A novel technique for localizing pulmonary nodules through percutaneous catheter puncture

Introduction

With the development of low-dose computed tomography (CT) for lung cancer screening, pulmonary nodules suspected to be malignant are detected more frequently (1). In the past, lobectomy was the standard treatment for patients with early-stage non-small cell lung cancer (NSCLC) (2). Some clinical trials have recently confirmed that sublobar resection is comparable to lobectomy in the efficacy of clinical stage IA NSCLC patients (3-5). However, because pulmonary nodules are not superficial or too small, achieving accurate localization of pulmonary nodules is difficult during video-assisted thoracoscopic surgery (VATS) (6). This may result in resection failure, necessitating extended resection or conversion to thoracotomy (7). Therefore, accurate localization of pulmonary nodules is the key to the success of thoracoscopic sublobar resection.

A variety of localization techniques have been reported for thoracoscopic sublobar resection (8-14). Common techniques include preoperative CT-guided percutaneous placement of hook wires and microcoils. However, these procedures are associated with complications, including pneumothorax, haemothorax and an increased the risk of displacement (15). Other techniques involve CT-guided injection of vital inert dye, which may cause an irritating cough and create inflammation in lung tissue that can alter the histological analysis (9,10). Electromagnetic navigational bronchoscopy (ENB) and robotic-assisted bronchoscopy (RAB) are safe and precise for injecting indocyanine green (ICG), but they are complex, costly, and difficult to generalize (13,14). Intraoperative ultrasound represents a straightforward technique. However, its effect may be compromised if the lung tissue is poorly collapsed or contains gas (16). Therefore, a safe, accurate and suitable localization technique for pulmonary nodules is necessary.

In this study, we have developed a novel technique for the localization of pulmonary nodules termed ‘‘percutaneous catheter puncture localization” to assist in resecting pulmonary nodules, then prospectively evaluated the safety, efficacy and suitability. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-54/rc).

Methods

Study design

This was a prospective, single-center, single-group observational study. The present study was designed to preliminarily assess the safety, efficacy and suitability of the nodule localization using the newly developed technique. Patients who underwent percutaneous catheter puncture localization at the West China Hospital of Sichuan University from September 2023 to July 2024 were prospectively enrolled in this study. The study was approved by the Institutional Review Board of West China Hospital (No. 2024-1022), and informed consent was taken from all the patients. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments (17).

Inclusion and exclusion criteria

Patients with indeterminate pulmonary nodules who were scheduled for thoracoscopic sublobar resection were approached by a trained research assistant to evaluate their eligibility. The inclusion criteria were defined as follows: (I) patients with suspicious-appearing malignant pulmonary nodules ≤2 cm in diameter on CT; (II) the surgeon of the patient confirmed with research assistant the necessity for pulmonary nodule localization; (III) the inner edge of the target nodule was at least 2 cm from major arteries or veins to allow for secure nodule excision through wedge resection; (IV) prior to surgery the patient had already undergone a chest CT at our hospital. The exclusion criteria were defined as follows: (I) patients with 2 or more pulmonary nodules that needed to be localized; (II) patients who exhibited extensive pleural adhesion; (III) the solid component of the pulmonary nodule was ≥50% (wedge resection has been shown to be effective for tumors with consolidation tumor ratio (CTR) ≤0.5 but lacks sufficient evidence for CTR >0.5).

Localization and surgical procedure

The thoracic longitudinal surface marker lines and intercostal space are essential bases for the preoperative determination of the puncture point (Figure 1). Based on the CT images, the chest wall projection point of pulmonary nodules and their relation to the thoracic longitudinal surface marker lines and intercostal space were preoperatively planned. According to the plan, the suitable intercostal space and the suitable thoracic longitudinal surface marker line were selected to intersect. The point of intersection of these lines was designated as the puncture site (Figure 2A).

Figure 1 Intercostal space and longitudinal surface marker lines. The intercostal space and longitudinal surface marker lines were shown from three distinct perspectives: anterior (A), posterior (B), and lateral (C) aspects of the chest wall.

