Small Peripheral Pulmonary Nodules Research Articles

Robot-Assisted Bronchoscopy for Identification of Lung Nodules During Minimally Invasive Pulmonary Resection.

Small pulmonary nodules can be difficult to identify during minimally invasive surgical (MIS) resection. Previous investigators have reported using standard bronchoscopy with electromagnetic navigation to identify small pulmonary nodules. Robot-assisted bronchoscopy has been introduced into clinical practice and has shown utility for the biopsy of small lesions. We report our experience using robot-assisted bronchoscopy with dye marking to aid in minimally invasive pulmonary resection. Patients with peripheral pulmonary nodules underwent robot-assisted bronchoscopy before a planned minimally invasive resection. Indocyanine green or methylene blue was injected directly into the targeted lesion. Surgical resection was then immediately performed. Success was defined as dye visualization leading to sublobar resection of the target nodule without the need for lobectomy or thoracotomy. Thirty patients with a single targeted nodule underwent robot-assisted bronchoscopy followed by MIS resection. The median lesion size was 9 mm (4 to 25 mm), and the median distance from the pleura was 5 mm (1 to 32 mm). The success rate was 83.3% (25 of 30). There were 3 cases in which the dye was not visualized, and in 2 cases there was free extravasation of dye. The targeted nodule was identified in these 5 patients without the need for thoracotomy or lobectomy. Pathology revealed non-small cell lung cancer (n = 13, 43.3%), metastatic disease (n = 11, 36.7%), and benign disease (n = 6, 20%). There were no complications related to the use of robot-assisted bronchoscopy. Robot-assisted bronchoscopy with dye marking is safe and effective for guiding minimally invasive resection of small peripheral pulmonary nodules.

Rapid on-site evaluation of touch imprint cytology in navigation bronchoscopy for small peripheral pulmonary nodules.

Rapid on-site evaluation (ROSE) of cytopathology plays an important role in determining whether representative samples have been taken during navigation bronchoscopy. With touch imprint cytology (TIC), histologic samples can be assessed using ROSE. Although advised by guidelines, there have been almost no studies on the performance of TIC during navigation bronchoscopy. The objective of this study was to evaluate the value of TIC-ROSE (forceps/cryobiopsy) in combination with conventional ROSE (cytology needle/brush). In this single-center, prospective cohort study, patients who had pulmonary nodules with an indication for navigation bronchoscopy were consecutively included. The primary outcome of the study was the concordance of ROSE and the procedural outcome. The concordance rates of TIC-ROSE and the combination of TIC-ROSE plus conventional ROSE were compared. Fifty-eight patients with 66 nodules were included. Conventional ROSE and TIC-ROSE were assessable in 61 nodules (90.9%) each. By combining both ROSE techniques, all sampled lesions were assessable. Combining conventional ROSE with TIC-ROSE showed concordant results in 51 of 66 cases (77.3%) versus 44 of 66 (66.7%) and 48 of 66 (72.8%) concordant results for conventional ROSE and TIC-ROSE alone, respectively, compared with the procedural outcome. There was no indication of tissue depletion as a result of TIC. The combined ROSE approach had a statistically significant higher concordance rate compared with conventional ROSE alone. TIC-ROSE is a cheap, easily implementable technique that can result in higher concordant ROSE outcomes. This could lead to more efficient procedures and possibly higher diagnostic results. In a monomodality sampling setting with only histologic samples, TIC can provide ROSE.

Comparative analysis of the efficacy and safety of electromagnetic navigation bronchoscopy combined with x-ray or radial endobronchial ultrasound biopsy in the diagnosis of small peripheral pulmonary nodules.

