Cumulative Experience of Preoperative Real-time Augmented Fluoroscopy-guided Endobronchial Dye Marking for Small Pulmonary Nodules: An Analysis of 30 Initial Patients

Background/purpose: Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) for use in guiding endobronchial dye marking of small pulmonary nodules prior to thoracoscopic surgery is still under development. We sought to evaluate the effect of the cumulative experience on procedural parameters of CBCT-AF-guided endobronchial dye marking for preoperative localization of small pulmonary nodules.

Methods: Clinical variables and treatment outcomes of the 30 initial patients with small pulmonary nodules who were managed with CBCT-AF-guided endobronchial dye marking followed by thoracoscopic resection in our institution were analyzed. Two sequential groups of patients (group I and group II, n = 15 each) were compared with regard to localization time and radiation doses. The Mann-Whitney U test and chi-square test or Fisher exact test were used in the statistical analyses.

Results: In the entire cohort, the median size of solitary pulmonary nodules on preoperative computed tomography (CT) images was 9.3 mm (interquartile range, 7.4-13.6 mm), and their median distance from the pleural surface was 15.2 mm (interquartile range, 10.3-27.1 mm). The median tumor depth-to-size ratio was 1.6 (interquartile range, 1.1-2.3). A significant reduction in single DynaCT radiation (3690.4 versus [vs.] 1132.3 μGym; P < 0.001) and total radiation exposure (median, 4878.8 vs. 1673.8 μGym; P < 0.001) was noted in group II (late patients) compared with group I.

Conclusion: Our initial results of CBCT-AF-guided lung marking demonstrate that the cumulative experience with several technical modifications can achieve the same purpose of endobronchial localization with less procedure-related radiation exposure.