Electromagnetic Navigation-Guided One-Stage Dual Localization of Small Pulmonary Nodules

Abstract

We read with interest the study by Park and colleagues1Park C.H. Han K. Hur J. et al.Comparative effectiveness and safety of preoperative lung localization for pulmonary nodules: a systematic review and meta-analysis.Chest. 2017; 151: 316-328Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar in a previous issue of CHEST (February 2017) investigating the optimal method for preoperative localization of pulmonary nodules. The study concluded that hook-wire localization had lower successful operative field targeting rates, lipiodol localization had the highest overall success rates, and microcoil localization had the lowest complication rates.1Park C.H. Han K. Hur J. et al.Comparative effectiveness and safety of preoperative lung localization for pulmonary nodules: a systematic review and meta-analysis.Chest. 2017; 151: 316-328Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar From a surgeon’s perspective, there are other concerns when determining the optimal method of localization, in addition to success rates and complication rates. The location of the pulmonary nodule and the workflow are also important issues. The location of the lesion is important. A hook wire is associated with a higher dislodge rate for a nodule with a short pleura-to-lesion distance. Moreover, a hook wire is not a good choice when the length of the needle traversing the lung is not included in the extent of resection.2Wu C.H. Hsu P.K. Yeh Y.C. Chen C.K. Achieving a shorter pleura-to-lesion distance by using a coil to mark the fissure side in preoperative lung nodule localization.Kaohsiung J Med Sci. 2017; 33: 104-106Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Furthermore, identifying the target lesion will be difficult if a single microcoil is placed deep within the lung parenchyma. We propose a “dual localization” technique using indocyanine green (ICG) and a microcoil. It was possible to identify the position of the target lesion on the basis of the clear images created by ICG on the pleural surface (Fig 1A), and the distance required between the microcoil and the resection could be confirmed by intraoperative fluoroscopy (Fig 1B). The workflow is crucial. A two-stage workflow with localization performed in a radiology suite followed by resection in an OR increases the risks of dislodgement and migration. Furthermore, potential complications such as pneumothorax and hemorrhage can occur since the duration between localization and surgery may last for hours. A one-stage workflow, namely, localization in the OR followed by immediate resection, can be achieved using a thoracic navigation system. Similar to navigational bronchoscopy, the SPiN Perc thoracic navigation system (Veran Medical Technologies)3Arias S. Lee H. Semaan R. et al.Use of electromagnetic navigational transthoracic needle aspiration (E-TTNA) for sampling of lung nodules.J Vis Exp. 2015; 99: e52723Google Scholar determines the sensor device’s spatial location, which is overlaid onto existing anatomic images; thus, the movement of the sensor device can be tracked relative to images of the patient’s anatomy. Of note, the sensor device is placed on the stylet of a percutaneous needle that can be advanced through the chest wall toward the target lesion under electromagnetic navigational guidance (Fig 1C). The localization procedure can be completed percutaneously, regardless of the accessibility of the lesion by bronchoscopy. Importantly, a hybrid OR is not necessary. Although various techniques have been reported as solutions for small pulmonary lesions, studies comparing different methods are limited. The work done by Park and colleagues is commendable. However, we propose a one-stage dual-localization technique using ICG and a microcoil, and guided by an electromagnetic navigation system, as an efficient method for precise resection of small pulmonary nodules. Comparative Effectiveness and Safety of Preoperative Lung Localization for Pulmonary Nodules: A Systematic Review and Meta-analysisCHESTVol. 151Issue 2PreviewAn optimal method of preoperative localization for pulmonary nodules has yet to be established. This systematic review and meta-analysis aimed to compare the success and complication rates associated with three pulmonary nodule localization methods for video-assisted thoracoscopic surgery (VATS): hook-wire localization, microcoil localization, and lipiodol localization. Full-Text PDF ResponseCHESTVol. 154Issue 6PreviewThis is in response to the letter by Drs Hsu and Wu, which added a new perspective to our article1 comparing three preoperative lung localization methods. Full-Text PDF