To compare the clinical value and safety of electromagnetic navigation bronchoscopy (ENB) combined with radial endobronchial ultrasound (R-EBUS) or x-ray in the diagnosis of small peripheral pulmonary nodules that cannot be diagnosed by conventional bronchoscopy. Fifty-six patients with peripheral pulmonary nodules of <3 cm in diameter who underwent bronchoscopy at the First Affiliated Hospital of Soochow University and Dushu Lake Hospital of Soochow University from February 2019 to January 2022 were selected as the study subjects, including 24 patients who underwent ENB combined with x-ray and 32 patients who underwent ENB combined with R-EBUS. ENB was used as the guiding method in both groups, and x-ray group and R-EBUS group were combined with x-ray and R-EBUS, respectively, to determine whether the lesion was reached. In x-ray group, biopsy and brushing were performed under fluoroscopic guidance. Using the results of surgery, puncture pathology, or clinical follow-up 1 year as the gold standard, the diagnostic sensitivity, specificity, negative predictive value (NPV), diagnostic yield, negative likelihood ratio (LR-), Youden index, missed diagnosis rate, success rate, and κ value were compared between the two groups, and the occurrence of postoperative complications was also compared between the two groups. The negative predictive value of the R-EBUS group was significantly better than that of the x-ray group (p = 0.006). Even with smaller nodule diameters, the negative predictive value of ENB combined with R-EBUS were still higher than that of the x-ray group.

Cone-Beam Computed-Tomography-Derived Augmented Fluoroscopy-Guided Biopsy for Peripheral Pulmonary Nodules in a Hybrid Operating Room: A Case Series

Lung cancer is the most lethal cancer type in Taiwan and worldwide. Early detection and treatment advancements have improved survival. However, small peripheral pulmonary nodules (PPN) biopsy is often challenging, relying solely on bronchoscopy with radial endobronchial ultrasound (EBUS). Augmented fluoroscopy overlays the intra-procedural cone-beam computed tomography (CBCT) images with fluoroscopy enabling real-time three-dimensional localization during bronchoscopic transbronchial biopsy. The hybrid operating room (HOR), equipped with various types of C-arm CBCT, is a perfect suite for PPN diagnosis and other interventional pulmonology. This study shares the single institute experience of EBUS transbronchial biopsy of PPN with the aid of augmented fluoroscopic bronchoscopy (AFB) and CBCT in an HOR. We retrospectively enrolled patients who underwent robotic CBCT, augmented fluoroscopy-guided, radial endobronchial ultrasound-confirmed transbronchial biopsy and cryobiopsy in a hybrid operating room. Patient demographic characteristics, computed tomography images, rapid on-site evaluation cytology, and final pathology reports were collected. Forty-one patients underwent transbronchial biopsy and 6 received additional percutaneous transthoracic core-needle biopsy during the same procedure. The overall diagnostic yield was 88%. The complications included three patients with pneumothorax after receiving subsequent CT-guided percutaneous transthoracic needle biopsy, and two patients with hemothorax who underwent transbronchial cryobiopsy. Overall, the bronchoscopic biopsy of PPN using AFB and CBCT as precise guidance in the hybrid operating room is feasible and can be performed safely with a high diagnostic yield.

Localization of small peripheral pulmonary nodules for surgical resection: a new intraoperative technique in hybrid operating room

ObjectiveThe purpose of this study was to introduce a new feasible and effective intraoperative localization technique for small peripheral pulmonary nodules in hybrid operating room.MethodsBetween June 2020 and June 2021, the intraoperative localization was performed in 27 patients for 35 small pulmonary nodules at our institution. The procedure was undergone under thoracoscopic observation. After making the VATS ports, a titanium clip was clipped at the visceral pleura as near the pulmonary nodule as possible to be a marker for the nodule. VATS resection was performed next.ResultsA total of 27 patients were included in this study, including 6 males and 21 females. The median age was 58 years (range 34–78 years). All surgeries were performed by two-port VATS. A total of 35 pulmonary nodules underwent intraoperative localization. The mean diameter of nodules was 10.6 ± 3.7 mm. The distance of nodules to visceral pleura was 8.3 ± 8.7 mm. The mean localization time was 23.3 ± 3.3 min. The median time of C-arm scanning was 3 (range 2–4) times. The median times for clipping were 2 (range 1–3) times. All the nodules were localized successfully and resected precisely. No VATS were converted to thoracotomy. There were no complications related to localization procedures.ConclusionsThis new intraoperative localization technique was feasible, safe and effective. And also the intraoperative procedure could avoid extra suffering for patients.

