The value of thoracoscopic ultrasound for the localization of ground-glass opacities with incomplete lung collapse in video-assisted thoracoscopic surgery
Original Article

The value of thoracoscopic ultrasound for the localization of ground-glass opacities with incomplete lung collapse in video-assisted thoracoscopic surgery

Cong-Xuan Zhao1, Nan Sun2, Lin-Wei Hong1, Fang-Xu Li1, Fu-Zhi Pan3, Ning-Ning Gao3, Dong-Man Ye3, Tao Yu3, Xin-Wu Cui4

1Department of Ultrasound, Liaoning University of Traditional Chinese Medicine Affiliated Hospital, Shenyang, China; 2Department of Thoracic Surgery, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital, Shenyang, China; 3Department of Ultrasound, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital, Shenyang, China; 4Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

Contributions: (I) Conception and design: XW Cui, T Yu; (II) Administrative support: T Yu; (III) Provision of study materials or patients: N Sun, T Yu; (IV) Collection and assembly of data: CX Zhao, N Sun, FZ Pan, FX Li; (V) Data analysis and interpretation: CX Zhao, FX Li; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Tao Yu, PhD. Department of Ultrasound, Cancer Hospital of Dalian University of Technology, Liaoning Cancer Hospital, 44 Xiaoheyan Road, Dadong District, Shenyang 110042, China. Email: yutao@cancerhosp-ln-cmu.com; Xin-Wu Cui, PhD. Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Qiaokou District, Wuhan 430030, China. Email: cuixinwu@live.cn.

Background: Video-assisted thoracoscopic surgery (VATS) has been widely used for the resection of lung lesions. However, it is difficult to palpate or see small lesions, especially ground-glass opacities (GGOs) during VATS. Thoracoscopic ultrasound has definite value in locating pulmonary parenchymal nodules. However, due to the air in the lung parenchyma, its wide application is limited. This study investigated the value of thoracoscopic ultrasound for the localization of GGOs with incomplete lung collapse in VATS.

Methods: A retrospective analysis was conducted on patients diagnosed with ground-glass nodules (GGNs) on computed tomography (CT) at Liaoning Province Tumor Hospital from November 2018 to August 2019, who underwent thoracoscopic ultrasound localization and VATS. Screening was conducted for patients who did not achieve complete collapse of the lungs after natural collapse during surgery, the success rate was calculated, and preoperative CT features and thoracoscopic ultrasound features of GGNs were summarized and analyzed.

Results: The success rate of GGOs’ localization by thoracoscopic ultrasound in incomplete collapse lung was 56.67%. Of all preoperative CT features, only the distance between the nodule and the pleura was statistically different (P=0.001). The closer the GGO was to the pleura, the easier it was to be detected.

Conclusions: Thoracoscopic ultrasound could effectively locate GGO in the condition of incomplete lung collapse and not affect the surgical field, especially when the GGO is close to the pleura, which provides an alternative method for GGO localization in patients who cannot achieve complete lung collapse during VATS.

Keywords: Ground-glass opacities (GGOs); thoracoscopic ultrasound; localization; video-assisted thoracoscopic surgery (VATS); incomplete lung collapse


Submitted Jan 19, 2024. Accepted for publication Oct 18, 2024. Published online Nov 29, 2024.

doi: 10.21037/qims-24-43


Introduction

Ground-glass opacity (GGO) is defined as a radiological finding in computed tomography (CT) and consists of a dense hazy opacity with clear or unclear boundary that does not obscure the underlying bronchial structures or pulmonary vessels (1). According to whether there is a solid component, GGO can be divided into pure GGO (p-GGO) and mixed GGO (m-GGO). Recent screening studies by the International Early Lung Cancer Action Program (I-ELCAP) showed a detection rate of 4.2% for p-GGO and 5.0% for m-GGO in the population (2). Pulmonary GGO has complex etiology and imaging features, and could develop rapidly or slowly (3,4). The incidence rate of malignant lesions in lung GGO has been reported as 63%. At present, most researchers have suggested that the majority of GGOs are early manifestations of pulmonary malignant tumors, which has gained increasing concern in the clinic (5-7).

