Chest ACCP Career Connection
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (5)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Asano, F.
Right arrow Articles by Ishihara, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Asano, F.
Right arrow Articles by Ishihara, Y.
(Chest. 2004;126:1687-1693.)
© 2004 American College of Chest Physicians

Ultrathin Bronchoscopic Barium Marking With Virtual Bronchoscopic Navigation for Fluoroscopy-Assisted Thoracoscopic Surgery*

Fumihiro Asano, MD, PhD; Joe Shindoh, MD, PhD; Kikuo Shigemitsu, MD, PhD; Kiichi Miya, MD, PhD; Takashi Abe, MD, PhD; Michiaki Horiba, MD, PhD and Yoichiro Ishihara, MD

* From the Departments of Internal Medicine (Drs. Asano and Ishirara) and Surgery (Dr. Miya), National Health Insurance Sekigahara Hospital, Gifu, Japan; and the Departments of Respiratory Medicine (Drs. Shindoh, Abe, and Horiba) and Thoracic Surgery (Dr. Shigemitsu), Ogaki Municipal Hospital, Gifu, Japan.

Correspondence to: Fumihiro Asano, MD, PhD, Department of Internal Medicine, National Health Insurance Sekigahara Hospital, 2490–29 Sekigahara-cho, Fuwa-gun, Gifu 503-1514, Japan; e-mail: asano-fm{at}ceres.ocn.ne.jp


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To facilitate marking and to reduce its complications, we performed barium marking using an ultrathin bronchoscope with virtual bronchoscopic (VB) navigation before thoracoscopic surgery for small pulmonary peripheral lesions. We then evaluated the feasibility, safety, and efficacy of this technique.

Design: A pilot study.

Setting: A tertiary teaching hospital.

Patients: The subjects were consecutive patients with small pulmonary peripheral lesions (ie, ≤ 10 mm) showing a CT scan-confirmed pure ground-glass opacity pattern between December 2001 and August 2003.

Interventions: VB images to the planned marking sites near each lesion were produced from helical CT scan data. Based on these images, an ultrathin bronchoscope was advanced to the target bronchus under direct vision. Under CT scan and radiographic fluoroscopy, a catheter was inserted to the planned site via the bronchoscope, and barium sulfate suspension was instilled for marking.

Results: The subjects were 23 patients (8 men and 15 women) who had a total of 31 lesions. The bronchial branching patterns seen in VB images were highly consistent with those confirmed using the ultrathin bronchoscope. Therefore, the ultrathin bronchoscope could be guided under direct vision to a median of the sixth generation bronchi (range, fourth to ninth generation bronchi) toward the planned marking sites. Marking was achieved without causing complications in any of the patients. The median marking time was 23.5 min, and the median shortest distance between the barium marker and the lesion was 4 mm (within 10 mm in 27 lesions). In patients undergoing thoracoscopic surgery, all barium-marked sites were identified by intraoperative radiographic fluoroscopy, and all lesions were resected. A pathologic examination demonstrated primary lung cancer in 17 lesions (bronchioloalveolar carcinoma, 15; adenocarcinoma, 2), atypical adenomatous hyperplasia in 12 lesions, and pneumonia in 2 lesions.

Conclusions: This method can be readily performed without complications and is a useful marking method before thoracoscopic surgery for small pulmonary peripheral lesions.

Key Words: lung cancer • marking • navigation • small peripheral pulmonary lesion • thoracoscopic surgery • ultrathin bronchoscope • virtual bronchoscopy


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The recent advances in and widespread use of CT apparatuses, particularly the introduction of low-dose helical CT scans to lung cancer screening,12 have increased the detection rate of small pulmonary peripheral lesions. In particular, CT scanning has demonstrated the presence of many lesions with a ground-glass opacity (GGO) pattern that cannot be detected on plain chest radiographs.12 Nakata et al3 reported that most small lesions (ie, ≤ 10 mm) with a persistent pure GGO pattern are atypical adenomatous hyperplasia (AAH) or bronchioloalveolar carcinoma (BAC),4 the latter of which are noninvasive lesions. The prognosis of patients with such lesions after thoracoscopic wedge resection has been reported to be very good.35 Therefore, thoracoscopic surgery has been increasingly used not only for the diagnosis of small pulmonary peripheral lesions but also for treatment. However, because small lesions without pleural changes cannot be directly observed using a thoracoscope, they require preoperative marking.6

