A new technique to mark peripheral pulmonary lesions (PPLs) before surgical resection was studied by Ganesh Krishna, M.D., a pulmonary/critical care medicine specialist, researcher and interventional pulmonologist at Sutter’s Palo Alto Medical Foundation (PAMF). Dr. Krishna is also Director of Interventional Pulmonology at El Camino Hospital in Mountain View, CA.
As described last month as a top story in the journal CHEST® Pulmonary, Dr. Krishna led Sutter's participation in a retrospective, multisite study of a novel technique—indocyanine green-soaked fiducial (ICG-F) markers for lung nodules prior to thoracic surgery—for marking PPLs before surgical resection.
“Methods to improve PPL marking to facilitate surgical resection are imperative because more lesions will continue to be identified. Our experience with bronchoscopic ICG-F marking appears to be a safe and accurate approach to facilitate lung sparing surgery for otherwise undetectable lesions immediately after bronchoscopy or up to 13 days later,” says Dr. Krishna.
He notes the approach may facilitate surgery for patients without ready access to thoracic surgeons, thus potentially allowing better outcomes at centers of excellence. “Additionally, it may solve logistical challenges at institutions when trying to coordinate performing both marking and surgery under one anesthetic event,” says Dr. Krishna.
He and colleagues retrospectively studied the data of patients with PPLs undergoing bronchoscopy with ICG-F marking (54 nodules) before resection, then compared with 63 unmarked nodules. Demographic data, nodule characteristics, procedural and surgical information and final pathology results were obtained.
Patients were evaluated at El Camino Hospital/Palo Alto Medical Foundation, Advocate Aurora Medical Center of Kenosha, Emory University and the University of California at Davis for newly found pulmonary nodules. At each center, all consecutive patients who underwent bronchoscopy with ICG-F before surgical resection were included in the ICG-F marked group. The decision to undergo ICG-F was at the discretion of the local medical team.
Demographics were similar between the groups. PPLs were smaller in the ICG-F marked group (axial, P = .0036; coronal, P = .0214). All ICG-F marked lesions were visible with illumination at surgery immediately after bronchoscopy or up to 13 days later. Mean weight (P < .001) and size (P < .001 for all) of the resected ICG-F specimens were significantly decreased compared with unmarked PPLs. Operative time was increased in the ICG-F marked group (P = .0021).
Dr. Krishna says the study limitations include its design as a retrospective, comparative cohort study rather than a prospective, randomized controlled study and the potential for selection bias.
“The use of new technologies also presents the possibility of new challenges. Surgical time was significantly increased by an additional 29 minutes in the ICG-F marked group. This increased surgical time may be attributed to the need to meticulously dissect complex, deeper anatomic structures while performing segmentectomies and lobectomies for marked PPLs compared with taking a more generous piece of unmarked tissue,” says Dr. Krishna.
Lung cancer is the leading cause of cancer-related deaths in the U.S. and an illness with low rates of five-year overall survival. “Early diagnosis aided by more precise screening and surgical methods is critical to preventing advanced stages of the disease where treatment options are limited,” says Dr. Krishna.
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Journal
CHEST Pulmonary