Localization approaches to improve surgical resection of peripheral pulmonary lesions: a clinical practice review
Review Article

Localization approaches to improve surgical resection of peripheral pulmonary lesions: a clinical practice review

Abhilash Bhat Marakini, Megan Satterfield, Graham G. Stockdale, Bryan S. Benn ORCID logo

Pulmonary Department, Cleveland Clinic Foundation, Cleveland, OH, USA

Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Bryan S. Benn, MD, PhD. Pulmonary Department, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Email: Bennb@ccf.org.

Abstract: With the increasing use of chest computed tomography (CT), more peripheral pulmonary lesions (PPLs) are being identified through lung cancer screening or incidental pathways. Once a PPL has been detected, guidelines exist to help determine the next best steps and decisions for management. While the majority of detected PPLs will be benign and require no further follow up or serial imaging, many will need a biopsy or surgical resection. Because subsolid or ground-glass lesions and PPLs located far away from the pleural surface are difficult to visualize or palpate, marking of PPLs may be employed to facilitate a surgical resection, which is an area of increasing interest with the renewed emphasis on minimally invasive, lung sparing surgeries. Numerous approaches to PPL localization exist, including utilization of metallic markers, dyes, targeted optical imaging agents, or a combination of these methods that can be deployed via percutaneous approach with CT guidance or through bronchoscopy. Each of these methods has both benefits and limitations. In this clinical practice review, we will provide a brief overview of the current landscape regarding preoperative marking of PPLs, providing a summary of localization techniques and available approaches by reviewing the current literature, and discuss some recent developments in the field that will continue to move this topic forward.

Keywords: Peripheral pulmonary lesion (PPL); lung nodule; fiducial marking; dye marking; indocyanine green (ICG)


Received: 03 January 2024; Accepted: 13 June 2024; Published online: 26 June 2024.

doi: 10.21037/ccts-23-25


Introduction

Computed tomography (CT) is an important diagnostic modality in both the workup and differentiation of pulmonary and thoracic pathology. With the results of randomized control trials showing a reduced lung cancer mortality with CT chest screening (1,2) and the United States Preventive Services Task Force recommendations for serial low-dose CT scans in high-risk individuals (3), the proliferation of CT chest imaging has continued to accelerate. A byproduct of this growing utilization has been an increased incidence of indeterminate peripheral pulmonary lesions (PPLs). An analysis of one large, integrated health system showed that from 2006 to 2012 the annual rate of pulmonary nodule identification increased from 3.9 to 6.6 per 1,000 person-years (4). When this value was applied to the general United States population, it was estimated that more than 1.5 million pulmonary nodules would be identified yearly, a value ten times greater than previously believed (4).

Once PPLs are identified, challenges from both a diagnostic and management perspective exist. Fortunately, calculators and guidelines exist to help assess risk. The pretest probability of malignancy can be determined by clinical intuition and/or validated prediction calculators (5,6). Calculators have been shown to offer significant diagnostic utility when trying to determine whether pulmonary nodules are malignant or benign (7) and improve physician management (8). Similarly, guidelines exist to assist with initial and follow up management of incidentally found nodules (9,10). However, physician adherence to these recommendations is variable (11).

Although the combination of CT imaging with risk calculators and guidelines can provide meaningful information regarding the risk of malignancy for PPLs, tissue biopsy is still needed in many cases. If a tissue diagnosis is required, guidelines recommend consideration of CT-guided biopsies, bronchoscopic biopsies, or surgical resection (9). While early recognition and phenotyping of lung cancer is important from a treatment perspective, excision of PPLs may be technically challenging from a surgical perspective. Nodules that are not amenable to direct visualization or palpation often require excess tissue removal to ensure appropriate resection of the concerning lesion or conversion from a minimally invasive approach to a more invasive open surgery (12-14). While several strategies exist currently to improve identification of thoracoscopically “invisible” nodules, evidence suggests that placement of markers facilitates improved visualization of PPLs during surgery (15-17).

In this paper, we hope to provide a brief overview of the current landscape regarding preoperative marking of PPLs, providing a summary of localization techniques, current literature, and perhaps, most importantly, possible steps forward.


Indication for PPL localization techniques

A critical aspect of any surgery is determining which structures should undergo resection and which structures must be preserved. Historically, surgeons have relied on manual palpation and visual examination to achieve this result (18). Despite best efforts to ensure appropriate removal of the desired target and clear margins, suboptimal outcomes do occur. Studies have shown that tumor margins of less than 1 cm are a significant risk factor for local recurrence in early-stage surgical lung cancer after limited resection (19). In contrast, a larger tumor margin distance is associated with lower risk of lung cancer recurrence and longer overall survival in patients undergoing wedge resections for non-small cell lung cancers less than or equal to 2 cm in size (20). Similar findings regarding margin length have been seen for the risk of recurrence in surgically resected metastatic lung lesions (21). Additionally, there exists the potential for injury to pivotal vascular structures. While the incidence of major vascular injuries during minimally invasive thoracic surgery is rare (22,23), its occurrence may increase the risk of morbidity and mortality due to longer operating time, further lung manipulation, an increased risk of damage to adjacent tissues, and an increased blood loss (24).

