Continuing Education
Diagnosis and radio-guided surgery of lung nodulesDiagnóstico y cirugía radioguiada de nódulos pulmonares

https://doi.org/10.1016/j.remnie.2020.06.014Get rights and content

Abstract

The detection of pulmonary nodules has increased in recent decades due to the introduction of lung cancer screening programs and the massive use of routine chest computed tomography in patients with malignant neoplasms. Percutaneous biopsy cannot always characterize these nodules, making surgical biopsy sometimes necessary, often requiring presurgical localization. Radioguided occult lesion localization (ROLL) described for breast lesions was first applied in the resection of pulmonary nodules in 2000, becoming an alternative to other presurgical localization techniques such as hook-wire. The technique provides a high detection rate with minimal morbidity, enhancing multidisciplinary work with specialists in Radiology and Chest Surgery. The present paper describes the different pre-surgical localization techniques currently available, the methodological procedure of the ROLL technique and the results collected over 20 years of experience.

Resumen

La detección de nódulos pulmonares se ha incrementado en las últimas décadas debido a la introducción de los programas de cribado del cáncer de pulmón y al aumento de las exploraciones rutinarias de tomografía computarizada en los pacientes con neoplasias. La biopsia percutánea de estos nódulos no siempre permite caracterizarlos, por lo que en ocasiones es necesaria la biopsia quirúrgica, que a menudo requiere de localización prequirúrgica. La resección radioguiada de lesiones ocultas (ROLL) descrita para las lesiones mamarias se aplicó por primera vez en la resección de nódulos pulmonares en el año 2000, siendo en la actualidad una alternativa a otras técnicas de localización prequirúrgica como la resección guiada por arpón. La técnica aporta elevada tasa de detección con mínima morbimortalidad, potenciando el trabajo multidisciplinar entre los especialistas en Medicina Nuclear y los especialistas de radiodiagnóstico y cirugía torácica. En este trabajo, se describen las diferentes técnicas de localización prequirúrgica disponibles, los procesos metodológicos de la técnica ROLL y los resultados acumulados en 20 años de experiencia.

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

  • 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.

  • 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.

  • TP3. Typical carcinoid tumors which generally present as proximal endobronchial nodules usually show scarce or no avidity for FDG.

  • 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.

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