Preoperative computed tomography-guided localization of lung nodules with needle placement: a series of cases

ABSTRACT Objective: to report the preoperative localization of pulmonary nodules with the placement of a guidewire oriented by Computed Tomography. Methods: the nodules were marked using a needle in the shape of a hook or another in the shape of a Q, guided by tomography. The choice of the location for the marking was the shortest distance from the chest wall to the nodule. The marking procedure was performed under local anesthesia and a tomographic control was obtained immediately at the end. Patients were referred to the operating room. Surgical resection occurred less than two hours after the needle placement. Results: between February 2017 and October 2019, 22 patients aged 43 to 82 years (mean 62.1) were included. The nodules had diameters that varied from 4 to 30 mm and the distance between the nodules and the pleural surface varied from 2 to 43 mm. The location and resection of the nodules were successfully performed in all cases. The guidewire was displaced in five cases. Five patients presented pneumothorax, with the space between the visceral and parietal pleura varying from 2 to 19 mm. In nine patients, an intraparenchymal hematoma of 6 to 35 mm in length was observed without signs, symptoms, or hemodynamic and ventilatory repercussions. The histopathological study was conclusive in all patients. Conclusions: the localization of pulmonary nodules through guidewires proved to be safe, reliable, and feasible in this series of cases. There was no need for surgical intervention to treat complications.


INTRODUCTION
I n the last three decades, minimally invasive surgery has been constantly and swiftly developing, greatly changing the surgeon's routine. The incessant search for diagnostic techniques and more efficient and effective treatment, with fewer complications, lower response to trauma, and ever faster recovery time are the objectives of laparoscopic surgery, which allowed the best surgical results when compared with other techniques 1 .
Thoracic surgery followed this process and today thoracoscopy is a routine procedure, although in Brazil this is not the reality in most services 2 . From more simple procedures, such as pleuroscopy and sympathectomy, to even more complex ones, such as lung lobectomy, bronchoplasty, vascular anastomosis, and radical lymphadenectomy are possible through the minimally invasive approach 3 .
Nodules less than 10 mm in size located more than 10 mm from the pleural surface are a real challenge as for their perioperative locating 4

RESULTS
Between February 2017 and October 2019, 22  There was dislodging of the guidewire in five cases, four of them hook-shaped and one, Q-shaped.
They were found loose in the pleural space, but it was possible to identify the visceral pleura entry site, allowing locating the lesion, though not ideal. Pneumothorax occurred in five cases (inter-pleural distance 2 mm to 19

Fogolin
Preoperative computed tomography-guided localization of lung nodules with needle placement: a series of cases mm) and intraparenchymal hematoma, in nine cases (6 mm to 35 mm in diameter), with no signs, symptoms or any hemodynamic or ventilatory repercussions. We did not observe pleuritic pain, air embolism, or hemothorax.
However, for resection of pulmonary nodules, location and size can be limiting factors. When the nodules are visible in the collapsed lung or cause retraction of the visceral pleura, there is no need for preoperative marking.
Nonetheless, nodules less than 10 mm in size or the ones deep in relation to the pleural surface cannot be located at thoracoscopy 4 .
Nodules with a distance greater than 5 mm from the lung periphery and less than 10 mm in size have a 63% probability of locating failure, with 46% of videoassisted thoracoscopic surgeries needing to be converted to open procedures due to failure in locating the nodule to be resected 9 .
Even nodules with a distance less than 5 mm from the visceral pleura may be difficult to locate, since  Fogolin Preoperative computed tomography-guided localization of lung nodules with needle placement: a series of cases wires provide more effective marking in relation to the hook-shaped one, displaying a lower risk of displacement from the lung, as was the case with four patients. There is a limitation to the use of those wires due to their very high cost when compared with the hook-shaped one; they are usually not covered by health insurance carriers or by the public health system. It is believed that the marking wire is best positioned when released immediately proximal to the lesion, so that if it is pulled, the hook will anchor in the nodule instead of away from it 11 . A previous study has reported pleuritic pain in some of the patients and chest wall hematoma 12