LOCALIZATION OF PERIPHERAL PULMONARY NODULES FOR THORACOSCOPIC EXCISION - VALUE OF CT-GUIDED WIRE PLACEMENT

OBJECTIVE. One of the indications for the rapidly expanding use of tho racoscopic surgery as an alternative to thoracotomy is the excision of peripheral lung nodules. Nodules judged too small or too far from the pleural surface to be seen or palpated during thoracoscopy must be lo calized beforehand. The purpose of this study was to evaluate the feas ibility and effectiveness of percutaneous placement of spring hook-wir es to localize such nodules before video-assisted thoracoscopy. SUBJEC TS AND METHODS. Under CT guidance, 17 nodules in 14 patients were preo peratively localized with the Kopans breast lesion localization system . Three patients who had solitary nodules had thoracoscopic resections for diagnosis because a previous transthoracic needle or transbronchi al biopsy had been unsuccessful. Four patients who had lesions less th an 8 mm in diameter had thoracoscopic biopsies because transthoracic f ine-needle aspiration biopsy was not likely to be diagnostic. Seven pa tients, who had a total of 10 nodules, had therapeutic wedge resection s of either limited metastases or a second bronchogenic carcinoma. Mea n nodule diameter was 10 mm (range, 3-20 mm). The mean distance from n odule to costal pleura was 9 mm (range, 0-25 mm). At the end of the pr ocedure, wire placement was confirmed by CT scanning. After thoracosco py, the surgeons were questioned about the stability and utility of ea ch hookwire localization. RESULTS. In all 17 procedures, a hookwire wa s placed successfully. In one case, the wire dislodged before thoracos copy (after a 6-hr preoperative delay and severe bending of the wire d uring induction of anesthesia). In 16 of the 17 resections, the surgeo n thought that thoracoscopic identification of the lesion would not ha ve been possible without hookwire localization. Only one localization, across a major fissure, required placement of a second wire to locali ze a nodule. Wire-related complications included two instances of seri ous pain, five cases of clinically insignificant pneumothorax, and one large pneumothorax requiring drainage before a second nodule in the s ame lung was localized. CT scanning showed presumed local pulmonary he morrhage in six cases without hemoptysis or hemothorax. CONCLUSION. CT -guided hookwire localization is easily and safely performed and permi ts thoracoscopic resection of lung nodules, which might otherwise be i mpossible.