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Japanese Journal of Clinical Oncology Pages 204-205

CT-Guided Bronchoscopic Barium Marking for Resection of a Fluoroscopically Invisible Peripheral Pulmonary Lesion
Technique
References

CT-Guided Bronchoscopic Barium Marking for Resection of a Fluoroscopically Invisible Peripheral Pulmonary Lesion

CT-Guided Bronchoscopic Barium Marking for Resection of a Fluoroscopically Invisible Peripheral Pulmonary Lesion Toshiaki Kobayashi1, Masahiro Kaneko1, Haruhiko Kondo2, Haruhiko Nakayama2, Hisao Asamura2, Ryosuke Tsuchiya2, Tsuguo Naruke2 and Tadao Kakizoe2

1Endoscopy Division and 2Surgical Oncology Division, National Cancer Center Hospital, Tokyo, Japan

Key words: thoracoscopic surgery - CT-guided bronchoscopy - lung cancer - barium marking

Fluoroscopically invisible peripheral pulmonary lesions are increasingly detected by CT. Thoracoscopic resection is one option for histo-cytologic diagnosis of these lesions. Its diagnostic accuracy approximates to 100%. However, localization of such lesions is difficult thoracoscopically. Present localization aids include transthoracic needle implantation of wires. However, this carries the risk of pneumothorax and wire dislodgment. We therefore performed transbronchial placement of a barium sulfate suspension to serve as a fluoroscopic marker for a fluoroscopically invisible peripheral pulmonary lesion. This was done via CT-guided bronchoscopy (1 ).

TECHNIQUE

A 68-year-old man with a 1.1 * 0.6 cm lesion in left S6a underwent CT-guided bronchoscopic barium marking, having given informed consent. The patient was instructed not to take anything orally before the procedure (including the meal immediately before). The lesion site and the related bronchus were confirmed by thin section CT (2 mm-collimation) prior to the procedure. This provided information on the three dimensional relationships of the lesion and other anatomical structures, i.e. blood vessels, vertebrae. The information was used to approximate the lesion site on the postero-anterior and lateral chest x-ray views during fluoroscopy.

Under local anesthesia using 4% lidocaine, an FUR-9P ultrathin fiberscope (Asahi Optical Co. Ltd, Tokyo, Japan) with a 3.0 mm distal rigid portion diameter and a 1.2 mm working channel was inserted orally into the related bronchus using a transoral approach. The fiberscope was guided fluoroscopically to the estimated lesion site. When the fiberscope was considered to be close enough to the lesion site, the patient was moved into a CT system (Xvision, Toshiba Corporation, Tokyo, Japan). The fiberscope was further guided to the lesion under CT fluoroscopy which provides 6 images (3 mm-collimation) per second with a 0.67 second delay. Subsequently, the inner needle of an NA-2C TBAC needle (Olympus Optical Co., Ltd., Tokyo, Japan) without its tip was inserted and guided to the lesion under CT fluoroscopy. The needle was positioned lateral to the lesion immediately under the pleura. The location was verified by thin section CT (2 mm- collimation). Barium sulfate suspension (Fushimi Pharmaceutical Co., Ltd., Kagawa, Japan), 0.5 ml of 100 w/v%, was then instilled under CT fluoroscopy. The three dimensional relation of the lesion and the barium marker was ascertained by thin section CT (Fig. 1 ). Clarity of the barium marker was confirmed fluoroscopically (Fig. 2 ).


Figure 1. The barium marker is clearly observed in the region lateral to the lesion immediately under the pleura. No excess artifact due to the barium marker is seen.

Twenty-five minutes were spent on CT-guided bronchoscopic marking and the patient tolerated the procedure well. No untoward complications such as fever occurred during or after barium marking. Neither migration nor disappearance of the marker occurred up to the time of resection 7 days later. The barium marker was clearly visible on the fluoroscope during the resection. The frozen section of the resected specimen revealed an adenocarcinoma which was not compromized by the barium marker. As such, left lower lobectomy was done.


Figure 2. The barium maker is distinct even on fluoroscopy. No unnecessary bronchograms surround the marker.

Barium sulfate suspension is commonly used for barium swallow and was formerly used for bronchography (2 ,3 ). The histologic effects of barium sulfate are the same or even less than those of oily propyliodine which was the standard contrast medium for bronchography (2 ). During a barium swallow, unintentional aspiration results in a bronchogram that is seldom problematic unless the aspiration is massive. However, barium sulfate suspension is not commonly used for bronchography because it is retained for quite some time in the lung. This feature makes the suspension a potential marker for fluoroscopy. Theoretically, complications such as pneumothorax and hemoptysis are not anticipated. Dislodging of the marker should not be a problem. Barium instillation via CT-guided bronchoscopy affords wider accessibility to the bronchi and more accurate placement in any appropriate bronchus. Therefore, the barium marker can be placed in several ways, i.e., a spot at the lesion, a spot proximal to the lesion and at the orifice of the lesion to create a bronchogram. Discriminatory marking can define the related bronchus, facilitate dissection of regional lymph nodes and even delineate resection lines for segmentectomy.

We consider CT-guided bronchoscopic barium marking to be a safe, reliable and versatile marking technique for thoracoscopic resection.

References

1. Kobayashi T, Shimamura K, Hanai K, Kaneko M. Computed tomography-guided bronchoscopy with an ultrathin fiberscope. Diagn Therap Endosc 1996;2:229-32.

2. Nelson SW, Christoforidis A, Pratt PC. Barium sulfate and bismuth subcarbonate suspensions as bronchographic contrast media. Radiology 1959;72:829-38.

3. Nelson SW, Christoforidis AJ, Pratt PC. Further experience with barium sulfate as a bronchographic contrast medium. AJR 1964;92:595-614.

Received April 4, 1997; accepted April 17, 1997
For reprints and all correspondence: Toshiaki Kobayashi, Endoscopy Division, National Cancer Center Hospital, 1-1, Tsukiji 5-chome, Chuo-ku, Tokyo 104, Japan

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Last modification: 19 May 1998
Copyright© Japanese Journal of Clinical Oncology, 1997.
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