Clinical Experience With Radiotracer-Guided Thoracoscopic Biopsy of Small, Indeterminate Lung Nodules Brendon M. Stiles, MD, Talissa A. Altes, MD, David.

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Clinical Experience With Radiotracer-Guided Thoracoscopic Biopsy of Small, Indeterminate Lung Nodules Brendon M. Stiles, MD, Talissa A. Altes, MD, David R. Jones, MD, K. Robert Shen, MD, Gorav Ailawadi, MD, Spencer B. Gay, MD, Juan Olazagasti, MD, Patrice K. Rehm, MD, Thomas M. Daniel, MD The Annals of Thoracic Surgery Volume 82, Issue 4, Pages 1191-1197 (October 2006) DOI: 10.1016/j.athoracsur.2006.04.059 Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Patient selection for radiotracer localization was based on anticipated difficulty in thoracoscopically locating nodules with visualization and palpation alone. Some patients were selected on the basis of the depth of the nodule (A), whereas others were selected on the basis of the location of the lesion. The lesion seen in (B) was judged to be pleural based, but was abutting the mediastinum. The Annals of Thoracic Surgery 2006 82, 1191-1197DOI: (10.1016/j.athoracsur.2006.04.059) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 After computed tomographic–guided technetium Tc 99m macro-aggregated albumin injection into or near the nodule, an immediate postprocedure scintigram is obtained to confirm intraparenchymal location of the radiotracer. The left panel shows a lateral view of the patient’s scintigram with the radiotracer appearing as a white spot in the superior segment of the right lower lobe where the nodule was marked by the technetium/albumin injection. The right panel shows the anterior-posterior view of the same patient with the marker in the superior segment of the right lower lobe. The Annals of Thoracic Surgery 2006 82, 1191-1197DOI: (10.1016/j.athoracsur.2006.04.059) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 We successfully localized 96% (44 of 46) of the lesions in our series. The two failures were related to radiotracer spillage into the pleural cavity, which was recognized preoperatively. In this scintigram, the lesion is marked with an arrowhead, and the spilled tracer is denoted with an arrow. Placement of the radiotracer deep to subpleural lesions minimizes the chances of inadvertent pleural space injection. The Annals of Thoracic Surgery 2006 82, 1191-1197DOI: (10.1016/j.athoracsur.2006.04.059) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions