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Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya

Diagnostic Methods in Solitary Pulmonary Nodules: Diagnostic

Surgical Approach

Cengiz GEBİTEKİN, FETCSUludağ Üniversitesi Tıp Fakültesi

Göğüs Cerrahisi ABD, BURSA


SPN 5-year survival in stage I Lung

carcinoma diagnosed as SPN – med.%70*

Stage I symptomatic patients %10**

Stage I according to Chest X-ray %30***, CT -%85*****Flehinger BJ. Chest 1992;101:1013-1018, **Melamed MR.Chest 1984;86:44-53 ***Fontana RS. J Occuo Med 1986;28:746-750, ****Swensen SJ Am J Respir Crit Care Med 2002;165:508-

11111513


Surgery: When, to Whom?Primary Lung Carcinoma

SPNs with spiculary margin SPNs with irregular margin, %83

malignant, with spiculated margins %90 malignant

PET/CT positive SPNs ≥1.5cm in size- high malignancy Increased 5-year survival with

early surgery Low Morbidity and mortality


Stage of the disease Neoadjuvant treatment Chemotherapy VATS or open surgery for

diagnosis and treatment

Surgery: When and to Whom?Primary Malignancy with

metachronous/syncronous SPN


SPN – History of Malignancy

What is the risk of follow-up?


Primary Squamous Cell Ca. and Primary Lung Adenocarcinoma


Videothoracoscopic Surgery

Finger Palpation

Easy to palpate lesions 2cm away from pleura

Intrathoracic US Radiologic procedures- ”needle

wire”, stains, radiolabelled guiding


SPN- Reassurence of Patient Surgical approach? Follow-up? Complications? Mortality?


Hamartoma with spiculated margins

Follow-up? Direct surgery?


History of malignancy: Breast, Colon and malignant melanomas

SPNs less than 1.5 cm At least 2cm away from the

pleura med.2.6±0.5cm Intrathoracic US (ITUS)+finger

palpation (FP) Radio-guided tracing (RGT)

+finger palpaption


ITUS %96 FP %76 RGT %80 Finger Palpation %80 p=NS Finding with US med.8min., finger

palpation med.6min. and radio-guided 21 min.

%40 pneumothorax with RGT The most reliable method - ITUS


40 patients SPN 5-10 mm Without finger palpation Thoracic surgical decision

according to characterstics and growt rate of the SPN

RTG VATS resection Lobectomy if malignant



Total 54 patients Peripheric lesions not visible in

fluroscopy med. 2.2±0.7 cm Intrabronchial EBUS and biopsy Lesion was found in 48 (%89)

patients Diagnosis in 38 (%70) patients Avoidance of 9 (%17) thoracotomy Surgery for 16 patients


%11 patients lesion was not found Med. procedure time 12 dak. Median 4.5 biopsies taken 16 (%30) patients was sent for surgical biopsy



Yatış Süresi


VATS resections in 429 patients Med. size 1.8cm %54 smoker Resection with VATS - %77 Minithoracotomy %23 Med. Size for malignant lesions

2.3cm Median hospital stay 4.6days %14 malignant lesions


129 patients with SPN %76 minithoracotomy, %24 VATS

resections, at least 2cm. Healty resection margin

Malignant lesions %63 (%47 primary, %16 secondary malignancy)

Med. Hospital stay 6 days Mortality %2.3 5-year survival %66 for primary lung

cancer


Toplam 276 hasta

%28 %50 %22



Reasons for Lobectomy Primer lung cancer Deep SPN Technical difficulties


Uludağ University Medical Faculty Thoracic Surgery Department

1997-2008 Total 62 patients- 24/62 (%39) Malignant- 38/62 (%61) Benign

Metastases 9/24 (%37.5) History of malignancy in all patients Carcinoid 2/24 (%8) Primary Lung Ca. 13/24 (%54.5) Thoracotmy 21/24 (%87.5) Lobectomy 7/13 (%54) Segmentectomy 6/13 (%46)


Benign Lezyonlar 38/62 - %61

Hamartoma 18 (%47) Tuberculoma 12 (%31) Benign 4 (%10) Organizing Pneumonia 1 (%3) Leimyoma 1 (%3) Pseudo inflmatory Tm. 1 (%3) Alveolar Fibrozis 1 (%3) Thoracoscopy % 53 Thoracotomy % 47


Minithoracotomy-Wedge ResectionCarcinoid Tm-Wedge


Toracoscopic wedgeHamartoma


Toracoscopic SegmentectomyBronchioloalveolar carcinoma

PET-SUV1.5


Open excisionInf. pseudotümör


VATS WedgeAdeno Ca Lobectomy


Resection with full muscle sparing minithoracotomy

Approx. 8-10 cm. incision


Left Pneumonectomy


Conclusion

Surgery in patients with malignancy history

VATS in all patients Main problem is palpation Finger palpation is reliable

procedure Minithoracotomy/VATS no difference Short hospital stay (med.2.3 days) Diagnostic value 100% Early return to daily activities


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