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(Radiology. 1999;211:561-565.)
© RSNA, 1999

Technical Developments

Lung Nodules: Improved Wire for CT-guided Localization1

Brian F. Mullan, MD, William Stanford, MD, William Barnhart, RTR and Jeffrey R. Galvin, MD

1 From the Department of Radiology, University of Iowa College of Medicine, 200 Hawkins Dr, 3953 JPP, Iowa City, IA 52242-1077. Received January 21, 1998; revision requested April 2; revision received August 10; accepted November 5. Address reprint requests to B.F.M.


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The authors designed three localization wires that increase the utility of percutaneous localization of lung nodules performed in conjunction with video-assisted thorascopic resection. In 17 patients, the custom-made wires dislodged less frequently than did commercially available wires (two of 11 vs three of six, respectively) while allowing the surgeon to apply gentle retraction pressure, which aided the resection.

Index terms: Lung, biopsy, 60.126 • Lung, nodule, 60.311, 60.32, 60.33 • Lung neoplasms, surgery, 60.311, 60.32, 60.33 • Thorascopy, 60.1269


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Evaluation of a solitary pulmonary nodule has been greatly aided by the development of minimally invasive resection by means of a combination of endoscopic surgery and computed tomography (CT)-guided percutaneous placement of a localizing wire. Although wire localization has been found to be effective in localizing the majority of lesions, the wires used have generally been designed for use in breast parenchyma. As lung tissue is substantially less dense than is breast tissue, these wires have a tendency to pull away from the nodule during the procedure, which necessitates a much larger resection or open thoracotomy. On the basis of our experience in thoracic and breast localization techniques, we developed a nitinol wire specifically for lung tissue that both localizes the nodule and allows application of gentle retraction pressure to aid the surgeon's resection.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
From September 1995 through May 1998, 18 patients were referred for needle localization of a solitary lung nodule of indeterminate nature depicted at plain radiography and CT. Seventeen of the 18 nodules were successfully resected. One nodule, which had initially been found at thick-section (10 mm) CT, was found at thin-section (3 mm) localization CT to be benignly calcified. In consultation with the surgeon, we elected to follow up this lesion conservatively and not perform the localization.

Of the remaining 17 nodules, three were localized with a Kopans hook wire (Cook, Bloomington, Ind), one with a Miller corkscrew wire, (Cook), and two with Hawkins II hook wires (Medi-tech/Boston Scientific, Watertown, Mass) (Fig 1). Eleven were localized with wires of our own design.



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  		Figure 1. Commercially available localization wires used in this study.

 
Our custom-made wires were helical, double-coil, and cloverleaf. These localization wires were made of 30-gauge nitinol wire by using a mandrel to obtain the desired shape. One helical wire was made. It was a 1.5-cm-long coil with a 1-cm-diameter base and a 0.5-cm-diameter apex. The coil included 31/2 turns. Five double-coil wires were made that consisted of two nitinol wires twisted together with the distal 2 cm free. These two ends each formed a 5-mm-diameter coil. Five cloverleaf wires were made that are modifications of the double-coil wire. During deployment, the wires formed the initial coils, then were twisted 90° and formed second coils, resulting in four coils oriented at 90° to each other.

Of our custom-made wires, a helical wire was used once, a double-coil wire (Fig 2) was used five times, and a cloverleaf wire (Fig 3) was used five times. The patients were not randomly assigned with respect to the wire used. Rather, the wires were used sequentially, first the helical wire, then the five double-coil wires, and then the five cloverleaf wires. One surgeon performed all the surgical procedures in this study, as he was the surgeon performing the thorascopic resections in our institution at the time. He had no input about which wire was used in which case but only gave feedback at the conclusion of the case. The surgeon's criteria for considering resection were that the nodule was visible at thin-section CT, that the resection was clinically appropriate, and that the patient's health would allow the surgery. No patient referred to us by the surgeons was declined, that is, no nodule was deemed unapproachable with this technique.



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  		Figure 2. Double-coil custom-made localization wire.

 


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  		Figure 3. Cloverleaf custom-made localization wire.

