Single-step localization and excision of small pulmonary nodules using a mobile 3D C-arm

Abstract

Objectives: The use of a hybrid operating room equipped with robotic C-arm cone-beam computed tomography for single-step localization and excision of small pulmonary nodules finds high cost barriers. The new generation of 3D C-arm system not only depicts soft tissues with high contrast but also offers a more affordable and sustainable solution. This approach has been chiefly applied in the field of orthopedic surgery. In this case series, we describe the use of a mobile 3D C-arm system for localizing and removing small pulmonary nodules.

Methods: Between July and September 2020, we identified 14 patients who underwent localization and removal of small pulmonary nodules with a 3D C-arm system. We retrospectively reviewed clinical records to document the feasibility and safety of the procedure.

Results: The median tumour size was 7.5 mm [interquartile range (IQR): 5 - 9.75 mm], with a median distance from the pleural surface of 4.2 mm (IQR: 0.5 - 6.45 mm). We successfully visualized all of the pulmonary lesions by intraoperative CT imaging. Localization was achieved in 13 patients, who subsequently underwent complete thoracoscopic resection. The median time required to localize lesions was 41.5 min (IQR: 33.75 - 53.25 min), with a median radiation exposure (expressed through the skin absorbed dose) of 143.45 mGy (IQR: 86.1 - 194.6 mGy). Failure to localize occurred in 1 patient because of pneumothorax caused by repeated needle puncture. All patients were successfully discharged and the median length of stay was 2.5 days (IQR: 2 - 3 days).

Conclusions: This case series demonstrates the feasibility of single-step localization and excision of small pulmonary nodules using a mobile 3D C-arm.

Keywords: 3D C-arm; Localization; Small pulmonary nodules.

Figure 1:

Cios Spin (Siemens Healthineers AG, Forchheim, Germany) mobile 3D C-arm with a patient lying in the lateral decubitus position.

Figure 2:

Representative images (A and B) of properly designed fields of view which included both tumour (red dotted circle) and skin entry site (yellow circle). The green arrow denotes the proposed puncture route. Representative images (C and D) of poorly designed fields of view which allowed visualization of the tumour (red dotted circle) but not of the skin entry point.

Figure 3:

Respiratory motion artifacts during cone-beam computed tomography imaging of subsolid lesions. The subsolid lesion (red dotted circle) identified on cone-beam computed tomography (A) was barely visible in the presence of persistent lung ventilation (B) but was clearly identifiable under inspiration breath-hold (C).