Role of Lung Marking in the Age of Sublobar Resection

In light of recent clinical trials, we are witnessing a paradigm shift towards lung parenchyma-preserving, sublobar resection for early-stage lung cancers. When performing sublobar resection via thoracoscopy, sometimes locating the lesion can be challenging. Thoracoscopy does not provide the same exposure and tactile feedback as open thoracotomy; as a result, detecting subsolid, small, and deep lesions can be difficult for the thoracic surgeon. This problem can be obviated by preprocedural marking of lesions. Various CT-guided transthoracic and bronchoscopic techniques have been reported. Transthoracic techniques include injecting dye into the lesions and placing fiducials and hook wires. Although these procedures are widely performed, complications, such as pneumothorax, air embolism, dye dissipation and extravasation, and hook-wire dislodgement have been reported. Conventional bronchoscopy can be used in conjunction with real-time 3-dimensional imaging for transbronchial marking of pulmonary lesions. However, given the limitations of conventional bronchoscopy, navigating to peripheral lesions can be tough. Robotic bronchoscopy, with or without real-time 3-dimensional imaging, is a safe and accurate modality for marking pulmonary lesions. Robotic bronchoscopy can be used to perform dye injection into the lesion, potentially in the same setting as the resection. Robotic bronchoscopy can also be used to bronchoscopically deploy dye-soaked coils. Robotic bronchoscopy may not be widely available and may have a learning curve. Ultimately, the choice of lung marking modality depends on available resources, institutional expertise, and the specific advantages and disadvantages of each modality.