, fluoroscopic, agar marking, and needle wire methods for localizing pulmonary nodules.Methods: Original, peer-reviewed, and full-length articles in English were searched with PubMed and ISI Web of Sciences. Case reports and case series with less than 10 patients were excluded.Results: All localization techniques showed good reliability, but some carry a high rate of major or minor complications and drawbacks.Conclusion: No ideal localization technique is available; thus, the choice still depends on surgeon's preference and local availability of both specialists and instruments.

Background. Our aim was to evaluate the best intrathoracoscopic localization technique in patients with single pulmonary nodule and a history of malignancy.Methods. We divided 50 patients in two groups, well matched for diameter and depth of the pulmonary lesion. In 25 patients we performed intrathoracoscopic ultrasound to locate the pulmonary nodule (group A), whereas in the other 25 patients the radio-guided technique was adopted (group B). In both group A and group B, the localization techniques were compared with finger palpation. In group A, 12 nodules were in the left lung and 13 in the right one; in group B, 11 lesions were in the left and 14 in the right lung. In both groups, the distance of the nodule from the pleural surface was 2.6 +/- 0.5 cm (2 to 2.5 cm in 14 patients, and >2.5 cm for the remaining 11). The diameter of the nodule was 1.26 +/- 0.22 (<= 1 cm in 10 patients, and 1 to 1.5 cm in 15) in both groups. All patients underwent thoracoscopic wedge resection, and 10 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy.Results. In group A, ultrasound localized the nodule in 24 of 25 patients (96%) whereas finger palpation localized it in 19 of 25 (76%; not significant). In group B, both the radio-guided and finger palpation techniques localized the nodule in 20 of 25 patients (80%; not significant). No complications were recorded with the ultrasound technique; however, 10 cases of pneumothorax were detected after the radio-guided technique (p < 0.01).Conclusions. Both the ultrasound and radio-guided techniques are accurate to detect solitary pulmonary nodules, but the radio-guided method yields complications as compared with the ultrasound.

Background/Aims: An adequate preoperative disease staging is highly required before surgical treatment, even in gastrointestinal malignancies. Our study wants to give a contribution in order to define echolaparoscopy weight in gastrointestinal tumors and its impact in surgical therapy.Methodology: 33 patients were affected by pancreas, 22 by stomach, 16 by extrahepatic biliary tract and 18 by liver cancers; every patient was considered worthy of radical or palliative surgery according to preoperative staging (thorax-abdominal CT and percutaneous ultrasonography). Paired sample t-tests were used to analyze the results of each methodical and probability values of less than 0.05 were considered significant.Results: Preoperative instrumental examinations gave correct evaluations only in 44 of 89 cases (49%) while echolaparoscopic gave correct evaluations in 82 on 89 cases (92%) (P<0.05). So after echolaparoscopic in only 7 cases we performed an explorative laparotomy.Conclusions: Laparoscopy and ultrasound impact on therapy is worthy of attention. It seems to be able to give advantages in staging gastrointestinal malignancies, except for pancreas cancers, in which some limits and negative aspects have been demonstrated, regarding the possibility of giving correct diagnosis of portal axis infiltration.

We would like to congratulate Janssen-Heijnen et al 1 on their well performed study and on their significant contribution to resolving the problem of treatment in patients with non-small cell lung cancer (NSCLC) and co-morbidity. However, we could not find a description of the surgical approach used and would like to ask the authors to provide details of the surgical procedures adopted and the accompanying survival rates. We think,2 in agreement with other authors3 that, for patients with early stage NSCLC and co-morbidity, a less invasive surgical approach should be used. This view is supported by studies in elderly patients or in patients with co-morbidity showing that a less invasive approach does not influence survival rates. Only the recurrence …

