CT guided injection of 99mTc-MAA for lung nodule localization prior to VATS


      • CT guided 99mTc-MAA injection is a feasible technique for pulmonary nodule localization before VATS procedure.
      • It has a high success and low complication rate.
      • Nodule size, nodule depth, final needle position, and radiotracer injection to incision interval did not impact the procedure success.



      CT guided technetium99m-macroaggregated albumin (99mTc-MAA) injection for lung nodule localization prior to video-assisted thoracoscopic surgery (VATS) is employed at our institution for more than a decade. We retrospectively studied the success rate, factors that affect outcomes, and complications of this procedure.

      Materials and methods

      147 patients with 164 nodules underwent this procedure before VATS. Imaging and procedure characteristics, complications of the procedure, successful intra-operative localization and wedge resection, if there was conversion of primary VATS to open thoracotomy and if so the reason, and histopathological diagnosis for each nodule were reviewed by two radiologists in consensus. In case of unsuccessful wedge resection, reasons for failure were derived from electronic medical record. The impact of nodule and procedure characteristics on successful intra-operative localization was assessed.


      Excluding 9 nodules with unsuccessful localization due to non-procedure related reasons, the CT guided procedure was successful in 96.1% for intraoperative localization (149/155). Pleural leak of the radiotracer, split injection within the lobe, injection into a wrong nodule and gamma probe malfunction were primary reasons for failure. Nodule size, depth from pleura, and time between radiotracer injection and surgical incision did not impact success of the procedure. Among the 6 cases with procedure related failure, only 1 required conversion to open thoracotomy.