The percutaneous marking method789101112131415 that is widely used at present is associated with a high incidence of complications such as pneumothorax and hemorrhage. Tumor dissemination16 and fatal air embolism17 also have been reported. Another disadvantage of the percutaneous method is that marking must be done immediately before surgery, since marked sites sometimes fail to be identified if the marker has been dislodged or disappears over time. Transbronchial marking is not widely used because of its technical difficulties.181920

The ultrathin bronchoscope, which has entered clinical use in recent years, can be inserted into more peripheral bronchi than the conventional flexible bronchoscope.2122 It is, therefore, useful for the diagnosis of small pulmonary peripheral lesions.2223 Even with the use of an ultrathin bronchoscope, however, it is difficult to identify the bronchial route to the pulmonary peripheral lesion under direct observation within the limited examination time. On the other hand, virtual bronchoscopy (VB) is a three-dimensional expression resembling bronchoscopic images but based on helical CT scan images.24 Rarely, though, has it been used in the bronchoscopic examination of pulmonary peripheral lesions.25 This is partly because VB images cannot be used effectively, since the observation area of the routinely used thick bronchoscope is limited. We previously reported on a method of ultrathin bronchoscopy combined with VB navigation in which VB images to the target are produced based on thin-section CT (TSCT) scan images and are used as a navigator for the insertion of an ultrathin bronchoscope.2627

To facilitate marking and to reduce the complications from the procedure in patients with small pulmonary peripheral lesions for which thoracoscopic wedge resection is planned, we performed barium marking by ultrathin bronchoscopy with VB navigation, and evaluated the feasibility, safety, and efficacy of this method.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Subjects
The subjects studied were consecutive patients with small pulmonary peripheral lesions (ie, ≤ 10 mm) that had a CT scan-confirmed pure GGO pattern who were seen at National Health Insurance Sekigahara Hospital between December 2001 and August 2003. In each patient, observation for at least 1 month after the initial CT scan showed neither a decrease in the shadow nor the disappearance of the lesion. The exclusion criteria were lesions with a size of < 5 mm, and lesions in which thoracoscopic wedge resection was not indicated due to the anatomic location of the lesion, poor general condition of the patient, or complications. Also excluded were lesions accompanied by pleural changes, from which thoracoscopic identification of the location during surgery appeared to be possible. The institutional review board for human research approved this study protocol. All patients were given detailed descriptions of the examination and were informed that this was a new approach. Informed consent was obtained from all patients.

Ultrathin Bronchoscopic Barium Marking and VB Navigation
The procedure was basically the same as that used in our previous studies.28 First, to determine the marking sites, CT scan examination was performed using a helical CT scanner (HighSpeed Fx/i [between December 2001 and August 2002] and HighSpeed Nx/i [September 2002 to August 2003]; General Electric Medical Systems; Tokyo, Japan) with the following parameters: 1-mm collimation; single detector, pitch 1 (Fx/i scanner); dual detectors, pitch 3 (Nx/i scanner); and rotation time, 0.8 s. Helical CT scan data sets were acquired from an area centering on the lesion during single-breath-hold inhalations. The positional relationship between the lesion and the surrounding bronchi was evaluated on TSCT scan images obtained by reconstruction at 0.5-mm intervals using the chest algorithm from helical CT scan data. A site that was immediately below the pleura in principle, and that was as close as possible to the lesion without overlapping it, was selected as the planned marking site. In lesions that were considerably apart from the pleura, the following two marking sites were selected: a site close to the lesion; and a site immediately below the pleura. Based on helical CT scan data, VB was performed using appropriate software (Navigator, Advantage Windows, version 2.0: GE Medical Systems), and VB images to the planned marking site were produced in about 10 min.

