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

Abstract

ObjectiveTo 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 MethodsFrom 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.ResultsAll 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.ConclusionCT-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.

CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature

“…In one series, there was a delay up to one day after contrast injection until VATS resection, although this time lag did not affect the success of the procedure (47). The sole use of methylene blue, India ink, lipiodol and barium have also be reported in a few small series (48)(49)(50)(51)(52). Similar to the microcoil technique described above, most series involve the percutaneous placement of the contrast material yet some recent reports are using bronchoscopic guidance for pleural dye marking (53,54).…”

Pulmonary subsolid nodules: what radiologists need to know about the imaging features and management strategy

“…Lee et al (54) recently reported their results on CT-guided percutaneous barium marking of SSNs prior to video-assisted thoracoscopic surgery (VATS) (Fig. 8).…”

“…Because SSNs are often impalpable in the operation field and indistinguishable from the normal parenchyma exteriorly, preoperative marking techniques have been reported for localization during thoracoscopic surgery using a dye, colored collagen, barium, lipiodol, microcoil, or a metallic wire (53). Either a percutaneous approach or a transbronchial approach can be used (54).…”

“…Today, metallic hook wire localization under CT guidance is the most widely used technique (54). CT-guided hook wire localization is accurate in localizing the lesion, is simple to operate, and helps facilitate the complete excision of the nodule by the use of an endostapler because the presence of a wire hook makes it possible to exert slight traction (55).…”

“…8). In their study, all target nodules were marked within a 3 mm distance from the injected barium sulfate suspension, and all barium balls were completely resected after visualization by intraoperative fluoroscopy (54).…”