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J Thorac Cardiovasc Surg 2003;126:609
© 2003 The American Association for Thoracic Surgery

Letter to the editor

Preoperative localization techniques during thoracoscopic operations: Reply to the editor

^a Second Department of Surgery, Akita University School of Medicine, Akita City, Japan

We appreciate the opportunity to comment on the letter by Sortini and associates regarding our recent article on the indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery.¹ We agree that intraoperative ultrasonography is noninvasive and effective in locating the solid target nodules.

We have some experience with intraoperative ultrasonographic examination with an ultrasound scanner (B&K Medical, Gentofte, Denmark) with a linear scan multifrequency probe (5-7.5 MHz), and we encountered the same limitations in patients as those faced by Sortini and colleagues.² Chief was difficulty in obtaining an image as long as any air remained in the lung, caused by an incomplete lung collapse. Visualizing pulmonary lesion by ultrasonography requires complete collapse of the lung, which is often impossible in patients with obstructive disease such as emphysema. Formless abnormalities may be particularly difficult to visualize. In our experience, intraoperative ultrasonography is effective in locating the multiple solid pulmonary nodules, such as multiple metastatic pulmonary tumors. On the other hand, small and deep nodules may be missed by ultrasonography. Especially soft nodules, such as localized bronchioloalveolar cell carcinoma (BAC), could be more difficult to separate from normal but collapsed lung because the image is soft, small, faint and of similar consistency to the surrounding normal lung parenchyma. BAC shows a replacement growth of atypical cells with mild thickening of the alveolar septa, sometimes without fibrotic foci.³ BAC is not uncommon; it actually accounted for 45% (n = 32/71 patients) of the adenocarcinoma seen during our study. In such cases, preoperative localization can be more effective. The technical differences mentioned may explain in part the poor yield of ultrasonography in our hands in distinguishing BAC. It is generally accepted, however, that localization with intraoperative ultrasonography has several limitations.^4,5

From a practical standpoint, we use a preoperative localization technique because at our institution most small pulmonary nodules that require localization are BAC. The procedure is safe and accurate, and we believe that the requirement for preoperative localization will remain as long as the application of thoracoscopic surgery increases. Thus discussion of the indications for preoperative localization is still important.

Again, we agree that intraoperative ultrasonography is effective in selected cases in our experience. We need to make the right choice of localizing method in each case for minimally invasive surgery.

	References

Top References

 

1. Saito H, Minamiya Y, Matsuzaki I, Tozawa K, Taguchi K, Nakagawa T, et al. Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery. J Thorac Cardiovasc Surg. 002;124:1198-202
   
2. Sortini A, Carrella G, Sortini D, Pozza E. Single pulmonary nodules: localization with intrathoracoscopic ultrasound—a prospective study. Eur J Cardiothorac Surg. 2002;22:440–442
   
3. Noguchi M, Morikawa A, Kawasaki M, Matsuno Y, Yamada T, Hirohashi S, et al. Small adenocarcinoma of the lung: histologic characteristics and prognosis. Cancer. 1995;75:2844–2852
   
4. Greenfield AL, Steiner RM, Liu JB, Cohn HE, Goldberg BB, Rawool NM, et al. Sonographic guidance for the localization of peripheral pulmonary nodules during thoracoscopy. AJR Am J Roentgenol. 1997;168:1057–1060
   
5. Santabrogio R, Montorsi M, Bianchi P, Mantovani A, Ghelma F, Mezzetti M. Intraoperative ultrasound during thoracoscopic procedure for solitary pulmonary nodules. Ann Thorac Surg. 1999;68:218–222
   

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