Video-assisted thoracoscopic surgery (VATS) has been widely used for the resection of lung lesions. However, it is difficult to palpate or see small lesions, especially GGOs, during VATS (8). Performing ultrasound intraoperatively is a real-time and alternative approach to localize small, non-visible, and non-palpable pulmonary lesions without injury to lung parenchyma. It has been confirmed that thoracoscopic ultrasound has definite value in the localization of parenchymal nodules in pulmonary (9). However, its widespread usage has been limited due to the air in the lung parenchyma.

One-lung ventilation (OLV) is used to facilitate surgical exposure in the chest by collapsing the ipsilateral lung, which is necessary in thoracoscopic surgery. Collapse of the non-dependent lung and atelectasis of the dependent lung during OLV increases intrapulmonary shunting and leads to the development of intraoperative hypoxemia (10,11). At present, an expert consensus on the clinical application of perioperative lung protective ventilation strategy has suggested adopting a lung protective ventilation strategy during surgery to maximize the expansion of the patient’s alveoli, and reduce adverse gas exchange and respiratory dysfunction (12,13). Therefore, complete collapse of the lungs requires close cooperation between the patient and the anesthesiologist. Not all the patients could achieve complete collapse of the surgical side lungs. Compared with traditional thoracotomy, VATS has smaller operation space and higher requirements for lung collapse. A lung collapse scale (LCS) score of 8 means that the lung at the operation side collapsed basically, and some gas remained in the lung, but the lung was not ventilated, and the exposure of the operation field was satisfactory. LCS is assessed by surgeons.

This study aimed to explore the value of thoracoscopic ultrasound in locating ground-glass nodules (GGNs) under conditions that the lungs naturally collapse without reaching complete collapse. We present this article in accordance with the STROCSS reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-24-43/rc).


Methods

A retrospective analysis was conducted on patients diagnosed with GGNs on CT at Liaoning Cancer Hospital from November 2018 to August 2019 and treated with thoracoscopic surgery. All patients underwent CT-guided accurate localization before thoracoscopic lobectomy. Among these patients, 43 cases were located by ultrasound of the GGN under thoracoscope during operation. Screening was conducted for patients who did not achieve complete collapse of the lungs after natural collapse during surgery, the success rate was calculated, and preoperative CT features and thoracoscopic ultrasound features of GGNs were summarized and analyzed.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study protocol was approved by the Institutional Review Board of Liaoning Cancer Hospital (No. 20140707-2). All patients gave their oral informed consent.

Patients

The collapse state of the lungs was evaluated by the surgeon. In this single center retrospective study, maximum diameter of GGO ≤30 mm on CT before operation and LCS score of 8 during surgery were selected as inclusion criteria for patients. Patients with chronic obstructive pulmonary disease, pulmonary fibrosis, and asthma were excluded, as were those with serious heart disease (Figure 1).

Figure 1 Flow chart of patient selection. CT, computed tomography; LCS, lung collapse scale.

Instruments and equipment

Danish BK Pro Focus 2202 ultrasonic diagnostic instrument (BK Medical, Burlington, MA, USA), equipped with intraoperative thoracoscopic 8,666 probe, frequency 5.0–10.0 MHz was applied (Figure 2).

Figure 2 Intraoperative thoracoscopic ultrasound probe.

Data collection and test methods

A total of 30 GGOs were assessed from 30 eligible patients. The maximum diameter on CT, average CT value, and the shortest distance between the lesion and pleura (comparing the shortest distance between pleura and interlobular pleura, and recording the shorter distance as the shortest distance) were recorded before operation. The probe was sterilized by low temperature plasma. After general anesthesia, the patient underwent OLV. After natural collapse of the lung on the affected side, two senior surgeons, who had participated in specialization and related training before operation, evaluated the collapse state and obtained an LCS score. The ultrasound probe, which was operated by the two surgeons respectively, was placed on the surface of specific lobes in the possible area of the nodule, which was scanned from top to bottom and from outside to inside. When a suspicious echo was found, the image was frozen and the size of the focus measured, the image was saved (Figure 3). If the effect of thoracoscopic examination was not ideal, the operator pressed the probe properly and observed whether the image quality was improved. If the ultrasound could clearly show the echo of blood vessels and bronchi in the lung, it indicated that the lung was completely collapsed; otherwise, if it only showed the focus area and other areas were still gas hyperechoic, it meant that the lung was not completely collapsed. At the end of the examination, the largest and smallest diameter of the nodule, the internal echo, shape and edge characteristics of the nodule, and the shortest distance between the nodule and the lung surface were recorded.

