NEW TECHNOLOGY

Ultrasonographic Identification of PeripheralPulmonary Nodules Through Uniportal Video-Assisted Thoracic SurgeryGaetano Rocco, MD, FRCSEd, Marcellino Cicalese, MD, Carmine La Manna, MD,Antonello La Rocca, MD, Nicola Martucci, MD, and Rosario Salvi, MD

Department of Thoracic Surgery and Oncology, Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation,Naples, Italy

Pascale Foundatiogaetano.rocco@bto

© 2011 by The SPublished by El

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Purpose. An intrinsic limitation of video-assisted thoracic surgery (VATS) resides in theimpossibility to palpate the lung to identify embedded nodules. We wanted to investigate theuse of intraoperative ultrasonography to detect pulmonary nodules during uniportal VATS.

Description. We describe our initial experience with the identification of peripheralpulmonary nodules with an articulating ultrasound probe introduced through a singleVATS incision. The instrument was used in 2 patients with solitary pulmonary nodulesand previous history of extrathoracic cancer.

Evaluation. The lung nodules were identified by the articulating probe and resected onwide tumor-free margins through uniportal VATS. Subsequent lung palpation throughminithoracotomy confirmed the absence of additional lesions.

Conclusions. Intraoperative ultrasound scanning of the lung with an articulating probecan be successfully used through uniportal VATS to identify peripheral nodules.

(Ann Thorac Surg 2011;92:1099–101)

© 2011 by The Society of Thoracic Surgeons

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An intrinsic limitation of video-assisted thoracic sur-gery (VATS) resides in the impossibility to palpate

the lung to identify embedded nodules. We wanted toinvestigate the use of intraoperative ultrasonography todetect pulmonary nodules during uniportal VATS.

Technology

As in traditional three-port video-assisted thoracic sur-gery (VATS), a limitation in the accuracy of single-access(uniportal) VATS for removal of peripheral pulmonarynodules is the inability to palpate the lung to identify anotherwise invisible lesion. Recently, the placement ofdifferent types of wire and the injection of dye andnuclear isotopes have been proposed to help localize theperipheral nodule [1]. In this setting, ultrasonographicprobing has shown promising results despite obvioustechnical difficulties resulting from imaging air-containing structures [2]. In a future scenario of outpa-tient thoracic surgery, the combination of uniportalVATS approach and awake/locoregional anesthesia mayresult in facilitated diagnostic and therapeutic pathways[3]. As a consequence, the ability to precisely identify a

Accepted for publication March 11, 2011.

Address correspondence to Dr Rocco, Department of Thoracic Surgeryand Oncology, Division of Thoracic Surgery, National Cancer Institute,

un, Via Terminio 1, Serino (Avellino) 83028, Italy; e-mail:penworld.com.

ociety of Thoracic Surgeonssevier Inc

solitary pulmonary nodule may become the conclusivebreakthrough for the definitive diffusion of VATS surgeryamong thoracic surgeons.

Technique

Under general anesthesia and one lung ventilation, asingle incision is created opposite to the target lesion tobe resected already identified on chest computed tomog-raphy [4]. The 2 cm to 2.5 cm incision usually accommo-dates a 5-mm, 0-degree videothoracoscope, along with anarticulating grasper and endovascular stapler. To facili-tate localization of the lesion through the endoscopicultrasound device, conductive gel is applied to the pa-renchyma. Thereafter, a laparoscopic 10-mm ultrasoundprobe (B-K Medical, Herlev, Denmark [Fig 1]) is insertedthrough the single incision along with the 5-mm, 0-de-gree videothoracoscope and an articulating grasper. Thislaparoscopic ultrasound probing device is characterizedby a frequency range of 5 to 10 MHz, a focal range of 5 to95 mm, a 36-degree sector angle, and a contact surface of30 � 5 mm. In addition, the articulating end enables theurgeon to increase the scanning capability by deepeninghe probe into the parenchyma [4]. Once the lesion isdentified and the lung surface marked with electrocau-ery, a wedge resection is carried out as per the usual

niportal VATS technique [4].

0003-4975/$36.00doi:10.1016/j.athoracsur.2011.03.030

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Clinical Experience

Patient 1A 32-year-old woman who had never smoked was referredto our attention 6 months after removal of a cutaneousmelanoma of the thigh. At that time, the patient presentedwith two solitary lesions embedded in the parenchyma ofthe left lower lobe that were enucleated. Final pathologyconfirmed a metastatic melanoma. Four months later, shewas shown to have another suspicious pulmonary nodulein the periphery of the right lower lobe (Fig 2A). The nod-ule was negative by positron emission tomography. Giventhe location of the nodule and to exclude further disease inthe right lung, it was agreed with the patient to start with auniportal VATS aided by intraoperative ultrasound probingto identify the parenchymal lesion. Subsequently, and re-gardless of the successful removal of the lung lesion byuniportal VATS, the lung would have been palpatedthrough a minithoracotomy to rule out residual disease. Infact, after receiving histologic confirmation by frozen sec-tion, a minithoracotomy was performed without findingadditional lesions by thorough palpation. Final pathologyshowed a 5 cm � 2 cm wedge resection containing a 1 cm

etastatic melanoma.