 
The procedure was virtually identical in all cases and was basically a modification of fine-needle aspiration with the patient in a decubitus or supine position. Briefly, after a nodule was localized with thin-section CT, the introducer needle was advanced to a position just past the nodule. Ideally, but not always, the needle passed through the nodule. Then, the localization wire was deployed at this location, and the position was confirmed with CT prior to removal of the introducer needle (Fig 4). With the commercially available wires and the first four custom-made wires (the helical wire and three double-coil wires), the localization wire was in place in the lumen of the introducer needle during insertion. With the remaining custom-made wires, a stylet was in place during insertion. The stylet was exchanged for the localization wire after proper placement was confirmed. The external portion of the wire was loosely coiled on the patient's chest and draped with sterile covers. Then the patient was escorted to the preoperative holding area by the radiologist.



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  		Figure 4. Axial CT scan shows the cloverleaf localization wire deployed in normal lung parenchyma, adjacent to the target nodule (1). Two of the four coils (3) are visible. 2 = introducer needle.

 
Our localization system consisted of three parts (Fig 5). The introducer needle was a 20-gauge Chiba biopsy needle (Becton Dickinson, Rutherford, NJ). To easily exchange the localization wire for the Chiba stylet, we used an insertion device that is a 3-cm-long segment of standard 20-gauge needle stock burnished at each end. After the introducer needle was properly positioned, the stylet was withdrawn and the insertion device, with the preloaded localization wire, was placed in the hub of the Chiba needle. The wire was advanced into the needle. Owing to the curve of the distal end of the wire, friction of the wire within the Chiba lumen or the absence of friction if the wire tip exited the needle could be felt relatively easily. The wire was deployed, and its position was confirmed before the introducer needle was moved. If the position was not ideal, the localization wire was withdrawn into the localizer needle, which was then repositioned. When adequate localization was confirmed, the wire was anchored by the radiologist with one hand and the needle was withdrawn.



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  		Figure 5. Custom localization system consists of three parts: a 20-gauge Chiba biopsy needle for localization of the nodule, a 3-cm-long segment of 20-gauge needle stock for insertion of the localizing wire into the Chiba needle, and the 30-gauge nitinol localization wire.

 

   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
All 17 of the nodules were successfully localized (the position of the localization wire in or adjacent to the nodule was confirmed at thin-section CT) and resected. The nodules were an average 7.9 mm ± 2.5 (SD) in diameter (range, 4–12 mm) and an average 1.8 cm ± 1.4 from the pleural surface (range, 1.0–6.0 cm). Seven nodules were malignant (four metastases, three primary to lung), and 10 were benign (eight granulomas and two fibrous scars.)

In the five localization procedures with commercial needles, one asymptomatic pneumothorax resulted. Three of the five commercial wires dislodged prior to resection. At surgery, one Kopans hook wire had withdrawn, with its tip located in the chest wall. A puncture mark was seen on the visceral pleura indicating prior entry of the wire into the lung. We initially positioned the wire while the patient was in a decubitus position with her arm over her head. Even though this was also the position for surgery, she was allowed to lower her arms in the preoperative holding area, and the resultant movement of the chest wall and musculature presumably resulted in the wire pulling out. The lack of wire guidance necessitated conversion of the procedure to open thoracotomy, and successful biopsy was accomplished. In a second patient, a Hawkins II wire was seen within the pleural space but not within the lung after deflation. On the basis of our previous experience, patient motion was limited, and the wire presumably pulled out during deflation of the lung at surgery. Again, the lack of wire guidance necessitated open thoracotomy to accomplish the biopsy. The Miller corkscrew was the third wire that dislodged. In this case, the wire remained in the correct place during the initial phases of the surgery, including lung deflation. However, when the surgeon applied gentle retraction on the wire to aid his resection, the wire pulled out. As this nodule was relatively large (9 mm diameter) and superficial (1.5 cm deep in the inflated lung), the surgeon could palpate it through a port and accomplished the resection thorascopically. The remaining two hook wires, one Hawkins II and one Kopans, remained in place throughout the resections. These two wires were the first placed, and the surgeon purposefully did not apply retraction pressure to them.

In the 11 localizations with custom-made wires, five cases of asymptomatic pneumothorax were seen. One was approximately 20% pneumothorax, and the others were less than 5%. None required intervention. Three of the five cases of pneumothorax occurred in the first four placements of custom-made wires, in which the localization wire was placed in the lumen of the insertion needle prior to placement. In light of this, we modified our technique by placing the insertion needle with a stylet in the lumen; we then exchanged the stylet for the localization wire after the needle was in an appropriate position. After this change in technique, we have had two cases of pneumothorax in seven placements.

