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Computed Tomographically Guided Injection of Cyanoacrylate in Association With Preoperative Radioguided Occult Lesion Localization of Ground-Glass Opacities
Computed Tomographically Guided Injection of Cyanoacrylate in Association With Preoperative Radioguided Occult Lesion Localization of Ground-Glass Opacities Chiang J. Tyng, MD, Victor Hugo V. Nogueira, MD, Almir G. V. Bitencourt, PhD, Luiz Carlos M. Santos, MD, Thiago Vinícius P. Souza, MD, Marcelo B. Zilio, MD, Paula N. V. P. Barbosa, MD, Eduardo N. P. Lima, PhD, Jefferson L. Gross, PhD, and Rubens Chojniak, PhD
Intraoperative localization of a ground-glass opacity (GGO) is difficult because it is not easy to palpate and may be invisible at radioscopy. Therefore various techniques have been developed to improve intraoperative localization of these lesions, allowing adequate surgical resection. We report 2 cases of preoperative localization
of GGOs through computed tomographically guided injection of cyanoacrylate in association with radioguided occult lesion localization (ROLL).
G
Technique
round-glass opacities (GGOs) are known to exhibit high malignancy potential and therefore require tissue confirmation for proper treatment planning [1]. However, intraoperative localization of these lesions can be a difficult task for the thoracic surgeon because they are not easy to palpate, even at thoracotomy, and are invisible at radioscopy. Therefore, various techniques have been developed to improve intraoperative localization of GGOs and allow adequate surgical resection [2–4]. Radioguided operations have proved to be a safe and effective alternative in selected cases in which suspected lesions may be difficult to identify intraoperatively because of their dimensions or anatomical location in different organs [5]. The localization of pulmonary nodules by the radioguided occult lesion localization (ROLL) technique has been shown to be reliable, allowing successful localization and excision of small nodules in 95% to 96% of cases [6–8]. However, there are no specific studies describing this technique for the preoperative localization of GGOs. In addition, there are some potentials drawbacks such as the fast diffusion of radionuclide solution in the pulmonary parenchyma surrounding the nodule because of the rich vascularization of the lung [6]. We report a technique of preoperative localization of GGOs through computed tomographically guided ROLL with the injection of cyanoacrylate in association with the radiotracer.
Accepted for publication Jan 16, 2015. ˇ
FEATURE ARTICLES
Departments of Imaging and Thoracic Surgery, AC Camargo Cancer Center, S~ ao Paulo-SP, Brazil
Address correspondence to Dr Tyng, Rua Prof Antonio Prudente, 211, 01509-010, S~ ao Paulo-SP, Brazil; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:1838–40) Ó 2015 by The Society of Thoracic Surgeons
The procedure was performed on the same day as the operative procedure. Patient positioning on the computed tomography table varied depending on the lesion location. The preferred position is the one that makes the patient more comfortable during the procedure, which was performed under monitored conscious sedation with midazolam and fentanyl. After marking the skin entry point and performing local anesthesia, a coaxial 19-gauge needle was introduced into the lesion. A solution composed of 0.2 mL of 99mTC sulfur colloid (Sn-99mTc) with an activity count of 0.5 to 1.0 mCi (18.5 to 37 MBq) and 0.5 to 1.0 mL of n-butyl-2-cyanoacrylate (Histoacryl; Tissue Seal/B. Braun, Bethlehem, PA) was then injected with a long 22-gauge needle. This solution was contained in a special syringe protected by a lead container specific for radioprotection. In the same procedure, a metallic clip was also introduced to confirm the location of the radioactivity in the suspected area and to help posterior pathologic analysis. A successive computed tomographic scan was obtained to confirm the precise location of the clip within the GGO, which could be located through intraoperative fluoroscopy if necessary. Immediately after the injection, the patient was transferred to the nuclear medicine department and singlephoton emission computed tomography/computed tomography (SPECT-CT) imaging was performed to confirm the location and technical quality of the injection. The marked lesions were identified intraoperatively using a gamma probe and were excised with safety margins. The radioactivity of the tissue was measured 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.043
Ann Thorac Surg 2015;99:1838–40
in vivo and after excision, as was the radioactivity of the surgical bed, to confirm that the marked lesion had been fully excised.
