Introduction
Background
Rationale and knowledge gap
Objective
Methods
Participants
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a) Lesions located close to the lateral thoracic pleura (< 10 mm), as the hookwire irritation of the pleura can cause significant pain post-localization while awaiting general anaesthesia for surgery.
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b) Lesions requiring a posterior approach, as the hookwire is more easily dislodged when the patient is turned from prone to supine position for transfer from the IR suite to the OR.
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c) Lesions where the hookwire needs to traverse a long soft tissue tract, which also increases the risk of hookwire dislodgement during transfer from the IR suite to the OR.
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d) Patients with significant emphysema, which increases the risk of large pneumothorax if hookwire dislodgement occurs.
Localization procedure
Surgical procedure
Variables and statistical analysis
Results
Patient and nodule characteristics
Patient characteristics | ||||
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Variable | Total (n = 30) n (%) or mean (SD) | Pre-Op Localization (n = 13) n (%) or mean (SD) | Intra-op Localization (n = 17) n (%) or mean (SD) | |
Age (years) | 62.4 (10.7) | 60.4 (13.6) | 64.0 (8.0) | |
Gender | Male | 15 (50%) | 6 (46.2%) | 9 (52.9%) |
Female | 15 (50%) | 7 (53.8%) | 8 (47.1%) | |
Smoking status | Current | 5 (16.7%) | 1 (7.7%) | 4 (23.5%) |
Previous | 6 (20.0%) | 4 (30.8%) | 2 (11.8%) | |
Life-long non-smoker | 19 (63.3%) | 8 (61.5%) | 11 (64.7%) | |
Previous ipsilateral Lobectomy | 4 (13.3%) | 2 (11.8%) | 2 (11.8%) | |
Previous malignancy | 18 (60.0%) | 10 (76.9%) | 8 (61.5%) | |
Charlson comorbidity Index | 5.2 (2.5) | 5.3 (2.9) | 5.1 (2.1) |
Nodule characteristics | ||||
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Variable | Total (n = 36) n (%) or mean (SD) | Pre-Op Localization (n = 16) n (%) or mean (SD) | Intra-op Localization (n = 20) n (%) or mean (SD) | |
Nodule size (mm) | 10.5 (4.6) | 10.4 (5.0) | 10.6 (4.3) | |
Distance to pleura (mm) | 7.6 (6.5) | 7.4 (7.1) | 7.7 (6.2) | |
Location† | RUL | 5 (14.0%) | 4 (25.0%) | 1 (5.0%) |
RML | 2 (6.0%) | 0 (0.0%) | 2 (10.0%) | |
RLL | 15 (42.0%) | 3 (19.0%) | 12 (60.0%) | |
LUL | 7 (19.0%) | 5 (31.0%) | 2 (10.0%) | |
LLL | 7 (19.0%) | 4 (25.0%) | 3 (15.0%) | |
Radiological characteristic | Ground-glass | 13 (36.0%) | 4 (25.0%) | 9 (45.0%) |
Mixed solid-ground glass | 10 (28.0%) | 7 (44.0%) | 3 (15.0%) | |
Solid | 13 (36.0%) | 5 (31.0%) | 8 (40.0%) | |
Number of nodules in each patient | 1 | 26 (86.7%) | 11 (84.6%) | 15 (88.2%) |
2 | 2 (6.7%) | 1 (7.7%) | 1 (5.9%) | |
3 | 2 (6.7%) | 1 (7.7%) | 1 (5.9%) |
Localization outcomes
Localization technique used for each nodule | |||
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Total nodules (n = 36) n (%) | Pre-op localization (n = 16) n (%) | Intra-op localization (n = 20) n (%) | |
Hookwire only | 9 (25.0%) | 4 (25.0%) | 5 (25.0%) |
Hookwire + ICG† | 21 (58.0%) | 8 (50.0%) | 13 (65.0%) |
Hookwire + ICG† + Lipiodol | 3 (8.0%) | 1 (6.0%) | 2 (10.0%) |
Microcoil + ICG† | 3 (8.0%) | 3 (19.0%) | 0 (0.0%) |
Summary of localization procedural complications | |||
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Total Patients (n = 30) n (%) | Pre-op Localization (n = 13) n (%) | Intra-op Localization (n = 17) n (%) | |
All | 14 (47.0%) | 7 (54.0%) | 7 (41.0%) |
Minor pneumothorax‡ | 8 (26.7%) | 3 (23.1%) | 5 (29.4%) |
Significant pneumothorax‡ | 3 (10.0%) | 2 (15.4%) | 1 (5.9%) |
Hookwire/ Coil dislodgement | 3 (10.0%) | 2 (15.4%) | 1 (5.9%) |
Statistical analyses of outcomes | ||||||||||||
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Outcome | Mean (SD) or Median (IQR) | Mean Difference (95% CI) or Median Difference | t-Statistic (df) or U-statistic | p-Value | ||||||||
