Needlescopic Resection of Small and Superficial Pulmonary Nodule After Computed Tomographic Fluoroscopy-Guided Dual Localization with Radiotracer and Hookwire



The aim of this study was to evaluate the feasibility of a needlescopic resection for small and superficial pulmonary nodules after dual localization with radiotracer and hookwire.


Computed tomography (CT) fluoroscopy-guided dual marking with hookwire and 99mTc-phytate was performed on 36 small and superficial pulmonary nodules of 34 patients, just before the needlescopic procedure. This method was carried out through one introducer needle, after an initial single puncture. After detection of the hookwire-marked site through needlescopy, the precise lesion was confirmed using a thoracoscopic gamma probe by calculating the highest radioactivity. The pulmonary nodule was resected and diagnosed by pathologic examination.


The mean size of the nodules was 12.5 ± 5.4 mm (range 3–20), and their mean distance from the pleural surface was 5.6 ± 5.8 mm (range 0–18.7). The time of the dual localization procedure was 10.8 ± 3.6 min (range 5–18). Pneumothorax was developed in 6 of 34 patients (17.6 %) after preoperative localization, but did not require any treatment. Seven hookwires dislodged during the operation. Nevertheless, radiotracer markings detected on a gamma probe guided a successful wedge resection without difficulty in all seven cases. All nodules were successfully resected under needlescopy, except conversion to the 5-mm-sized thoracoscopy in four patients due to pleural adhesion.


Dual marking with radiotracer and hookwire under CT fluoroscopy is a safe and not time-consuming procedure, and has made needlescopy-assisted lung resection for small and superficial nodules or ground-glass opacity lesions easier, more convenient, and less hazardous.

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This work was supported by a Grant from the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (No. A121074), and a National Research Foundation of Korea grant funded by the Ministry of Education, Science and Technology (No. 2012012166).


Kyung Won Doo, Hwan Seok Yong, Hyun Koo Kim, Sungeun Kim, Eun-Young Kang, and Young Ho Choi have nothing to disclose with regard to commercial support.

Author information

Correspondence to Hyun Koo Kim MD, PhD.

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Kyung Won Doo and Hwan Seok Yong have contributed equally to this work.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Operative video of needlescopic resection of small and superficial pulmonary nodule after computed tomographic fluoroscopy-guided dual localization with radiotracer and hookwire (WMV 94362 kb)

Operative video of needlescopic resection of small and superficial pulmonary nodule after computed tomographic fluoroscopy-guided dual localization with radiotracer and hookwire (WMV 94362 kb)

This shows a complexity of the thoracoscopic lung biopsy using dual localization with hookwire and lipiodol. It needs two big medical devices; thoracoscopic system and C-arm fluoroscopic system (arrows indicated thoracoscopic system, and triangles indicated C-arm fluoroscopic system) (TIFF 2093 kb)

A dislodged hookwire was still helpful in the localization of the target lesion because the hookwire remained anchored to the chest wall right above the target lesion (black arrow). The target lung lesion was usually lacerated by detachment of the hookwire (white arrow) (TIFF 1461 kb)

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Doo, K.W., Yong, H.S., Kim, H.K. et al. Needlescopic Resection of Small and Superficial Pulmonary Nodule After Computed Tomographic Fluoroscopy-Guided Dual Localization with Radiotracer and Hookwire. Ann Surg Oncol 22, 331–337 (2015) doi:10.1245/s10434-014-3884-2

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  • Pulmonary Nodule
  • Preoperative Localization
  • Pleural Surface
  • Dual Localization
  • Compute Tomography Fluoroscopy