Marking was performed using an ultrathin bronchoscope (BF-type XP40; Olympus; Tokyo, Japan) [external diameter, 2.8 mm; channel diameter, 1.2 mm] and a prototype catheter used for barium infusion28 (Olympus) [external diameter, 1 mm; whole length, 110 cm] in a room equipped with CT and radiographic fluoroscopy apparatuses. Each patient was premedicated with 25 mg hydroxyzine and 0.5 mg atropine sulfate. Local anesthesia of the upper respiratory tract was performed using a 2% lidocaine solution. Based on the VB images, an ultrathin bronchoscope was advanced to the target bronchus as far as possible under direct vision. A catheter was inserted via the channel of the bronchoscope. The position of the tip of the catheter at the planned marking site was confirmed by CT scan and corrected when necessary. Under radiographic fluoroscopy, a 100% (w/v) barium sulfate suspension (Maruishi Pharmaceutical Co, Ltd; Osaka, Japan) was instilled into the sites near the lesion via the catheter using a 1-mL syringe. After confirming adequate visibility of the barium marker by radiographic fluoroscopy, ultrathin bronchoscopy was terminated. After marking, TSCT scan examination (2-mm collimation) was performed, the three-dimensional relationship between the barium marker and the lesion was confirmed, and their distance was measured.

Fluoroscopy-Assisted Thoracoscopic Surgery
The interval between marking and surgery depended on the operative schedule and not on the time of marking. The patient was placed in the standard lateral recumbent position, and thoracoscopic surgery was performed under differential lung ventilation. Three thoracoports were placed on the lateral chest. The affected lung was completely collapsed and a thoracoscope was inserted. Under direct vision and radiographic fluoroscopy using a C-arm-type portable fluoroscopic apparatus (Mobile C-arm model BV29G; Philips Medical Systems; Tokyo, Japan), the position of the barium marker was identified. Based on the three-dimensional positional relationship between the marker and the lesion that had been evaluated by TSCT scan, the location of the lesion was estimated. An endostapler was applied to a lung site > 1 cm from the lesion. After confirmation of the location of the lesion and marker on the resected lung side by radiograph fluoroscopy, the lung was partially resected with the endostapler. The absence of residual barium marker in the remaining lung was confirmed by radiographic fluoroscopy. The specimen was immediately examined to ascertain the completeness of the resection and then was sent to a pathologist.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The 30 patients initially included in this study had a total of 38 small pulmonary peripheral lesions (ie, ≤ 10 mm) that showed a pure GGO pattern on CT scans taken at National Health Insurance Sekigahara Hospital between December 2001 and August 2003. In five lesions in five patients, thoracoscopic wedge resection was not indicated. This was because three patients were elderly and had a poor general condition, while the other two patients had a lesion very far from the pleura. Two lesions in two other patients were accompanied by pleural changes, and thoracoscopic location of both of these lesions appeared to be possible during an operation. After excluding these 7 lesions, 23 patients with 31 lesions were finally entered into this study. The subjects were 8 men and 15 women with a median age of 65 years (age range, 53 to 77 years). Abnormalities were detected by low-dose helical CT scan in lung cancer screening for inhabitants in 12 patients and by chest CT scan during follow-up observation of other lesions in the remaining 11 patients. None of the lesions was detected on chest radiographs. A single lesion was observed in 16 of the 23 patients, two lesions were observed in 6 patients, and three lesions were observed in 1 patient. As shown in Table 1 , the median size of the lesions was 7 mm, and the median shortest distance between the lateral margin of the lesion and the pleura on CT scan images was also 7 mm.


