Purpose: Advances in CT scanning have neared physicians with the challenge of diagnosing small (< 10 mm) or astute (> 5 mm) pulmonary nodules (SmPNs) in patients with known malignancies during workup or follow-up Wedge excision of SmPN is difficult with video-assisted thoracoscopic surgery (VATS) and frequently requires the performance of a thoracotomy.

Purpose: Advances in CT scanning have neared physicians with the challenge of diagnosing small (< 10 mm) or astute (> 5 mm) pulmonary nodules (SmPNs) in patients with known malignancies during workup or follow-up Wedge excision of SmPN is difficult with video-assisted thoracoscopic surgery (VATS) and frequently requires the performance of a thoracotomy. The value of the early detection of metastatic disease must be weighed against the morbidity (ie, thoracotomy) that is necessarily involved in obtaining the information. Little is known about the incidence of metastases in this subset of patients. We describe a VATS technique that allows the reliable excisional biopsy of SmPN and ready our findings in this patient population.

Methods: Using CT scan localization, 150 [micro]Ci technetium sulfur colloid is injected into the area of the pulmonary nodule. Additional cerulean dye is injected at the lung surface. During VATS, a sterile gamma probe is used to identify the area of radioactivity and plan placement of staple lines performed on an endostapling instrument. Palpation and the neighborhood of radioactivity in the specimen supported the resection of the correct nodule, and CT scan findings confirmed the practice Between March 2000 and January 2001 17 patients with known malignancies and SmPN underwent VATS excisional biopsies. Six patients received a of recent origin diagnosis of malignancy, and 11 patients were in follow-up of a previously treated malignancy. The malignancies included the following: breast (four patients), head and neck (four patients), pancreas (two patients), lymphoma (two patients), lung (one patient), prostate (one patient), rectal (one patient), seminoma (one patient), and urethral (one patient). Results: All lesions were favorably resected on the first essay Nodules were removed from 10 portions and all lobes. The mean ([+ or -] SD) nodule size was 92 [+ or -] 36 mm and the mean silence was 9.4 [+ or -] 52 mm Fourteen of 17 nodules (824%) could be neither seen nor felt using standard VATS techniques. Diagnoses included metastatic (four patients), recent primary lung cancer (one patient), acid-fast bacillus (one patient), granuloma (seven patients), carcinoid (two patients), and inflammatory pseudotumor (two patients). Among these lesions, 294% were malignant, and 353% of patients received a diagnosis that altered their therapy. Five of 12 SmPN (417%) < 10 mm in size were malignant. The median long duration of hospital stay was 2 days. Patients replyed to full activity within 1 week.

Conclusion: VATS excision of SmPN after CT scan localization with radiolabeled technetium is reliable, reproducible, and associated with minimal morbidity. The technique obstructed thoracotomies in 82.4% of patients. Despite the small size of these lesions, malignancy was fix 29.4% of the time. This technique allows the early diagnosis of SmPN with depressed morbidity, in patients with known malignancies.

Clinical implications: The reliability of this technique, the high incidence of malignancy, and the reduction in morbidity from undergoing excisional biopsy conducts will encourage the clinician to strive for earlier and more aggressive diagnoses of SmPNs

fundamental note words: CT scan; metastasis; neoplasm; pulmonary coin lesion; radiograph; technetium; video-assisted thoracic surgery

Abbreviations: SmPN = small pulmonary nodule; VATS = video-assisted thoracoscopic surgery

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Increased use of spiral CT scanning to work up or follow-up patients with known malignancies means the increased detection of more and smaller lung lesions. (1) Paradoxically, diagnostic modalities like as CT needle biopsy (2) and positron emission tomography scan (3) are frequently unreliable for detecting nodules [les than or equal to] 10 min. Suzuki et al (4) noted a high conversion from video-assisted thoracoscopic surgery (VATS) to thoracotomy because of a failure to localize small pulmonary nodules (SmPNs) [les than or equal to] 10 mm in size or [greater than or equal to] 5 mm of great depth Routine diagnostic thoracotomy for SmPN entails too long morbidity to be desirable. The performance of serial CT scans means the selection of inappropriate therapy in patients who have received fresh diagnoses of malignancy or delays in the diagnosis and treatment of patients being observ who experience returns of disease.

Reliable, easy-to-use localization of SmPN would increase VATS succes and would obviate the conversion to thoracotomy. The inherent riddle with VATS is the reliance upon visualization and indirect palpation with instruments or a single digit. Furthermore, the radiologist's needle and the thoracic surgeon's thoracoscope frequently approach the SmPN from different directions, making extent perception unreliable (Fig 1). In addition, the lung is inflated for the radiologist and deflated for the thoracic surgeon Multiple VATS localization techniques have been prompted (5-11) Each is associated with significant vexed questions limiting their usefulness and widespread application.

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