Thoracoscopic detection of occult indeterminate pulmonary nodules using bronchoscopic pleural dye marking

Abstract

BackgroundThe annual incidence of a small indeterminate pulmonary nodule (IPN) on computed tomography (CT) scan remains high. While traditional paradigms exist, the integration of new technologies into these diagnostic and treatment algorithms can result in alternative, potentially more efficient methods of managing these findings.MethodsWe report on an alternative diagnostic and therapeutic strategy for the management of an IPN. This approach combines electromagnetic navigational bronchoscopy (ENB) with an updated approach to placement of a pleural dye marker. This technique lends itself to a minimally invasive wedge resection via either video-assisted thoracoscopic surgery (VATS) or a robotic approach.ResultsSubsequent to alterations in the procedure, a cohort of 22 patients with an IPN was reviewed. Navigation was possible in 21 out of 22 patients with one patient excluded based on airway anatomy. The remaining 21 patients underwent ENB with pleural dye marking followed by minimally invasive wedge resection. The median size of the nodules was 13.4 mm (range: 7–29). There were no complications from the ENB procedure. Indigo carmine dye was used in ten patients. Methylene blue was used in the remaining 11 patients. In 81% of cases, the visceral pleural marker was visible at the time of surgery. In one patient, there was diffuse staining of the parietal pleura. In three additional patients, no dye was identified within the hemithorax. In all cases where dye marker was present on the visceral pleural surface, it was in proximity to the IPN and part of the excised specimen.ConclusionsENB with pleural dye marking can provide a safe and effective method to localize an IPN and can allow for subsequent minimally invasive resection. Depending on the characteristics and location of the nodule, this method may allow more rapid identification intraoperatively.

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

“…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). Although a potentially promising technique, success rates as low as 81% have been reported due to both diffusion of the dye in the pleural space and lack of visualization of the dye (53).…”

“…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). Although a potentially promising technique, success rates as low as 81% have been reported due to both diffusion of the dye in the pleural space and lack of visualization of the dye (53). This technique has also been used in children, with one series reporting lung tattooing and VATS resection during the same general anaesthetic (55,56).…”

A novel technique for tumor localization and targeted lymphatic mapping in early-stage lung cancer

“…Total procedure time including NB-guided peritumoral injection was similar to previous reports adding on average 20 minutes to the operative time for both diagnosis, when indicated, and labeling of the lesions 29 . Importantly, other approaches to intraoperative detection of pulmonary nodules have been described, including lesion localization with blue dyes, microcoils, percutaneous wire placement and intravenous ICG, but none of these techniques permit concurrent SLN mapping for the lesion of interest 30–35 .…”

MDT lung cancer care: Input from the Surgical Oncologist

“…Electromagnetic navigational bronchoscopy uses sensor-location technology in concert with a 3D reconstruction of CT scan data in order to guide a bronchoscopic probe to a lung nodule. 11,12 This yields a virtual bronchoscopic reconstruction that can be paired with true bronchoscopic images to facilitate injection of dye or fiducial. The few reported human studies on this topic are small case series.…”

“…11 Bolton et al reported 100% localization in 11 patients using methylene blue dye via electromagnetic navigational bronchoscopy followed by robotic wedge resection. 12 Both studies reported no need for conversion to open resection or adverse events related to the marking procedure.…”