- Open Access
Localization of nonpalpable pulmonary nodules using CT-guided needle puncture
© Hsu et al. 2015
- Received: 12 April 2015
- Accepted: 28 July 2015
- Published: 15 August 2015
Surgical resection of small pulmonary nodule is challenging via thoracoscopic procedure. We describe our experience of computed tomography (CT)-guided needle puncture localization of indeterminate pulmonary nodules prior to video-assisted thoracoscopic surgery (VATS).
From January 2011 to July 2014, 78 consecutive patients underwent CT-guided marking for the localization of 91 small pulmonary nodules. We retrospectively reviewed the clinical data, technical details, surgical findings and pathologic results, and complications associated with CT-guided localization.
Seventy-eight consecutive patients (36 men and 42 women) underwent CT-guided marking localization of 91 indeterminate pulmonary nodules (62 pure ground-glass opacity nodules, 27 part-solid nodules, and 2 solid nodules). The mean size of the nodules was 8.6 mm (3.0–23.0 mm). The mean pleural distance between the nodule and lung surface was 11.5 mm (3.0–31.3 mm). The mean procedure time of CT-guided localization was 15.2 min (8–42 min). All patients stood the procedures well without requiring conversion to open thoracotomy. Twenty-four patients (30.77 %) developed pneumothorax after the procedures. Only one patient required retention of the puncture needle introducer for air drainage. The mean visual assessment pain score was 1.7 (0–3). Fifty-seven nodules (62.63 %) were confirmed as malignances, including 45 primary lung cancer, and 34 nodules (37.37 %) were confirmed as benign lesions.
CT-guided needle puncture can be an effective and safe procedure prior to VATS, enabling accurate resection and diagnosis of small pulmonary nodules.
- Methylene Blue
- Pulmonary Nodule
- Sclerosing Hemangioma
- Thoracoscopic Procedure
- Small Pulmonary Nodule
As the use of computed tomography (CT) becomes widespread in clinical practice, we have increasingly encountered small or faint lesions on CT . Low-dose CT greatly increases the likelihood of detection of small nodules, and 51.7 % of detected lung cancers found during baseline screening were ground-glass opacity (GGO) . The accurate early diagnosis of these small nodules is challenging, even with dedicated CT, positron emission tomography–computed tomography (PET–CT), or image-guided percutaneous biopsy. Video-assisted thoracoscopic surgery (VATS) is a minimally invasive surgery for management of lung nodules, both for curative resection and diagnostic procedures. One of the major problems often encountered during VATS is localization of the target nodule, which depends on its location, size, and characteristics such as nodule consistency. Further, when small nodules are located more than 2 cm below the pleural surface, it is difficult for the surgeon to determine their exact location during operation . Failure to localize pulmonary nodules often results in the conversion of VATS to open thoracotomy. Conversion rates have been reported to be as high as 59 % [4–6]. Several preoperative and intraoperative techniques have been described for nodule localization when performing VATS. These procedures include metallic hookwire localization under CT guidance , CT-guided micro-coil , a localization technique using barium [9–11], and intraoperative ultrasound . However, most of these procedures have some limitations. Here, we present an alternative simple method, CT-guided needle puncture, for preoperative localization of pulmonary nodules before VATS.
This retrospective study was approved by our institutional review board of Tri-Service General Hospital (TSGHIRB No.: 1-103-05-126), and written informed consent was not required because of strict maintenance of patient anonymity and the observational nature of the study.
Patients and procedures
From January 2011 to July 2014, 78 consecutive patients with pulmonary nodules detected by CT scan (incidental findings, follow up because of previous malignancy, or underlying diseases) were included. Clinical parameters, including age, sex, smoking status, histology, and stage, were recorded for each patient. The characteristics of CT findings were recorded for each lesion: (a) lesion size, (b) location, (c) density, and (d) lesion distance from pleural distance (PD). All CT images were evaluated in consensus by two chest radiologists (H.H.H. and K.H.K., with 23 and 7 years of experience, respectively). Lesion size was defined as longest lesion dimension and was measured manually with electronic calipers on our picture archiving and communication system (PACS, EBM Technologies Incorporated, Taiwan). Each nodule was classified according to its density as pure nodular GGO, part solid, or solid pattern. GGO was defined as a hazy increase in lung density without obscuration of the underlying bronchial or vascular structures. A nodule was classified as part solid if it contained patches that completely obscured the lung parenchyma. We defined a solid nodule as a nodule that completely obscures the entire lung parenchyma within it.