The helical wire was placed easily, and it was in place after lung deflation. As the surgeon applied gentle traction on the wire, however, it withdrew from the lung completely. The surgeon was able to follow the wire tract to the nodule and accomplished the biopsy thorascopically.

When a double-coil wire was deployed, the coils were opposed to one another with their broad surface in line with the long axis of the wire. Three of the five double-coil wires remained in place throughout the procedures. The surgeon reported increased confidence with their use as retraction devices. Of the two double-coil wires that dislodged, the tip of one was seen to be within the pleural space after lung deflation. In this case, there was a 4-hour delay between localization and surgery. We gave instructions to minimize patient movement, but some patient arm movement was unavoidable during the long delay; therefore, we do not know whether the wire dislodged preoperatively or during lung deflation. The second double-coil wire that dislodged was also found within the pleural space. Unlike with the other wires that had dislodged, however, there was no mark on the visceral pleura to indicate that the wire had entered the lung. Although the wire appeared to enter the lung on the CT scan, the patient developed a 20% pneumothorax early in the localization procedure and prior to wire deployment. This not only made the localization more difficult but also brought the nodule close to the pleura. We presume the apparent intraparenchymal location was erroneous due to volume averaging.

The five cloverleaf wires deployed easily and remained firmly anchored despite what the surgeon reported as "moderately strong" retraction. The surgeon reported that the ability to use the wire as a retraction device made it his favorite among the wires used in this study.

The relationships of noticeable migration of the localization wire (defined as migration that obviated use of the wire for adequate localization) to nodule size, depth from the pleura, and malignancy versus benignancy are shown in Table 1.


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  		TABLE 1. Rate of Migration of Localization Wire after Placement
 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Preoperative wire localization, first described by Mack et al (1), to our knowledge, involves placement of a wire with CT guidance in or adjacent to a pulmonary nodule. The wire then provides a guide for the surgeon to the lesion to be resected at video-assisted thoracic surgery. The procedure has been described and slightly modified by several authors (2–8). Asymptomatic pneumothorax occurs in about 30% of patients and small parenchymal hemorrhages are not uncommon, but these rarely effect the outcome of the procedure. Dislodgment of the wire after placement, however, occurs in 6%–20% of cases and is more problematic (2,4). Although most of the biopsy procedures can be salvaged by means of wide excision or, if necessary, conversion to open thoracotomy, this negates the advantages of the minimally invasive surgery.

Currently, there is no localizing wire available that is specifically designed for lung tissue. The Kopans and Hawkins II systems and other systems are designed for use in breast tissue, in which, ideally, the wire is placed through the nodule with the hook deployed on the opposite side, allowing the wire to be braced by the nodule itself. However, for nodules less than 1 cm in diameter, for which the procedure with combined CT and video-assisted thoracic surgery is ideal, this placement is rarely possible. The small size and relative mobility of pulmonary nodules, as well as the inability of some patients to reproducibly suspend respiration during placement, generally result in the spring wire being deployed in the surrounding lung tissue. The anchoring power of the hook wire is due to the cross-sectional area of the hook in the plane of tension. These wires have a very small cross-sectional area and, thus, produce large forces per square centimeter. Although the relatively dense connective tissue of the breast can resist these forces, the relatively sparse parenchyma of the lung provides much less resistance for the spring hook. In effect, the hook acts as a garrote, ripping through the tissue when pulled, and it is thus much more easily dislodged.

A wire is generally dislodged at one of three times. As the patient is transported to surgery, the wire can be pulled as the chest wall and shoulder girdle move relative to the lung. During surgical deflation of the lung, the friction between the wire and wall can be considerable as the wire is pulled through the chest wall, resulting in entrapment of the wire in the chest wall and displacement of the tip in the lung. The third time of dislodgment is during the resection when the surgeon will often apply gentle retraction on the wire to tent the lung to allow easier access to the resection site and removal of the tissue.

