预充式CT引导下肺内小结节微弹簧圈穿刺定位法的初步探讨
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摘要
背景与目的肺内小结节微弹簧圈穿刺定位是微创手术切除肺内小结节常用的术前定位方法,然而该方法仍有操作复杂、轻微并发症多等不足之处,我们将原有方法进行了优化。本研究旨在探讨优化后的预充式计算机断层扫描(computed tomography, CT)引导下肺内小结节微弹簧圈穿刺定位法在临床中的应用价值。方法对2018年9月-2019年1月间31例患者的35枚肺结节,于术前采用预充式CT引导下肺内小结节微弹簧圈穿刺定位,然后施行胸腔镜下(video-assisted thoracoscopic surgery, VATS)手术。统计分析定位操作相关数据、成功率、并发症、病理结果等。结果定位成功率97.1%,VATS切除成功率100%。CT定位时间平均10.1 min(5 min-31 min),微创切除病灶所需时间平均38.2 min(10 min-100 min)。术中发现微弹簧圈脱位回缩至胸壁内1例,通过充气膨肺状态下自胸壁穿刺点刺入穿刺针,成功定位肺内结节并予以切除。3例患者定位后发生微量气胸,但无需闭式引流处理。3例患者出现肺内血肿。35枚肺结节术后病理结果为:高分化腺癌15例,原位癌7例,微浸润腺癌5例,非典型腺瘤样增生4例,肺内淋巴结增生、炎性结节各2例。结论采用预充式微弹簧圈定位肺内小结节简便、安全、有效,值得推广。
Background and objective Preoperative computed tomography(CT) guided microcoil localization is a common method for small lung nodules before video-assisted thoracoscopic surgery(VATS). However, this method still has some limitation such as complicated operation and slight complications. We have optimized the original method. The purpose of this study was to investigate the clinical value of this optimized method. Methods 35 pulmonary nodules from 31 patients between September 2018 and January 2019 were localized by the optimized method before VATS. The success rate, complications, pathological results and localization operations related data were statistically analyzed. Results The success rate of localization was 97.1%, and the success rate of VATS removal was 100%.The average operation time was 10.1 min(5 min-31 min), and the average time required for resection of lesions was 38.2 min(10 min-100 min). During the surgery, the microcoil of one patient was found to be dislocated and retracted into the chest wall. A puncture needle was inserted intolung tissue from the chest wall puncture point after the lung was inflated, and then the pulmonary nodule were successfully located and removed. A minor pneumothorax occurred in 3 patients, but no closed drainage was needed. Three patients developed intrapulmonary hematoma. The pathological results of 35 pulmonary nodules included 15 well-differentiated adenocarcinoma, 7 carcinoma in situ, 5 microinvasive adenocarcinoma, 4 atypical adenomatoid hyperplasia, 2 intrapulmonary lymph node hyperplasia, 2 inflammatory nodules. Conclusion For small pulmonary nodules requiring thoracoscopic surgery, the optimized computed tomographyguided pulmonary nodule microcoil localization technique is convenient, safe and effective, and worthy of promotion to use.
Background and objective Preoperative computed tomography(CT) guided microcoil localization is a common method for small lung nodules before video-assisted thoracoscopic surgery(VATS). However, this method still has some limitation such as complicated operation and slight complications. We have optimized the original method. The purpose of this study was to investigate the clinical value of this optimized method. Methods 35 pulmonary nodules from 31 patients between September 2018 and January 2019 were localized by the optimized method before VATS. The success rate, complications, pathological results and localization operations related data were statistically analyzed. Results The success rate of localization was 97.1%, and the success rate of VATS removal was 100%.The average operation time was 10.1 min(5 min-31 min), and the average time required for resection of lesions was 38.2 min(10 min-100 min). During the surgery, the microcoil of one patient was found to be dislocated and retracted into the chest wall. A puncture needle was inserted intolung tissue from the chest wall puncture point after the lung was inflated, and then the pulmonary nodule were successfully located and removed. A minor pneumothorax occurred in 3 patients, but no closed drainage was needed. Three patients developed intrapulmonary hematoma. The pathological results of 35 pulmonary nodules included 15 well-differentiated adenocarcinoma, 7 carcinoma in situ, 5 microinvasive adenocarcinoma, 4 atypical adenomatoid hyperplasia, 2 intrapulmonary lymph node hyperplasia, 2 inflammatory nodules. Conclusion For small pulmonary nodules requiring thoracoscopic surgery, the optimized computed tomographyguided pulmonary nodule microcoil localization technique is convenient, safe and effective, and worthy of promotion to use.