Pulmonary nodules were followed with high-resolution CT over an interval of 3 to 6 months. Indications of tissue diagnosis for these patients included increasing nodule size, increasing soft tissue component, and underlying malignancy. Obtaining diagnostic tissue before surgery was difficult for all of these patients after consultation of radiology physicians. The nodules were not amenable for preoperative tissue diagnosis because of small lesion (less than 1 cm), location (near the vessel), and patient’s concern (refuse biopsy).
Preoperative studies included PET–CT, abdominal ultrasound, and cardiopulmonary function. All the patients gave informed consent before the procedures. The technical details, operative findings, and pathological features of nodules were evaluated.
Data were entered into a spreadsheet program (Excel, Microsoft, Redmond, WA, USA). All analyses were performed using commercially available software (SPSS, version 12.2, 2004; SPSS, Chicago, IL, USA). The descriptive data were expressed as means ± standard deviation. Student’s t test was used to analyze continuous variables. The χ 2 test was used to compare categorical variables between groups. Results were regarded as significant when p < 0.05.
Clinical and CT characteristics of 91 nodules in 78 patients
Mean age (years)
57.24 ± 9.40
Mean, 8.6; range, 3.0–23.0
Nodule from pleural distance (mm)
Mean, 11.5; range, 3.0–31.3
Procedure associated complications and results
CT-guided marking complications (rate)
24 (26.4 %)
23 (29.49 %)
1 (1.28 %)
Conversion to thoracotomy (rate)
Mean procedure time (minutes)
Needle puncture >1
VAS pain score
Possible risk factors for pneumothorax
OR (95 % CI)
Age (>65 years)
Histopathologic results of indeterminate nodules
Chronic granulomatous inflammation
Summary of localization procedures
Chest wall pain, pneumothorax
Low complication rate
Same as above
Lung parenchyma damage
CT-guided barium spray
Same as above
Inflammatory reaction of tissue
Difficult for emphysematous lung
For lesion more than 1 cm
Diffuse into surrounding lung
Fluoroscopic-aided contrast medium
Adequate margins of resections on fluoroscopic imaging
Radio-guided thoracoscopic surgery
Real-time verifying stapled margin
Gamma ray detector
Diffusion or pleural spillage
Bronchoscopic metallic coil marking
Avoid pneumothorax, secondary hematoma, and the intravascular injection of substances originating in needling
Coil migration, cost
No dye, radiotracer, or contrast medium
Cooperation with radiologist
The most widely used technique is percutaneous hookwire placement. The hookwire technique showed a variable sensitivity (58 to 97.6 %) and a relatively high failure rate because of the dislodgment of the wire [13–15]. Radioactive technetium [16, 17] to localize pulmonary nodules could achieve high success rate, leading to flexible scheduling of the operation room (with 6 h half-life of radionuclide). However, the center must have the equipment and radiation protection to offer this procedure. The ultrasonography localization method offers a quick, more affordable, less invasive way of localizing lesions and high sensitivities of 92.6 to 100 % [12, 18, 19]. However, it is highly operator dependent and is limited by the emphysematous lungs. Methylene blue staining of the nodules provides an accurate method for localizing pulmonary nodules [19, 20]. In some cases of methylene blue localization, a tendency to diffuse rapidly into the surrounding lung parenchyma after dye injection was observed [19, 20]. It obstructed the use of this procedure. Fluoroscopic-aided resection using contrast media also yielded high success rates [21–23]. CT-guided percutaneous transthoracic barium localization can be an effective and convenient preoperative localization procedure. However, several studies have reported that barium can provoke a mild acute inflammatory and edematous reaction and may make the pathological diagnosis difficult [9–11]. Radio-guided localization of pulmonary nodules is a feasible and quick procedure with a high successful rate . However, spillage to the pleural space can lead to a wider area of radioactivity, which reduces the precision of the resection. In addition, the requirement for use of intraoperative gamma probes and the potential harmfulness of the radiotracer may limit the application of this technique. CT-guided bronchoscopic metallic coil marking might be a useful method for fluoroscopy-assisted thoracoscopic resection of pulmonary nodules . The advantage of this procedure can avoid complications such as pneumothorax and hematoma because of transbronchial route administration of metallic coil. However, this technique may not be applicable for lesions near the hilum of the lung. It also resulted in coil migration. In addition, the cost of coil and ultra-thin bronchoscope is expensive.
