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OBJECTIVE: Increasingly, localization of small lung nodule (solid or ground glass) is needed for thoracoscopic resection of accurate diagnostic and/or curative intent. Hook wire implantation is one of important localization techniques. Meanwhile, tumor recurrence in the chest wall of the percutaneous FNA tract is well known in thoracic malignancy, particularly lung cancer.
METHODS: We report the case of a 64-year-old-man with tumor recurrence of the chest wall. Eight months earlier, he underwent hook wire-guided thoracoscopic resection of RUL nodule and further anterior segmentectomy because of intraoperative diagnosis of NSCLC (squamous cell carcinoma, pT1aN0M0 IA). Location of the chest wall tumor was coincident with the hook wire tract. The tumor was resected en-bloc, and reported as a metastatic squamous cell carcinoma.
RESULTS: If a small lung nodule (solid or ground glass) is suspected to be malignant on CT and/or PET scan, but neither visualized nor palpable on thoracoscopic exploration, preoperative or intraoperative localization techniques is mandatory for its detection. Hook wire implantation is one of important localization techniques, and its procedure is similar to transthoracic fine needle aspiration (FNA) techniques except keeping hook wire after pulling the needle back. Meanwhile, tumor recurrence in the chest wall of the percutaneous FNA tract (Needle Tract Implantation or seeding) is well known in thoracic malignancy, particularly lung cancer. Aspiration biopsy of lung tumor has resulted in implantation metastasis in pleura, skeletal muscles, and subcutaneous tissue along the needle tract. This is the first report of tumor recurrence related with hook wire localization in the PubMed search.
CONCLUSIONS: To reduce the risk of the tumor recurrence related with localization techniques, thoracic surgeons had better know very well the topographical anatomy of lung. Unnecessary localization can be avoided by careful visual examination of the corresponding segment containing the GGN, and digital or instrumental palpation after complete lung atelectasis, occasionally wide wedge or segmentectomy. Additionally, the hook wire is recommended to be withdrawn through the VATS port rather than percutaneously.