      CT guided 99mTc-MAA injection for intra-operative lung nodule localization is a feasible procedure with a high success rate and low complication rate. Attention to technique can potentially avoid procedure failure.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Imaging
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gould M.K.
        • Tang T.
        • Liu I.-L.A.
        • Lee J.
        • Zheng C.
        • Danforth K.N.
        • et al.
        Recent trends in the identification of incidental pulmonary nodules.
        Am J Respir Crit Care Med. 2015; 192: 1208-1214
        • MacMahon H.
        • Naidich D.P.
        • Goo J.M.
        • Lee K.S.
        • Leung A.N.C.
        • Mayo J.R.
        • et al.
        Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner society 2017.
        Radiology. 2017; 284: 228-243
        • Landreneau R.J.
        • Mack M.J.
        • Hazelrigg S.R.
        • Naunheim K.S.
        • Keenan R.J.
        • Ferson P.F.
        The role of video-assisted thoracic surgery in thoracic oncological practice.
        Cancer Invest. 1995; 13: 526-539
        • Berry M.F.
        Role of segmentectomy for pulmonary metastases.
        Ann Cardiothorac Surg. 2014; 3: 176-182
        • Martin-Ucar A.E.
        • Delgado Roel M.
        Indication for VATS sublobar resections in early lung cancer.
        J Thorac Dis. 2013; 5: S194-S199
        • Schneider B.J.
        • Saxena A.
        • Downey R.J.
        Surgery for early-stage small cell lung cancer.
        J Natl Compr Canc Netw. 2011; 9: 1132-1139
        • Sortini D.
        • Feo C.
        • Maravegias K.
        • Carcoforo P.
        • Pozza E.
        • Liboni A.
        • et al.
        Intrathoracoscopic localization techniques. Review of literature.
        Surg Endosc. 2006; 20 (Title page with author identifiers): 1341-1347
        • Ordemann J.
        • Gellert K.
        • Rückert J.C.
        • Rogalla P.
        • Müller J.M.
        Localization of pulmonary nodules before thoracoscopic surgery: value of percutaneous staining with indigocarmine blue and CT-guided wire placement.
        Minim Invasive Ther Allied Technol. 1997; 6: 158-161
        • Lin M.-W.
        • Chen J.-S.
        Image-guided techniques for localizing pulmonary nodules in thoracoscopic surgery.
        J Thorac Dis. 2016; 8: S749-S755
        • Boni G.
        • Bellina C.R.
        • Grosso M.
        • Lucchi M.
        • Manca G.
        • Ambrogi M.C.
        • et al.
        Gamma probeguided thoracoscopic surgery of small pulmonary nodules.
        Tumori. 2000; 86: 364-366
        • Daniel T.M.
        • Altes T.A.
        • Rehm P.K.
        • Williams M.B.
        • Jones D.R.
        • Stolin A.V.
        • et al.
        A novel technique for localization and excisional biopsy of small or ill-defined pulmonary lesions.
        Ann Thorac Surg. 2004; 77 (discussion 1762): 1756-1762
        • Al-Ameri M.
        • Bergman P.
        • Franco-Cereceda A.
        • Sartipy U.
        Video-assisted thoracoscopic versus open thoracotomy lobectomy: a swedish nationwide cohort study.
        J Thorac Dis. 2018; 10: 3499-3506
        • Higuchi M.
        • Yaginuma H.
        • Yonechi A.
        • Kanno R.
        • Ohishi A.
        • Suzuki H.
        • et al.
        Long-term outcomes after video-assisted thoracic surgery (VATS) lobectomy versus lobectomy via open thoracotomy for clinical stage IA non-small cell lung cancer.
        J Cardiothorac Surg. 2014; 9: 88
        • Suzuki K.
        • Nagai K.
        • Yoshida J.
        • Ohmatsu H.
        • Takahashi K.
        • Nishimura M.
        • et al.
        Videoassisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking.
        Chest. 1999; 115: 563-568
        • Burdine J.
        • Joyce L.D.
        • Plunkett M.B.
        • Inampudi S.
        • Kaye M.G.
        • Dunn D.H.
        Feasibility and value of video-assisted thoracoscopic surgery wedge excision of small pulmonary nodules in patients with malignancy.
        Chest. 2002; 122: 1467-1470
        • Chella A.
        • Lucchi M.
        • Ambrogi M.C.
        • Menconi G.
        • Melfi F.M.
        • Gonfiotti A.
        • et al.
        A pilot study of the role of TC-99 radionuclide in localization of pulmonary nodular lesions for thoracoscopic resection.
        Eur J Cardiothorac Surg. 2000; 18: 17-21
        • Sugi K.
        • Kaneda Y.
        • Hirasawa K.
        • Kunitani N.
        Radioisotope marking under CT guidance and localization using a handheld gamma probe for small or indistinct pulmonary lesions.
        Chest. 2003; 124: 155-158
        • Grogan E.L.
        • Jones D.R.
        • Kozower B.D.
        • Simmons W.D.
        • Daniel T.M.