Kanazawa et al (9,10) tried to decrease the resistance of the wire when passing it through the chest wall. Instead of using a long wire, they developed a short (10-mm-long) wire with a long nylon suture attached to the proximal end. The wire is thus free to move with the lung while the suture provides guidance to the surgeon. While they report only three dislodgments in 37 localizations (8%), their design does not address two fundamental problems. First, a hook that is only 7 mm long and 0.28 mm in diameter provides the basic purchase in the lung. This presents a very small cross-sectional area to the lung in the direction of the tension. As with the Kopans and Hawkins II hook wires, this will allow dislodgment whether the force is applied through a suture or wire. The second limitation to their system is that the hook cannot be repositioned once it is deployed. This is a major limitation, as the actual deployment of any wire is performed blindly with confirmation of position at CT coming only later. Indeed, in 8% of the nodules localized, placement of a second wire was required because the first was improperly placed but could not be moved.

Since September 1995, we have placed 17 wires for localization. In our first five patients, we used two Kopans hook wires, two Hawkins II hook wires, and one Miller corkscrew wire. Although all the biopsies were successful, three of the wires dislodged or migrated noticeably prior to surgery. Owing to the nature of the wire design, the wires could not be repositioned once they were deployed. Further, our surgeon noted that he could not use the commercial wires for retraction and that the ability to do so would be a great help, particularly when the staple line was deployed during resection. In response to this need, we made three wires of our own design. Our requirements for the new wires were that they had to increase the surface area of the wire exposed to the lung, be repositionable, and be easy to deploy. Our measures of success were accurate localization, the ability to reposition the wire if necessary, no symptomatic complications during placement or prior to surgery, and the ability for the surgeon to use the wire as a retractor.

Our basic design hypothesis was that a coil anchor would increase the surface area of the wire in contact with the lung while allowing a natural "screwing in" motion of the wire during deployment. Our initial design, a helical coil, deployed very smoothly and could be easily retracted into the introducer needle if repositioning was necessary. However, when the surgeon applied gentle retraction to the wire to aid access to the lesion during resection, the gentle force was sufficient to dislodge the wire.

Our second design incorporated two wires braided together that deployed two loops coiled back to back (double-coil wire). This increased the surface area of the wire in contact with the lung compared to that of the breast wires, allowed a natural coiling of the wire through the lung during deployment, and allowed easy repositioning. Because these single smaller loops coiled 180° on themselves, they were less likely to uncoil. Additionally, as each coil contributed holding strength independent of the other, an overall greater holding force would be developed. Subjectively, this type of wire provided more purchase than did the Kopans hook wire. The surgeon reported the ability to apply mild retractile force without obvious movement of the wire, but it did not provide the desired anchoring power.

Our third design was a cloverleaf, with the four loops in 90° opposition to each another. Additionally, the plane of each loop was slightly out of plane with the axis of tension. This design exposed the greatest surface area of wire to the lung tissue. Although the wire was deployed in normal lung tissue adjacent to the nodules, the wire did not move despite what the surgeon called "significant" retractile force.

Given our small sample, several factors may effect our results. We found that the size of a nodule appeared to have little effect on whether a wire migrated (Table 2). This is consistent with the fact that, given the small average size of the nodules, most of the localization wires were deployed in the tissue adjacent to the nodule. This adjacent tissue looked unremarkable at thin-section CT, and we saw no noticeable variation in the appearance of the perinodular tissue among patients. Therefore, the fact that migration occurred more often with malignant nodules (43%, Table 1) than with benign nodules (20%) is probably more a function of our small sample than of alterations in the underlying tissue. Likewise, although there were fewer migrations with the custom-made wires, they tended to be used in the localization of lesions that were deeper (average distance from pleura, 2.1 cm) than those with the commercial wires (average distance from pleura, 1.2 cm). Since the holding strength of the wire is generated at the distal tip and not along the shaft, it is difficult to attribute fewer migrations to an additional 1-cm-long shaft. However, this aspect was not controlled in our study.