Total patients (n = 30) | Pre-op Localization (n = 13) | Intra-op Localization (n = 17) | ||||||||||
Localization duration (min) | 48.6 (20.2) | 46.7 (15.5) | 50.0 (23.6) | − 3.3 ( − 18.8 to 12.2) | − 0.4 (28) | 0.66* | ||||||
Effective radiation dose (mSV) § | 4.2 (2.3 to 10.5) | 10.4 (3.9 to 14.7) | 3.2 (1.9 to 4.4) | 7.2 | 50.00 | 0.01** |
Outcome | Total Patients (n = 30) n (%) | Pre-op Localization (n = 13) n (%) | Intra-op Localization (n = 17) n (%) | χ2—statistic (df) | P-value | |||||||
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Complication | Yes | 14 (47.0%) | 7 (54.0%) | 7 (41.0%) | 0.475 (1) | 0.5** | ||||||
No | 16 (53.0.%) | 6 (46.0%) | 10 (59.0%) |
Surgical outcomes
Surgical technique used for each patient | |||
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Total Patients (n = 30) n (%) | Pre-op Localization (n = 13) n (%) | Intra-op Localization (n = 17) n (%) | |
Wedge | 25 (83.0%) | 11 (85.0%) | 14 (82.0%) |
Wedge + Lobectomy | 5 (17.0%) | 2 (15.0%) | 3 (18.0%) |
Conversion to thoracotomy | 0 | 0 | 0 |
Successful resection of lesion with wedge resection | 30 (100.0%) | 13 (100.0%) | 17 (100.0%) |
Summary of post-surgical complications | |||
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Total Patients (n = 30) n (%) | Pre-op Localization (n = 13) n (%) | Intra-op Localization (n = 17) n (%) | |
All | 8 (27.0%) | 3 (23.0%) | 3 (19.0%) |
Prolonged air leak | 5 (19.0%) | 2 (18.0%) | 3 (19.0%) |
Atrial Fibrillation | 1 (4.0%) | 0 | 1 (6.0%) |
Pneumonia | 1 (4.0%) | 0 | 1 (6.0%) |
Chylothorax | 1 (4.0%) | 1 (9.0%) | 0 |
Statistical analyses of outcomes | ||||||
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Outcome | Mean (SD) | Mean Difference (95% CI) | t-statistic (df) | p-Value | ||
Total Patients (n = 30) | Pre-op Localization (n = 13) | Intra-op Localization (n = 17) | ||||
Surgery duration (min) | 103.2 (43.2) | 105.0 (46.8) | 101.8 (41.7) | 3.2 (29.9 to 36.4) | 0.2 (28) | 0.84* |
Intraoperative blood loss (ml) | 31.0 (49.9) | 33.1 (42.5) | 29.4 (56.1) | 3.7 ( − 34.6 to 41.9) | 0.19 (28) | 0.84* |
Post-operative hospital stay (days) | 5.4 (3.0) | 5.0 (2.7) | 5.7 (3.2) | − 0.8 ( − 3.0 to 1.5) | − 0.69 (28) | 0.49* |
Mortality | 0 | 0 | 0 |
Outcome | Total patients (n = 30) n (%) | Pre-op Localization (n = 13) n (%) | Intra-op Localization (n = 17) n (%) | P-Value | |
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Complication | Yes | 8 (27.0%) | 3 (23.0%) | 5 (29.0%) | > 0.99** |
No | 22 (73.0%) | 10 (77.0%) | 12 (71.0%) |
Lung nodule histopathology with correlation to radiological characteristic | |||
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Histology | Radiological Characteristic | ||
All Nodules (n = 36) n (%) | Solid (n = 13) n (%) | Mixed or Ground-glass (n = 23) n (%) | |
Primary Lung Cancer or Pre-Malignant Lesions | 31 (86.0%) Invasive Adenocarcinoma: 24 Invasive Mucinous Adenocarcinoma: 2 Minimally Invasive Adenocarcinoma: 3 Atypical Adenomatous Hyperplasia: 2 | 8 (62.0%) | 23 (100.0%) |
Metastatic Lesions | 2 (7.0%) Leiomyosarcoma: 1 Thymoma: 1 | 2 (15.0%) | 0 |
Benign Lesions | 3 (7.0%) Scar Tissue: 2 Intraparenchymal Lymph Node: 1 | 3 (23.0%) | 0 |
Statistical analyses of lung nodule histopathology | |||||
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Histology | All Nodules (n = 36) n (%) | Solid (n = 13) n (%) | Mixed or Ground-glass (n = 23) n (%) | p-Value | |
Malignant | Yes | 33 (92.0%) | 10 (77.0%) | 23 (100.0%) | 0.04§ |
No | 3 (8.0%) | 3 (23.0%) | 0 |
Parenchymal resection margins of primary lung cancer, pre-malignant lesions and metastatic lesions | ||||||
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Mean (SD) | Mean Difference (95% CI) | t-Statistic (df) | p-Value | |||
Total Nodules (n = 32)† | Pre-op Localization (n = 14)† | Intra-op Localization (n = 18) | ||||
Parenchymal resection margins (mm) | 9.8 (5.43) | 9.0 (4.76) | 10.4 (5.97) | − 1.39 ( − 5.26 to 2.48) | − 0.73 (30) | 0.47 |