View this table:
[in this window]
[in a new window]

  		Table 1.. Characteristics of the Lesions*

 
Table 2 shows the results of ultrathin barium marking with VB navigation. VB images were able to be produced to a median of the sixth-generation bronchi (range, fourth to ninth generation), and the bronchial branching patterns seen in VB images were highly consistent with the actual patterns confirmed by ultrathin bronchoscopy (Fig 1 ). Therefore, we were able to insert the ultrathin bronchoscope to a median of the sixth-generation bronchi toward the marking site under direct vision. Marking was performed at one site for 19 lesions and at two sites for 12 lesions (Fig 2 ). The median shortest distance between the barium marker and the lesion was 4 mm, and marking within 10 mm was possible in 27 lesions. In 4 of the 27 lesions, barium overlapped a part of the lesion. The median time from insertion to removal of the bronchoscope was 23.5 min. No complications were observed in any patient.


View this table:
[in this window]
[in a new window]

  		Table 2.. Results of Ultrathin Bronchoscopic Barium Marking With VB Navigation*

 


View larger version (112K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.. Upper panels: VB images to the target. Top left: fifth-generation bronchus. Top right: seventh-generation bronchus. Lower panels: ultrathin bronchoscopic images. The bronchial branching patterns seen in VB images were highly consistent with the actual bronchial branching patterns, and VB images were useful for the navigation of the ultrathin bronchoscope during insertion.

 


View larger version (82K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2.. Left: a TSCT scan image (collimation, 2 mm) during marking. An ultrathin bronchoscope (thick arrow) has been inserted to the seventh-generation bronchus. The tip (thin arrow) of the catheter for barium infusion has been positioned near the lesion (white arrowhead) under CT scan and fluoroscopic guidance. Right: a TSCT scan image (collimation, 2 mm) after marking. Barium sulfate suspension was instilled into a site (black arrowhead) immediately below the pleura, close to and on the right of the lesion.

 
The median interval between marking and fluoroscopy-assisted thoracoscopic surgery was 9 days (range, 1 to 22 days). The lesion itself could not be observed using a thoracoscope in any of the patients, but the barium marker was identified by intraoperative radiographic fluoroscopy in all patients. Using a thoracoscope, the barium marker placed immediately below the pleura was observed as a white dot. In all patients, the lesions could be resected together with the barium marker without residual lesions or the addition of thoracotomy. The median size of the resected specimens was 65 mm (range, 42 to 80 mm) x 31 mm (range, 17 to 50 mm). No complications were observed in any of the patients.

Pathologic examination of the 31 lesions showed primary lung cancer in 17 lesions (BAC, 15 lesions; adenocarcinoma, 2 lesions), AAH in 12 lesions, and pneumonia in 2 lesions. BAC alone was observed in nine patients, adenocarcinoma alone was observed in two patients, AAH alone was observed in four patients, and pneumonia alone was observed in 1 patient. Two BAC lesions were observed in one patient, two AAH lesions were observed in two patients, and one BAC lesion plus one AAH lesion were observed in three patients. One patient had the following three diseases: one BAC lesion plus one AAH lesion, and one pneumonia lesion. In all lesions, negative surgical margins were obtained microscopically. There were no lesions in which the pathologic diagnosis was made difficult by the influence of barium instillation, even among lesions that the barium marker overlapped. Of the 17 lesions in the 16 patients who received diagnoses of lung cancer, 15 lesions in 14 patients were diagnosed as BAC. Because the prognosis of patients with this type of lung cancer is very good,35 these 14 patients were not treated by lobectomy and have been observed to the present. None of them have shown any recurrence (median observation period, 413 days; range, 65 to 727 days). In the two patients with two lesions that were diagnosed as adenocarcinoma, additional curative lobectomy was not performed because of the advanced age of one patient and the risk of poor respiratory function in the other. These patients have been observed for 425 days and 110 days, respectively, to the present, but neither has shown a recurrence.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In thoracoscopic surgery, the identification of a lesion during the operation is important. Suzuki et al6 reported that it is difficult to thoracoscopically observe lesions that have diameters of ≤ 10 mm and that are ≥ 5 mm from the pleura. Although this study included lesions within 5 mm from the pleura, these lesions could not be observed by thoracoscopy. In most resected specimens, the lesions were not palpable. This may be because the lesions were small and had a pure GGO pattern on CT scan images. Thus, in thoracoscopic surgery for small lesions (ie, ≤ 10 mm) that show a pure GGO pattern and are not accompanied by pleural changes, preoperative marking is indispensable.

