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Electromagnetic Navigational Bronchoscopy with Dye Marking for Identification of Small Peripheral Lung Nodules during Minimally Invasive Surgical Resection
Juan A. Munoz, Virginia Litle, Hiran C. Fernando.
Boston University School of Medicine, Boston, MA, USA.

OBJECTIVE: Identification of small peripheral lung nodules during minimally invasive resection can be challenging. Electromagnetic Navigational Bronchoscopy (ENB) with injection of dye to identify nodules is an approach that can be performed by the surgeon in the operating room immediately prior to resection. We evaluated the effectiveness of ENB with dye marking to aid minimally invasive resection.
METHODS: Patients with peripheral nodules underwent ENB before planned Thoracoscopic or Robotic-Assisted Thoracoscopic resection. Methylene blue (0.5mL) was injected directly into the lesion for pleural-based lesions or peripherally for lesions deep to the pleural surface. Surgical resection was then immediately performed. Technical success was defined as identification of the dye marking within/close to the lesion with pathological confirmation of the lesion within the initial wedge resection.
RESULTS: Sixteen patients with 18 lung nodules underwent ENB with dye marking followed by resection. Mean age was 59 years (44-81) and 88% (14/16) were women. Mean lesion size was 11.5mm (range 4 - 32) and the median distance from the pleura was 9.7mm (1-40mm). Overall success rate for the 18 nodules was 78% (14/18). In 2 (11%; 2/18) the dye was not visualized, (one requiring conversion to thoracotomy). In two (11%) there was extravasation of dye into the pleural space with no helpful tattooing of the lung parenchyma. There were trends favoring technical success for nodules that were larger or closer to the pleural surface (see table). Unlike prior studies, the presence of a bronchus sign had no impact on success rate. Five patients required adhesiolysis to visualize the target lesion and all were successful. There were no significant adverse events and a definitive diagnosis was ultimately accomplished in all patients.
CONCLUSIONS: ENB with dye marking is useful for guiding minimally invasive resection of small peripheral lung nodules. This can be performed by surgeons immediately before resection, improving workflow and avoiding the need for a seperate interventional radiology procedure.
FactorSuccess/n (%)Success/n (%)P value
Lesion size< 1 cm; 7/10 (70%)>/= 1 cm; 7/8 (87.5%)0.3
Distance from Pleura (median = 9.75mm)< Median; 7/8 (87.5%)>/= Median; 7/10 (70%)0.3
Lesion TypeSolid; 7/10 (70%)Mixed/GGO; 7/8 (87.5%)0.3
Bronchus SignYes; 4/5 (80%)No; 10/13 (77%)0.8

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