Augmented fluoroscopic bronchoscopy (AFB) versus percutaneous computed tomography-guided dye localization for thoracoscopic resection of small lung nodules: a propensity-matched study

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Dye localization is a useful method for the resection of unidentifiable small pulmonary lesions. This study compares the transbronchial route with augmented fluoroscopic bronchoscopy (AFB) and conventional transthoracic CT-guided methods for preoperative dye localization in thoracoscopic surgery.


Between April 2015 and March 2019, a total of 231 patients with small pulmonary lesions who received preoperative dye localization via AFB or percutaneous CT-guided technique were enrolled in the study. A propensity-matched analysis, incorporating preoperative variables, was used to compare localization and surgical outcomes between the two groups.


After matching, a total of 90 patients in the AFB group (N = 30) and CT-guided group (N = 60) were selected for analysis. No significant difference was noted in the demographic data between both the groups. Dye localization was successfully performed in 29 patients (96.7%) and 57 patients (95%) with AFB and CT-guided method, respectively. The localization duration (24.1 ± 8.3 vs. 21.4 ± 12.5 min, p = 0.297) and equivalent dose of radiation exposure (3.1 ± 1.5 vs. 2.5 ± 2.0 mSv, p = 0.130) were comparable in both the groups. No major procedure-related complications occurred in either group; however, a higher rate of pneumothorax (0 vs. 16.7%, p = 0.029) and focal intrapulmonary hemorrhage (3.3 vs. 26.7%, p = 0.008) was noted in the CT-guided group.


AFB dye marking is an effective alternative for the preoperative localization of small pulmonary lesions, with a lower risk of procedure-related complications than the conventional CT-guided method.

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  1. 1.

    Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A (2015) Global cancer statistics, 2012. CA Cancer J Clin 65:87–108

  2. 2.

    National Lung Screening Trial Research Team, Church TR, Black WC, Aberle DR, Berg CD, Clingan KL, Duan F, Fagerstrom RM, Gareen IF, Gierada DS, Jones GC, Mahon I, Marcus PM, Sicks JD, Jain A, Baum S (2013) Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med 368:1980–1991

  3. 3.

    Yang SM, Hsu HH, Chen JS (2017) Recent advances in surgical management of early lung cancer. J Formos Med Assoc 116:917–923

  4. 4.

    Saito H, Minamiya Y, Matsuzaki I, Tozawa K, Taguchi K, Nakagawa T, Hashimoto M, Hirano Y, Ogawa J (2002) Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery. J Thorac Cardiovasc Surg 124:1198–1202

  5. 5.

    Suzuki K, Nagai K, Yoshida J, Ohmatsu H, Takahashi K, Nishimura M, Nishiwaki Y (1999) Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest 115:563–568

  6. 6.

    Lin MW, Chen JS (2016) Image-guided techniques for localizing pulmonary nodules in thoracoscopic surgery. J Thorac Dis 8:S749–755

  7. 7.

    Lin MW, Tseng YH, Lee YF, Hsieh MS, Ko WC, Chen JY, Hsu HH, Chang YC, Chen JS (2016) Computed tomography-guided patent blue vital dye localization of pulmonary nodules in uniportal thoracoscopy. J Thorac Cardiovasc Surg 152:535–544

  8. 8.

    Sato M, Kuwata T, Yamanashi K, Kitamura A, Misawa K, Imashimizu K (2017) Safety and reproducibility of virtual-assisted lung mapping: a multicentre study in Japan. Eur J Cardiothorac Surg 51:861–868

  9. 9.

    Awais O, Reidy MR, Mehta K, Bianco V, Gooding WE, Schuchert MJ, Luketich JD, Pennathur A (2016) Electromagnetic navigation bronchoscopy-guided dye marking for thoracoscopic resection of pulmonary nodules. Ann Thorac Surg 102:223–229

  10. 10.

    Hohenforst-Schmidt W, Zarogoulidis P, Vogl T, Turner JF, Browning R, Linsmeier B, Huang H, Li Q, Darwiche K, Freitag L, Simoff M, Kioumis I, Zarogoulidis K, Brachmann J (2014) Cone beam computertomography (CBCT) in interventional chest medicine—high feasibility for endobronchial realtime navigation. J Cancer 5:231–241

  11. 11.

    Pritchett MA, Schampaert S, de Groot JAH, Schirmer CC, van der Bom I (2018) Cone-beam CT with augmented fluoroscopy combined with electromagnetic navigation bronchoscopy for biopsy of pulmonary nodules. J Bronchology Interv Pulmonol 25:274–282

  12. 12.

    Hogarth DK (2018) Use of augmented fluoroscopic imaging during diagnostic bronchoscopy. Future Oncol 14:2247–2252

  13. 13.

    Yang SM, Yu KL, Lin KS, Liu YL, Sun SE, Meng LH, Ko HJ (2019) Cumulative experience of preoperative real-time augmented fluoroscopy-guided endobronchial dye marking for small pulmonary nodules: an analysis of 30 initial patients. J Formos Med Assoc 118:1232–1238

  14. 14.

    Yang SM, Yu KL, Lin KS, Liu YL, Sun SE, Meng LH, Ko HJ (2019) Real-time augmented fluoroscopy-guided lung marking for thoracoscopic resection of small pulmonary nodules. Surg Endosc 2019:1–18.

  15. 15.

    Murphy MJ, Balter J, Balter S, BenComo JA Jr, Das IJ, Jiang SB (2007) The management of imaging dose during image-guided radiotherapy: report of the AAPM Task Group 75. Med Phys 34:4041–4063

  16. 16.

    Christner JA, Kofler JM, McCollough CH (2010) Estimating effective dose for ct using dose-length product compared with using organ doses: consequences of adopting international commission on radiological protection publication 103 or dual-energy scanning. Am J Roentgenol 194:881–889

  17. 17.