Patient 1
Patient 2 A 55-year-old female patient who was asymptomatic and a passive smoker presented with a GGO in the superior segment of the right lower lobe measuring 24 22 mm (Fig 2A). This lesion remained stable at follow-up
1839
examinations, and the thoracic surgeon opted for surgical resection for better evaluation. The patient also underwent preoperative localization in which the solution with the Sn-99mTc and cyanoacrylate was injected into the lesion through a coaxial 19-gauge needle (Fig 2B). In this case, we also injected dextran-99mTC to try to detect the sentinel lymph node. SPECT-CT confirmed the location of the radiotracer in the GGO after the procedure and demonstrated a discrete radiotracer concentration in a small intrapulmonary lymph node in the great fissure adjacent to the target lesion (Fig 2C). At operation, only 1 area of increased radioactivity in the superior segment of the right lower lobe was identified with the gamma probe adjacent to the major fissure. Radioguided VATS segmentectomy was successfully performed. Histologic examination confirmed the diagnosis of nonmucinous adenocarcinoma in situ of the lung. The lymph node was also resected in the segmentectomy and histologic examination was negative for malignancy.
Comment The injection of liquid materials for marking pulmonary nodules, including methylene blue dye, contrast medium, and radionuclides, has been studied over the years. A limiting factor of these techniques is the potential for the spread of these materials in the lung or pleural space in the time interval between injection and operation, thus making localization at operation difficult [9]. Our technique involves the computed tomographically guided injection of a radiotracer in association with cyanoacrylate in the center of the GGO. Cyanoacrylate polymerizes immediately after injection into the lung parenchyma, forming a hard nodule [10]. When mixed
Fig 1. (A) Computed tomographic scan of 77-year-old woman presenting with nodular ground-glass opacity (GGO) in posterior segment of right upper lobe. (B) After placement of coaxial needle through computed tomographic guidance into GGO, solution with radiotracer and cyanoacrylate was injected, followed by (C) introduction of metallic clip. (D) Single-photon emission computed tomography/computed tomography (SPECT-CT) confirmed location of radiotracer in GGO after procedure.
FEATURE ARTICLES
A 77-year-old asymptomatic female patient underwent screening chest CT, which showed a nodular GGO in the posterior segment of the right upper lobe, measuring 18 16 mm, with a 7-mm solid component inside (Fig 1A). Surgical resection of this lesion was indicated because of a slight increase in the dimensions in relation to the examination performed 6 months earlier. The patient underwent preoperative localization on the same day of the operation using the described technique. After a coaxial 19-gauge needle was introduced into the lesion (Fig 1B), the solution with Sn-99mTc and cyanoacrylate was injected, followed by the introduction of a metallic clip (Fig 1C). SPECT-CT confirmed the location of the radiotracer in the GGO after the procedure (Fig 1D). At video-assisted thoracoscopic surgery (VATS), an area of increased radioactivity in the right upper lobe was easily identified with the gamma probe, and lung segmentectomy was then performed in association with mediastinal lymph node dissection. Histologic examination showed a moderately differentiated lepidic-predominant invasive lung adenocarcinoma, with areas of solid and acinar growth patterns. Mediastinal lymph nodes were negative, and the final stage of disease was IA (T1N0M0).
HOW TO DO IT TYNG ET AL CYANOACRYLATE ASSOCIATED WITH ROLL
1840
HOW TO DO IT TYNG ET AL CYANOACRYLATE ASSOCIATED WITH ROLL
Ann Thorac Surg 2015;99:1838–40
FEATURE ARTICLES
Fig 2. (A) Computed tomographic scan of 55-year-old female patient presenting with a nodular ground-glass opacity (GGO) in superior segment of right lower lobe. (B) After placement of coaxial needle through computed tomographic guidance inside the GGO, solution with the radiotracer and cyanoacrylate was injected. Tridimensional reconstructed single-photon emission computed tomography/computed tomography (SPECT-CT) confirmed location of radiotracer in GGO after procedure and demonstrated (C) discrete radiotracer concentration in small intrapulmonary lymph node in great fissure adjacent to target lesion.
with the radiotracer, this node becomes identifiable during the operation using a gamma probe, either for open lung biopsy or VATS. This technique reduces the chance of spreading the radiotracer in the lung parenchyma or pleural space. Compared with other methods, the described technique has some advantages for the localization of GGOs: it does not require intraoperative fluoroscopy or a skilled ultrasonographer, there is no risk of dislocation of the marker, all needed components (radiotracer, TC technology and gamma probes) are readily available at most hospitals, it does not interfere with frozen section or histologic examination, and minimal morbidity is associated with the procedure [7, 8]. The most common complications are pneumothorax and mild parenchymal hemorrhage [9]. However, the incidence of complications is lower than in the hookwire technique [11]. In conclusion, our initial experience shows that the association of the radiotracer (ROLL technique) with cyanoacrylate is an effective and promising method for precise identification and resection of GGOs during operation. Further studies should be addressed to access its efficacy and possible complications.
