Image-Guided Chest Wall Resection Enables Accurate, Minimally Invasive Removal of Non-Palpable Rib Lesions with Clear Margins

Abstract

Aim: Surgeons are increasingly called upon to resect small, non-palpable rib lesions for tissue diagnosis and radical treatment of oligometastases. Cases of incorrect rib resections have been documented. We present the utilisation of intraoperative Cone-Beam CT (CBCT) for precise localisation of rib lesions, facilitating accurate incision placement and providing confirmation of complete resection. Method(s): A CT scan encompassing the first rib to the target lesion is obtained intraoperatively to ensure accurate rib counting and precise lesion localisation. The boundaries for resection, including an adequate margin, are delineated using 21G needles. An incision is made between the two needles, followed by resection of the designated rib segment. A post-resection CT scan is then performed to verify the complete removal of the lesion along with its margins. Result(s): Cone-Beam CT was utilised for the surgical resection of non-palpable rib lesions in six patients treated at Barts Thoracic Centre, London, between 2017 and 2023. The mean patient age was 49.5 years (range 33-79), comprising one male and five females. The primary pathology in five patients was breast cancer, while one patient had lung cancer. Five lesions were confirmed as breast cancer metastases, and one as a lung cancer metastasis, all of which were successfully and completely resected. All cases were complication-free, except one instance involving a small apical space. The average hospital stay was 2 days (range 1-4 days). Conclusion(s): Cone-Beam CT allows for rapid and accurate localisation of rib lesions and resection margins and facilitates precise incision placement to minimise unnecessary or exploratory incisions.