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  		TABLE 2. Nodule Size and Distance from Pleura versus Migration of Localization Wire
 
There are several limitations to this study. First, the sample is relatively small. At our institution, small nodules are usually resected by means of open wedge resection, partially because of the belief that localization wires may migrate and necessitate an open procedure. Perceived improvements in reliability and utility with our custom-made wires, however, have resulted in increased confidence in and use of them in localization procedures. Second, we have no objective measure of wire anchoring strength. The only reported example of such a study, to our knowledge, was in breast parenchyma (11). We are currently developing a similar means to evaluate holding strength in normal and diseased lung tissue. Until these data are collected, however, the surgeon's subjective evaluation should be carefully considered. The surgeon is the end user of our technique and the ultimate judge of its utility. Although the breast localization wires can be used in the lung, our surgeons repeatedly request a wire with anchoring strength, which indicates a continuing need. In our study, the surgeon's subsequent evaluation and wire preferences matched what we considered to be design improvements, which suggests that our design considerations are appropriate.

In conclusion, we developed a cloverleaf localization wire that specifically takes into account the nature of lung tissue. Our design increases the surface area of the wire exposed to the lung tissue and allows repositioning and gentle retraction. This custom-made wire can be deployed in normal lung tissue. Therefore, it can be used not only to localize nodules of any size (the lower limit being as small as deemed resectable by the surgeon) but also to guide endoscopic biopsy of specific regions of the lung involved in more diffuse diseases. By enabling successful minimally invasive sampling of lung disease depicted at CT, this method will establish a link between the earlier detection of abnormalities and the earlier diagnosis of disease. Further, it may do so in a manner that will decrease patient morbidity, discomfort, and cost.


   Footnotes
 
Author contributions: Guarantor of integrity of entire study, B.F.M.; study concepts, B.F.M., J.R.G.; study design, all authors; definition of intellectual content, B.F.M.; literature research, B.F.M.; clinical studies, B.F.M., W.S., J.R.G.; experimental studies, B.F.M., W.B.; data acquisition, B.F.M., W.S., J.R.G.; data analysis, B.F.M.; manuscript preparation, B.F.M.; manuscript editing, B.F.M., W.S.; manuscript review, B.F.M., W.S., J.R.G.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Mack MJ, Gordon MJ, Postma TW, et al. Percutaneous localization of pulmonary nodules for thorascopic lung resection. Ann Thorac Surg 1992; 53:1123-1124.[Abstract]
  2. Plunkett MB, Peterson MS, Landreneau RJ, Ferson PF, Posner MC. Peripheral pulmonary nodules: preoperative percutaneous needle localization with CT guidance. Radiology 1992; 185:274-276.[Abstract/Free Full Text]
  3. Shennib H. Intraoperative localization techniques for pulmonary nodules. Ann Thorac Surg 1993; 56:745-748.[Abstract]
  4. Shah RM, Spirn PW, Salazar AM, Steiner RM. Localization of peripheral pulmonary nodules for thorascopic excision: value of CT-guided wire placement. AJR 1993; 161:279-283.[Abstract/Free Full Text]
  5. Templeton PA, Krasna M. Localization of pulmonary nodules for thorascopic resection: use of needle/wire breast biopsy system. AJR 1993; 160:761-762.[Free Full Text]
  6. Lenglinger FX, Schwarz CD, Artmann W. Localization of pulmonary nodules before thorascopic surgery: value of percutaneous staining with methylene blue. AJR 1994; 163:297-300.[Abstract/Free Full Text]
  7. Gossot D, Miaux Y, Guermazi A, Celerier M, Frija J. The hook wire technique for localization of pulmonary nodules during thorascopic resection. Chest 1994; 105:1467-1469.[Abstract/Free Full Text]
  8. Shepard JO, Mathiasoen DJ, Muse VV, Bhalla M, McLoud TC. Needle localization of peripheral lung nodules for video assisted thorascopic surgery. Chest 1994; 105:1559-1563.[Abstract/Free Full Text]
  9. Kanazawa S, Ando A, Yasui K, Tanaka A, Hiraki Y. Localization of small pulmonary nodules for thorascopic resection: use of a newly developed hookwire system. Cardiovasc Intervent Radiol 1995; 18:122-124.[Medline]
  10. Kanazawa S, Ando A, Yasui K, et al. Localization of pulmonary nodules for thorascopic resection: experience with a system using a short hookwire and suture. AJR 1998; 170:332-334.[Free Full Text]
  11. Czarnecki DJ, Berridge DL, Splittgerber GF, Goell WS. Comparisons of the anchoring strengths of the Kopans and Hawkins II needle–hook wire systems. Radiology 1992; 183:573-574.[Abstract/Free Full Text]



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