Ion: Technology and Techniques for Shape-sensing Robotic-assisted Bronchoscopy

PurposeThis report describes the Ion Endoluminal System (Intuitive Surgical, Inc, Sunnyvale, CA) and practices for safe and effective use in patients with small peripheral pulmonary nodules (PPNs). DescriptionThis shape-sensing robotic-assisted bronchoscopy system allows airway visualization and navigation to reach and biopsy small PPNs through a stable platform. The system provides 3-dimensional mapping and visualization of the airways, a flexible and fully articulating 3.5-mm (outer diameter) catheter, a peripheral vision probe, and system-specific biopsy needles. EvaluationThe Ion Endoluminal System was evaluated in an ongoing prospective, multicenter trial including 241 patients with 270 PPNs (largest mean cardinal measurement, 18.8 ± 6.5 mm). Mean time to register and navigate decreased from 10 minutes in the first 10 cases to 7 minutes in the subsequent cases. Asymptomatic pneumothorax occurred in 8 patients (3.3%), 1 (0.4%) with pigtail catheter placement. Two patients (0.8%) experienced airway bleeding; both cases of bleeding resolved within 5 minutes of tamponade. ConclusionsThe Ion Endoluminal System’s unique shape-sensing technology can be leveraged to facilitate localization and sampling of PPNs and potentially improve diagnostic accuracy.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection.

BackgroundThoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.MethodsFrom January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.ResultsForty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9–14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6–16 mm). The median ENB length was 25 min (19–33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.ConclusionsENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Ultrasound-Guided Percutaneous Core Needle Biopsy of Peripheral Pulmonary Nodules ≤ 2cm: Diagnostic Performance, Safety and Influence Factors.

PurposeTo evaluate diagnostic performance and safety of ultrasound-guided needle biopsy in the diagnosis of peripheral pulmonary nodules (PPLs) ≤ 2 cm, and the influence factors of sample adequacy and safety.Materials and Methods194 patients (99 men, 95 women; mean age, 56.2 ± 13.7 years) who received biopsy for PPLs ≤ 2 cm between January 2014 to January 2019 were included. Variables including patient demographics, lesion location, lesion size, presence of lesion necrosis, presence of emphysema on CT, patient position, biopsy needle size and number of needle passes were recorded. Univariate analysis and multivariate logistic regression analysis were performed to explore the influence factor of sample adequacy and safety.ResultsBiopsy specimens were adequate for diagnosis in 161/194 (83%) cases; the diagnostic accuracy was 81.4% (158/194). The overall complication rate was 8.8% (17/194), including pneumothorax, hemoptysis and pleural effusion, which occurred in 2.1% (4/194), 5.2% (10/194), and 1.5% (3/194) of patients, respectively. The incidence of pneumothorax in the 16-gauge-needle group were significantly higher than that of the 18-gauge-needle group (5.6% vs 0%, P=0.018). Adequate sampling of 16-gauge and 18-gauge needles were achieved in 90.3%(65/72) and 78.7%(96/122) cases, respectively. Multivariate logistic regression analysis revealed needle size (16-gauge vs 18-gauge) was an independent influence factors of sample adequacy (P=0.015, odds ratio=3.419). A receiver operating characteristic curve was plotted and the area under the curve was 0.774.ConclusionUS-guided percutaneous needle biopsy is a feasible and safe technique for small PPLs ≤ 2 cm. Needle size is an independent influence factor of sample adequacy and post-procedure pneumothorax. Sixteen-gauge needle has the advantage of achieving adequate sample for pathological analysis, though the risk of pneumothorax should be alerted.