Figure 2 Three strategies of percutaneous catheter puncture localization. The intersection of intercostal space and longitudinal surface marker lines was used as the puncture point based on CT images (A). Three localization strategies for pulmonary nodules were shown from three distinct perspectives: lateral (B), posterior (C), and anterior (D) aspects of the chest wall. CT, computed tomography.

According to the specific location of pulmonary nodules and the difference of adjacent structures, three technical strategies were used for percutaneous catheter puncture localization of pulmonary nodules: (I) direct localization method, which is suitable for the localization of pulmonary nodules in the thorax without bone tissue shielding and far away from the heart, large vessels, diaphragm and other important organs (within the red line in Figure 2), and the puncture point was chest wall projection point of pulmonary nodules. The patients who had identified the puncture point were placed in the surgical position (lateral position) under anesthesia. During the operation, the double-lumen endotracheal intubation was used to ensure continuous two-lung ventilation to maintain the respiratory stability of the patients and maintain the preoperative CT image status of pulmonary nodules as much as possible. The 16G single-lumen central venous catheter kit was inserted vertically into the skin at the marked puncture point, reaching a depth 1 cm greater than the chest wall thickness measured preoperatively on the CT scan to ensure placement of the catheter into the lung tissue (Figure 3). Upon catheter removal, a hemorrhagic spot appeared on the lung surface, representing the projection site of the pulmonary nodule on the lung surface, and was marked by knotting. Subsequently, the resection range was determined based on the lung surface markers (the projection site of the pulmonary nodule on the lung surface) and the depth of the nodule to the pleura measured by preoperative CT. (II) Parallel-shifting localization method is for the localization of pulmonary nodules with bone tissue in the thorax or nodules close to sensitive areas such as important organs and spine (within the blue line in Figure 2). Direct puncture at the chest wall projection point of the nodules is impractical for nodules located in this region. Therefore, based on CT images, intercostal space, and thoracic longitudinal surface marker lines, we selected the appropriate puncture point in the direct puncture method area (Figure 4). The puncture process is the same as the direct positioning method. During the operation, the hemorrhagic spot left by the removed catheter on the lung surface was marked by knotting. However, this is not the location of the projection site of the pulmonary nodule on the lung surface. Based on preoperative CT image, the distance from the chest wall projection point of the target pulmonary nodule to the puncture point is measured. This distance is adjusted according to the degree of lung deflation and subsequently displaced in parallel to determine the projection site of the nodule on the lung surface, where it is marked again by knotting (Video 1). (III) Thoracoscopic-assisted vision localization method, which is suitable for pulmonary nodules located near the heart, large vessels, diaphragm and other important organs, especially in the precordial area and the diaphragm (within the black line in Figure 2), and the puncture point was chest wall projection point of pulmonary nodules. However, direct puncture of the nodules in this area is very dangerous, and thoracoscopic assistance is required during the puncture process. The 16G single-lumen central venous catheter kit was inserted vertically into the skin at the marked puncture point, and the thoracoscopy was placed through the surgical incision to observe the puncture process. Prior to the penetration of the chest wall, the anesthesiologist inflated the patient’s lungs to facilitate the subsequent penetration of the puncture needle into the lung tissue without injuring other vital tissues (Video 2). Before closing the thoracic wounds, the surgeon had already changed gloves to ensure sterility.

Figure 3 Catheter puncture of pulmonary nodules. The patient was placed in the surgical position under anesthesia (A). The puncture needle was inserted vertically into the thoracic cavity and penetrated into the lung tissue (B,C).

Figure 4 Parallel displacement localization based on preoperative planning of CT images. The puncture point was located in the sixth intercostal space, 5 cm from the linea mediana posterior. The puncture needle was inserted 4 cm to leave hemorrhagic spots on the lung surface, which were marked by knotting. The pulmonary nodule was located 3.5 cm anterior to the marker and 2 cm deep from the pleura. CT, computed tomography.

All patients underwent uniportal thoracoscopic wedge resection through an incision 3 cm long over the fourth or fifth intercostal space of the anterior axillary line. In this study, lobe-specific dissection of the lymph nodes was performed on all the patients.

Evaluation

The relevant data of the patients were recorded. The primary endpoints of the study were the safety (complication rate) and efficacy (successful resection rate, distance from localization point to the nodule and surgical margin). The recorded complications were pneumothorax and parenchymal hemorrhage. Successful resection was defined as a distance of ≤1.5 cm between the nodule and the location point, surgical margin ≥1.5 cm, and ensuring that the nodule was found in the lung tissue that had been cut down (18). The secondary outcomes included suitability (localization times and patient comfort). Patient comfort refers to how the patient feels during the puncture or the waiting period before surgery.

Statistical analysis

All statistical analyses were performed using R (version 3.6.3, www.r-project.org). Quantitative data were analyzed by t-test, presented as median and range. Fisher’s exact test was used for categorical data, presented as numbers and percentages. All statistical analyses were 2-sided, and P<0.05 was considered statistically significant.

Results

Patient characteristics

A total of 107 patients were enrolled, with 79 females (73.8%) and a median age of 52 years (range, 25–80 years). Pulmonary nodules were mainly in the right upper lobe [46 patients (43%)] and right lower lobe [26 patients (24.3%)]. In terms of benign and malignant, postoperative pathology confirmed that pulmonary nodules were dominated by malignant, with a total of 101 patients (94.4%). The median diameter of pulmonary nodules was 1 cm (range, 0.5–1.6 cm). The median distance from nodule to pleura was 0.8 cm (range, 0.4–2 cm) (Table 1).

The outcome of localization and surgical resection

None of the operations required conversion to thoracotomy or lobectomy. Lesions of all 107 patients (100%) were successfully resected with satisfactory surgical margins and a median distance of 2.0 cm (range, 1.5–3.0 cm). The distance from the localization point to the nodule was less than or equal to 1.5 cm in all patients, less than or equal to 1 cm in 87.9% of patients, and less than 0.5 cm in 39.3% of patients. None of the patients (0%) experienced any complications or pain. The localization time of all patients (100%) was within 5 minutes (Table 2).

Subgroup analyses

The subgroup analysis results are shown in Table S1. In the percutaneous catheter puncture localization, nodule location, distance from nodule to pleura, and age were correlated with accurate localization. In patients with a distance from the nodule to the pleura of <1.0 cm, the distance from the location point to the nodule was less than 0.5 cm in 28 patients (50.0%) and between 0.5–1.0 cm in 22 patients (39.3%). In patients with a distance from the nodule to the pleura of ≥1.0 cm, the distance from the location point to the nodule was less than 0.5 cm in 12 patients (23.5%) and between 0.5–1.0 cm in 32 patients (62.8%). The difference was significant with P=0.02. In patients aged <60 years, the distance from the location point to the nodule was less than 0.5 cm in 34 patients (44.7%) and between 0.5–1.0 cm in 33 patients (43.4%). In patients aged ≥60 years, the distance from the location point to the nodule was less than 0.5 cm in 6 patients (19.3%) and between 0.5–1.0 cm in 21 patients (67.8%). The difference was significant with P=0.04. In patients with a nodule located in the left upper lobe, the distance from the location point to the nodule was less than 0.5 cm in 10 patients (62.5%) and between 0.5–1.0 cm in 6 patients (37.5%). In patients with a nodule located in the right lower lobe, the distance from the location point to the nodule was less than 0.5 cm in 4 patients (15.4%) and between 0.5–1.0 cm in 20 patients (76.9%). The difference was significant with P=0.003.

Discussion

We have reported our early experience with a novel localization technique for pulmonary nodules termed “percutaneous catheter puncture localization”. The following features characterize this technique. First, the technique has a short preoperative waiting time, which reduces the possibility of complications. Secondly, the technique can accurately locate pulmonary nodules using only preoperative CT images, resulting in a short localization time, no pain and cost-effectiveness. Finally, the lesions of 107 patients were successfully resected using this localization technique, demonstrating its efficacy.