In cases of PPLs suspected of representing, or confirmed to be, early-stage lung cancer, recent studies have shown comparable results for lung sparing surgery versus lobectomy. For stage T1a–bN0 (<2 cm in size, node negative) tumors, sublobar resection was comparable to lobectomy with respect to disease-free survival (25), had less postoperative complications (26), and improved post-operative measures of quality of life (27). For patients undergoing segmentectomy, 5-year overall survival was actually superior (28). Given these comparable to improved survival results and the improved perioperative mortality, morbidity, and median length of hospital stay, there is an increasing emphasis on performing minimally invasive, lung sparing surgery (29).

To facilitate this process, attempts are made prior to surgery to precisely pinpoint the location of PPLs. Various methods have been developed for localizing PPLs that usually rely on the placement of metallic markers or the injection of liquid dyes (30-32). While the effectiveness and safety of these methods are variable (30-32), an optimal localization technique would facilitate definitive resection of the target while preventing extensive resection of non-involved lung parenchyma. It should exhibit a high accuracy rate and minimal risk of procedural complications, be completed in a reasonable amount of time, last long enough to provide adequate time between the localization procedure and surgery, allow access to the entire lung parenchyma, and be readily available at institutions without a significant cost-increase.

Studies have shown that the failure to localize a PPL is related to the distance between the PPL and the closest pleural surface. A retrospective study showed that the main reason for conversion from video-assisted thoracoscopic surgery (VATS) to a thoracotomy was due to inability to localize the lesion (33). Univariate and multivariate analyses showed that distance to the nearest pleural surface was the one significant risk factor that led to failure to detect the nodules with a 63% failure rate for lesions <10 mm in size located more than >5 mm from the pleural surface (33).

Ground-glass lesions, which are being detected with increasing prevalence on outpatient CT scans (34), represent another challenge for resection as these lesions are not visible or palpable. A randomized control trial showed that preoperative marking of PPLs increases the diagnostic yield of initial VATS wedge resection without the need for thoracotomy, decreased operative time to nodule excision, and reduced stapler firings (35). Thus, utilization of localization techniques prior to VATS for ground-glass lesions, subcentimeter nodules, and lesions greater than 1cm from the pleura has become more commonplace at equipped facilities (30-32).


Types of PPL localization techniques

Preoperative localization of PPLs necessitates the use of image guidance, traditionally involving CT, and can be broadly categorized into two major types. The first type of localization technique involves the placement of a metallic marker, such as hook wires, micro-coils, and fiducial markers. The second approach is to inject a liquid material such as methylene blue (MB), India ink, barium, lipiodol, indocyanine green (ICG), or radionuclides via a fine needle.


Metallic markers

The original PPL localization technique is the image-guided hook wire localization. Commonly used in breast lesion localization since the 1970s, the hook wire approach was first used in the lung in 1992 to percutaneously mark PPLs (36) and has become a widely utilized strategy since (30) (Table 1). While boasting high procedural accuracy for PPL localization of 90% or greater (30,37,38) and mechanical simplicity that negates the need for intraoperative fluoroscopy, this technique has the potential for several complications. Risk of dislodgement prior to resection is increased when the hook wire is located proximal to the pleura (38), with an incidence ranging from 2.4% to 6.9% (30). Additionally, an increasing amount of length of the hook wire placed within the lung parenchyma is correlated with an increased risk of hemorrhage (39), occurring in 13.9% to 35% of cases (30). Other complications include pneumothorax, post-resection hook wire retention and rarely, air embolism (16,40).