引文
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2 Heuvelmans MA, Oudkerk M. Management of subsolid pulmonary nodules in CT lung cancer screening. J Thorac Dis, 2015, 7(7):1103-1106. doi:10.3978/j.issn.2072-1439.2015.07.23
3 Naidich DP, Bankier AA, Macmahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT:a statement from the Fleischner Society. Radiology, 2013, 266(1):304 -317. doi:10.1148/radiol.12120628
4 Macmahon H, Naidich DP, Goo JM, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images:From the Fleischner Society 2017. Radiology, 2017, 284(1):228 -243. doi:10.1148/radiol.2017161659
5 Jiang GN, Chen C, Zhu YM, et al. Shanghai pulmonary hospital experts consensus on the management of ground glass nodules suspected as lung adenocarcinoma(version 1). Zhongguo Fei Ai Za Zhi, 2018, 21(3):147-159.[姜格宁,陈昶,朱余明,等.上海市肺科医院磨玻璃结节早期肺腺癌的诊疗共识(第一版).中国肺癌杂志,2018, 21(3):147-159.] doi:10.3779/j.issn.1009-3419.2018.03.05
6 Lin MW, Chen JS. Image-guided techniques for localizing pulmonary nodules in thoracoscopic surgery. J Thorac Dis, 2016,8 (Suppl 9):S749-S755. doi:10.21037/jtd.2016.09.71
7 Sui XZ, Yang F, Zhao H, et al. CT-guided microcoil localization for pulmonary small solid nodules and ground-glass opacity prior to thoracoscopic resection:a pilot study. Zhonghua Xiong Xin Xue Guan Wai Ke Za Zhi, 2014, 30(12):711-714.[隋锡朝,杨锋,赵辉,等.胸腔镜术前肺微小结节磨玻璃影微弹簧圈定位.中华胸心血管外科杂志, 2014, 30(12):711-714.] doi:10.3760/cma.j.issn.1001-4497.2014.12.002
8 Suzuki K, Nagai K, Yoshida J, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules:indications for preoperative marking. Chest, 1999, 115(2):563-568. doi:10.1378/chest.115.2.563
9 Kondo R, Yoshida K, Hamanaka K, et al. Intraoperative ultrasonographic localization of pulmonary ground-glass opacities. J Thorac Cardiovasc Surg, 2009, 138(4):837-842. doi:10.1016/j.jtcvs.2009.02.002
10 Mcconnel l PI, Feola GP, Meyers RL. Methylene blue-stained autologous blood for needle localization and thoracoscopic resection of deep pulmonary nodules. JPediatr Surg, 2002, 37(12):1729-1731. doi:10 .1053/jpsu.2002.36707
11 Wang T, Ma SH, Yan TS, et al. Computed tomography guided hookwire precise localization and minimally invasive resection of pulmonary nodules. Zhongguo Fei Ai Za Zhi, 2015, 18(11):680-685.[王通,马少华,闫天生,等. CT引导下Hook-wire精确定位并微创切除肺结节.中国肺癌杂志, 2015, 18(11):680-685.] doi:10.3779/j.issn.1009-3419.2015.11.04
12 Li FW, Chen YT, Bian JW, et al. Preoperative computed tomographyguided microcoil localization for multiple small lung nodules before video-assisted thoracoscopic surgery. Zhongguo Fei Ai Za Zhi, 2018,21(11):857-863.[李凤卫,陈应泰,边建伟,等.肺内多发小结节术前CT引导下微弹簧圈定位的初步探讨.中国肺癌杂志, 2018, 21(11):857 -863.] doi:10.3779/j.issn.1009-3419.2018.11.08
13 Kha L C, Hanneman K, Donahoe L, et al. Safety and efficacy of modified preoperative lung nodule microcoil localization without pleural marking:a pilot study. J Thorac Imaging, 2016, 31(1):15-22. doi:10 .1097/RTI.0000000000000188
14 Hwang S, Kim TG, Song YG. Comparison of hook wire versus coil localization for video-assisted thoracoscopic surgery. Thorac Cancer,2018, 9(3):384-389. doi:10.1111/1759-7714.12589
15 Thaete FL, Peterson MS, Plunkett MB, et al. Computed tomographyguided wire localization of pulmonary lesions before thoracoscopic resection:results in 101 cases. J Thorac Imaging, 1999, 14(2):90-98.doi:10.1097/00005382-199904000-00004