In this study, we show that CT-guided needle puncture is a simple, alternative procedure for localization of pulmonary nodules before VATS. There is no requirement for involvement of additional facilities such as ultrasound, radiotracer, barium, or contrast injection. All of these nodules in our patients were detectable by CT-guided needle punctures. There was no instance of conversion to open thoracotomy. Initially, we used a 20-gauge needle, but in some patients, the puncture holes could only be found after careful inspection. In some patients, we indentified the puncture hole after inflation/deflation of the lung (air bubble emerged from the puncture hole). With accumulation of the experiences, the puncture hole could be visualized easily with use of 17-gauge needle. The occurrence of pneumothorax was not significantly different between different needle sizes. However, because of the small size of this study, verification of this relationship may require additional patient data. In our preliminary experiences, there was no life-threatening pneumothorax. It was no necessary to put chest tube even if development with symptomatic pneumothorax even if there is development of symptomatic pneumothorax. In addition, a small percentage of pneumothorax may provide the clue of precise puncture of lung parenchyma.
Comparison of one versus two punctures
Single puncture group (n = 66)
Two punctures group (n = 25)
56.27 ± 8.98
59.80 ± 10.19
1.14 ± 0.69
1.15 ± 0.81
The advantage of this procedure is that the pre-localization CT scan can confirm the presence of nodules. Two patients avoided a VATS procedure after the pre-localization CT scan showed decreased size or disappearance of the lesion. This procedure is performed by radiologists and is very similar to the procedure for a CT-guided core needle biopsy, which most radiologists are very familiar, so that there was no additional learning curve or difficulty in performing this procedure. In addition, the procedure does not require additional facilities as do procedures such as radiotracer, contrast injection, coil insertion, or special ultrasound. There was no additional radiation exposure for the patients or physician during the operation and no necessity of a gamma probe to detection.
The limitations of this study are its small size and that it was a single-institution retrospective study. More convinced data should be obtained via including more patients and long-term follow-up. In addition, the cooperation of the radiologist and the use of available operating rooms are important. Prospective clinical trials of patients with indeterminate pulmonary nodules should be conducted to clarify the need for two punctures and the feasibility of using the technique for deeper lesions.
In conclusion, CT-guided needle puncture localization is feasible and simple for indeterminate pulmonary nodules before VATS. The procedure can result in a high success, low complications, and low cost without any additional facilities.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Swensen SJ, Jett JR, Hartman TE, Midthun DE, Mandrekar SJ, Hillman SL, et al. CT screening for lung cancer: five-year prospective experience. Radiology. 2005;235:259–65.View ArticlePubMedGoogle Scholar
- Henschke CI, McCauley DI, Yankelevitz DF, Naidich DP, McGuinness G, Miettinen OS, et al. Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet. 1999;354:99–105.View ArticlePubMedGoogle Scholar
- Congregado M, Merchan RJ, Gallardo G, Ayarra J, Loscertales J. Video-assisted thoracic surgery (VATS) lobectomy: 13 years’ experience. Surg Endosc. 2008;22:1852–7.View ArticlePubMedGoogle Scholar
- Powell TI, Jangra D, Clifton JC, Lara-Guerra H, Church N, English J, et al. Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic resection after computed tomography-guided localization using platinum microcoils. Ann Surg. 2004;240:481–8.PubMed CentralView ArticlePubMedGoogle Scholar
- Suzuki K, Nagai K, Yoshida J, Ohmatsu H, Takahashi K, Nishimura M, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest. 1999;115:563–8.View ArticlePubMedGoogle Scholar
- Cardillo G, Regal M, Sera F, Di Martino M, Carbone L, Facciolo F, et al. Videothoracoscopic management of the solitary pulmonary nodule: a single-institution study on 429 cases. Ann Thorac Surg. 2003;75:1607–11.View ArticlePubMedGoogle Scholar