References 1. Infante M, Lutman RF, Imparato S, et al. Differential diagnosis and management of focal ground-glass opacities. Eur Respir J 2009;33:821–7.
2. Tyng CJ, Baranauskas MV, Bitencourt AG, et al. Preoperative Computed Tomography-Guided Localization of GroundGlass Opacities With Metallic Clip. Ann Thorac Surg 2013;96:1087–9. 3. Kondo R, Yoshida K, Hamanaka K, et al. Intraoperative ultrasonographic localization of pulmonary ground-glass opacities. J Thorac Cardiovasc Surg 2009;138:837–42. 4. Huang W, Ye H, Wu Y, et al. Hook wire localization of pulmonary pure ground-glass opacities for video-assisted thoracoscopic surgery. Thorac Cardiovasc Surg 2014;62:174–8. 5. Bitencourt AG, Lima EN, Pinto PN, Martins EB, Chojniak R. New applications of radioguided surgery in oncology. Clinics 2009;64:397–402. 6. Sortini D, Feo CV, Carcoforo P, et al. Thoracoscopic localization techniques for patients with solitary pulmonary nodule and history of malignancy. Ann Thorac Surg 2005;79: 258–62. 7. Stiles BM, Altes TA, Jones DR, et al. Clinical experience with radiotracer-guided thoracoscopic biopsy of small, indeterminate lung nodules. Ann Thorac Surg 2006;82:1191–6. 8. Grogan EL, Jones DR, Kozower BD, et al. Identification of small lung nodules: technique of radiotracer-guided thoracoscopic biopsy. Ann Thorac Surg 2008;85:S772–7. 9. Bellomi M, Veronesi G, Trifir o G, et al. Computed tomography-guided preoperative radiotracer localization of nonpalpable lung nodules. Ann Thorac Surg 2010;90(6): 1759–64. 10. Yoshida J, Nagai K, Nishimura M, et al. Computed tomography-fluoroscopy guided injection of cyanoacrylate to mark a pulmonary nodule for thoracoscopic resection. Jpn J Thorac Cardiovasc Surg 1999;47:210–3. 11. Gonfiotti A, Davini F, Vaggelli L, et al. Thoracoscopic localization techniques for patients with solitary pulmonary nodule: hookwire versus radio-guided surgery. Eur J Cardiothorac Surg 2007;32:843–7.
Intraoperative localization of a ground-glass opacity (GGO) is difficult because it is not easy to palpate and may be invisible at radioscopy. Therefore various techniques have been developed to improve intraoperative localization of these lesions, allowing adequate surgical resection. We report 2 cases of preoperative localization
of GGOs through computed tomographically guided injection of cyanoacrylate in association with radioguided occult lesion localization (ROLL).
G
Technique
round-glass opacities (GGOs) are known to exhibit high malignancy potential and therefore require tissue confirmation for proper treatment planning [1]. However, intraoperative localization of these lesions can be a difficult task for the thoracic surgeon because they are not easy to palpate, even at thoracotomy, and are invisible at radioscopy. Therefore, various techniques have been developed to improve intraoperative localization of GGOs and allow adequate surgical resection [2–4]. Radioguided operations have proved to be a safe and effective alternative in selected cases in which suspected lesions may be difficult to identify intraoperatively because of their dimensions or anatomical location in different organs [5]. The localization of pulmonary nodules by the radioguided occult lesion localization (ROLL) technique has been shown to be reliable, allowing successful localization and excision of small nodules in 95% to 96% of cases [6–8]. However, there are no specific studies describing this technique for the preoperative localization of GGOs. In addition, there are some potentials drawbacks such as the fast diffusion of radionuclide solution in the pulmonary parenchyma surrounding the nodule because of the rich vascularization of the lung [6]. We report a technique of preoperative localization of GGOs through computed tomographically guided ROLL with the injection of cyanoacrylate in association with the radiotracer.
