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Frequency and Mortality of the Most Commonly Diagnosed Cancers

Novel Surgical Approach for Localization and Excisional Biopsy of Small or Ill-defined Pulmonary Lesions Thomas M. Daniel, M.D. Section of General Thoracic Surgery University of Virginia School of Medicine Charlottesville, Virginia. Frequency and Mortality of the Most

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Frequency and Mortality of the Most Commonly Diagnosed Cancers

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  1. Novel Surgical Approach for Localization and Excisional Biopsy of Small or Ill-defined Pulmonary Lesions Thomas M. Daniel, M.D. Section of General Thoracic Surgery University of Virginia School of Medicine Charlottesville, Virginia

  2. Frequency and Mortality of the Most Commonly Diagnosed Cancers Number (x103) 150 200 0 50 100 Cure Rate 171,000 Lung 12% 158,900 94,700 Colon 50% 47,500 176,300 Breast 75% 43,700 179,300 Prostate 80% 37,000 Deaths New cases 1999 Cancer Facts and Figures, American Cancer Society

  3. Characteristics of 95 nodules seen in 184 patients entered in UVA lung cancer screening program • Calcified 5% • < 3 mm 36% • 3 to 6 mm 43% • >6 and <10 mm 6% • = to or >10 mm 10% • 52% had nodules. 85% were less than 10mm!

  4. Review of Intraoperative Localization Techniques for Excisional Biopsy of Small Lung Nodules • Needle localization • Ultrasound localization • Fluoroscopic localization using solid and liquid radio-opaque substances • Radiotracer localization

  5. Needle Localization Experiments • attempt to mimic breast biopsy experience • UVA animal laboratory experiment using four different hook needle designs • Goal: Test ability of hooks to stay in place near small lung lesions to guide thoracoscopic biopsy

  6. 4 hook needle designs Depth gauge

  7. Results of Needle Localization Experiments • ALL needles failed to remain in place with minimal standardized resistance • Summary: • - needle localization in lung tissue is ineffective

  8. Solid Marker Localization Experiments • Neurosurgical coil with ultrasound localization under saline – UVA ex vivo sample coil

  9. Solid Marker Localization Experiments • CT fluoroscopy guided injection of cyanoacrylate via 22 gauge needle- Yoshida-Japanese JTCVS 1999; 47: 210-3 • Summary- Hardness of both localization materials with coil and cyanoacrylate made subsequent frozen pathologic evaluation difficult. Both techniques exposed OR team and patient to fluoroscopy.

  10. Liquid Radio-Opaque Nodule Localization Techniques • CT-guided bronchoscopic barium sulfate marker • placed in or near nodule • Subsequent fluoroscopy-assisted thoracoscopic • excisional biopsy ( FATS-BM ) • 20 patients- all nodules successfully biopsied. • Average distance from outer margin of lesion to • nearest pleural margin was 6.5mm ( 0-18 mm) Okumura-ATS 2001;71:439-42

  11. Lung nodule CT fluoroscopy Barium placed near nodule

  12. Fluoroscopic view E= thoracoscopic stapling device F= endograsper with nodule

  13. Liquid Radio-Opaque Techniques-continued • Percutaneously placed Lipiodol using CT • guidance- 21 gauge needle- aspirate first! • Simultaneous use of colored collagen for • pleural localization • Fluoroscopically-assisted thoracoscopic biopsy • 66 patients- • Average distance from nodule margin to pleura • was 19mm ( 8-30mm). Average nodule size 7mm. Nomori-ATS 2002;74:170-3

  14. Lung nodule Percutaneously placed Lipiodal

  15. Liquid radio-opaque techniques Limitations • preoperative bronchoscopic localization takes time, • high level of skill and exposes bronchoscopist and • patient to radiation from fluoroscopy • Both techniques require intraoperative fluoroscopy which is of limited use with the patient in the • lateral decubitus position and exposes patient and staff • to radiation from fluoroscopy

  16. Radiotracer Nodule Localization Study • Percutaneous injection of Technetium labeled • human serum albumin microspheres using CT guidance and 22 gauge needle • Thoracoscopic biopsy 2 hours later using gamma ray detector- 11mm diameter • 39 patients- all nodules successfully located. • Mean nodule size 8.3mm. • Mean distance from pleura 13mm ( 6-30mm) Chella-European JCTS 2000;18:17-21

  17. Digital display of gamma ray emissions zero degree radioprobe Videoscopic view of radiation probe

  18. University of Virginia nodule localization study • First step-laboratory testing of technique using small animal model and three readily-available Technetium radiotracers ( MAA- used in lung perfusion scans, Sulfur colloid- used in breast cancer sentinel node location, and unbound pertechnetate as control) • Second step- clinical application with IRB approval

  19. University of Virginia nodule localization experience November 2002-August 2004 • 29 patients age 48-85 • 19 males 10 females • 27 had >20PY smoking history • average distance from pleural surface to lesion on CT scan- 13.3 mm (1-50) • average nodule size- 11mm (1-22)

  20. Results • 2 pneumothoraces during needle placement. No surgical complications • 2 lesions had disappeared and were not present on day-of-surgery CT scans • 96% of remaining 27 lesions successfully localized and biopsied • 13 of 27 lesions were malignant • 10 primary lung cancers- 9 Stage IA, I Stage IB • 3 solitary metastatic lesions in smokers with previous history of malignancy (colon, 2 melanoma)

  21. - Requires no special technology. - Permits predictable localization and thoracoscopic biopsy of small or ill-defined lung nodules - Remains useful for nodule localization if VATS is converted to open thoracotomy due to location or pleurodesis - BUT endoscopic stapling technique for excision of small nodules is awkward and often results in excessive lung tissue removal Tc-99m MAA lung nodule localization

  22. Laboratory experiment combining radiotracer localization technique with 1318-nm Nd:YAG laser excision • eightpig lungs studied using open thoracotomy • Tn 99m MAA radiotracer solution injected transpleurally up to 1 cm deep to create a “lesion” • Gamma radioprobe used to guide 1318-nm Nd:YAG laser excision of radioactive “lesion” • lung specimens evaluated with combined scintigram/radiogram to determine accuracy of excision

  23. A C Combined technology experiment for nodule localization and excision A – injection of radiotracer to create lesion B – YAG laser excision guided by radioprobe C – combined scintigram/radiograph showing complete excision of lesion B

  24. Ventilated pig lung with saline-filled biopsy site after cautery excison (left) and 1318 YAG excision (right)

  25. Conclusions • Radiotracer localization allows accurate and predictable localization of small or ill-defined lung lesions in patients at high risk for lung cancer • Current lung stapling technology limits its use • 1318-nm Nd:YAG laser technology when adapted to radiotracer-guided thoracoscopic surgery may allow excisional biopsy of small pulmonary lesions without excessive tissue removal

  26. Acknowledgements Department of Radiology- University of Virginia Talissa Altes, MD Patrice Rehm, MD Mark Williams, PhD Alexander Stolin, MS Bijoy Kundu, PhD Spencer Gay, MD Juan Olazagasti, MD Matthew Bassignani, MD Jonathan Ciambotti, MD Fachkrankenhaus Coswig- Germany Dr. Axel Rolle Department of Surgery- University of Virginia David Jones, MD Brendon Stiles, MD Kirk Barbieri Brian Trotta, 2nd year UVA Medical Student

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