We would like to comment on the article by Daniel and associates [1Daniel T.M. Altes T.A. Rehm P.K. et al.A novel technique for localization and excisional biopsy of small or ill-defined pulmonary lesions.Ann Thorac Surg. 2004; 77: 1756-1762Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar]. We congratulate the authors on the well-conducted study, with experimental studies followed by human application. Most notably, it seems that the authors have solved the problem [2Chella A. Lucchi M. Ambrogi M.C. et al.A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection.Eur J Cardiothorac Surg. 2000; 18: 17-21Crossref PubMed Scopus (130) Google Scholar, 3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar] with the use of a radio-guided technique to locate pulmonary nodules. However, we have some questions and remarks. We agree that macroaggregated albumin does not spread into perinodular lung parenchyma, and localizes radioactivity, which is an advantage compared with other tracers. Regarding surgical technique and histopathology, did Daniel and associates search for the sentinel node or did they only use the radio-guided technique to locate the pulmonary nodule? We think that the main advantage of the radio-guided technique is to locate a sentinel node in patients with very small pulmonary nodules or to guide lymphoadenectomy, to detect N2 lung cancer [4Choi Y.S. Shim Y.M. Kim J. Kim K. Mediastinoscopy in patients with clinical stage I non-small cell lung cancer.Ann Thorac Surg. 2003; 75: 364-366Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar]. Did the authors see hematoma intraoperatively, or in the specimen after injection of macroaggregated albumin [3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar]? The majority of the pulmonary nodules described in the article were close to the pleural surface, and we wonder whether any preoperative localization technique was needed [5Susuky K. Nagai K. Yoshida J. et al.Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules indication for preoperative marking.Chest. 1999; 115: 563-568Crossref PubMed Scopus (356) Google Scholar]. In fact, 8 of 13 nodules (61%) were within 1 cm of the pleural surface. Preoperative localization should not be necessary, because complete deflation of the lung would allow localization. The authors also report a nodule deeper than 4 cm; in our opinion, this patient should have had a lobectomy because wedge resection removes considerable parenchyma. In our opinion, intrathoracoscopic ultrasonography can locate pulmonary nodules not seen by chest computed tomography and offers several advantages over other preoperative localization techniques. Ultrasonography is simple and quick, and is the only technique without side effects or complications [3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar]. Lastly, we would like to know the authors’ opinion about the ultrasound rotary probe. In our experience, missed localizations were limited to posterior and deep nodules, owing to the size and rigidity of the ultrasound probe. Therefore, we think that a rotary probe could be of help [3Sortini D. Feo C.V. Carrella G. et al.Thoracoscopic localization’s techniques for patients with single pulmonary nodule and positive oncological anamnesis. A prospective study.J Laparoendosc Adv A. 2003; 13: 371-375Crossref PubMed Scopus (5) Google Scholar]. ReplyThe Annals of Thoracic SurgeryVol. 79Issue 6PreviewWe enjoyed the comments by Dr Sortini and associates regarding our technique and experience with radiotracer lung nodule localization and excisional biopsy. Full-Text PDF

We thank Dr Sortini and colleagues from the University of Ferrara for their comments on our article. The first two questions refer to the same subject: the relationship between the need for thoracotomy in order to locate the pulmonary nodule and/the probability of a nodule to be malignant, and the high conversion rate of malignant lesions. In our experience (429 cases) the need for thoracotomy for localizing the nodule proved to be a strong, statistically significant factor (univariate and multivariate analysis) in predicting the probability of a solitary pulmonary nodule (SPN) to be a neoplasm (OR 7.4; 95% CI 4.1–13.3; OR adjusted 6.6; 95% CI adjusted 3.2–13.2). The reason for this ratio between the location of a nodule and the risk of malignancy is related to the firm consistency of benign nodules (83.5% being hamartomas, 7.3% being tubercular lesions, and 5.7% being fibrous scars) compared with neoplasms (either non-small cell lung cancer or metastases). The slight difference in size between benign and neoplastic lesions (1.88 cm vs. 2.31 cm) did not alter this ratio. Ultrasound or radio-guided techniques appear promising, although the low number of reported patients—13 in the experience of Dr Sortini and colleagues [1Sortini A. Carrella G. Sortini D. Pozza E. Single pulmonary nodules localization with intrathoracoscopic ultrasound—a perspective study.Eur J Cardiothorac Surg. 2002; 22: 440-442Crossref PubMed Scopus (26) Google Scholar], and 18 in the experience of Santambrogio 1999 [2Santambrogio 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: 218-222Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]—raises some doubt about their use on a wide scale. The last question regards the high number of benign nodules resected in our series (379/429, 86.2%). Many surgeons consider operating on benign lesions to be a failure or a waste of time. We, on the contrary, believe that great importance should be given to the patients' sentiments: most patients prefer a quick and safe video-assisted thoroscopic operation rather than repeated computed tomographic scans and consequential anxiety. We should never risk leaving any cancer in a patients' chest, even if this involves operating on many patients with resulting benign tumors. Furthermore, we remind our colleagues from Ferrara that the computer-aided diagnosis to distinguish benign from malignant SPN proposed by Shirashi and co-workers [3Shiraishi J. Abe H. Engelmann R. Aoyama M. MacMahon H. Doi K. Computer-aided diagnosis to distinguish benign from malignant solitary pulmonary nodules on radiographs ROC analysis of radiologists' performance—initial experience.Radiology. 2003; 227: 469-474Crossref PubMed Scopus (71) Google Scholar] represents an initial experience only. Finally, the assessment of the doubling time over a short period needs further improvement. The 18-fluorodeoxyglucose positron emission tomographic scan will certainly help us in the decision making, even if in our published series we employed this procedure very rarely (1.8%).

minimal in the neonatal period, which is why the commissurotomy was done at 15 months, at the time of repair.We would like to take this opportunity to provide follow-up information about our patient.Three years after repair, our patient is doing well.Right ventricular pressure as estimated by echo-Doppler is 50 mm Hg for 104 mm Hg arterial pressure.A 17 mm Hg peak gradient is measured across the aortic valve.A previous letter suggested by our case report of tetralogy of Fallot with aortic stenosis was published in The Annals [4,5].This association would be interesting to consider for further studies.

Background: The clinical value of sonographic guidance during video-assisted thoracoscopic surgery (VATS) was studied in 26 patients with peripheral pulmonary nodules. Methods: Twenty-six patients underwent VATS between June 2000 and March 2001 for primary lung cancer (n = 15), pulmonary metastasis (n = 6), and various benign tumors (n = 5). Results: Sonographic guidance successfully visualized peripheral pulmonary tumors in 21 of the 26 patients (81%). Among them, rich intratumoral blood flow signal was identified in 8 of the 15 primary lung cancers by using color Doppler sonography. The peak velocity was 26 ± 12.8 cm/s in primary lung cancer and 9.4 ± 1.7 cm/s in pulmonary metastasis, respectively (p < 0.01). Conclusion: Sonographic guidance during VATS is helpful for locating lesions and determining the extent of surgical resection. The color Doppler method was also useful for evaluating intratumoral blood flow, which yielded significant information for differentiating primary lung cancer, metastatic tumors, and various benign tumors.

INTRODUCTION Our aim was to evaluate the best intrathoracoscopic localization technique in patients with a single pulmonary nodule and a history of malignancy. METHOD We divided 30 patients into two groups, well matched for diameter and depth of the pulmonary lesion. In 15 patients (group A) we performed intrathoracoscopic ultrasound (US) to locate the pulmonary nodule, while in the other 15 patients (group B) intrathoracoscopic radioguided occult lesion localization (ROLL) was used. In both groups, the localization technique was compared to finger palpation. In group A, 6 nodules were in the left lung and 9 in the right; in group B, 7 lesions were in the left and 8 in the right lung. In each group, the distance of the nodule from the pleural surface was 2-2.5 cm in 8 patients, and > 2.5 cm in the remaining 7. In both groups, the diameter of the nodule was </= 1 cm in 6 patients, and 1-1.5 cm in 9 patients. All patients underwent thoracoscopic wedge resection, and 6 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy. RESULTS In group A, US localized the nodule in 15 of 15 patients (100%) while finger palpation located the nodule in 11 of 15 (73%) (P = NS). In group B, both ROLL and finger palpation localized the nodule in 12 of 15 patients (80%) (P = NS). CONCLUSION Intrathoracoscopic US seems superior to radioguided and finger palpation localization techniques for single pulmonary nodules. Thus, we are now routinely using intraoperative US to identify single pulmonary nodules.

HomeRadiologyVol. 228, No. 1 PreviousNext Letters to the EditorIntrathorascopic US: Usefulness in Localization of Solitary Pulmonary Nodules [letter]Andrea Sortini, Davide Sortini, Enzo Pozza, Giovanni CarrellaAndrea Sortini, Davide Sortini, Enzo Pozza, Giovanni CarrellaAuthor AffiliationsDepartment of Surgical, Anaesthesiological and Radiological Sciences, University of Ferrara, C.so Giovecca 203, Ferrara 44100, Italy. e-mail: [email protected]Andrea SortiniDavide SortiniEnzo PozzaGiovanni CarrellaPublished Online:Jul 1 2003https://doi.org/10.1148/radiol.2281030064MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In 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. Link, Google Scholar2 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. Crossref, Medline, Google Scholar3 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. Crossref, Medline, Google Scholar4 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. Crossref, Medline, Google Scholar5 Sortini A, Sortini D, Carrella G. Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery. J Thorac Cardiovasc Surg. (in press). Google ScholarArticle HistoryPublished in print: July 2003 FiguresReferencesRelatedDetailsCited ByIntrathoracoscopic localization techniquesD.Sortini, C.Feo, K.Maravegias, P.Carcoforo, E.Pozza, A.Liboni, A.Sortini2006 | Surgical Endoscopy, Vol. 20, No. 9Thoracoscopic Localization Techniques for Patients With Solitary Pulmonary Nodule and History of MalignancyDavideSortini, Carlo V.Feo, PaoloCarcoforo, GiovanniCarrella, EnzoPozza, AlbertoLiboni, AndreaSortini2005 | The Annals of Thoracic Surgery, Vol. 79, No. 1Thoracoscopic Localization Techniques for Patients with a Single Pulmonary Nodule and Positive Oncological Anamnesis: A Prospective StudyDavideSortini, Carlo V.Feo, GiovanniCarrella, LeonardoBergossi, GiorgioSoliani, PaoloCarcoforo, EnzoPozza, AndreaSortini2003 | Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol. 13, No. 6Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 228, No. 1 Metrics Altmetric Score PDF download