- Chen S, Zhou J, Zhang J, Hu H, Luo X, Zhang Y, et al. Video-assisted thoracoscopic solitary pulmonary nodule resection after CT-guided hookwire localization: 43 cases report and literature review. Surg Endosc. 2011;25:1723–9.View ArticlePubMedGoogle Scholar
- Lizza N, Eucher P, Haxhe JP, De Wispelaere JF, Johnson PM, Delaunois L. Thoracoscopic resection of pulmonary nodules after computed tomographic-guided coil labeling. Ann Thorac Surg. 2001;71:986–8.View ArticlePubMedGoogle Scholar
- Kobayashi T, Kaneko M, Kondo H, Nakayama H, Asamura H, Tsuchiya R, et al. CT- guided bronchoscopic barium marking for resection of a fluoroscopically invisible peripheral pulmonary lesion. Jpn J Clin Oncol. 1997;27:204–5.View ArticlePubMedGoogle Scholar
- Okumura T, Kondo H, Suzuki K, Asamura H, Kobayashi T, Kaneko M, et al. Fluoroscopy-assisted thoracoscopic surgery after computed tomography-guided bronchoscopic barium marking. Ann Thorac Surg. 2001;71:439–42.View ArticlePubMedGoogle Scholar
- Asano F, Shindoh J, Shigemitsu K, Miya K, Abe T, Horiba M, et al. Ultrathin bronchoscopic barium marking with virtual bronchoscopic navigation for fluoroscopy-assisted thoracoscopic surgery. Chest. 2004;126:1687–93.View ArticlePubMedGoogle Scholar
- Khereba M, Ferraro P, Duranceau A, Martin J, Goudie E, Thiffault V, et al. Thoracoscopic localization of intraparenchymal pulmonary nodules using direct intracavitary thoracoscopic ultrasonography prevents conversion of VATS procedures to thoracotomy in selected patients. J Thorac Cardiovasc Surg. 2012;144:1160–5.View ArticlePubMedGoogle Scholar
- Gonfiotti A, Davini F, Vaggelli L, De Francisci A, Caldarella A, Gigli PM, et al. Thoracoscopic localization techniques for patients with solitary pulmonary nodule: hookwire versus radio-guided surgery. Eur J Cardiothorac Surg. 2007;32:843–7.View ArticlePubMedGoogle Scholar
- Bernard A. Resection of pulmonary nodules using video-assisted thoracic surgery. The Thorax Group. Ann Thorac Surg. 1996;61:202–4.View ArticlePubMedGoogle Scholar
- Mack MJ, Shennib H, Landreneau RJ, Hazelrigg SR. Techniques for localization of pulmonary nodules for thoracoscopic resection. J Thorac Cardiovasc Surg. 1993;106:550–3.PubMedGoogle Scholar
- Burdine J, Joyce LD, Plunkett MB, Inampudi S, Kaye MG, Dunn DH. Feasibilily and value of video-assisted thoracoscopic surgery wedge excision of small pulmonary nodules in patients with malignancy. Chest. 2002;122:1467–70.View ArticlePubMedGoogle Scholar
- Chella A, Lucchi M, Ambrogi MC, Menconi G, Melfi FM, Gonfiotti A, et al. A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection. Eur J Cardiothorac Surg. 2000;18:17–21.View ArticlePubMedGoogle Scholar
- Piolanti M, Coppola F, Papa S, Pilotti V, Mattioli S, Gavelli G. Ultrasonographic localization of occult pulmonary nodules during video-assisted thoracic surgery. Eur Radiol. 2003;13:2358–6.View ArticlePubMedGoogle Scholar
- Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with methylene blue. AJR Am J Roentgenol. 1994;163:297–300.View ArticlePubMedGoogle Scholar
- McConnell PI, Feola GP, Meyers RL. Methylene blue-stained autologous blood for needle localization and thoracoscopic resection of deep pulmonary nodules. J Pediatr Surg. 2002;37:1729–31.View ArticlePubMedGoogle Scholar
- Watanabe K, Nomori H, Ohtsuka T, Kaji M, Naruke T, Suemasu K. Usefulness and complications of computed tomography-guided lipiodol marking for fluoroscopy-assisted thoracoscopic resection of small pulmonary nodules: experience with 174 nodules. J Thorac Cardiovasc Surg. 2006;132:320–4.View ArticlePubMedGoogle Scholar
- Moon SW, Wang YP, Jo KH, Kwack MS, Kim SW, Kwon OK, et al. Fluoroscopy-aided thoracoscopic resection of pulmonary nodule localized with contrast media. Ann Thorac Surg. 1999;68:1815–20.View ArticlePubMedGoogle Scholar
- Nomori H, Horio H, Naruke T, Suemasu K. Fluoroscopy-assisted thoracoscopic resection of lung nodules marked with lipiodol. Ann Thorac Surg. 2002;74:170–3.View ArticlePubMedGoogle Scholar
- Ambrogi MC, Melfi F, Zirafa C, Lucchi M, De Liperi A, Mariani G, et al. Radio-guided thoracoscopic surgery (RGTS) of small pulmonary nodules. Surg Endosc. 2012;26:914–9.View ArticlePubMedGoogle Scholar
- Toba H, Kondo K, Miyoshi T, Kajiura K, Yoshida M, Kawakami Y, et al. Fluoroscopy-assisted thoracoscopic resection after computed tomography-guided bronchoscopic metallic coil marking for small peripheral pulmonary lesions. Eur J Cardiothorac Surg. 2013;44:e126–32.View ArticlePubMedGoogle Scholar