16 Lu D, Lv WF, Xu SB, et al. Value of CT-guided placement of microcoils prior to video-assisted thoracoscopic surgery for small solitary pulmonary nodules. Zhongguo Yi Xue Ji Suan Ji Cheng Xiang Za Zhi,2016, 22(5):407-411.[鲁东,吕维富,徐世斌,等. CT引导下肺小结节胸腔镜术前微弹簧圈定位.中国医学计算机成像杂志, 2016, 22(5):407 -411.] doi:10.3969/j.issn.1006-5741.2016.05.004
17 Olaiya B, Gilliland CA, Force SD, et al. Preoperative computed tomography-guided pulmonary lesion marking in preparation for f luoroscopic wedge resection-rates of success, complications, and pathology outcomes. Curr Probl Diagn Radiol, 2019, 48(1):27-31. doi:10 .1067/j.cpradiol.2017.10.012
18 Su TH, Fan YF, Jin L, et al. CT-guided localization of small pulmonary nodules using adjacent microcoil implantation prior to video-assisted thoracoscopic surgical resection. Eur Radiol, 2015, 25(9):2627-2633.doi:10.1007/s00330-015-3676-5
19 Powell TI, Jangra D, Clifton JC, et al. Peripheral lung nodules:f luoroscopically guided video-assisted thoracoscopic resection after computed tomography-guided localization using platinum microcoils.Ann Surg, 2004, 240(3):481-488, 488-489. doi:10.1097/01.sla.0000137132.01881.57
20 Yang F, Zhao H, Sui XZ, et al. Clinical study on preoperative computed tomography-guided microcoil localization for pulmonary pure groundglass opacity. Zhonghua Xiong Xin Xue Guan Wai Ke Za Zhi, 2014(3):167-169.[杨锋,赵辉,隋锡朝,等.微弹簧圈用于肺内单纯磨玻璃影术前定位.中华胸心血管外科杂志, 2014(3):167-169.] doi:10.3760/cma.j.issn.1001-4497.2014.03.011
21 Seo JM, Lee HY, Kim HK, et al. Factors determining successful computed tomography-guided local izat ion of lung nodules. J Thorac Cardiovasc Surg, 2012, 143(4):809-814. doi:10.1016/j.jtcvs.2011.10.038.
2 Heuvelmans MA, Oudkerk M. Management of subsolid pulmonary nodules in CT lung cancer screening. J Thorac Dis, 2015, 7(7):1103-1106. doi:10.3978/j.issn.2072-1439.2015.07.23
3 Naidich DP, Bankier AA, Macmahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT:a statement from the Fleischner Society. Radiology, 2013, 266(1):304 -317. doi:10.1148/radiol.12120628
4 Macmahon H, Naidich DP, Goo JM, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images:From the Fleischner Society 2017. Radiology, 2017, 284(1):228 -243. doi:10.1148/radiol.2017161659
5 Jiang GN, Chen C, Zhu YM, et al. Shanghai pulmonary hospital experts consensus on the management of ground glass nodules suspected as lung adenocarcinoma(version 1). Zhongguo Fei Ai Za Zhi, 2018, 21(3):147-159.[姜格宁,陈昶,朱余明,等.上海市肺科医院磨玻璃结节早期肺腺癌的诊疗共识(第一版).中国肺癌杂志,2018, 21(3):147-159.] doi:10.3779/j.issn.1009-3419.2018.03.05
6 Lin MW, Chen JS. Image-guided techniques for localizing pulmonary nodules in thoracoscopic surgery. J Thorac Dis, 2016,8 (Suppl 9):S749-S755. doi:10.21037/jtd.2016.09.71
7 Sui XZ, Yang F, Zhao H, et al. CT-guided microcoil localization for pulmonary small solid nodules and ground-glass opacity prior to thoracoscopic resection:a pilot study. Zhonghua Xiong Xin Xue Guan Wai Ke Za Zhi, 2014, 30(12):711-714.[隋锡朝,杨锋,赵辉,等.胸腔镜术前肺微小结节磨玻璃影微弹簧圈定位.中华胸心血管外科杂志, 2014, 30(12):711-714.] doi:10.3760/cma.j.issn.1001-4497.2014.12.002
8 Suzuki K, Nagai K, Yoshida J, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules:indications for preoperative marking. Chest, 1999, 115(2):563-568. doi:10.1378/chest.115.2.563