Figure 3 Intraoperative thoracoscopic ultrasound exploration.

Statistical analysis

Statistical analysis was performed by using SPSS 20.0 software (IBM Corp., Armonk, NY, USA). The CT/thoracoscopic ultrasound characteristics of GGO were reported as descriptive statistics. The measurement data was expressed as mean ± standard deviation, the comparison of two independent samples was conducted by Mann-Whitney U test. The data of a four-grid table was calculated by Fisher’s exact test. The continuous variables among multiple groups were analyzed by one-way analysis of variance (ANOVA). A P value <0.05 was considered statistically significant.


Results

Patients’ basic characteristics and preoperative CT features of GGOs

A total of 30 patients were assessed for eligibility, including 5 males and 25 females, with an average age of (58.67±11.60 years; range, 34–78 years). Of the total of 30 single nodules, 9 were clinging to the pleura or interlobular pleura on preoperative CT. The shortest distance to the pleura or interlobular pleura was 5.64±5.89 mm (range, 0.00–21.2 mm) (Table 1). All 30 cases were in the state of incomplete pulmonary collapse.

Table 1

Patients’ basic characteristics and preoperative CT features of GGOs

Characteristic Distribution Quantity or value
Gender Male 5
Female 25
Age (years) Range 34–78
Mean age 58.67±11.60
Size (diameter on CT) (mm) Range 5.0–28.0
Mean diameter 14.27±4.94
Distance from pleura (on CT) (mm) Range 0.00–21.2
Mean depth 5.64±5.89
Nodules p-GGO 12
m-GGO 18
CT value (HU) p-GGO −661.17±61.55
m-GGO −605.83±53.30

Data are presented as mean ± standard deviation, range, or number. CT, computed tomography; GGO, ground-glass opacity; p-GGO, pure ground-glass opacity; m-GGO, mixed ground-glass opacity; HU, Hounsfield unit.

Of the 30 patients enrolled, 17 patients with successful localization underwent pulmonary wedge resection and 13 patients with failed localization underwent segmental resection.

Features of GGOs

Of 30 patients, 17 patients (56.67%) with a single GGO were successfully detected by thoracoscopic ultrasound, including 4 p-GGOs and 13 m-GGOs. A total of 9 were in the upper lobe of right lobe, 1 was in the middle lobe of right lung, 5 were in the upper lobe of left lung, and 2 were in the lower lobe of left lung. For 13 patients (43.33%), single GGOs were failed to be detected by thoracoscopic ultrasound, including 7 p-GGOs and 6 m-GGOs. Regarding location, 3 were in the upper lobe of right lobe, 1 was in the middle lobe of right lung, 3 were in the lower lobe of right lung, 3 were in the upper lobe of left lung, and 3 were in the lower lobe of left lung. The detailed characteristics of the GGOs are summarized in Table 2.

Table 2

Detailed characteristics of the ground-glass opacities

Characteristics GGOs be detected GGOs failed to be detected
p-GGO m-GGO p-GGO m-GGO
Size (diameter under US) (mm) 13.45±3.85 (6.42–22.00)
Distance from pleura (under US) (mm) 0.62±0.79 (0–1.91)
Size (diameter under CT) (mm) 14.26±4.27 (7.00–22.00) 15.90±6.88 (8.00–28.00)
Preoperative CT value (HU) −620.25±76.20 −599.46±59.82 −669.57±23.86 −614.83±232.13
Distance from pleura (under CT) (mm) 5.34±6.43 1.96±1.70 13.36±4.45 6.09±6.18
Constituent ratio 4 (23.5) 13 (76.5) 7 (53.9) 6 (46.1)
   Location
    Upper lobe of right lung 2 7 1 2
    Middle lobe of right lung 1 0 1 0
    The lower lobe of right lung 0 0 0 3
    Upper lobe of left lung 0 4 2 1
    The lower lobe of left lung 1 2 3 0
   Pathological results
    Lung squamous cell carcinoma 1 5 1 0
    Adenocarcinoma in situ 1 2 0 0
    Invasive lung adenocarcinoma 2 4 4 4
    Invasive mucinous carcinoma 0 1 0 0
    Benign lesion 0 1 2 2