    Sutherland J, Belec J, Sheikh A, Chepelev L, Althobaity W, Chow BJW, Mitsouras D, Christensen A, Rybicki FJ, La Russa DJ (2019) Applying modern virtual and augmented reality technologies to medical images and models. J Digit Imaging 32:38–53

  18. 18.

    Bourier F, Reents T, Ammar-Busch S, Semmler V, Telishevska M, Kottmaier M, Lennerz C, Grebmer C, Kolb C, Deisenhofer I, Hessling G (2016) Transseptal puncture guided by CT-derived 3D-augmented fluoroscopy. J Cardiovasc Electrophysiol 27:369–372

  19. 19.

    Blanc R, Fahed R, Roux P, Smajda S, Ciccio G, Desilles JP, Redjem H, Mazighi M, Baharvahdat H, Piotin M (2018) Augmented 3D venous navigation for neuroendovascular procedures. J Neurointerv Surg 10:649–652

  20. 20.

    Hwang EJ, Kim H, Park CM, Yoon SH, Lim HJ, Goo JM (2018) Cone beam computed tomography virtual navigation-guided transthoracic biopsy of small (≤ 1 cm) pulmonary nodules: impact of nodule visibility during real-time fluoroscopy. Br J Radiol 91:20170805

  21. 21.

    Yang SM, Ko WC, Lin MW, Hsu HH, Chan CY, Wu IH, Chang YC, Chen JS (2016) Image-guided thoracoscopic surgery with dye localization in a hybrid operating room. J Thorac Dis 8:S681–S689

  22. 22.

    Lin CW, Ko HJ, Yang SM, Chen YC, Ko WC, Huang HC, Chen JS, Chang YC (2019) Computed tomography-guided dual localization with microcoil and patent blue vital dye for deep-seated pulmonary nodules in thoracoscopic surgery. J Formos Med Assoc 118:979–985

  23. 23.

    Sato M (2016) Virtual assisted lung mapping: navigational thoracoscopic lung resection. Cancer Res Front 2:85–104

  24. 24.

    Sato M, Aoyama A, Yamada T, Menjyu T, Chen F, Sato T, Sonobe M, Omasa M, Date H (2015) Thoracoscopic wedge lung resection using virtual-assisted lung mapping. Asian Cardiovasc Thorac Ann 23:46–54

  25. 25.

    Bhatt K, Tandon Y, Graham R, Lau CT, Lempel JK, Azok JT, Mazzone PJ, Schneider E, Obuchowski NA, Bolen MA (2018) Electromagnetic navigational bronchoscopy versus CT-guided percutaneous sampling of peripheral indeterminate pulmonary nodules: a cohort study. Radiology 286:1052–1061

  26. 26.

    Han Y, Kim H, Kong K, Kim SJ, Lee SH, Ryu YJ, Lee JH, Kim Y, Shim SS, Chang JH (2018) Diagnosis of small pulmonary lesions by transbronchial lung biopsy with radial endobronchial ultrasound and virtual bronchoscopic navigation versus CT-guided transthoracic needle biopsy: a systematic review and meta-analysis. PLoS ONE 13:e0191590

  27. 27.

    Wang C, Li X, Zhou Z, Zhao H, Li Z, Jiang G, Wang J (2016) Endobronchial ultrasonography with guide sheath versus computed tomography guided transthoracic needle biopsy for peripheral pulmonary lesions: a propensity score matched analysis. J Thorac Dis 8:2758–2764

  28. 28.

    Zhan P, Zhu Q, Miu Y, Liu YF, Wang XX, Zhou ZJ, Jin JJ, Li Q, Sasada S, Izumo T, Tu CY, Cheng WC, Evison M, Lv TF, Song Y (2017) Comparison between endobronchial ultrasound-guided transbronchial biopsy and CT-guided transthoracic lung biopsy for the diagnosis of peripheral lung cancer: a systematic review and meta-analysis. Transl Lung Cancer Res 6:23–34

  29. 29.

    Kuo SW, Tseng YF, Dai KY, Chang YC, Chen KC, Lee JM (2019) Electromagnetic navigation bronchoscopy localization versus percutaneous CT-guided localization for lung resection via video-assisted thoracoscopic surgery: a propensity-matched study. J Clin Med 8:379

  30. 30.

    Anayama T, Hirohashi K, Miyazaki R, Okada H, Kawamoto N, Yamamoto M, Sato T, Orihashi K (2018) Near-infrared dye marking for thoracoscopic resection of small-sized pulmonary nodules: comparison of percutaneous and bronchoscopic injection techniques. J Cardiothorac Surg 13:5

  31. 31.

    Murakami J, Ueda K, Tanaka T, Kobayashi T, Kunihiro Y, Hamano K (2017) The validation of a no-drain policy after thoracoscopic major lung resection. Ann Thorac Surg 104:1005–1011

  32. 32.

    Yang SM, Wang ML, Hung MH, Hsu HH, Cheng YJ, Chen JS (2017) Tubeless uniportal thoracoscopic wedge resection for peripheral lung nodules. Ann Thorac Surg 103:462–468

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We thank the staff of the Biotechnology R&D Center, National Taiwan University Hospital Hsin-Chu Branch for their assistance in the study design and statistical analysis.

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Correspondence to Pei-Ming Huang.

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Yang, S., Chen, Y., Ko, W. et al. Augmented fluoroscopic bronchoscopy (AFB) versus percutaneous computed tomography-guided dye localization for thoracoscopic resection of small lung nodules: a propensity-matched study. Surg Endosc (2020).

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  • Dye localization
  • Augmented fluoroscopy
  • CT-guided
  • Small lung nodules
  • Thoracoscopy