        Identification of small lung nodules: technique of radiotracer-guided thoracoscopic biopsy.
        Ann Thorac Surg. 2008; 85: S772-S777
        • Bellomi M.
        • Veronesi G.
        • Trifirò G.
        • Brambilla S.
        • Bonello L.
        • Preda L.
        • et al.
        Computed tomography-guided preoperative radiotracer localization of nonpalpable lung nodules.
        Ann Thorac Surg. 2010; 90: 1759-1764
        • Galetta D.
        • Rampinelli C.
        • Funicelli L.
        • Casiraghi M.
        • Grana C.
        • Bellomi M.
        • et al.
        Computed tomography-guided percutaneous radiotracer localization and resection of indistinct/small pulmonary lesions.
        Ann Thorac Surg. 2019; 108: 852-858
        • Nardini M.
        • Bilancia R.
        • Paul I.
        • Jayakumar S.
        • Papoulidis P.
        • ElSaegh M.
        • et al.
        99mTechnetium and methylene blue guided pulmonary nodules resections: preliminary British experience.
        J Thorac Dis. 2018; 10: 1015-1021
        • Gonfiotti A.
        • Davini F.
        • Vaggelli L.
        • De Francisci A.
        • Caldarella A.
        • Gigli P.M.
        • et al.
        Thoracoscopic localization techniques for patients with solitary pulmonary nodule: hookwire versus radio-guided surgery.
        Eur J Cardio-Thoracic Surg. 2007; 32: 843-847
        • Ambrogi M.C.
        • Melfi F.
        • Zirafa C.
        • Lucchi M.
        • De Liperi A.
        • Mariani G.
        • et al.
        Radio-guided thoracoscopic surgery (RGTS) of small pulmonary nodules.
        Surg Endosc. 2012; 26: 914-919
        • Azari F.
        • Kennedy G.
        • Singhal S.
        Intraoperative detection and assessment of lung nodules.
        Surg Oncol Clin N Am. 2020; 29: 525-541
        • Zaman M.
        • Bilal H.
        • Woo C.Y.
        • Tang A.
        In patients undergoing video-assisted thoracoscopic surgery excision, what is the best way to locate a subcentimetre solitary pulmonary nodule in order to achieve successful excision?.
        Interact Cardiovasc Thorac Surg. 2012; 15: 266-272
        • Brady J.J.
        • Hirsch Reilly C.
        • Guay R.
        • Dasika U.
        Combined hookwire and methylene blue localization of pulmonary nodules: analysis of 74 patients.
        Innovations (Phila). 2018; 13: 184-189
        • Sui X.
        • Zhao H.
        • Yang F.
        • Liu G.
        • Hu L.
        • Chen C.
        • et al.
        Analysis of factors affecting successful microcoil localization for pulmonary nodules.
        J Surg Res. 2018; 224: 193-199
        • Chen Y.-R.
        • Yeow K.-M.
        • Lee J.-Y.
        • Su I.-H.
        • Chu S.-Y.
        • Lee C.-H.
        • et al.
        CT-guided hook wire localization of subpleural lung lesions for video-assisted thoracoscopic surgery (VATS).
        J Formos Med Assoc. 2007; 106: 911-918
        • Kleedehn M.
        • Kim D.H.
        • Lee F.T.
        • Lubner M.G.
        • Robbins J.B.
        • Ziemlewicz T.J.
        • et al.
        Preoperative pulmonary nodule localization: a comparison of methylene blue and hookwire techniques.
        AJR Am J Roentgenol. 2016; 207: 1334-1339
        • Hanauer M.
        • Perentes J.Y.
        • Krueger T.
        • Ris H.-B.
        • Bize P.
        • Schmidt S.
        • et al.
        Pre-operative localization of solitary pulmonary nodules with computed tomography-guided hook wire: report of 181 patients.
        J Cardiothorac Surg. 2016; 11: 5 016-0404-4
        • Muñoz-Largacha J.A.
        • Litle V.R.
        • Fernando H.C.
        Navigation bronchoscopy for diagnosis and small nodule location.
        J Thorac Dis. 2017; 9: S98-S103
        • Kondo A.
        • Ishii H.
        • Aoki S.
        • Suzuki M.
        • Nagasawa H.
        • Kubota K.
        • et al.
        Phase IIa clinical study of [18F]fluciclovine: efficacy and safety of a new PET tracer for brain tumors.
        Ann Nucl Med. 2016; 30: 608-618
        • Khereba M.
        • Ferraro P.
        • Duranceau A.
        • Martin J.
        • Goudie E.
        • Thiffault V.
        • et al.
        Thoracoscopic localization of intraparenchymal pulmonary nodules using direct intracavitary thoracoscopic ultrasonography prevents conversion of VATS procedures to thoracotomy in selected patients.
        J Thorac Cardiovasc Surg. 2012; 144: 1160-1166
        • Doo K.W.
        • Yong H.S.
        • Kim H.K.
        • Kim S.
        • Kang E.-Y.
        • Choi Y.H.
        Needlescopic resection of small and superficial pulmonary nodule after computed tomographic fluoroscopy-guided dual localization with radiotracer and hookwire.
        Ann Surg Oncol. 2015; 22: 331-337