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Localization for Wedge Resection Prevents Lobectomy

LOCALIZATION FOR LEFT LOWER LOBE (LLL) WEDGE RESECTION
Author
Dr. Lanny Dunham

General Surgeon

Sky Ridge Medical Center

Lone Tree, Colorado

Patient Information: 58 y/o, F

Scan Protocol: Veran’s Inspiration/Expiration CT Scan Protocol

Nodule: LLL 6mm

Target Motion: 8mm

Biopsy Results: Adenocarcinoma

Instruments Used: Always-On Tip Tracked® Forceps & SPiN Perc

Conclusion: Stage 4 Adenocarcinoma—Chemotherapy

Observations

The targeted 6mm nodule was within 8mm of the aorta and moved 8mm during the respiratory cycle. The precision and accuracy of the Veran SPiN Thoracic Navigation System™ played a vital role in obtaining a diagnosis to avoid an unnecessary lobectomy.

Patient History
The 58 year-old female presented with an 8cm mass in the LUL as well as a 6mm nodule in the LLL that was approximately 8mm from the aorta. Localization of the 6mm nodule was needed for wedge resection in order to determine stage 3 or stage 4 Adenocarcinoma. If the 6mm nodule had been negative, the patient would have undergone a LUL lobectomy. However, the 6mm nodule was positive for Adenocarcinoma, indicating stage 4 cancer. This diagnosis saved the patient from having an unnecessary lobectomy and allowed for her to start chemotherapy much earlier.

Planning
Due to the size, location (8mm adjacent to the aorta) and the inability to palpate, a SPiN Perc™ plan was created to the 6mm nodule for Methylene Blue localization.

Procedure
A respiratory-gated scan was performed with the patient in prone position. Prior to the procedure starting, the patient was supine while intubated and then repositioned to prone position on the OR table. The procedure began with the Always-On Tip Tracked® forceps to verify accuracy with a main and secondary carina check, followed by a lumen refinement. The patient was prepped and draped in sterile fashion. Dr. Dunham was able to quickly access the target using SPiN Perc™ and accurately inject 0.5mL of Methylene Blue while avoiding all vital structures. After the localization, Dr. Dunham performed a wedge resection of the targeted area using robotic VATS. Upon entering the thoracic cavity, Dr. Dunham was able to quickly visualize the Methylene Blue and successfully resected the area of interest. Inspection of the excised wedge found the nodule to be so small that it would have been impossible to palpate. Pathology determined the nodule was Adenocarcinoma, determining stage 4 cancer. Instead of continuing with the lobectomy the patient was then referred to Medical Oncology for chemotherapy.

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