9 Kondo R, Yoshida K, Hamanaka K, et al. Intraoperative ultrasonographic localization of pulmonary ground-glass opacities. J Thorac Cardiovasc Surg, 2009, 138(4):837-842. doi:10.1016/j.jtcvs.2009.02.002
10 Mcconnel l PI, Feola GP, Meyers RL. Methylene blue-stained autologous blood for needle localization and thoracoscopic resection of deep pulmonary nodules. JPediatr Surg, 2002, 37(12):1729-1731. doi:10 .1053/jpsu.2002.36707
11 Wang T, Ma SH, Yan TS, et al. Computed tomography guided hookwire precise localization and minimally invasive resection of pulmonary nodules. Zhongguo Fei Ai Za Zhi, 2015, 18(11):680-685.[王通,马少华,闫天生,等. CT引导下Hook-wire精确定位并微创切除肺结节.中国肺癌杂志, 2015, 18(11):680-685.] doi:10.3779/j.issn.1009-3419.2015.11.04
12 Li FW, Chen YT, Bian JW, et al. Preoperative computed tomographyguided microcoil localization for multiple small lung nodules before video-assisted thoracoscopic surgery. Zhongguo Fei Ai Za Zhi, 2018,21(11):857-863.[李凤卫,陈应泰,边建伟,等.肺内多发小结节术前CT引导下微弹簧圈定位的初步探讨.中国肺癌杂志, 2018, 21(11):857 -863.] doi:10.3779/j.issn.1009-3419.2018.11.08
13 Kha L C, Hanneman K, Donahoe L, et al. Safety and efficacy of modified preoperative lung nodule microcoil localization without pleural marking:a pilot study. J Thorac Imaging, 2016, 31(1):15-22. doi:10 .1097/RTI.0000000000000188
14 Hwang S, Kim TG, Song YG. Comparison of hook wire versus coil localization for video-assisted thoracoscopic surgery. Thorac Cancer,2018, 9(3):384-389. doi:10.1111/1759-7714.12589
15 Thaete FL, Peterson MS, Plunkett MB, et al. Computed tomographyguided wire localization of pulmonary lesions before thoracoscopic resection:results in 101 cases. J Thorac Imaging, 1999, 14(2):90-98.doi:10.1097/00005382-199904000-00004
16 Lu D, Lv WF, Xu SB, et al. Value of CT-guided placement of microcoils prior to video-assisted thoracoscopic surgery for small solitary pulmonary nodules. Zhongguo Yi Xue Ji Suan Ji Cheng Xiang Za Zhi,2016, 22(5):407-411.[鲁东,吕维富,徐世斌,等. CT引导下肺小结节胸腔镜术前微弹簧圈定位.中国医学计算机成像杂志, 2016, 22(5):407 -411.] doi:10.3969/j.issn.1006-5741.2016.05.004
17 Olaiya B, Gilliland CA, Force SD, et al. Preoperative computed tomography-guided pulmonary lesion marking in preparation for f luoroscopic wedge resection-rates of success, complications, and pathology outcomes. Curr Probl Diagn Radiol, 2019, 48(1):27-31. doi:10 .1067/j.cpradiol.2017.10.012
18 Su TH, Fan YF, Jin L, et al. CT-guided localization of small pulmonary nodules using adjacent microcoil implantation prior to video-assisted thoracoscopic surgical resection. Eur Radiol, 2015, 25(9):2627-2633.doi:10.1007/s00330-015-3676-5
19 Powell TI, Jangra D, Clifton JC, et al. Peripheral lung nodules:f luoroscopically guided video-assisted thoracoscopic resection after computed tomography-guided localization using platinum microcoils.Ann Surg, 2004, 240(3):481-488, 488-489. doi:10.1097/01.sla.0000137132.01881.57
20 Yang F, Zhao H, Sui XZ, et al. Clinical study on preoperative computed tomography-guided microcoil localization for pulmonary pure groundglass opacity. Zhonghua Xiong Xin Xue Guan Wai Ke Za Zhi, 2014(3):167-169.[杨锋,赵辉,隋锡朝,等.微弹簧圈用于肺内单纯磨玻璃影术前定位.中华胸心血管外科杂志, 2014(3):167-169.] doi:10.3760/cma.j.issn.1001-4497.2014.03.011
21 Seo JM, Lee HY, Kim HK, et al. Factors determining successful computed tomography-guided local izat ion of lung nodules. J Thorac Cardiovasc Surg, 2012, 143(4):809-814. doi:10.1016/j.jtcvs.2011.10.038.