Evaluation of Pulmonary Nodules in Metastatic Lung Disease

Background and Aims: Minimally-Invasive Surgery in Oncological Surgery is slowly gaining acceptance: the use of thoracoscopy (TS) for pulmonary nodules (PN), in particular, is often debated, mainly due to concerns about the possibility to identify all PN with this technique. This study aims to compare the outcome of PN removal, TS versus thoracotomicmanual lung palpation (TT). Methods: We evaluated surgical approach and history of the nodule (form targeting to removal), to histological result. The primary outcome was the identification of variation in the ratio between neoplastic (positive) and non-neoplastic (negative) nodules. Results: Between January 2007 and December 2018, 41 patients (median age 14 years), underwent 65 surgical procedures for pulmonary metastases: 35 TT and 30 TS (6 converted to TT for difficult localization of the PN). An average of 2 PN were targeted at pre-operative imaging overall (range 1-6, total 125) and same average removed during surgery (range 1-15, total 173). In 20 procedures (4 TS, 16 TT), more nodules than targeted were identified and removed during surgery (1 to 13/patient, total 47; 3 during TS, 44 during TT). Twenty-nine nodules (62%) were histologically confirmed to be metastases not targeted pre-operatively; all were in 5 patients with further multiple imaging-targeted nodules. The positive/negative ratio is similar in imaging-identified and surgically removed nodules among TS and TT approach, 1,9 and 1,8 respectively (p=ns). Conclusions: TS may useful to remove targeted PN in selected groups of patients and following multidisciplinary discussion. Manual lung palpation in this series does not seem to increase the percentage of positive nodules overall. The presence of multiple nodules seems to benefit of manual palpation, while few nodules are efficiently addressed by target excision. Further prospective studies are needed to confirm the present finding.