CT fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules

Study objective: To determine the diagnostic reliability and safety of a new marking technique using transbronchoscopic dye injection under CT fluoroscopy for preoperative localization of a small pulmonary nodule. Design: Prospective study. Setting: Hyogo Medical Center for Adults and Shizuoka Cancer Center in Japan. Patients: Seventeen patients who had a peripheral pulmonary nodule < 15 mm in size on CT scans that was suspected to be difficult to localize by visual inspection and manual palpation at our institutes between April 2000 and October 2002. Interventions: After a bronchoscope was inserted orally under local anesthesia and was introduced into the related bronchus of the target nodule, a Teflon sheath catheter with metal tip was inserted transbronchoscopically and was advanced into the visceral pleura. By monitoring CT fluoroscopy, the catheter tip was positioned at the nearest pleural surface of the nodule, and 0.5 mL indigo carmine was injected under deep inspiratory breathhold. CT scans were obtained to confirm the relationship between the injected dye area and the nodule. Measurements and results: The dye injections were performed completely in all 17 patients, who subsequently underwent lung resection guided by the dye staining. There were no complications or harmful effects of the surgery. The area of injected dye was demonstrated as a hazy focal lesion about 10 mm beneath the pleura on the high-resolution CT scan, and was clearly visible as a patchy dark blue area about 20 mm in size on the visceral pleura at surgery. The mean distance between the nodule and the dye was 20 mm on the CT scan (distance range, 0 to 30 mm). The mean examination time with this technique was approximately 35 min (range, 25 to 45 min). The mean CT fluoroscopic time was 60 s (range, 30 to 120 s). Conclusions: Our transbronchial "tattooing" technique is safe and reliable. We think it is superior to previous marking methods.