Simultaneous development of COVID-19 pneumonia and pulmonary metastasis in a known case of chondrosarcoma: a case report

BackgroundThe outbreak of coronavirus disease 2019 (COVID-19) started in December 2020, and is a global problem now. There are several sets of established data regarding computed tomography (CT) findings in COVID-19 pneumonia with many differential diagnoses. During the early days of the pandemic, there was little data regarding lung CT features of COVID-19 in a cancer patient. In this paper, we described a rare case of simultaneous presentation of COVID-19 with pulmonary metastasis.Case presentationA Persian patient with a history of chondrosarcoma presented to our clinic during the COVID-19 pandemic with a new-onset cough. He had experienced no recurrence during previous follow-up visits. Chest CT scan revealed numerous bilateral small peripheral and perilymphatic pulmonary nodules, unilateral ground-glass patch, and nodular interlobular septal thickening. Biopsy of the pulmonary nodules established pulmonary metastasis of chondrosarcoma origin, and pharyngeal reverse transcription polymerase chain reaction (RT-PCR) was positive for COVID-19.ConclusionPulmonary metastasis should be considered as a differential diagnosis of COVID-19 features in cancer patients in the pandemic era.

CT-Guided Microcoil Localization of Small Peripheral Pulmonary Nodules to Direct Video-Assisted Thoracoscopic Resection without the Aid of Intraoperative Fluoroscopy.

ObjectiveTo evaluate the feasibility, safety, and effectiveness of CT-guided microcoil localization of solitary pulmonary nodules (SPNs) for guiding video-assisted thoracoscopic surgery (VATS).Materials and MethodsBetween June 2016 and October 2019, 454 consecutive patients with 501 SPNs who received CT-guided microcoil localization before VATS in our institution were enrolled. The diameter of the nodules was 0.93 ± 0.49 cm, and the shortest distance from the nodules to the pleura was 1.41 ± 0.95 cm. The distal end of the microcoil was placed less than 1 cm away from the nodule, and the proximal end was placed outside the visceral pleura. VATS was performed under the guidance of implanted microcoils without the aid of intraoperative fluoroscopy.ResultsAll 501 nodules were marked with microcoils. The time required for microcoil localization was 12.8 ± 5.2 minutes. Microcoil localization-related complications occurred in 179 cases (39.4%). None of the complications required treatment. A total of 463 nodules were successfully resected under the guidance of implanted microcoils. VATS revealed 38 patients with dislocated microcoils, of which 28 underwent wedge resection (21 cases under the guidance of the bleeding points of pleural puncture, 7 cases through palpation), 5 underwent direct lobectomy, and the remaining 5 underwent a conversion to thoracotomy. In 4 cases, a portion of the microcoil remained in the lung parenchyma.ConclusionCT-guided microcoil localization of SPNs is safe and reliable. Marking the nodule and pleura simultaneously with microcoils can effectively guide the resection of SPNs using VATS without the aid of intraoperative fluoroscopy.

Electromagnetic navigational bronchoscopy-directed dye marking for locating pulmonary nodules

BackgroundSmall peripheral pulmonary nodules, which are usually deep-seated with no visual markers on the pleural surface, are often difficult to locate during surgery. At present, CT-guided percutaneous techniques are used...

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy.

Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection. To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study. NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort. The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10mm (range 4-22) and 83.3% were <20mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0mm from the pleura. The median ENB-specific procedure time was 11.5minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24). In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

First Human Use of a New Robotic-Assisted Fiber Optic Sensing Navigation System for Small Peripheral Pulmonary Nodules

Background: We tested a new, investigational robotic-assisted bronchoscope system with a remotely controlled catheter to access small peripheral bronchi with real-time driving under live visualization and distal tip articulation of the catheter. The unique catheter remains stationary once located at the biopsy position. Objectives: The primary objectives of this study were to evaluate the safety and feasibility of a new shape-sensing robotic bronchoscope system to bronchoscopically approach and facilitate the sampling of small peripheral pulmonary nodules of 1–3 cm. Secondary objectives included evaluating procedural characteristics and early performance trends associated with the use of the new robotic bronchoscope system. Methods: Subjects were enrolled according to study eligibility criteria at a single center. Navigation pathways were semi-automatically created using pre-procedure CT scans. Simultaneous (real-time) viewing of actual and virtual bronchi was used real time during navigation to the displayed target. An endobronchial ultrasound mini-probe was used to confirm lesion location. Flexible 19- to 23-G needles specifically designed to accommodate tight bend radii in transbronchial needle aspiration were used along with conventional biopsy tools. Enrolled subjects completed follow-up visits up to 6 months after the procedure. Results: The study included 29 subjects with a mean lesion size of 12.2 ± 4.2, 12.3 ± 3.3, and 11.7 ± 4.1 mm in the axial, coronal, and sagittal planes, respectively. The CT bronchus sign was absent in 41.4% of cases. In 96.6% of cases, the target was reached, and samples were obtained. No device-related adverse events and no instances of pneumothorax or excessive bleeding were observed during the procedure. Early performance trends demonstrated an overall diagnostic yield of 79.3% and a diagnostic yield for malignancy of 88%. Conclusion: This new robotic-assisted bronchoscope system safely navigated to very small peripheral airways under continuous visualization, and through maintenance of a static position, it provides a unique sampling capability for the biopsy of small solitary pulmonary nodules.

Intraoperative Percutaneous Microcoil Localization of Small Peripheral Pulmonary Nodules Using Cone-Beam CT in a Hybrid Operating Room.

OBJECTIVE. Thoracoscopic surgical resection of small peripheral pulmonary nodules can be challenging, and often preoperative localization techniques are needed to avoid conversion to open thoracotomy. In this article, we show the feasibility and benefits of performing intraoperative percutaneous microcoil localization with C-arm cone-beam CT in a hybrid operating room immediately before video-assisted thoracoscopic surgery for wedge resection of a small pulmonary nodule. CONCLUSION. This technique can provide safe and accurate localization while minimizing patient discomfort and thus enhancing the patient's experience.

Cryobiopsie endobronchique associée à la navigation électromagnétique peropératoire pour guider la résection chirurgicale des nodules pulmonaires périphériques de petite taille

Cryobiopsie endobronchique associée à la navigation électromagnétique peropératoire pour guider la résection chirurgicale des nodules pulmonaires périphériques de petite taille

Microcoil-Guided Video-Assisted Thoracoscopic Excision of Nodules Suspicious for Metastasis in Patients With Extra-Thoracic Malignancies

The purpose of this study is to determine the utility of preoperative CT-guided microcoil localization followed by fluoroscopy guided video-assisted thoracoscopic resection in the diagnosis and management of small peripheral pulmonary nodules in patients with extra-thoracic malignancies. This study is a retrospective analysis of prospectively collected data between August 2003 and September 2013. Fifty patients with extra-thoracic malignancies underwent preoperative localization of small indeterminate pulmonary nodules using CT-guided microcoil localization. Nodules were then resected by video-assisted thoracoscopic resection wedge excision and intraoperative fluoroscopy guidance. Univariate and multivariate logistic regression analysis were conducted. Fifty patients with a history of 14 different extra-thoracic cancers (57% female, mean age 62 years) had 55 nodules resected (mean size = 12 mm, depth from visceral pleura = 22 mm). Histology of resected nodules showed metastasis (25 of 50 patients), benign (10 of 50), and (15 of 50) early stage primary lung cancer. Smokers were found 6 times more likely to present with primary lung cancer than metastasis (P < 0.009). CT-guided microcoil localization procedure was successful in all patients with a mean time of 31(10) minutes and allowed successful wedge resection in all cases with no major complications. The mean operative time and fluoroscopy time were 27(12) minutes and 3(5) minutes, respectively. Microcoil-guided thoracoscopic wedge resection was effective in achieving early definitive diagnosis and changed management in 50% of patients with presumed metastasis with minimal morbidity.