In this study, transbronchial marking was performed. Before thoracoscopic surgery, percutaneous marking methods have been the primary techniques used, including marking with wire,7891011 dyes,12 color collagen,13 contrast media,14 and radioisotopes.15 However, percutaneous marking often causes complications. The rate of pneumothorax as a complication of percutaneous marking was reported to be 8 to 50%, and the rate requiring emergency treatment was 0 to 6%, while the rate of hemorrhage was reported to be 0 to 35%.789101112131415 In addition, fatal complications such as tumor dissemination16 and air embolism17 also have been reported. Due to these high complication rates, it is risky to mark more than one site. Therefore, percutaneous marking is risky when there are multiple or bilateral lesions. Puncturing is also difficult on the lung apex, the back surface of the scapula, areas near the thoracic spine, and areas in contact with the interlobular surface. In addition, since wire dislodgement occurs in 5 to 20% of cases,7891011 and dyes12 disappear with time, the rate of failure of intraoperative identification has been reported to be 0 to 5%. For these reasons, marking immediately before surgery is necessary. Intraoperative echo marking29 also has been reported, but small lesions showing faint radiographic images are difficult to detect. In transbronchial marking, on the other hand, dyes18 and barium1920 have been used. The primary theoretical advantage of transbronchial marking is the absence of complications such as pneumothorax and hemorrhage. However, in the transbronchial approach, the insertion of a routinely used bronchoscope (external diameter, about 5 to 6 mm) itself is difficult in some areas such as the lung apex showing marked bronchial bending.23 In addition, bronchoscopes with this thickness can be inserted only to about the third-generation bronchi, and the insertion of an inflexible catheter to a site near the shadow requires skill.18 Therefore, bronchoscopic marking is rarely used at present.

One of the characteristics of our transbronchial barium marking is the use of an ultrathin bronchoscope. The bronchoscope used in this study had an external diameter of 2.8 mm and could be inserted to a median of the sixth-generation bronchi, including those in the lung apex. Since the ultrathin bronchoscope itself had been inserted closer to the lesion than a conventional bronchoscope could be, the catheter could be accurately and readily inserted to the planned site. Another characteristic is the use of VB navigation for the insertion of the ultrathin bronchoscope. In this study, VB images to about the sixth-generation bronchi could be produced, and the bronchial branching patterns seen in VB images were highly consistent with the actual bronchial patterns. Therefore, a bronchoscope could be inserted to the target bronchus under direct vision. Using VB navigation, the bronchi into which the bronchoscope should be inserted can be clarified in advance, and the bronchoscope can be guided very easily.2627 In addition, it is not necessary to confirm, through radiographic fluoroscopy or CT scanning, that the bronchoscope is being inserted in the right direction whenever the bronchoscope passes the bronchial branching site, and thus VB navigation shortens the examination time.262730 Using these two methods (ie, ultrathin bronchoscopy and VB navigation), marking was completed in a median time of 23.5 min in the 31 lesions, and within 10 mm in 27 of 31 lesions. Since the marker was placed very close to the lesion, and their distance was further shortened due to collapse of the lung during operation, the estimation of the location of the lesion was easy. This barium marker was useful for locating lesions during thoracoscopic surgery. Because this method causes no special complications and can be performed in a short time,28 it therefore is also applicable to multiple lesions. In this study, multiple lesions were observed in seven patients, of whom three had bilateral lesions, but marking was performed without a problem. Since BAC and AAH often develop multicentrically,31 this method is especially useful. In addition, this method allows the marking of more than one site for one lesion. In this study, two sites were marked in 12 lesions. The lesion and resection area was three-dimensionally indicated by marking two sites with the lesion between them (eg, barium instillation into one site immediately below the pleura and into another site on the proximal side of the lesion). This method was also useful in lesions that were distant from the pleura.

