Revista Española de Medicina Nuclear e Imagen Molecular (English Edition)
Continuing EducationDiagnosis and radio-guided surgery of lung nodulesDiagnóstico y cirugía radioguiada de nódulos pulmonares⋆
Introduction
Resection of small-sized pulmonary nodules has become a challenge for chest surgeons in the 21st century. The detection of pulmonary lesions has exponentially increased in the last decades due to the rise in the number of routine studies with computed tomography (CT) which are increasingly more usual in our setting. Greater detection of these lesions is also related to better follow-up of patients with neoplasias, leading to the detection of second primary tumors or metastasis in early phases. In parallel, the development of lung cancer screening programs such as those carried out in some countries, has led to an increase in the detection of small pulmonary lesions. Thus, the characterization of a solitary pulmonary nodule (SPN) detected incidentally or during lung cancer screening with CT is an important challenge today.
Therefore, the working groups of Oncology and Radioguided Surgery of the Spanish Society of Nuclear Medicine and Molecular Imaging (SEMNIM) have collaborated in performing this Continuing Education article aimed at describing the current status of the detection and radioguided surgery of SPNs.
Section snippets
Detection of pulmonary nodules
One of the main public health problems is lung cancer which, despite great efforts in prevention, still remains the cause of the greatest number of cancer-related deaths in high-income countries. Another problem is the characterization of a SPN detected incidentally or during lung cancer screening with CT. Below we describe the current approaches in diagnostic-therapeutic decision making for the evaluation of pulmonary nodules in general, and more specifically, for early detection and
Need for SPN localization
More than 50% of the pulmonary lesions detected in any of the scenarios mentioned are malignant.20 In addition, in another important number of cases, the radiological characteristics will not rule out malignancy. This implies the need for histological diagnosis of these nodules, which is difficult to achieve with transthoracic puncture due to its low profitability, overall in cases of lesions less than 1 cm in size. Therefore, a relevant percentage of patients with pulmonary nodules must
Presurgical localization techniques
There are different techniques to help in intraoperative localization of pulmonary nodules, and these are described below. Their main advantages and disadvantages are shown in Table 1. A recent review reported the principal techniques of presurgical localization. According to the material used, the techniques can be metallic, such as the hook wire or non metallic.
The hook wire was first described in 1992.28, 29 There are many types of hook wires, and this is the technique most commonly used in
Radiopharmaceutical
As mentioned previously, the radiotracer most commonly used is [99mTc]Tc-MAA TP7. Although the use of a solution composed of 0.1–0.2 mL of [99mTc]Tc-MAA (5–15 MBq) plus 0.1 mL of non-ionic contrast is more extended, 0.1–0.2 mL of [99mTc]Tc-MAA can be injected without contrast since a slight increase of diffuse density (ground glass) will appear in contact with the nodule (Fig. 3) in the post-puncture CT.
Technique
The sequence of the processes for radioguided localization of pulmonary nodules is
Scientific evidence published
In 2000, Chella and cols. published the first study on resection of pulmonary nodules by radioguided surgery as an alternative to other guided methods for resection. The study described the preliminary results of 39 patients34 and included lesions less than 2 cm with a distance of at least 5 mm from the visceral pleura. The methodology used was the reference in later studies and is currently used in most health care centers. It includes the use of a 22G needle, a reduced volume of human albumin
Key points
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TP1. [18F]FDG PET/CT is a diagnostic technique that is indicated for the characterization of solid pulmonary nodules undetermined in the CT and with a diameter greater than 8 mm.
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TP2. Some adenocarcinomas (mainly in situ or minimally invasive) may present with ground glass opacities and may be negative in the [18F]FDG PET/CT study.
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TP3. Typical carcinoid tumors which generally present as proximal endobronchial nodules usually show scarce or no avidity for FDG.
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TP4. The factors determining the need
Conflict of interests
The authors declare no conflict of interest.
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Please cite this article as: Paredes P, Suils J, Danús M, Delgado Bolton RC, Sánchez-Lorente D, Rodríguez Martínez D, et al. Diagnóstico y cirugía radioguiada de nódulos pulmonares. Rev Esp Med Nucl Imagen Mol. 2020;39:327–336.