Korean J Radiol.  2012 Dec;13(6):694-701. 10.3348/kjr.2012.13.6.694.

CT-Guided Percutaneous Transthoracic Localization of Pulmonary Nodules Prior to Video-Assisted Thoracoscopic Surgery Using Barium Suspension

• Lee NK
• Park CM
• Kang CH
• Jeon YK
• Choo JY
• Lee HJ
• Goo JM

• KMID: 1397499
• DOI: http://doi.org/10.3348/kjr.2012.13.6.694

Abstract

OBJECTIVE
To describe our initial experience with CT-guided percutaneous barium marking for the localization of small pulmonary nodules prior to video-assisted thoracoscopic surgery (VATS).
MATERIALS AND METHODS
From October 2010 to April 2011, 10 consecutive patients (4 men and 6 women; mean age, 60 years) underwent CT-guided percutaneous barium marking for the localization of 10 small pulmonary nodules (mean size, 7.6 mm; range, 3-14 mm): 6 pure ground-glass nodules, 3 part-solid nodules, and 1 solid nodule. A 140% barium sulfate suspension (mean amount, 0.2 mL; range, 0.15-0.25 mL) was injected around the nodules with a 21-gauge needle. The technical details, surgical findings and pathologic features associated with barium localizations were evaluated.
RESULTS
All nodules were marked within 3 mm (mean distance, 1.1 mm; range, 0-3 mm) from the barium ball (mean diameter, 9.6 mm; range, 8-16 mm) formed by the injected barium suspension. Pneumothorax occurred in two cases, for which one needed aspiration. However, there were no other complications. All barium balls were palpable during VATS and visible on intraoperative fluoroscopy, and were completely resected. Both the whitish barium balls and target nodules were identifiable in the frozen specimens. Pathology revealed one invasive adenocarcinoma, five adenocarcinoma-in-situ, two atypical adenomatous hyperplasias, and two benign lesions. In all cases, there were acute inflammations around the barium balls which did not hamper the histological diagnosis of the nodules.
CONCLUSION
CT-guided percutaneous barium marking can be an effective, convenient and safe pre-operative localization procedure prior to VATS, enabling accurate resection and diagnosis of small or faint pulmonary nodules.

Keyword

CT; Localization; Percutaneous; Lung; Nodule; Barium

MeSH Terms

Adult
Aged
Barium Sulfate/*diagnostic use
*Contrast Media
Female
Humans
Lung Neoplasms/radiography/*surgery
Male
Middle Aged
*Radiography, Interventional
Solitary Pulmonary Nodule/radiography/*surgery
*Thoracic Surgery, Video-Assisted
*Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Percutaneous localization of part-solid nodule in left upper lobe using barium sulfate in 68-year-old woman. A. Appropriate barium injection site and needle route were determined using pre-procedural CT. Note part-solid nodule (arrowhead) in left upper lobe and radiopaque grid made of metallic wires on chest wall. B. Barium sulfate suspension was injected adjacent to target nodule (arrow) and appears as radiopaque ball on post-procedural CT image. C. Intraoperative fluoroscopic image shows radiopaque barium ball (arrow) in left upper lung zone. D. Injected barium sulfate appears as brownish materials dispersed within alveolar space. Note nodule seen as part-solid nodule on CT (arrowheads) near injected barium materials. There are acute inflammatory reactions containing many neutrophils, histiocytes and some eosinophils around injected barium material (original magnification, × 200; Hematoxylin-Eosin stain). Target nodule was confirmed as adenocarcinoma-in-situ, pathologically.

• 

  Fig. 2 Percutaneous transthoracic localization of tiny solid nodule prior to VATS using barium sulfate in 56-year-old man with medical history of colon cancer. A. Tiny solid nodule was found on routine follow-up CT scan (arrow). B. Post-procedural CT image shows injected barium ball encroaching target nodule (arrow). C. Intraoperative fluoroscopic image shows radiopaque barium ball (arrow) in right lower lung zone. D. Brownish barium sulfate is shown around target nodule confirmed as intrapulmonary lymph node, pathologically. VATS = video-assisted thoracoscopic surgery

• 

  Fig. 3 Preoperative localization of pure ground-glass nodule using barium sulfate in right upper lobe found in 62-year-old man. A. Thin-section chest CT scan shows 1 cm pure ground-glass nodule (arrowhead) in right upper lobe. B. Injected barium near target nodule is clearly demonstrated on post-procedural CT (arrow). Note small amount of pneumothorax which occurred during localization procedure. C. Intraoperative fluoroscopic imaging shows radiopaque barium ball (arrow) in right upper lung zone. D. Scattered brownish colored barium with acute inflammation reaction is shown. Lesion was confirmed as atypical adenomatous hyperplasia, pathologically.

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