Barium remains in the lung for a long period.32 In this study, the maximum interval between marking and surgery was 22 days, but the barium marker was identified by fluoroscopy in all patients, showing its effectiveness. The instillation of barium is considered to be safe in small amounts.1920 Considering the possibility that not all of the barium marker can be removed surgically, we used the smallest possible amount of barium that would allow identification by radiographic fluoroscopy. As a result, no coughing occurred in any patient during barium instillation, and neither fever nor pneumonia developed after marking. Barium overlapped four of the lesions, although this caused no difficulty in the pathologic diagnosis. Overlap may be avoided by moving the marking site further from the lesion or instilling barium under confirmation by CT fluoroscopy. However, if overlap causes no problems, this marking method may be technically more feasible than expected. Further studies, using other cases, are necessary to evaluate the influence that the barium overlap of lesions has on pathologic diagnoses.

We performed wedge resection for lesions (size, ≤ 10 mm) showing a CT scan-confirmed pure GGO pattern. The natural course of such lesions is still unclear. However, it is suspected that AAH as a precancerous lesion develops into BAC as a noninvasive lesion, and then into adenocarcinoma as an invasive lesion.3334 The standard surgical method for resection of adenocarcinoma is lobectomy with systemic lymph node dissection, which is more invasive than wedge resection. Lesions with a GGO pattern are often multiple, and there is a possibility that another new lesion will appear after the operation, requiring reoperation. Therefore, before lobectomy becomes necessary, wedge resection is also useful for preserving respiratory function. On the other hand, since BAC is considered to slowly progress,335 observation of the course by CT scan can be a choice. However, adenocarcinoma accounted for about 40% of lesions showing a GGO pattern accompanied by a solid compartment in the central area, or lesions (ie, > 10 mm) showing a pure GGO pattern.3 Therefore, not only the size of lesions but also changes in the features of the GGO pattern should be carefully observed by TSCT scan, but the early detection of changes is difficult. In addition, the period that requires observation of the course and appropriate intervals of CT scan examination for each lesion are not clear. To establish surgical indications, timing, and technique as well as an appropriate course observation protocol for small lesions with a pure GGO pattern, the characteristics and natural course of these lesions should be further clarified.

In conclusion, ultrathin bronchoscopic barium marking with VB navigation, which is readily performed and causes no complications such as those observed in percutaneous marking, may be a useful marking method for small pulmonary peripheral lesions before thoracoscopic surgery.


   Acknowledgements
 
We express deep gratitude to Dr. Masato Urano and Dr. Hiroshi Tsuya, both in the Department of Surgery Sekigahara Hospital, for performing thoracoscopic surgery in these patients.


   Footnotes
 
Abbreviations: AAH = atypical adenomatous hyperplasia; BAC = bronchioloalveolar carcinoma; GGO = ground-glass opacity; TSCT = thin-section CT; VB = virtual bronchoscopy

This work was supported in part by a grant from the Japanese Foundation for Research and Promotion of Endoscopy.

