CT-Guided Percutaneous Transthoracic Localization of Pulmonary Nodules Prior to Video-Assisted Thoracoscopic Surgery Using Barium Suspension

Authors: Nyoung Keun Lee, MD,1 Chang Min Park, MD,1 Chang Hyun Kang, MD,2 Yoon Kyung Jeon, MD,3 Ji Yung Choo, MD,1 Hyun-Ju Lee, MD,1 and Jin Mo Goo, MD1

1Department of Radiology, Seoul National University College of Medicine, and Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul 110-744, Korea.
2Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul 110-744, Korea.
3Department of Pathology, Seoul National University College of Medicine, Seoul 110-744, Korea.


Objective


To describe our initial experience with CT-guided percutaneous barium marking for the localization of small pulmonary nodules prior to video-assisted thoracoscopic surgery (VATS).





Materials and Methods


From October 2010 to April 2011, 10 consecutive patients (4 men and 6 women; mean age, 60 years) underwent CT-guided percutaneous barium marking for the localization of 10 small pulmonary nodules (mean size, 7.6 mm; range, 3-14 mm): 6 pure ground-glass nodules, 3 part-solid nodules, and 1 solid nodule. A 140% barium sulfate suspension (mean amount, 0.2 mL; range, 0.15-0.25 mL) was injected around the nodules with a 21-gauge needle. The technical details, surgical findings and pathologic features associated with barium localizations were evaluated.





Results



All nodules were marked within 3 mm (mean distance, 1.1 mm; range, 0-3 mm) from the barium ball (mean diameter, 9.6 mm; range, 8-16 mm) formed by the injected barium suspension. Pneumothorax occurred in two cases, for which one needed aspiration. However, there were no other complications. All barium balls were palpable during VATS and visible on intraoperative fluoroscopy, and were completely resected. Both the whitish barium balls and target nodules were identifiable in the frozen specimens. Pathology revealed one invasive adenocarcinoma, five adenocarcinoma-in-situ, two atypical adenomatous hyperplasias, and two benign lesions. In all cases, there were acute inflammations around the barium balls which did not hamper the histological diagnosis of the nodules.





Conclusion


CT-guided percutaneous barium marking can be an effective, convenient and safe pre-operative localization procedure prior to VATS, enabling accurate resection and diagnosis of small or faint pulmonary nodules.