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Needle Localization of Small Pulmonary Nodules - Lessons Learned in Over 250 Cases
*Patricia A Thistlethwaite, Jonathan Gower, Andrew Picel, Anne Roberts
University of California, San Diego, La Jolla, CA

BACKGROUND:
Lung masses that are small and deep within lung parenchyma are often challenging to localize with VATS. Here we describe our cumulative experience using needle localization of small masses prior to surgical resection. We report procedural tips, operative results, as well as lessons learned over time.
METHODS:
From July 1, 2009 until December 2016, 253 patients underwent needle localization of lung masses ranging between 0.5 - 1.1 cm under CT guidance, prior to surgery. Nodules were localized by placing two 20-gauge Hawkins III needles from different trajectories with tips adjacent to the mass, injection of 0.4 cc of methylene blue, deployment of 2 hook wires, and needle removal. Surgical wedge resection then established the diagnosis of adenocarcinoma in 139 patients, metastatic carcinoma in 45 patients, squamous cell carcinoma in 24 patients, fungal disease in 22 patients, large cell carcinoma in 9 patients, tuberculosis in 6 patients, sarcoidosis in 4 patients, radiation scar in 2 patients, and carcinoid in 2 patients. Intraoperative and perioperative outcomes were assessed.
RESULTS:
Needle localization was successful in 243 patients (96.0%). Failures included: 1) wires falling out of lung parenchyma prior to operation (7 patients), 2) wire migration (2 patients), and 3) bleeding resulting in hematoma requiring transfusion (1 patient). The most common complication of needle localization was asymptomatic pneumothorax (12/254 total patients; 4.7%), and was higher in patients with bullous emphysema (9/55 patients; 16.4%). Only 1 patient required chest tube placement for symptomatic pneumothorax prior to operation. Of the 10 individuals who had unsuccessful needle localization, 9 had successful wedge resection in the area of methylene blue injection that included the mass; 1 required segmentectomy for diagnosis. Completion lobectomy (158 VATS, 2 mini-thoracotomy/172 patients) or VATS segmentectomy (12/172 patients) were performed based on preoperative pulmonary function testing, for patients with an intraoperative diagnosis of non-small cell carcinoma. The average length of hospital stay for wedge resection was 1.4 days, for VATS segmentectomy was 1.9 days, for VATS lobectomy was 3.1 days, and for mini-thoracotomy was 4.9 days. Perioperative survival was 100%.
CONCLUSIONS:
Needle localization is an effective strategy to localize small, deep lung lesions for wedge resection and diagnosis. Multidisciplinary coordination between the thoracic surgeon and interventional radiologist is key to the success of this procedure.


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