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University of Ferrara, Ferrara, Italy
Correspondence to: Davide Sortini, MD, Dipartimento di Scienze Chirurgiche, Anestesiologiche e Radiologiche, Università di Ferarra C.so Giovecca 203, 44100 Ferrara, Italy; e-mail:sors{at}libero.it
To the Editor:
In response to the article of Sugi and colleagues (July 2003),1 we would like to express our opinion about some aspects of their article. We congratulate the authors on the results obtained in their study, but we think that radio-guided surgery is not better than other localization techniques,2 such as intrathoracoscopic ultrasound.
The localization of pulmonary nodules by radio-guided technique has shown to be reliable, but revealing some drawbacks.3 Most important is the notable and fast diffusion of contrast medium in the pulmonary parenchyma surrounding the nodule, due to the rich vascularization of the lung. A second problem is locating deep and posterior nodules due to the dimension and structure of the probe, which cannot move freely in the thorax.
However, the intrathoracoscopic ultrasound technique has been shown, in experienced hands, to be very sensitive for the localization of pulmonary nodules.4 In addition, intrathoracoscopic ultrasound is less expensive than the radio-guided technique, and it allows study of the structures surrounding the nodule (eg, vessels, bronchi, and lymph nodes). Furthermore, intrathoracoscopic ultrasound may play a role predicting the pathology of the nodule. In fact, in all patients the lesion appeared as a homogeneous hypoechoic pattern with the sonographic disappearance of the hyperechoic pulmonary surface. Heterogeneous echogenicity of the lesion was observed in two patients, due to air bronchogram, presence of different tissue, or hamartoma. This ultrasound pattern, however, was not able to distinguish between malignant or benign lesions.4 5 Unfortunately, the radio-guided technique does not give any additional information about the pathology of the nodule.
Other drawbacks of radio-guided techniques are pneumothorax or mild intrapulmonary bleeding.1 6 We are sure that in most cases these complications are nonsymptomatic, but they can negatively influence the health of the patient and the surgical approach; bleeding, for example, can influence the margins at resection.
In conclusion, intrathoracoscopic ultrasound seems to be superior to the radio-guided and finger palpation techniques to locate small pulmonary lesions, but we know that ultrasound is strongly operator dependent. Fortunately, at our institution there are very experienced colleagues in ultrasound imaging. Thus, we are now using ultrasound routinely to localize solitary pulmonary nodules.
References
Sanyo National Hospital, Yamaguchi, Japan
Correspondence to: Kazuro Sugi, MD, DMedSc, Sanyo National Hospital, Yamaguchi University School of Medicine, Higashikiwa 685, Ube, Yamaguchi, Japan 755-0241; e-mail: ksugi{at}sanyou.hosp.go.jp
To the Editor:
We received the letter from Carcoforo et al concerning our article published in CHEST (July 2003).1 We would like to express our gratitude for their interest in our article and the kind comments.
In our article,1 we demonstrated that a radioisotope imaging (RI) method was effective in determining the position of small tumors in the periphery of the lung and that of tumors that present as a faint shadow on CT scanning. In a trial using an RI method, we were able to identify tumors in all 25 patients, enabling thoracoscopic resection and a tissue diagnosis for the tumors.
Carcoforo et al responded to our article by saying that ultrasonographic tumor identification is safer than using our RI method and is superior, in that the intratumor ultrasonic pattern can be used to distinguish between benign and malignant tumors. The injected RI disperses readily, moreover, making identification difficult, and deeply or dorsally located tumors are particularly difficult to delineate. These criticisms are not, however, correct. We experienced no cases in which a radioisotope that had been injected the day before the procedure dispersed, making tumor identification impossible. Furthermore, the RI probe was able to reach the entire lung surface, and we did not encounter any site-related difficulties with tumor identification. The only complications we encountered that were associated with the RI method were some minor cases of pneumothorax and intrapulmonary hemorrhage in a few patients.
We have not attempted ultrasonographic tumor identification, so we may not properly understand the technique, but we think that there may be a subset of tumors in which identification using ultrasonography is difficult. An example would be bronchioalveolar carcinoma, a small tumor presenting as a faint shadow on CT scans. To identify such a tumor ultrasonographically, it would be necessary to collapse the lung completely. It might be difficult to identify a bronchioalveolar carcinoma, which does not form an obvious mass, even in a completely collapsed lung.
As Carcoforo et al note, tumor identification using ultrasonography requires considerable training and expertise. The RI method is technically simpler and does not require any particular training or expertise. Both the ultrasonographic and RI methods of tumor identification can be considered as options for determining the position of masses that are difficult to distinguish macroscopically during surgery because they are small or present only as a faint shadow radiographically. The choice of method should be made according to the circumstances at each institution, and the expertise and preference of the proceduralist.
References
This article has been cited by other articles:
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  W. Chen, L. Chen, S. Yang, Z. Chen, G. Qian, S. Zhang, and J. Jing A Novel Technique for Localization of Small Pulmonary Nodules Chest, May 1, 2007; 131(5): 1526 - 1531. [Abstract] [Full Text] [PDF]
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