Data are presented as mean ± standard deviation, (range), or number (frequency). GGO, ground-glass opacity; p-GGO, pure ground-glass opacity; m-GGO, mixed ground-glass opacity; US, ultrasound; CT, computed tomography.

Detailed thoracoscopic ultrasound features of pulmonary opacities detected

The GGOs successfully detected during surgery demonstrated hyperechoic (53%) and mixed-echoic (47%) patterns. All p-GGOs (n=4) presented hyperechoic patterns, whereas m-GGOs (n=5) presented hyperechoic patterns, and (n=8) had mixed ultrasound patterns with both hyperechoic and hypoechoic components.

Postoperative pathology showed that 6 GGOs were squamous cell carcinoma of the lung, among which 5 demonstrated hyperechoic patterns and 1 demonstrated a mixed-echoic pattern; 1 adenocarcinoma in situ was high echogenicity. Among 3 adenocarcinomas in situ, 1 was hyperechoic and 2 were mixed-echoic; among 6 invasive lung adenocarcinomas, 2 were hyperechoic and 4 were mixed-echoic; 1 invasive mucinous carcinoma and 1 benign lesion were mixed-echoic (Table 3; Figures 4,5).

Table 3

The echo characteristics of GGOs with different pathological results

Pathological results Echo characteristics (n)
p-GGO m-GGO
Lung squamous cell carcinoma 1 hyperechoic 5: 4 hyperechoic; 1 mixed-echoic
Adenocarcinoma in situ 1 hyperechoic 2: 1 hyperechoic; 1 mixed-echoic
Invasive lung adenocarcinoma 2 hyperechoic 4 mixed-echoic
Invasive mucinous carcinoma 0 1 mixed-echoic
Benign lesion 0 1 mixed-echoic

GGO, ground-glass opacity; p-GGO, pure ground-glass opacity; m-GGO, mixed ground-glass opacity.

Figure 4 A 72-year-old female: (A) CT showed a ground-glass opacity in the left upper lobe of the lung, approximately 13 mm × 9 mm; (B) thoracoscopic ultrasound findings: irregular mix-echoic nodule, approximately 15.4 mm × 6.2 mm. Postoperative pathological diagnosis: adenocarcinoma in situ. CT, computed tomography.
Figure 5 A 55-year-old female: (A) CT showed a ground-glass opacity in the right upper lobe of the lung, with a diameter of approximately 8 mm; (B) thoracoscopic ultrasound findings: irregular hyperechoic nodule, approximately 6.2 mm × 7.2 mm. Postoperative pathological diagnosis: adenocarcinoma in situ. CT, computed tomography.

Of all the detected GGOs, 9 (52.94%) were hyperechoic and 8 (47.06%) were mixed-echoic; color Doppler flow imaging (CDFI) showed no blood flow signal. Most of the opacities had a clear boundary (n=12, 70.59%) (Table 4).

Table 4

Detailed echo characteristics of thoracoscopic ultrasound

Thoracoscopic ultrasound Echogenicity (n) Margin (n) Shape (n) Blood flow signal
Hyperechoic Mixed-echoic Distinct Indistinct Regular Irregular Presence or absence
p-GGO 2 2 2 2 1 3 Absence
m-GGO 7 6 10 3 8 5 Absence

p-GGO, pure ground-glass opacity; m-GGO, mixed ground-glass opacity.

