Korean J Radiol.  2019 Nov;20(11):1498-1514. 10.3348/kjr.2019.0155.

Planting Seeds into the Lung: Image-Guided Percutaneous Localization to Guide Minimally Invasive Thoracic Surgery

• Lee JW
• Park CH
• Lee SM
• Jeong M
• Hur J

• KMID: 2459418
• DOI: http://doi.org/10.3348/kjr.2019.0155

Abstract

Image-guided localization materials are constantly evolving, providing options for the localization of small pulmonary nodules to guide minimally invasive thoracic surgery. Several preoperative methods have been developed to localize small pulmonary lesions prior to video-assisted thoracic surgery. These localization techniques can be categorized into 4 groups according to the materials used: localization with metallic materials (hook-wire, microcoil, or spiral coil), localization with dye (methylene blue or indigo carmine), localization with contrast agents (lipiodol, barium, or iodine contrast agents), and radiotracers (technetium-99m). However, the optimal localization method has not yet been established. In this review article, we discuss the various localization techniques and the advantages and disadvantages of localization techniques as well as the available safety and efficacy data on these techniques.

Keyword

Localization; Tomography, X-ray computed; Ultrasonography; Coloring agents; Contrast media; Thoracic surgery, video-assisted

MeSH Terms

Barium
Coloring Agents
Contrast Media
Indigo Carmine
Iodine
Lung*
Methods
Plants*
Thoracic Surgery*
Thoracic Surgery, Video-Assisted
Tomography, X-Ray Computed
Ultrasonography
Barium
Coloring Agents
Contrast Media
Indigo Carmine
Iodine

Figure

• 

  Fig. 1 Preoperative hook-wire localization for part-solid nodule in right upper lobe in 59-year-old man.A. Axial CT image with lung window shows 15-mm part-solid nodule (arrow) in right upper lobe. B. Post-procedure axial CT image with lung window shows that horn of hook-wire is positioned in target nodule (arrow).

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  Fig. 2 Diagrams showing two localization methods using microcoil.A. Drawing illustrates entire microcoil was inserted into lung tissue. B. Drawing illustrates that microcoil was partially inserted, and end tail of microcoil remained above visceral pleura.

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  Fig. 3 Preoperative localization with indigo carmine for part-solid nodule in left upper lobe in 60-year-old woman.A. Axial CT image with lung window during localization shows 22-gauge Chiba needle introduced into nodule (arrow). B. Video-assisted thoracoscopic image shows deposition of indigo carmine as purple area around inserted area of needle (arrow).

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  Fig. 4 Preoperative lipiodol localization for part-solid nodule in right upper lobe in 48-year-old woman.A. Axial CT image with lung window during lipiodol localization in prone position shows 22-gauge Chiba needle introduced into nodule (arrow) in left upper lobe. B. Post-procedure axial CT image with lung window shows lipiodol accumulation (arrow) in target nodule after procedure.

• 

  Fig. 5 Preoperative lipiodol localization for part-solid nodule in right upper lobe in 35-year-old woman.A. Axial CT image with lung window shows 15-mm part-solid nodule (arrow) in right upper lobe. Post-procedure axial CT images with mediastinal (B) and lung (C) windows demonstrate lipiodol spillage to right pleural, right chest wall (arrows) and bronchi of right upper lobe (arrowheads). Thoracoscopic wedge resection was successfully performed.

• 

  Fig. 6 Video-assisted thoracoscopic surgery after localization using hook-wire.Thoracoscopic surgery is performed with 3–5-cm utility incision at anterior axillary line at fourth or fifth intercostal space using endoscopic instruments without rib spreading and additional 2 or 3 ports for camera, stapler insertion, and assistant. After identification of marked nodule by thoracoscopic vision, thoracoscopic wedge resection is performed using endoscopic stapler with 1–2-cm margin from lesion.

• 

  Fig. 7 Images in 65-year-old woman undergoing lipiodol localization for part-solid nodule in right upper lobe.A. Axial CT image with lung window shows 11-mm part-solid nodule (arrow) in right upper lobe. B. Post-procedure axial CT image with lung window shows lipiodol accumulation (arrow) in right upper lobe. C. Intraoperative fluoroscopic images obtained during resection demonstrate radiopaque spot (arrow) representing lipiodol accumulation. D. After wedge resection, successful resection can be confirmed by identifying radiopaque spot (arrow) by intraoperative fluoroscopy.

• 

  Fig. 8 Pneumothorax as complication after localization.A. Lipiodol localization for right middle lobe part-solid nodule in 56-year-old woman. Post-procedure CT image shows right pneumothorax (arrows) after lipiodol localization. B, C. Hook-wire localization for left upper lobe part-solid nodule in 57-year-old man. Post-procedure CT image shows right pneumothorax (arrows) after hook-wire insertion. Thoracoscopic wedge resections were successfully performed in both patients.

• 

  Fig. 9 Pulmonary hemorrhage as complication after hook-wire localization.A. Axial CT image shows 10-mm ground glass nodules (arrow) in right upper lobe. B. Post-procedure axial CT image after hook-wire localization shows ground glass opacity around hook-wire, suggesting pulmonary hemorrhage (arrow) in right upper lobe. Patient was asymptomatic and required no treatment.

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  Fig. 10 ENB localization of lung nodule.A. ENB can convert preoperative CT data into virtual bronchial map. Steerable probe contains position sensor and allows navigation of turns in endobronchial tree. After guidance of steerable probe tip to targeted lung nodule, dye is injected to target nodule. B. Video-assisted thoracoscopic image shows deposition of dye as purple area around targeted nodule position after ENB localization. ENB = electromagnetic navigation bronchography

• 

  Fig. 11 Diagram showing intraoperative ultrasonography localization for left upper lobe nodule.Lung is collapsed and probe is placed firmly in area of target nodule.

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