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Pulmonary Metastases
Compiled from across the library · built automatically
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Failure to take out lymph nodes automatically upstages Wilms tumor patients Wilms Tumor Protocol Violations: 2018 Pediatric Surgery Practice Gap #3 · 0:00
Wilms Tumor Protocol Violations: 2018 Pediatric Surgery Practice Gap #3
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Drs. Todd Ponsky, Alex Casar, Alex Gibbons, and Rae Hanke review 2018 Practice Gap #3: Wilms Tumor Protocol Violations, as identified by the APSA Professional Development Committee.
video · Jun 2019
Image Guided Surgery Video Series, Episode 2 - Lung Nodule Localization &...
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We’re back with the second episode of our image guided surgery video series! In the first part of this episode we're discussing long nodule localization in hybrid OR with some of our Interventional Radiology and Pediatric Surgery colleagues
podcast17:19 · Jun 2022
Hybrid OR workflow for pediatric lung nodule localization and resection
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Weâre back with the second episode of our image guided surgery video series! In the first part of this episode we
podcast17:19 · Oct 2026
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Wilms Tumor Protocol Violations: 2018 Pediatric Surgery Practice Gap #3
Lymph nodes must be taken out during nephrectomy for Wilms tumor
guideline0:00 ↗
Failure to take out lymph nodes automatically upstages Wilms tumor patients
guideline0:00 ↗
There is both a local and systemic staging system for Wilms tumor
clinical0:00 ↗
Pulmonary metastases do not preclude primary nephrectomy in Wilms tumor
guideline0:00 ↗
Primary nephrectomy in metastatic Wilms tumor affects whether the patient receives radiation therapy
clinical0:00 ↗
There is a local stage for Wilms tumor and a patient staging for Wilms tumor
clinicalErlick0:50 ↗
Omission of lymph node biopsies is a major protocol violation in Wilms tumor surgery
opinionErlick0:50 ↗
Image Guided Surgery Video Series, Episode 2 - Lung Nodule Localization &...
Pre-hybrid OR, lung nodule localization was done in CT scan downstairs, then patient brought upstairs to operating room, requiring movement of the patient.
clinicalRajni Dasgupta1:17 ↗
Localization typically done with Copan's breast localization needle and wire plus minus methylene blue blood patch.
clinical1:49 ↗
More recently, localization done with microembolization coils, coils typically used for vascular embolization, advanced through Copan's needle with combination of microcoil and Copan's wire coming out in case wire becomes inadvertently pulled out during thoracoscopic resection.
clinical1:58 ↗
Microcoil technique is very technically challenging; IR needs to practice beforehand to control the coil because it must be deployed in the right place.
clinical2:40 ↗
Coils are smaller than guide needle for Copan; must be very careful and practice outside patient beforehand, must have holder for coils firmly established in hub, otherwise coil delivers in hub of Copan needle.
clinical2:40 ↗
Patients always have double-lumen ET tube or bronchial blocker depending on size of patient.
clinicalRajni Dasgupta3:45 ↗
Pre-hybrid OR workflow: intubate in OR, transfer patient on stretcher down to CT, get off stretcher onto CT gantry/table, do CT scan and localization, get off CT table with wire in place protecting it hoping it won't get dislodged, transfer back up to OR, position in thoracoscopic position.
clinicalRajni Dasgupta3:45 ↗
There are a number of opportunities for wire to get dislodged in pre-hybrid OR workflow.
clinical4:35 ↗
In hybrid OR, everything done more efficiently with less chance of wire becoming dislodged; when possible, position patient in thoracoscopic position to begin with so there's single prep and single draping.
clinical4:35 ↗
Cone beam CT is a type of tomography where C-arm rotates around patient completely 360 degrees while capturing multiple images from different angles, basically like a CT but done with C-arm.
clinicalDenise Liu5:28 ↗
Radiographs are a shot in time, fluoroscopy gives real-time 2D images, and latest fluoroscopic machines can do cone beam CT which performs 360-degree scan of designated 3D volume, giving cross-section images.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position5:44 ↗
Localization on CT is simple: draw line between skin surface and target on CT images; beauty of cross-sectional CT images is you can account for z-axis, giving 3D rendition or 3D space.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position5:44 ↗
Problems have been based on anesthesia staff not understanding the procedure.
clinical6:28 ↗
One of most important aspects of chest procedures is respiration motion; anesthesia plays crucial role in controlling respiration and giving apnea at precise moment for targeting lung lesion.
clinical6:28 ↗
Positioning important so procedure can be done in same position as thoracoscopy without having to re-drape.
clinical6:28 ↗
To localize lesion, go to workstation, put green line on, click on lesion with mouse, click on skin, system draws the line; advantage is line can be adjusted to go directly through middle of intercostal space above ribs to avoid arteries and nerves below rib.
clinical6:28 ↗
System arranges C-arm automatically in exactly the right position after planning line is drawn.
clinical6:28 ↗
Put needle into pleura to check position and stabilize with blue towels; very important to do it quickly—don't put needle in, do scan, then wait and fiddle around or you get pneumothorax or other complications.
clinical6:28 ↗
Really important to talk to anesthesiologist and explain need for same respiratory excursion whenever doing cone beam CT imaging, and that has to correspond to when actually advancing needle.
clinical7:54 ↗
If cone beam CT done with full inspiration, location of nodule will be different in 3D than if done in full expiration; planned paths are planned from respiratory excursion from first CT, so unless same respiratory excursion when advancing needle, will be off target.
clinical7:54 ↗
To ensure same respiratory effort, ask anesthesia colleagues to fully paralyze patient and disconnect tubes from ventilator so patient can exhale naturally and stop at very natural stopping point—most reproducible rather than having CPAP of 20 or 25.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position8:43 ↗
Having no positive pressure reduces chance of pneumothorax.
Host summaryRod Gerardo summarizing the discussion — not the host's own clinical position8:43 ↗
Even if complication occurs, most common one being pneumothorax, it's not a disaster—just put 5 French sheath or catheter and connect to low wall suction, which will take care of pneumothorax.
clinical9:14 ↗
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