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Eur J Cardiothorac Surg 2002;22:440-442
© 2002 Elsevier Science NL

How-to-do-it

Single pulmonary nodules: localization with intrathoracoscopic ultrasound — a prospective study

Department of Surgical, Radiological and Anaesthesiological Sciences, Section of Clinica Chirurgica, University of Ferrara, C.so Giovecca 203, 44100 Ferrara, Italy

Received 14 March 2002; received in revised form 13 May 2002; accepted 17 May 2002.

* Corresponding author. Tel.: +39-0532-236385; fax: +39-0532-207653
e-mail: sors{at}libero.it

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
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.

Key Words: Intrathoracoscopic ultrasound localization • Single pulmonary nodule

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
Ultrasound is generally considered a routine and effective diagnostic tool, and with wide fields of application and being less invasive and less expensive, it has become an important element of medical practice. Among all anatomic areas, ultrasound examination is least used in the thorax and so chest diseases are rarely investigated with this method.

If we consider intraoperative investigation, only in the last few years have many authors [1–3] reported about the use of ultrasound for the localization of pulmonary nodules. In our Division we started to adopt intrathoracoscopic ultrasound to localize single pulmonary nodules.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
From November 2000 to November 2001, we used intrathoracoscopic ultrasound on 13 patients with single pulmonary nodules. The hardware was an ultrasound-colour Doppler (Toshiba ECO-CEE^TM) with a linear scan multifrequency probe (5–8 MHz). The probe may be inserted through a 10 mm trocar and it has a length of 40 cm. The distal end of the probe has a rotating head that can be handled from outside the chest.

We treated six males and seven females with an average age of 63.5 years (range 42–78 years).

In six cases patients were free of symptoms, with chest X-ray (CXR) done for oncological follow-up (previous breast cancer, right arm melanoma and colon cancer). The average follow-up length was 31 months (range 19–44 months). Four patients were free of symptoms and had CXR done for non-oncologic reasons (forensic science, insurance, preoperative for other pathologies). Three patients had fever and cough.

All patients underwent a chest-mediastinal spiral high resolution CT scan. In seven cases a bronchoscopy with bronchoalveolar lavage was done without a positive result. In only one case did bronchoalveolar lavage show ‘atypical cells of uncertain interpretation’. Seven patients had a diagnosis of a single pulmonary nodule situated between 1.5 and 3 cm from the pleura surface. For six patients it was situated between 3 and 5 cm from the pleura surface according to the thorax CT. Eight nodules were in the left lung (five in the superior lobe and three in the inferior), and five nodules were in the right lung (two in the superior lobe, two in the middle and the last in the inferior). The width of the nodules was between 11 and 20 mm in five cases, for six cases the diameter was between 21 and 30 mm and for the last two cases the diameter was 10 mm. The operative technique was that used by Santambrogio [2]. The average localization time was 12 min (range 8–19 min). In all 13 cases ultrasound was able to localize the nodules shown by thorax CT, but did not localize the nodules that were not visible by thorax CT (Figs. 1 and 2) .

View larger version (139K): [in this window] [in a new window]   Fig. 1. Ultrasound thoracoscopic scan (transverse section): a subpleural node of 28 mm in diameter is seen.

View larger version (100K): [in this window] [in a new window]   Fig. 2. Ultrasound thoracoscopic scan (transverse section): hypoechoic structure near the nodule.

	3. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 
Questions arise as to when we diagnose the presence of a pulmonary nodule [4]. The first is in relation to the pathology of the nodule, and is extremely important in a patient with previous cancer, ever if the nodule is small and peripheral. The CXR, CT and bronchoscopy are often unable to give the answer, like more invasive diagnostic procedures (CT guided fine needle biopsy or transbronchial biopsy). The next step is use of a non-invasive surgical technique in order to perform an excisional biopsy of the tumour [5]. Minimal invasive video-assisted thoracic surgery is the best choice for this diagnostic purpose and, in selected cases, for the therapeutic purpose. The main limit of this technique is the difficulty in localizing the deep nodule. Many techniques [6–8] are used to localize the nodule if it is quite peripheral, but not enough to be seen through the pleural surface. A lot of these techniques do not have good sensibility and sometimes have side effects like pneumothorax, ematomas and parenchymal damage. For us ultrasound is the most effective method to localize lung nodules without side effects. It is useful not only for the localization of the nodules but also to study the near structures surrounding the nodule-like vessels, bronchi and lymph nodes, but can not play a role, even if marginal, in the histologic study of the nodule. In fact in ten patients the lesion appeared as a homogeneous hypoechoic pattern with the sonographic disappearance of the hyperechoic pulmonary surface. Heterogeneous echogenicity of the lesion was observed nevertheless in three of 13 patients, which may be due to air bronchograms, the presence of different tissue or hamartoma. However, this ultrasound pattern was not able to distinguish between benign or malignant lesions. In conclusion, we can confirm that intrathoracoscopic ultrasound is a safe, risk-free and inexpensive method to localize single pulmonary nodules.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Discussion References

 

1. Tatsumura T. Preoperative and intraoperative ultrasonographic examination as an aid in lung cancer operations. J Thorac Cardiovasc Surg 1995;110:606-612.[Abstract/Free Full Text]
2. Santambrogio R., Montorsi M., Bianchi P., Mantovani A., Ghelma F., Mezzetti M. Intraoperative ultrasound during thoracoscopic surgery for solitary pulmonary nodules. Ann Thorac Surg 1999;68(1):218-222.[Abstract/Free Full Text]
3. Hida Y., Kato H., Nishibe T. Value of intraoperative ultrasonography during video-assisted thoracoscopic pulmonary resection. Surg Laparosc Endosc 1996;6:472-475.[Medline]
4. Sortini A., Carcoforo P., Ascanelli S., Sortini D., Pozza E. Significance of a single pulmonary nodule in patients with previous history of malignancy. Eur J Cardiothorac Sur 2001;20(6):1101-1105.[Abstract/Free Full Text]
5. Yim A.P.C. Routine video-assisted thoracoscopy prior to thoracotomy. Chest 1996;109(4):1099-1100.[Abstract/Free Full Text]
6. Kerrigan D.C., Spence P.A., Crittenden M.D., Tripp M.D. Methylene blue guidance for simplified resection of a lung lesion. Ann Thorac Surg 1992;53:163-164.[Abstract]
7. Shepard J.O., Mathisen D.J., Muse V.V., Bhalla M., McLoud T.C. Needle localization of peripheral lung nodules for video-assisted thoracoscopic surgery. Chest 1994;105(5):1559-1563.[Abstract/Free Full Text]
8. Scheebaum S., Even-Sapir E., Cohen M., Shacham-Lehrman H., Gat A., Brazovsky E., Livehitz G., Stadler J., Skornick Y. Clinical applications of gamma-detection probes — radioguided surgery. Eur J Nucl Med 1999;26(4 Suppl):626-635.

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