Cone-beam Ct Guided Localization And Video-assisted Thoracoscopic Resection Of Peripheral Pulmonary Nodules
Mahesh Ramchandani, Min Kim, MD, Puja Gaur, MD, Ponraj Chinnadurai, MB, BS, Alan Lumsden, MD, FRCS.
Houston Methodist, Houston, TX, USA.
To illustrate the technique and report preliminary results of C-arm cone-beam CT (CBCT) guided localization and video-assisted minimally invasive thoracoscopic resection (VATS) of small peripheral pulmonary nodules and ground-glass opacities (GGO).
A retrospective review of CBCT guided localization followed by VATS done between December 2013 and 2016 was performed. CBCT images were acquired using a robotic C-arm angiography system in a hybrid operating room. Pulmonary nodules or GGOs were targeted under fluoroscopic and laser guidance using breast hook-wire localization needle and coils. Then the procedure was converted to VATS for minimally invasive wedge resection.
Figure 1 illustrates our technique for CBCT guidance localization and minimally invasive VATS resection. A total of 15 patients underwent CBCT guided localization followed by VATS for small peripheral nodules (n=10) and GGOs (n=5) during the study period. Median (± range) lesion size and distance from pleural surface were 9.85mm (5.1-24.3) and 15.1 mm (0, 47) respectively. In all patients, CBCT imaging identified all the pulmonary lesions diagnosed on pre-operative multi-slice CT imaging. Median number of CBCT (including collimated scans) and radiation dose-area-product (DAP) per scan for lesion localization were 2 scans (1,4) and 1145.1 microGy-m2 per scan. Median time from planning CBCT until lesion localization was 33:46 mins.
C-arm cone-beam CT image guided localization followed by minimally invasive thoracoscopic resection of peripheral pulmonary nodules and GGOs is technically feasible in a hybrid operating room setup. Current challenges associated with CBCT guided localization include field of view, patient positioning (in obese patients), respiratory motion (in lower-lobe lesions), and additional learning curve for intra-operative 3D imaging.
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