Accepted for publication Jan 16, 2015. ˇ
FEATURE ARTICLES
Departments of Imaging and Thoracic Surgery, AC Camargo Cancer Center, S~ ao Paulo-SP, Brazil
Address correspondence to Dr Tyng, Rua Prof Antonio Prudente, 211, 01509-010, S~ ao Paulo-SP, Brazil; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:1838–40) Ó 2015 by The Society of Thoracic Surgeons
The procedure was performed on the same day as the operative procedure. Patient positioning on the computed tomography table varied depending on the lesion location. The preferred position is the one that makes the patient more comfortable during the procedure, which was performed under monitored conscious sedation with midazolam and fentanyl. After marking the skin entry point and performing local anesthesia, a coaxial 19-gauge needle was introduced into the lesion. A solution composed of 0.2 mL of 99mTC sulfur colloid (Sn-99mTc) with an activity count of 0.5 to 1.0 mCi (18.5 to 37 MBq) and 0.5 to 1.0 mL of n-butyl-2-cyanoacrylate (Histoacryl; Tissue Seal/B. Braun, Bethlehem, PA) was then injected with a long 22-gauge needle. This solution was contained in a special syringe protected by a lead container specific for radioprotection. In the same procedure, a metallic clip was also introduced to confirm the location of the radioactivity in the suspected area and to help posterior pathologic analysis. A successive computed tomographic scan was obtained to confirm the precise location of the clip within the GGO, which could be located through intraoperative fluoroscopy if necessary. Immediately after the injection, the patient was transferred to the nuclear medicine department and singlephoton emission computed tomography/computed tomography (SPECT-CT) imaging was performed to confirm the location and technical quality of the injection. The marked lesions were identified intraoperatively using a gamma probe and were excised with safety margins. The radioactivity of the tissue was measured 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.043
Ann Thorac Surg 2015;99:1838–40
in vivo and after excision, as was the radioactivity of the surgical bed, to confirm that the marked lesion had been fully excised.
Patient 1
Patient 2 A 55-year-old female patient who was asymptomatic and a passive smoker presented with a GGO in the superior segment of the right lower lobe measuring 24 22 mm (Fig 2A). This lesion remained stable at follow-up
1839
examinations, and the thoracic surgeon opted for surgical resection for better evaluation. The patient also underwent preoperative localization in which the solution with the Sn-99mTc and cyanoacrylate was injected into the lesion through a coaxial 19-gauge needle (Fig 2B). In this case, we also injected dextran-99mTC to try to detect the sentinel lymph node. SPECT-CT confirmed the location of the radiotracer in the GGO after the procedure and demonstrated a discrete radiotracer concentration in a small intrapulmonary lymph node in the great fissure adjacent to the target lesion (Fig 2C). At operation, only 1 area of increased radioactivity in the superior segment of the right lower lobe was identified with the gamma probe adjacent to the major fissure. Radioguided VATS segmentectomy was successfully performed. Histologic examination confirmed the diagnosis of nonmucinous adenocarcinoma in situ of the lung. The lymph node was also resected in the segmentectomy and histologic examination was negative for malignancy.
Comment The injection of liquid materials for marking pulmonary nodules, including methylene blue dye, contrast medium, and radionuclides, has been studied over the years. A limiting factor of these techniques is the potential for the spread of these materials in the lung or pleural space in the time interval between injection and operation, thus making localization at operation difficult [9]. Our technique involves the computed tomographically guided injection of a radiotracer in association with cyanoacrylate in the center of the GGO. Cyanoacrylate polymerizes immediately after injection into the lung parenchyma, forming a hard nodule [10]. When mixed
Fig 1. (A) Computed tomographic scan of 77-year-old woman presenting with nodular ground-glass opacity (GGO) in posterior segment of right upper lobe. (B) After placement of coaxial needle through computed tomographic guidance into GGO, solution with radiotracer and cyanoacrylate was injected, followed by (C) introduction of metallic clip. (D) Single-photon emission computed tomography/computed tomography (SPECT-CT) confirmed location of radiotracer in GGO after procedure.
FEATURE ARTICLES
A 77-year-old asymptomatic female patient underwent screening chest CT, which showed a nodular GGO in the posterior segment of the right upper lobe, measuring 18 16 mm, with a 7-mm solid component inside (Fig 1A). Surgical resection of this lesion was indicated because of a slight increase in the dimensions in relation to the examination performed 6 months earlier. The patient underwent preoperative localization on the same day of the operation using the described technique. After a coaxial 19-gauge needle was introduced into the lesion (Fig 1B), the solution with Sn-99mTc and cyanoacrylate was injected, followed by the introduction of a metallic clip (Fig 1C). SPECT-CT confirmed the location of the radiotracer in the GGO after the procedure (Fig 1D). At video-assisted thoracoscopic surgery (VATS), an area of increased radioactivity in the right upper lobe was easily identified with the gamma probe, and lung segmentectomy was then performed in association with mediastinal lymph node dissection. Histologic examination showed a moderately differentiated lepidic-predominant invasive lung adenocarcinoma, with areas of solid and acinar growth patterns. Mediastinal lymph nodes were negative, and the final stage of disease was IA (T1N0M0).
