title: Thoracoscopic detection of occult indeterminate pulmonary nodules using bronchoscopic pleural dye marking.
abstract: BACKGROUND
  The annual incidence of a small indeterminate pulmonary nodule (IPN) on computed tomography (CT) scan remains high. While traditional paradigms exist, the integration of new technologies into these diagnostic and treatment algorithms can result in alternative, potentially more efficient methods of managing these findings.
  
  
  METHODS
  We report on an alternative diagnostic and therapeutic strategy for the management of an IPN. This approach combines electromagnetic navigational bronchoscopy (ENB) with an updated approach to placement of a pleural dye marker. This technique lends itself to a minimally invasive wedge resection via either video-assisted thoracoscopic surgery (VATS) or a robotic approach.
  
  
  RESULTS
  Subsequent to alterations in the procedure, a cohort of 22 patients with an IPN was reviewed. Navigation was possible in 21 out of 22 patients with one patient excluded based on airway anatomy. The remaining 21 patients underwent ENB with pleural dye marking followed by minimally invasive wedge resection. The median size of the nodules was 13.4 mm (range: 7-29). There were no complications from the ENB procedure. Indigo carmine dye was used in ten patients. Methylene blue was used in the remaining 11 patients. In 81% of cases, the visceral pleural marker was visible at the time of surgery. In one patient, there was diffuse staining of the parietal pleura. In three additional patients, no dye was identified within the hemithorax. In all cases where dye marker was present on the visceral pleural surface, it was in proximity to the IPN and part of the excised specimen.
  
  
  CONCLUSIONS
  ENB with pleural dye marking can provide a safe and effective method to localize an IPN and can allow for subsequent minimally invasive resection. Depending on the characteristics and location of the nodule, this method may allow more rapid identification intraoperatively.
authors.affiliation: Interventional Pulmonology, MedStar Franklin Square Hospital Center, Baltimore, MD, USA.
authors.forename: William S
authors.initials: WS
authors.lastname: Krimsky
authors.affiliation: Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Minnich
authors.affiliation: Thoracic Surgery, Anne Arundel Medical Center, Annapolis, MD, USA.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Cattaneo
authors.affiliation: Interventional Pulmonology, MedStar Franklin Square Hospital Center, Baltimore, MD, USA.
authors.forename: Saiyad A
authors.initials: SA
authors.lastname: Sarkar
authors.affiliation: Chief Thoracic Surgery, MedStar Franklin Square Hospital Center, Baltimore, MD, USA.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Harley
authors.affiliation: Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Finley
authors.affiliation: Division of Interventional Pulmonology, Walter Reed National Military Medical Center, Bethesda, MD, USA.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Browning
authors.affiliation: Division of Interventional Pulmonology, Walter Reed National Military Medical Center, Bethesda, MD, USA.
authors.forename: Scott C
authors.initials: SC
authors.lastname: Parrish
keywords: electromagnetic navigation; lung nodule; pleural dye marking; video-assisted thoracoscopic surgery