The safety of pulmonary nodule localization is essential for determining the prognosis of patients. CT-guided percutaneous placement of a hook wire or a microcoil into the nodule is one of the main methods used to assist surgeons in identifying pulmonary nodules before operation with high accuracy (7,8,12). However, these methods typically require percutaneous puncture under conscious conditions, followed by a prolonged waiting period (30 minutes to 2 hours or more) prior to interdepartmental transfer from the CT suite to the operating room for VATS. During the preoperative waiting period, patient movement frequently results in adverse events, including Parenchymal hemorrhage, pneumothorax, pain, and anxiety, and may even precipitate vasovagal syncope (7). In contrast, our technique is performed under general anesthesia, ensuring that the patient remains free from pain and discomfort throughout the procedure. Furthermore, surgery is conducted immediately after puncture and catheter, minimizing the risk of pneumothorax, parenchymal hemorrhage, and displacement of localization markers.

The acceptability and applicability of the localization technique are crucial to wide application. Delivery of markers via bronchoscopy and RAB intraoperative NIR imaging using ICG are accurate and safe methods to localize nodules (19-21). However, conventional bronchoscopic navigation techniques, such as electromagnetic navigation and virtual lung mapping, as well as the novel RAB, encounter challenges associated with limited equipment availability and high cost. Hook-wire localization of nodules in a hybrid-theatre setting achieves a high success rate while also minimizing the risk of pneumothorax and parenchymal hemorrhage (22). However, this technique also relies on advanced equipment, and the need for multiple scans increases patient radiation exposure, limiting its applicability in many medical facilities. In contrast, our technique required only a preoperative CT scan for data acquisition, and the localization process itself is completed in the operating room with the assistance of anesthesiologists, eliminating the need for additional CT scans. Moreover, it does not require expensive auxiliary equipment, relying only on an affordable central venous catheter, making it a cost-effective option that is more suitable for widespread adoption in resource-limited settings.

The primary purpose of percutaneous catheter puncture localization is to accurately locate the lesions. A meta-analysis of CT-guided localization of pulmonary nodules showed that the successful video-assisted thoracic surgery rates with hook wires, microcoil, and lipiodol localization were 0.96, 0.97, and 0.99, respectively (11). A direct comparison between our strategy utilizing percutaneous catheter puncture localization and other techniques is not feasible due to variations in patient cohorts and surgical techniques. The majority of patients with superficial nodules in our study may be a reason for our 100% success rate. Additionally, our technique does not provide direct intraoperative confirmation of whether the catheter is precisely positioned. This uncertainty could be of concern compared to other existing localization methods, such as robotic bronchoscopy, ICG injection, or CT-guided localization. However, it is noteworthy that all nodules measuring ≥1 cm from the pleural surface were successfully resected (this included some deep pulmonary nodules and a number of sub-centimeter nodules). This indicates that the technique possesses the capability to accurately localize deep nodules and sub-centimeter nodules.

Limitations

Our study has several limitations. First, it was a single-center study with a limited sample size, which may affect the generalizability of the results. Second, the absence of a control group prevents direct statistical comparisons with traditional localization methods, meaning that we cannot definitively conclude that our technique is superior. Third, the accuracy of pulmonary nodule localization using the percutaneous catheter puncture localization is more likely to be influenced by nodule location, distance from nodule to pleura, and age. Further multi-center, noninferiority randomized clinical trials should identify the subgroup of patients who are optimal candidates for percutaneous catheter puncture localization and assess the noninferiority of the efficacy and safety of our technique and compare it robustly with existing localization methods.

Conclusions

We have developed a novel technique for the localization of pulmonary nodules termed ‘‘percutaneous catheter puncture localization” to assist in resecting pulmonary nodules. In our preliminary experience, the technique is safe, painless, effective, and suitable prior to sublobar resection.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-54/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-54/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-54/prf

Funding: This research was supported by “Qimingxing” Research Fund for Young Talents, West China Hospital (No. HXQMX0034).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-54/coif). D.T. serves as an unpaid editorial board member of Journal of Thoracic Disease from March 2025 to February 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the Institutional Review Board of West China Hospital (No. 2024-1022), and informed consent was taken from all the patients. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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