HOW TO DO IT TYNG ET AL CYANOACRYLATE ASSOCIATED WITH ROLL
1840
HOW TO DO IT TYNG ET AL CYANOACRYLATE ASSOCIATED WITH ROLL
Ann Thorac Surg 2015;99:1838–40
FEATURE ARTICLES
Fig 2. (A) Computed tomographic scan of 55-year-old female patient presenting with a nodular ground-glass opacity (GGO) in superior segment of right lower lobe. (B) After placement of coaxial needle through computed tomographic guidance inside the GGO, solution with the radiotracer and cyanoacrylate was injected. Tridimensional reconstructed single-photon emission computed tomography/computed tomography (SPECT-CT) confirmed location of radiotracer in GGO after procedure and demonstrated (C) discrete radiotracer concentration in small intrapulmonary lymph node in great fissure adjacent to target lesion.
with the radiotracer, this node becomes identifiable during the operation using a gamma probe, either for open lung biopsy or VATS. This technique reduces the chance of spreading the radiotracer in the lung parenchyma or pleural space. Compared with other methods, the described technique has some advantages for the localization of GGOs: it does not require intraoperative fluoroscopy or a skilled ultrasonographer, there is no risk of dislocation of the marker, all needed components (radiotracer, TC technology and gamma probes) are readily available at most hospitals, it does not interfere with frozen section or histologic examination, and minimal morbidity is associated with the procedure [7, 8]. The most common complications are pneumothorax and mild parenchymal hemorrhage [9]. However, the incidence of complications is lower than in the hookwire technique [11]. In conclusion, our initial experience shows that the association of the radiotracer (ROLL technique) with cyanoacrylate is an effective and promising method for precise identification and resection of GGOs during operation. Further studies should be addressed to access its efficacy and possible complications.
References 1. Infante M, Lutman RF, Imparato S, et al. Differential diagnosis and management of focal ground-glass opacities. Eur Respir J 2009;33:821–7.
2. Tyng CJ, Baranauskas MV, Bitencourt AG, et al. Preoperative Computed Tomography-Guided Localization of GroundGlass Opacities With Metallic Clip. Ann Thorac Surg 2013;96:1087–9. 3. Kondo R, Yoshida K, Hamanaka K, et al. Intraoperative ultrasonographic localization of pulmonary ground-glass opacities. J Thorac Cardiovasc Surg 2009;138:837–42. 4. Huang W, Ye H, Wu Y, et al. Hook wire localization of pulmonary pure ground-glass opacities for video-assisted thoracoscopic surgery. Thorac Cardiovasc Surg 2014;62:174–8. 5. Bitencourt AG, Lima EN, Pinto PN, Martins EB, Chojniak R. New applications of radioguided surgery in oncology. Clinics 2009;64:397–402. 6. Sortini D, Feo CV, Carcoforo P, et al. Thoracoscopic localization techniques for patients with solitary pulmonary nodule and history of malignancy. Ann Thorac Surg 2005;79: 258–62. 7. Stiles BM, Altes TA, Jones DR, et al. Clinical experience with radiotracer-guided thoracoscopic biopsy of small, indeterminate lung nodules. Ann Thorac Surg 2006;82:1191–6. 8. Grogan EL, Jones DR, Kozower BD, et al. Identification of small lung nodules: technique of radiotracer-guided thoracoscopic biopsy. Ann Thorac Surg 2008;85:S772–7. 9. Bellomi M, Veronesi G, Trifir o G, et al. Computed tomography-guided preoperative radiotracer localization of nonpalpable lung nodules. Ann Thorac Surg 2010;90(6): 1759–64. 10. Yoshida J, Nagai K, Nishimura M, et al. Computed tomography-fluoroscopy guided injection of cyanoacrylate to mark a pulmonary nodule for thoracoscopic resection. Jpn J Thorac Cardiovasc Surg 1999;47:210–3. 11. Gonfiotti A, Davini F, Vaggelli L, et al. Thoracoscopic localization techniques for patients with solitary pulmonary nodule: hookwire versus radio-guided surgery. Eur J Cardiothorac Surg 2007;32:843–7.