Bronchoscopically Placed Dye Marking for Minimally Invasive Thoracic Surgery: A Surgeon’s Perspective

Pleural dye marking of lung nodules by electromagnetic navigation bronchoscopy

INTRODUCTION

Electromagnetic navigation bronchoscopy (ENB)-guided pleural dye marking is useful to localize small peripheral pulmonary nodules for sublobar resection.

OBJECTIVE

To report findings on the use of ENB-guided dye marking among participants in the NAVIGATE study.

METHODS

NAVIGATE is a prospective, multicentre, global and observational cohort study of ENB use in patients with lung lesions. The current subgroup report is a prespecified 1-month interim analysis of ENB-guided pleural dye marking in the NAVIGATE United States cohort.

RESULTS

The full United States cohort includes 1215 subjects from 29 sites (April 2015 to August 2016). Among those, 23 subjects (24 lesions) from seven sites underwent dye marking in preparation for surgical resection. ENB was conducted for dye marking alone in nine subjects while 14 underwent dye marking concurrent with lung lesion biopsy, lymph node biopsy and/or fiducial marker placement. The median nodule size was 10 mm (range 4-22) and 83.3% were <20 mm in diameter. Most lesions (95.5%) were located in the peripheral third of the lung, at a median of 3.0 mm from the pleura. The median ENB-specific procedure time was 11.5 minutes (range 4-38). The median time from dye marking to resection was 0.5 hours (range 0.3-24). Dye marking was adequate for surgical resection in 91.3%. Surgical biopsies were malignant in 75% (18/24).

CONCLUSION

In this study, ENB-guided dye marking to localize lung lesions for surgery was safe, accurate and versatile. More information is needed about surgical practice patterns and the utility of localization procedures.

Competence in navigation and guided transbronchial biopsy for peripheral pulmonary lesions

Options for non-surgical tissue diagnosis of the peripheral nodule include CT scan-guided TTNA, fluoroscopy-guided bronchoscopy, radial endobronchial ultrasound (EBUS), electromagnetic navigation bronchoscopy (ENB), and virtual bronchoscopy navigation (VBN). For physicians who choose to pursue non-surgical biopsy, the decision to perform CT scan-guided or ultrasound-guided TTNA, conventional bronchoscopy or bronchoscopy guided by EBUS, ENB, or VBN will depend on a number of factors. CT scan-guided TTNA is preferable for nodules located near the chest wall or for deeper lesions, provided that there is no need to go through the fissures and there is no surrounding emphysema. Ultrasound-guided TTNA requires contact between the lesion and the costal pleura. Bronchoscopic techniques are preferable for nodules ≥2 cm located near a patent bronchus, or in individuals at high risk for pneumothorax following TTNA. In most other situations, operator experience should guide the decision. Trainees must possess a perfect knowledge of anatomy and be fully competent in the interpretation of imaging (CT with contrast medium and PET) and have a thorough knowledge of navigation technology in all its complexities. Practical training can be performed on animal, cadaver or plastic models. In the last years, to improve diagnostic yield, navigational bronchoscopy has attracted significant attention.