Received for publication January 5, 2004. Accepted for publication May 7, 2004.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Kaneko, M, Eguchi, K, Ohmatsu, H, et al (1996) Peripheral lung cancer: screening and detection with low-dose spiral CT versus radiography. Radiology 201,798-802[Abstract/Free Full Text]
  2. Sone, S, Takashima, S, Li, F, et al Mass screening for lung cancer with mobile spiral computed tomography scanner. Lancet 1998;351,1242-1245[CrossRef][ISI][Medline]
  3. Nakata, M, Sawada, S, Saeki, H, et al Prospective study of thoracoscopic limited resection for ground-glass opacity selected by computed tomography. Ann Thorac Surg 2003;75,1601-1606[Abstract/Free Full Text]
  4. Travis, WD, Colby, TV, Corrin, B, et al Histological typing of lung and pleural tumors. WHO international histological classification of tumors 3rd ed. 1999,25-47 Springer. Geneva, Switzerland:
  5. Yamato, Y, Tsuchida, M, Watanabe, T, et al Early results of a prospective study of limited resection for bronchioloalveolar adenocarcinoma of the lung. Ann Thorac Surg 2001;71,971-974[Abstract/Free Full Text]
  6. Suzuki, K, Nagai, K, Yoshida, J, et al Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest 1999;115,563-568[Abstract/Free Full Text]
  7. Mack, MJ, Shennib, H, Landreneau, RJ, et al Techniques for localization of pulmonary nodules for thoracoscopic resection. J Thorac Cardiovasc Surg 1993;106,550-553[Abstract]
  8. Shah, RM, Spirn, PW, Salazar, AM, et al Localization of peripheral pulmonary nodules for thoracoscopic excision: value of CT-guided wire placement. AJR Am J Roentgenol 1993;161,279-283[Abstract/Free Full Text]
  9. Shepard, JO, Mathisen, DJ, Muse, VV, et al Needle localization of peripheral lung nodules for video-assisted thoracoscopic surgery. Chest 1994;105,1559-1563[Abstract/Free Full Text]
  10. Gossot, D, Miaux, Y, Guermazi, A, et al The hook-wire technique for localization of pulmonary nodules during thoracoscopic resection. Chest 1994;105,1467-1469[Abstract/Free Full Text]
  11. Kanazawa, S, Ando, A, Yasui, K, et al Localization of pulmonary nodules for thoracoscopic resection: experience with a system using a short hookwire and suture. AJR Am J Roentgenol 1998;170,332-334[Free Full Text]
  12. Wicky, S, Mayor, B, Cuttat, JF, et al CT-guided localizations of pulmonary nodules with methylene blue injections for thoracoscopic resections. Chest 1994;106,1326-1328[Abstract/Free Full Text]
  13. Nomori, H, Horio, H Colored collagen is a long-lasting point marker for small pulmonary nodules in thoracoscopic operations. Ann Thorac Surg 1996;61,1070-1073[Abstract/Free Full Text]
  14. Choi, BG, Kim, HH, Kim, BS, et al Pulmonary nodules: CT-guided contrast material localization for thoracoscopic resection. Radiology 1998;208,399-401[Abstract/Free Full Text]
  15. Sugi, K, Kaneda, Y, Hirasawa, K, et al Radioisotope marking under CT guidance and localization using a handheld gamma probe for small or indistinct pulmonary lesions. Chest 2003;124,155-158[Abstract/Free Full Text]
  16. Voravud, N, Shin, DM, Dekmezian, RH, et al Implantation metastasis of carcinoma after percutaneous fine-needle aspiration biopsy. Chest 1992;102,313-315[Abstract/Free Full Text]
  17. Horan, TA, Pinheiro, PM, Araujo, LM, et al Massive gas embolism during pulmonary nodule hook wire localization. Ann Thorac Surg 2002;73,1647-1649[Abstract/Free Full Text]
  18. Sakamoto, T, Takada, Y, Endoh, M, et al Bronchoscopic dye injection for localization of small pulmonary nodules in thoracoscopic surgery. Ann Thorac Surg 2001;72,296-297[Abstract/Free Full Text]
  19. Kobayashi, T, Kaneko, M, Kondo, H, et al CT-guided bronchoscopic barium marking for resection of a fluoroscopically invisible peripheral pulmonary lesion. Jpn J Clin Oncol 1997;27,204-205[Free Full Text]