Fig 1. (A) Ultrasonography device with de-tail of characteristics that make the probeuseful for single-access video-assisted tho-racic surgery (VATS). (B, C) In particular,the articulating end contributes to refinementof lung scanning.

Fig 2. (A) Patient 1: pulmonary nodule em-bedded in the right lower lobe. (B) Patient 2:right lower lobe lesion. Both nodules are notimmediately subpleural and are heteroge-neous in size.

Patient 2Two years after resection for a primary adenocarcinomaof the left colon, a 53-year-old woman was referred owingto the detection of a right lower lobe nodule on afollow-up chest computed tomography scan (Fig 2B)Preoperative work-up included positron emission to-mography (standardized uptake value � 7) and fine-needle aspiration biopsy, which yielded metastatic ade-nocarcinoma. At uniportal VATS, the lesion wasidentified through the endoscopic ultrasound device andresected. After frozen section confirmation, a minithora-cotomy was performed without yielding additional nod-ules. Final pathology showed a 6 cm � 2 cm wedgeresection containing a 2.5 cm nodule consistent withcolonic metastatic adenocarcinoma.

Comment

Endothoracic ultrasonography is a procedure with aspecific value in the assessment and staging of lungmalignancies [5]. The discriminating ability of ultra-sonography can be successfully used before “medicalthoracoscopy” for the diagnosis of pleural conditions [6].

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Ultrasonographic detection, performed through ex-trathoracic or intraoperative modalities, is among severaltechniques that have been devised to identify pulmonarynodules with an increasing invasiveness. Its use has beenreported in conjunction with VATS under local anesthe-sia and in children [7, 8]. Recently, Kondo and colleagues2] have described the use of intraoperative ultrasonog-aphy to identify ground glass opacities. The study in-luded 44 patients from whom 53 lesions had beenocalized and resected; in that report, the full potential ofntraoperative ultrasonography was outlined especiallyith regard to the accurate identification, on the fullyeflated lung, of the anatomic structures of the paren-hyma and the characteristics of ground glass opacities2]. In our patients, a radiologist with particular expertisen ultrasonography was present in the operating theatero help us with the identification of the pulmonaryodules. However, the visualization of the nodule by theltrasonographic probe appeared straightforward also to

he inexperienced eye.In the recent literature, there is a notable trend toward

expanding the domain of outpatient thoracic surgeryunder the pressure of third-party payers, mass media,and patients [9, 10]. The uniportal VATS approach in theawake patient can be considered a potential alternativefor selected cases, especially when solitary pulmonarynodules represent a diagnostic dilemma. By offeringsingle-access VATS with intraoperative ultrasound prob-ing, possibly under locoregional anesthesia, outpatientthoracic surgery may increasingly become a reliable,cost-effective, alternative option to repeated imaging of asuspicious nodule.

Disclosures and Freedom of Investigation

The tested technology was borrowed for the purpose of

the study. In addition, the authors had full control of the

design of the study, methods used, outcome parametersand results, analysis of data, and production of thewritten report.

References

1. Bellomi M, Veronesi G, Trifiro G, et al. Computed tomogra-phy-guided preoperative radiotracer localization of nonpal-pable lung nodules. Ann Thorac Surg 2010;90:1759–64.

2. Kondo R, Yoshida K, Hamanaka K, et al. Intraoperativeultrasonographic localization of pulmonary ground-glassopacities. J Thorac Cardiovasc Surg 2009;138:837–42.

3. Rocco G, Romano V, Accardo R, et al. Awake single-access(uniportal) video-assisted thoracoscopic surgery for periph-eral pulmonary nodules in a complete ambulatory setting.Ann Thorac Surg 2010;89:1625–7.

4. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedgepulmonary resections. Ann Thorac Surg 2004;77:726–8.

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6. Medford AR. Additional cost benefits of chest physician-operated thoracic ultrasound (TUS) prior to medical thora-coscopy (MT). Respir Med 2010;104:1077–8.

7. Medford AR. The utility of thoracic ultrasound before localanesthetic video-assisted thoracoscopy in patients with sus-pected pleural malignancy. J Clin Ultrasound 2010;38:222–5.

8. Gow KW, Saad DF, Koontz C, Wulkan ML. Minimallyinvasive thoracoscopic ultrasound for localization of pulmo-nary nodules in children. J Pediatr Surg 2008;43:2315–22.

9. Katlic MR, Facktor MA. Video-assisted thoracic surgeryutilizing local anesthesia and sedation: 384 consecutivecases. Ann Thorac Surg 2010;90:240–5.

10. Molins L, Fibla JJ, Mier JM, Sierra A. Outpatient thoracicsurgery. Thorac Surg Clin 2008;18:321–7.

Disclaimer

The Society of Thoracic Surgeons, the Southern ThoracicSurgical Association, and The Annals of Thoracic Surgeryneither endorse nor discourage use of the new technol-

ogy described in this article.