Analysis of preoperative CT features based on ultrasound exploration results

Of 17 detected nodules, the mean CT value was −604.35±62.09 Hounsfield units (HU; range, −730 to −473 HU); maximum diameter of opacities: CT measurement 14.26±4.27 mm (range, 7.00–22.0 mm); thoracoscopic ultrasound measurement 13.45±3.85 mm (range, 6.42–22.0 mm); postoperative pathological measurement 13.22±3.75 mm (range, 6.02–21.50 mm). The difference between the maximum diameter of each nodule measured by CT and thoracoscopic ultrasound and postoperative pathology, respectively, was not statistically different (F=0.321, P=0.727). We statistically analyzed the correlation between preoperative CT features of GGOs and intraoperative detection success. There was no statistical difference between the maximum diameter of preoperative CT and the success of detection, nor the CT value. However, the shortest distance between the nodule and the pleura was statistically different (Table 5).

Table 5

Comparison of CT features between the successful detected and failed group

Variables The whole group p-GGOs group m-GGOs group
Successful Failed P value Successful Failed P value Successful Failed P value
Distance from pleura (mm) 2.75±3.45 9.42±6.35 0.013 5.34±6.43 13.36±4.45 0.002 1.96±1.70 6.09±6.18 <0.01
CT value (HU) −604.35±62.09 −659.78±48.73 0.454 −620.25±76.20 −599.46±59.82 0.156 −599.46±59.82 −614.83±232.13 0.246
Maximum diameter on CT 14.26±4.27 15.90±6.88 0.491 11.00±4.55 12.87±4.76 0.461 15.26±3.80 17.74±6.74 0.703

Data are presented as mean ± standard deviation. CT, computed tomography; p-GGO, pure ground-glass opacity; m-GGO, mixed ground-glass opacity; HU, Hounsfield unit.

There was no significant difference in CT value between hyperechoic and mix-echoic GGOs (P>0.05) (Table 6).

Table 6

Comparison of GGOs echo with CT value

GGOs’ echo Number CT value (HU, x¯±s)
Mix-echoic 8 −579.50±64.59
Hyperechoic 9 −610.44±63.03
P value 0.963a

a, Fisher’s exact probability method. GGO, ground-glass opacity; CT, computed tomography; HU, Hounsfield unit.

The average duration of intraoperative ultrasound was 4.29±1.14 minutes, and all patients had no lung injury, postoperative infection, and other related complications.


Discussion

We carried out this study on the localization of GGOs by thoracoscopic ultrasound in condition of incomplete lung collapse. The success rate was 56.67% when the LSC score was 8. Thoracoscopic ultrasound could locate GGO in the condition of incomplete lung collapse safely and effectively and not affect the surgical field, which provides an alternative method for GGO localization in patients who cannot achieve complete lung collapse during VATS.

It has been confirmed that thoracoscopic ultrasound has a certain value in the localization of parenchymal nodules in pulmonary under conditions of complete collapse of the lungs (LCS score =10) (9,14). Lung collapse facilitates intrathoracic surgical procedures and is particularly important in minimally invasive thoracoscopic surgery. However, not all patients can achieve complete lung collapse in clinical work; conditions such as pleural adhesions, pulmonary bullae, and chronic obstructive pulmonary disease can all affect intraoperative pulmonary collapse. The number of such patients is not uncommon, and the incidence of poor quality pulmonary collapse is higher (15).

Previous study had shown that a satisfactory level of pulmonary collapse and sufficient operating space can been obtained when the LCS score was 8 (16). Therefore, this retrospective study selected an LCS score of 8 as the standard for satisfactory pulmonary collapse.

It had been reported that when the lung was completely collapsed, the localization diagnosis of intraoperative GGOs by thoracoscopic ultrasound could reach 100% (14,17,18). The complete collapse of the lung was not deliberately sought in this study. The detection rate of 56.67% (17/30) was lower than that reported in the previous studies. Some researchers (5,19) have asserted that gently pressing the surface of the lungs with an ultrasonic probe to reduce residual air beneath the sensor could be conducive to the location. However, appropriate pressure in this study could only yield a clearer display of the lesions close to the surface of the lung pleura. Therefore, we analyzed the limitations of thoracoscopic ultrasound in the localization of pulmonary GGOs. First, the requirement for lung collapse was high. Incomplete collapse of the lung could lead to residual gas in the lungs, making it difficult to identify GGOs in deep. Second, the essential characteristics of ultrasound make it difficult to clearly show GGOs in sub centimeter level with less solid components.

