Radioguided Surgery of Small Pulmonary Nodules

Abstract

The incidence of pulmonary nodules discovered by imaging is increasing. These pulmonary nodules may be discovered incidentally or through a computed tomography (CT) scan screening program. Small lesions suspicious for lung cancer may require tissue, and surgical resection may be necessary to rule out malignancy. Due to the small size of these lesions, intraoperative localization with minimally invasive surgical techniques may be challenging and require lesion localization prior to resection. Radioguided surgery using a radiotracer and a handheld gamma probe technology facilitates real-time pulmonary nodule localization and surgical resection. Most commonly, this involves two steps. First, a radiotracer (usually injectable technetium-99m) is preoperatively and percutaneously delivered into or immediately deep to the pulmonary nodule under CT guidance. Second, a handheld gamma probe is used to localize the pulmonary nodule for thoracoscopic resection. Alternatively, a radiotracer can be given intravenously, such as radiolabeled monoclonal antibodies, 18F-fluorodeoxyglucose (FDG), bleomycin derivatives, or DOTATATE (i.e., a highly selective somatostatin analog). These other techniques remain experimental. Radioguidance with transthoracic technetium-99m injection and intraoperative gamma probe detection offers several advantages over CT-guided hookwires or markers, locally administered radiopaque contrast and blue dyes, and thoracoscopic ultrasound. These techniques may be employed alone or in combination with radioguidance. Precise localization of small pulmonary nodules will become more pressing as national lung cancer CT screening guidelines are implemented.