Scientific Papers

Presurgical computed tomography-guided localization of lung ground glass nodules: comparing hook-wire and indocyanine green | World Journal of Surgical Oncology

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Detecting GGNs during VATS resection is challenging due to their frequently nonpalpable nature [13,14,15]. Therefore, accurately detecting GGNs is an essential stage in VATS resection. Preoperative GGN identification not only allows for precise resection, but also helps avoid unnecessary extensive resections in patients with GGNs [15]. Besides hook-wire- and liquid-based materials, micro-coil and radio-label are employed for presurgical GNN localization [7, 16,17,18]. Nevertheless, the microcoil localization technique is comparatively more complex than the liquid material and hook-wire techniques due to the requirement to maintain the microcoil’s end tail above the visceral pleura [16]. Furthermore, the utilization of radio-label-based localization requires the use of intraoperative fluoroscopic guidance, which has the potential to result in radiation-induced damage [17, 18].

In this study, we determined the localization success rates of hook-wire- and IG-based methods were both considerably enhanced, with rates of 97.4% and 100%, respectively (P = 1.000). The findings of our study were in consistent with those of previous research comparing hook-wire and IG localization methods [9], as well as those comparing hook-wire and methylene blue localization in the context of lung nodules [19]. The observed higher success rates of hook-wire and IG localization can be attributed to the detectability of these localization materials.

The dye localization materials mainly include IG and methylene blue [12, 19]. These 2 materials are commonly used for detecting the sentinel lymph nodes in breast cancer [20]. IG can exhibit higher detection rate and better accuracy than methylene blue in detecting sentinel lymph nodes because IG has the better affinity to the lymph nodes [20]. However, when using the IG and methylene blue for localization of lung nodules, there is no significant difference in technical aspects [21].

The technical failure of hook-wire- and IG-based localization is primarily caused by hook-wire dislodgement and IG diffusion. The hook-wire is commonly positioned within the lung parenchyma at an angle that allows it to protrude through the chest wall. Unfortunately, this results in dislodgement or migration during respiratory movement [12]. The key factor of IG-based localization is the injected IG volume. Several reports suggested that 0.3 ml IG is sufficient for lung nodule localization [12]. Upon injection of excess IG volume, the IG material can overflow. Alternately, < 0.3 ml may not be sufficient for proper localization [12].

The analysis strongly focuses on the crucial endpoints associated with localization-related complications. In this study, the IG-based localization method had a lower incidence of pneumothorax and lower VAS scores than the hook-wire-based localization method. There is a substantial relationship between hook-wire dislodgement and increased incidences of pneumothorax, lung hemorrhage, and chest discomfort [12]. However, the pneumothorax risk factors in this study were prolonged localization duration and non-upper lobe, and not hook-wire usage. This result may be due to our small sample population. Regardless, we demonstrated that hook-wire-based localization took significantly longer duration than IG-based localization. This indicates that hook-wire usage may trigger pneumothorax development. Non-upper lobe lesion is another risk factor for pneumothorax, and this finding may be because, relative to the upper lung fields, the lower lung field participates in more respiratory motion [22].

The VATS outcomes are generally independent of various localization materials [10, 12, 15]. In this study, we demonstrated that the rate of VATS sublobar resection, blood loss volume, and postsurgical hospitalization duration were comparable in both patient cohorts. Additionally, a significantly larger proportion of GGN patients (91.9%, 79/86) presented with pathological diagnoses below the level of invasive adenocarcinoma, preventing the need for lobectomy. Hence, the median blood loss volume was only 15 ml and 10 ml among the hook-wire and IG patients, respectively.

Although we have found some superiorities of IG when compared to hook-wire in this study, IG also has its own limitations [13]. First of all, the IG dye is prone to diffusion, resulting in failure of localization [13]. Secondly, IG localization is only marked on the surface of the lung, so we should judge the depth of the GGN according to the preoperative CT results. In contrast, hook-wire is partially inserted into the lung parenchyma, and thus we can directly judge the depth of GGN according to palpation of the hook-wire during the VATS.

This work has certain limitations. First, it is a retrospective study. Consequently, while using comparable baseline information can help reduce the risk of selection bias, it is important to note that the feasibility and safety of hook-wire and IG procedures may vary in different contexts. Therefore, it is necessary to conduct further well-designed prospective randomized trials. Second, our sample population was relatively small. Therefore, the risk factor for lung hemorrhage was not determined. Additionally, it is important to note that the patients included in this study were obtained exclusively from a single center. Consequently, it is recommended that further research be conducted with multiple facilities to ensure the generalization and reliability of these results.

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