Video-Assisted Thoracic Surgery Resection without Intraoperative Fluoroscopy after CT-Guided Microcoil Localization of Peripheral Pulmonary Nodules

The aim of this brief report is to determine the safety and reliability of minimally invasive video-assisted thoracic surgery (VATS) resection without the aid of intraoperative fluoroscopy after computed tomography (CT)–guided microcoil localization of small peripheral pulmonary nodules. Twenty patients with peripheral lung nodules underwent percutaneous needle localization with a microcoil that was tagged back to the visceral pleural surface. Same-day VATS resection was performed without the use of intraoperative fluoroscopy. All 20 nodules were successfully localized in the CT procedure room, and all 20 nodules were resected with negative margins and no major complications.

Computed tomography-guided preoperative localization of small lung nodules with indocyanine green.

Background Small, deep-seated lung nodules and sub-solid nodules are often difficult to locate without marking. Purpose To evaluate the success and complication rates associated with the use of indocyanine green (ICG) to localize pulmonary nodules before resection. Material and Methods This retrospective study was approved by our institutional review board. Informed consent for performing preoperative localization using ICG marking was obtained from all patients. Thirty-seven patients (14 men, 23 women; mean age = 63.1 years; age range = 10-82 years) with small peripheral pulmonary nodules underwent computed tomography (CT)-guided ICG marking immediately before surgery between March 2007 and June 2016. The procedural details and complication rates associated with ICG marking are described. Results The average nodule size and depth were 9.1 mm (range = 2-22 mm) and 9.9 mm (range = 0-33 mm), respectively. Marking was detected at the pleural surface in 35 patients (95%). Three cases of mild pneumothorax (8%), five cases of cough (14%), and one case of mild bloody sputum (3%) with no clinical significance were noted. There were no severe complications. The average duration required to perform the marking was 19.4 min (range = 12-41 min). Conclusion Our results indicate that CT-guided ICG marking is safe and useful for detecting the location of small pulmonary nodules preoperatively.

First Human Use of a New Robotic-Assisted Navigation System for Small Peripheral Pulmonary Nodules Demonstrates Good Safety Profile and High Diagnostic Yield

First Human Use of a New Robotic-Assisted Navigation System for Small Peripheral Pulmonary Nodules Demonstrates Good Safety Profile and High Diagnostic Yield

Noninvasive computed tomography-guided marking technique for peripheral pulmonary nodules.

Identification of the exact location of small peripheral pulmonary nodules during thoracoscopic wedge resection (TWR) is crucial. We describe a new method of computed tomography (CT)-guided marking without puncturing the visceral pleura (VP) for minimally palpable pulmonary nodules. Preoperative CT scans were performed 1 day before TWR with the patient in the lateral decubitus position. Under CT guidance, we marked the skin over the pulmonary nodule. During TS, an indwelling catheter was inserted perpendicular to the marked skin surface and put a mark with gentian violet (Pyoktanin blue®, Wako Pure Chemical Industries, Osaka, Japan) onto the VP. We palpated the nodules near the mark(s) and performed TWR. Between October 2012 and April 2016, we performed CT-guided marking in 54 patients (24 males and 30 females, median age 65 years). Cases included 39 primary lung cancers, 10 metastatic lung tumors, and 5 benign tumors. The mean diameter of the nodules was 10 mm (range, 3-26 mm), and the mean distance of the nodule from the VP was 4 mm (range, 0-17 mm). The mean time of intraoperative marking was 3.5 min (range, 1-4.5 min). The mean distance from the nodule to the marking point was 7.0 mm (range, 0-30 mm). We were able to identify the location of the nodule using this procedure in 53 patients (98%). Hematoma of the chest wall after marking was observed in one patient. There were no other complications. This marking technique is a simple, economic, and effective procedure to locate small peripheral pulmonary nodules during TWR.