Combined Hookwire and Methylene Blue Localization of Pulmonary Nodules: Analysis of 74 Patients

Because of decreased tactile sensation with thoracoscopic approaches to biopsy, localization preoperatively and intraoperatively is important for successful biopsy. Our study evaluated the technique of combined computed tomography-guided hookwire and methylene blue localization.

Seventy-five patients from November 2007 to August 2013 who underwent combined Hawkins hookwire and methylene blue localization of 76 total pulmonary nodules before video-assisted thoracic surgery-guided wedge resection were retrospectively reviewed. Multiple patient, nodule, and procedural characteristics were analyzed for correlation with successful wire localization and wire dislodgement. Successful wire localization was defined as absence of lesions requiring re-resection, wire dislodgement necessitating re-resection, or conversion to thoracotomy for localization.

Seventy-four patients were included in the study (75 pulmonary nodules - 1 patient had 2 lesions localized) and mean ± SD patient age was 65.8 ± 12.1 years and 50% were male. The mean ± SD largest nodule diameter was 14.6 ± 7.4 mm and 29.3% of these were subcentimeter pulmonary nodules. Increased age and history of malignancy were associated with malignant diagnoses (P = 0.037 and 0.009, respectively) Successful wire localization was present in 86.4% of patients. Lesions with lower mean distance to the pleura correlated with successful localization (P = 0.002). Wire dislodgement was present in 9.3% (7 patients) with 4 (5.3%) of these necessitating need for re-resection to establish pathologic diagnosis. Albeit wire dislodgement, 57.4% (4/7) still had successful thoracoscopic localization.

This study demonstrates that utilization of Hawkins hookwire in combination with methylene blue injection is an effective method to successfully localize pulmonary nodules for thoracoscopic wedge resection and should prompt further investigation for its utilization.