In addition, previous study considered that the area with CT values ranging from −900 to −500 HU was the normal ventilation zone of the lungs; CT value ranging from −100 to 100 HU represented the area of lung collapse (20). Previous studies had suggested that pure GGNs (with CT values less than −500 HU) were difficult to identify intraoperatively in vivo, and mixed GGNs (with CT values between −500 and −100 HU), were easily palpated (21).

However, in this study, mean CT value of detected GGOs’ was −604.35±62.09 HU (range, −730 to −473 HU), and there was no statistical difference between the CT value and the successful detection. The reason might be that the closer the GGO was to the pleura, the easier it was to be detected and less susceptible to the influence of CT values.

In our study and other researchers’ previous study, all p-GGOs presented as hyperechoic (14). As analyzed by Wang et al. (18), the smaller the CT value was, the less solid components of the lesions there were, and the less hypoechoic that it may have appeared by the thoracoscopic ultrasound; the further away the lesion was from the pleura, the more it required complete collapse of the lungs, thus highlighting the lesions containing hyperechoic gas in hypoechoic lung collapse. The closer the lesion was to the pleura, the shorter the time was required for lung collapse, and complete pulmonary collapse was not necessary (18). Similarly, in this study, of all preoperative CT features, only the distance between the nodule and the pleura showed a statistically significant difference (P=0.013), pointing out that the closer the GGO was to the pleura the easier it was to be detected.

The size of GGOs detected by intraoperative ultrasound was similar to that of preoperative enhanced CT and postoperative pathological specimens, suggesting that intraoperative ultrasound can not only assist in localization but also clarify the focus boundary to help surgeons to perform accurate surgical resection. Wedge resection of lung was performed in 17 cases with successful localization. Compared with segmental pneumonectomy, wedge pneumonectomy can accurately resect the lung within enough surgical margin while retaining the normal anatomical tissue and function of the lung to the maximum extent. The accurate positioning of thoracoscopic ultrasound during operation can maximize the benefits for patients.

Our study had some limitations. First, the sample size was small, which might have led to significant differences in the results compared to previous research. Second, the inclusion of patients was not comprehensive enough and the study was conducted on GGOs in patients with emphysema, chronic obstructive pulmonary disease, and other diseases that affect lung collapse. Third, this study failed to make an effective judgment on the impact of CT value on the localization of GGNs by thoracoscopic ultrasound. Finally, enhanced ultrasound can effectively guide the detection of pulmonary modules and percutaneous needle biopsy in tissue cellularity of lung malignancies (22); due to the limited conditions, many location methods cannot be carried out to make effective statistical analysis and comparison.


Conclusions

Thoracoscopic ultrasound could locate GGO in condition of incomplete lung collapse and not affect the surgical field, which provides an alternative method for GGO localization in patients who cannot achieve complete lung collapse during VATS. Thoracoscopic ultrasound would be an economical, cost-effective, convenient, and safe localization method that can increase the accuracy of VATS, especially when the GGO was close to the pleura.


Acknowledgments

Funding: This study was financially supported by a grant from the National Natural Science Foundation of China (No. 81872363).


Footnote

Reporting Checklist: The authors have completed the STROCSS reporting checklist. Available at https://qims.amegroups.com/article/view/10.21037/qims-24-43/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-43/coif). All authors report that this study was financially supported by a grant from the National Natural Science Foundation of China (No. 81872363). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study protocol was approved by the Institutional Review Board of Liaoning Cancer Hospital (No. 20140707-2). All patients gave their oral informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


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Cite this article as: Zhao CX, Sun N, Hong LW, Li FX, Pan FZ, Gao NN, Ye DM, Yu T, Cui XW. The value of thoracoscopic ultrasound for the localization of ground-glass opacities with incomplete lung collapse in video-assisted thoracoscopic surgery. Quant Imaging Med Surg 2024;14(12):8479-8488. doi: 10.21037/qims-24-43

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