This prospective study, based on 13 patients with single pulmonary nodules of width between 10 and 30 mm, was performed to verify the utility of intrathoracoscopic ultrasound to localize the single pulmonary nodule. In all 13 cases the ultrasound examination was able to localize the position of nodules, but the homogeneous hypoechoic pattern of nodules observed in ten of 13 cases did not prove whether the lesion was benign or malign. In conclusion, we can confirm that intrathoracoscopic ultrasound examination is a safe, risk-free and less expensive method of localizing the single pulmonary nodules.

The authors report a case of primary epithelioid (EH) in a 73-year-old female.

avoids interobserver variability, whereas discrimination between solid and gaseous microemboli may have important pathophysiologic, therapeutic, and prognostic implications. The limitation of undercounting showers of microemboli (such as during removal of crossclamps and side clamps) was, in fact, discussed in our article. Although Motallebzadeh and Jahangiri suggest that this limitation may be responsible for a large difference in embolic count relative to previous reports, a review of the literature reveals that there is already wide variability among different studies (Table 1) because of differences in detection characteristics among various transcranial Doppler systems. Furthermore, the phenomenon of “undercounting” may actually serve to underestimate the benefits of off-pump surgery with a “no touch” aortic technique, where such showers are not seen. At the time of our study, it was not our routine practice in Oxford to use arterial line filters. We now do so, although evidence for this is still not compelling. Others have reported an abundance of microemboli during cardiopulmonary bypass despite the use of 40m arterial filtration, and leukocyte-depleting arterial line filters have reportedly failed to improve neurocognitive outcome. On the other hand, the use of a cell saver in place of cardiotomy suction can potentially reduce the number of lipid microemboli. Although a combination of these techniques is likely to reduce microembolization during cardiopulmonary bypass, it is still unlikely to reach the levels seen in off-pump surgery with a “no touch” aortic technique. Yasir Abu-Omar, MRCS Paul M. Matthews, MD, DPhil, FRCP David P. Taggart, MD, PhD, FRCS Department of Cardiothoracic Surgery and Centre for Functional MRI of the Brain, John Radcliffe Hospital Oxford, United Kingdom

Mediastinoscopy is a useful technique in the diagnosis of mediastinal neoplasms and for staging of lung neoplasms. The procedure was developed by Carlens in 1959. Two are the leading problems of this technique: the very uncomfortable position of the operator and the impossibility of multiple teaching due to the narrowness of the operating field.The need of improvement was felt as well, so we decided to apply videoassisted devices to mediastinoscopy. At the beginning, as far as a specific technology lacked, we adopted a thoracoscopic camera inserted through the mediastinoscope. This solution, even if useful for ergonomic purposes, had limits due to disproportion of devices not created for mediastinoscopy.Recently we adopted a specific device concepted for mediastinoscopy: videoassisted mediastinoscope.

Thoracoscopic sympathectomy is the treatment of choice for palmar and axillary hyperhidrosis. It produces excellent long- and short-term results, and patients experience the benefits of minimally invasive surgery.Traditional approaches to surgical sympathectomy have involved the supraclavicular or cervical approach, the transaxillary approach, and the dorsal approach. The cervical approach, however, is associated with an incidence of permanent Homer's syndrome ranging from 1% to 57%. Brachial plexus contusion, phrenic nerve palsy, and major vessel damage have also been reported as a result of the cervical approach, which is rapidly being replaced by the thoracoscopic technique.The main indication for surgical sympathectomy today is palmar or axillary hyperhidrosis. Sympathectomy in the treatment of Raynaud's phenomenon has fallen into disrepute. It is occasionally required in the treatment of intractable causalgia and arterial occlusive disease of the upper limb. Since 1994 the approach of choice in our unit has been thoracoscopic sympathectomy.