  20. Okumura, T, Kondo, H, Suzuki, K, et al Fluoroscopy-assisted thoracoscopic surgery after computed tomography-guided bronchoscopic barium marking. Ann Thorac Surg 2001;71,439-442[Abstract/Free Full Text]
  21. Tanaka, M, Satoh, M, Kawanami, O, et al A new bronchofiberscope for the study of diseases of very peripheral airways. Chest 1984;85,590-594[Abstract/Free Full Text]
  22. Saka, H, Oki, M, Kumazawa, A, et al Diagnosis of pulmonary peripheral lesions using an ultrathin bronchoscope. J Jpn Soc Bronchol 2000;22,617-619
  23. Asano, F, Kimura, T, Shindou, J, et al Usefulness of CT-guided ultrathin bronchoscopy in the diagnosis of peripheral pulmonary lesions that could not be diagnosed by standard transbronchial biopsy. J Jpn Soc Bronchol 2002;24,80-85
  24. Vinning, DJ, Liu, K, Choplin, RH, et al Virtual bronchoscopy, relationships of virtual reality endobronchial simulations to actual bronchoscopic findings. Chest 1996;109,549-553[Abstract/Free Full Text]
  25. Moriya, H, Koyama, M, Honjo, H, et al Interactive virtual bronchoscopy as a guide for transbronchial biopsy in two cases. J Jpn Soc Bronchol 1998;20,610-613
  26. Asano, F, Matsuno, Y, Matsushita, T, et al Transbronchial diagnosis of a pulmonary peripheral small lesion using an ultrathin bronchoscope with virtual bronchoscopic navigation. J Bronchol 2002;9,108-111[CrossRef]
  27. Asano, F, Matsuno, Y, Takeichi, N, et al Virtual bronchoscopy in navigation of an ultrathin bronchoscope. J Jpn Soc Bronchol 2002;24,433-438
  28. Asano, F, Matsuno, Y, Ibuka, T, et al A barium marking method using an ultrathin bronchoscope with virtual bronchoscopic navigation (a case report). J Jpn Respir Soc 2003;41,54-58
  29. Greenfield, AL, Steiner, RM, Liu, JB, et al Sonographic guidance for the localization of peripheral pulmonary nodules during thoracoscopy. AJR Am J Roentgenol 1997;168,1057-1060[Abstract/Free Full Text]
  30. Shinagawa, N, Yamazaki, K, Onodera, Y, et al CT-guided transbronchial biopsy using an ultrathin bronchoscope with virtual bronchoscopic navigation. Chest 2004;125,1138-1143[Abstract/Free Full Text]
  31. McElvaney, G, Miller, RR, Muller, NL, et al Multicentricity of adenocarcinoma of the lung. Chest 1989;95,151-154[Abstract/Free Full Text]
  32. Erickson, LM, Shaw, D, MacDonald, FR Prolonged barium retention in the lung following bronchography. Radiology 1979;130,635-636[ISI][Medline]
  33. Noguchi, M, Morikawa, A, Kawasaki, M, et al Small adenocarcinoma of the lung: histologic characteristics and prognosis. Cancer 1995;75,2844-2852[CrossRef][ISI][Medline]
  34. Chapman, AD, Kerr, KM The association between atypical adenomatous hyperplasia and primary lung cancer. Br J Cancer 2000;83,632-636[CrossRef][ISI][Medline]
  35. Kodama, K, Higashiyama, M, Yokouchi, H, et al Natural history of pure ground-glass opacity after long-term follow-up of more than 2 years. Ann Thorac Surg 2002;73,386-393[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
K.-i. Watanabe, H. Nomori, T. Ohtsuka, M. Kaji, T. Naruke, and K. Suemasu
Usefulness and complications of computed tomography-guided lipiodol marking for fluoroscopy-assisted thoracoscopic resection of small pulmonary nodules: Experience with 174 nodules.
J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 320 - 324.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
F. Asano, Y. Matsuno, N. Shinagawa, K. Yamazaki, T. Suzuki, T. Ishida, and H. Moriya
A virtual bronchoscopic navigation system for pulmonary peripheral lesions.
Chest, August 1, 2006; 130(2): 559 - 566.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (5)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Asano, F.
Right arrow Articles by Ishihara, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Asano, F.
Right arrow Articles by Ishihara, Y.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS