"Tattooing" Suspicious Nodules Through Bronchoscopy Helps to Target Thoracotomy

Martha Kerr

October 26, 2007

October 26, 2007 (Chicago) — To localize a solitary suspicious pulmonary nodule on thoroscopy, investigators at St. Vincent's Medical Center in New York City are finding success with staining the nodule "from the inside out" via electromagnetic navigational bronchoscopy (EMNB).

"We can reach all the way to the surface of the lung, going through the airways and the alveoli to the pleural lining," said William Krimsky, MD, FCCP, interventional pulmonologist and principal investigator in a study of patients undergoing nodule tattooing.

Dr. Krimsky presented his findings with the first patients to undergo the technique here at Chest 2007, the American College of Chest Physicians 73rd Annual Scientific Assembly.

The study involved 5 patients with suspicious solitary nodules on computed tomography scanning. Using EMNB, Dr. Krimsky's team stained the nodules and then, using video-assisted thoroscopy (VATS), was able to easily identify the nodule and excise only a minimal amount of lung tissue compared with traditional thoracotomy, which would typically involve a much larger incision and excision of lung tissue to ensure that the nodule is captured.

Nodules ranged in size from 7 to 30 mm. "Staining was easily visible and outlined the area for excisional biopsy," Dr. Krimsky told Medscape Pulmonary Medicine. There were no procedure-related complications.

Four patients were diagnosed with adenocarcinoma and 1 with histoplasmosis after VATS. Three patients had wedge resections and 1 required a complete lobectomy.

Three patients were discharged within 24 hours, a fourth was discharged 3 days after surgery, and the patient requiring thoracotomy was discharged on postoperativeday 6.

" 'Tattooing' of pulmonary nodules allows precise locatability of the suspicious nodule, and it also directs the depth of resection," Dr. Krimsky reported. "Without staining, the visceral pleura would be unremarkable and the location of the nodule impossible, likely necessitating conversion to thoracotomy for identification prior to excision."

Dr. Krimsky said that now that the safety and feasibility of the procedure has been established, his team plans to expand their use of nodule tattooing.

P. Osi Udekwu, MD, director of general surgery and trauma at WakeMed in Raleigh, North Carolina, and assistant professor of surgery at the University of North Carolina in Chapel Hill, commented that although this technique is technically advanced, the findings are intriguing.

"The big issue is to differentiate between cancer and benign causes" of indeterminant computed tomography changes, Dr. Udekwu noted. "A major issue is when you can't find the nodule on thoroscopy."

"Approximately 480 solitary nodules in every 5000 turn out to be cancerous," Dr. Krimsky commented.

"Using this technique to take out the nodule and examining it on frozen section, you might be able to determine if it is cancerous or not within 15 minutes.... Fixed sections may take up to 24 hours," Dr. Udekwu noted.

The technique can sharply reduce the morbidity involved with standard thoracotomy, Dr. Udekwu pointed out. "You get an idea who needs surgery before you go in," Dr. Krimsky added.

Dr. Krimsky and Dr. Udekwu have disclosed no relevant financial relationships.

Chest 2007: American College of Chest Physicians 73rd Annual Scientific Assembly. Presented October 22, 2007.