Table 1

Summary of the different localization techniques for PPLs

Localization technique Pros Cons References
Metallic
   Hook wire localization High procedural accuracy (90% or greater) Risk of dislodgement prior to resection, especially when located proximal to the pleura (2.4% to 6.9% incidence); Increased risk of hemorrhage with more hook wire length within lung parenchyma (13.9% to 35% incidence) Park et al. (16), Lin et al. (30), Mack et al. (36), Miyoshi et al. (37), Zhao et al. (38), Zhang et al. (39), Tang et al. (40)
   Microcoil localization Decreased need for thoracotomy or VATS anatomic resection; comparable success rates to hook wire with fewer complications Requires fluoroscopic guidance during surgery Park et al. (16), Finley et al. (35), Velasquez et al. (41)
   Fiducial marker localization High success rates (95% or greater); various types allowing flexibility in surgical technique; allows surgery at later date or institution Requires fluoroscopy for visualization, risk of complications: pneumothorax, hemorrhage, vascular embolization, migration, depending on type used Lin et al. (30), Velasquez et al. (41), Sharma et al. (42), Sancheti et al. (43), Anantham et al. (44), Casutt et al. (45)
Dye markers
   MB injection Relatively safe, cost-effective, and no additional visualization equipment required; high PPL identification rates (usually >90%) Localization must be same day as surgery to prevent dispersion (up to 8% failure rate after 3-hour delay); potential interference from anthracotic pigment Vandoni et al. (46), Lenglinger et al. (47), McConnell et al. (48), Nomori et al. (49)
   Contrast media localization High success rates with fluoroscopic guidance during resection; lipiodol retained up to 3 months, preferred over barium for time delay cases Lipiodol poses embolism risk if accidentally injected into bloodstream; barium induces inflammatory response making histological interpretation challenging at times Lin et al. (30), McDermott et al. (31), Moon et al. (50), Watanabe et al. (51), Chella et al. (52), Bellomi et al. (53), Ambrogi et al. (54), Galetta et al. (55), Sortini et al. (56)
   Gamma-emitting radioisotope localization Effective localization with counter positioning during resection Surgery must be within 24 hours to maximize isotope effect; requires additional equipment, cost, radiation exposure Lin et al. (30), McDermott et al. (31), Chella et al. (52), Bellomi et al. (53), Ambrogi et al. (54), Galetta et al. (55), Sortini et al. (56)
   ICG marking Utilizes near infrared fluorescence for visualization during resection Potential accumulation in other organs with systemic injection; inhalational route has both feasibility and accessibility limitations Abbas et al. (57), Anayama et al. (58), Rho et al. (59), Li et al. (60), Okusanya et al. (61), Quan et al. (62), Wang et al. (63)
Emerging techniques
   Intraoperative molecular imaging Quick binding to target receptor; favorable tumor visualization Limited validation data; long term effectiveness and safety require further research Zhang et al. (64), Schouw et al. (65), Sarkaria et al. (66)

PPL, peripheral pulmonary lesion; VATS, video-assisted thoracoscopic surgery; MB, methylene blue; ICG, indocyanine green.

Microcoils are also utilized to mark PPLs. These metallic markers are placed percutaneously with imaging guidance with the distal end in or near the PPL of interest and the proximal end coiled in the pleural space to allow resection of the tumor and coil together with fluoroscopic guidance during surgery (35,41). Unlike the hook wire approach, no portion of the microcoil is visible outside of the patient. Initial studies showed that microcoil localization decreased the need for thoracotomy or VATS anatomic resection for the diagnosis of PPLs (35). Meta-analysis has shown comparable success rates for localization with microcoil compared to hook wire and less incidence of complications, including pneumothorax and pulmonary hemorrhage, suggesting that microcoils may be a safer, yet equally effective localization strategy (16).

In contrast to other metallic markers, fiducial markers are placed either percutaneously or via bronchoscopy within or near the PPL of interest with success rates of 95% or greater (30,41-44). Similarly to microcoils, fluoroscopy is needed to visualize fiducial markers and the entirety of the marker is placed within the patient. Various forms of fiducial markers exist, including linear, coil-tailed, coil-spring, and two-band fiducial markers (45). An advantage of fiducial markers is that they do not require the surgeon to approach the PPL via the path that the marker was placed in, thus allowing for flexibility in the surgical technique (42). Also, surgery may be performed at a later date or at a different institution based on logistical constraints. While pneumothorax, hemorrhage, vascular embolization, or migration can occur (30,41-44), it appears that the rate of migration may depend on the type of fiducial marker used, with data showing that the coil-tailed and coil-spring markers having the lowest migration rate, and thus providing some rationale for their preferential use, if available (45).


Dye markers

The principle behind MB injection is to stain the pleura above the nodule, allowing the surgeon to trace the blue tract to the target (46). MB is widely used in clinical practice as it is relatively safe, cost-effective, and does not require additional visualization equipment, such as fluoroscopy, during resection as no foreign body is implanted in the parenchyma or pleura (46,47). Patients tolerate the procedure well as there is no implantation of foreign bodies. PPL identification rates after MB placement are usually greater than 90% (30,41,46,47). However, a significant limitation to MB use is the necessity to perform localization on the same day as surgical resection, ideally within 2 to 3 hours of surgery, to prevent dye dispersion (47,48). Delays of 3 hours or more after MB injection appear to substantially impact the ability to localize the target PPL, with a failure rate of up to 8% (46). Attempts to prevent dispersion utilized mixtures of MB stained with autologous blood, contrast agents, collagen, or stained glue (48,49). Additionally, the presence of anthracotic pigment on the pleural surface may interfere with proper localization due to its similar appearance to the MB-stained PPL (47).

Contrast media, such as barium or lipiodol, may also be utilized for PPL localization through percutaneous or bronchoscopic methods. Using fluoroscopic guidance for visualization during surgical resection, nodules are located with a high degree or success (30,31,50,51). Because lipiodol can be retained in lung tissue for up to 3 months and is less likely to induce an inflammatory response seen with barium that may make histological interpretation of the resected PPL lesion more challenging, it is often preferred, especially when there is a time delay between marking and surgery (50,51). Although these properties of lipiodol are beneficial, it is water insoluble and accidental injection into bloodstream poses a risk of embolism, cerebrovascular accidents, and lymphatic obstruction (51).

Gamma-emitting radioisotope like technetium 99 may also be used to localize PPLs. Placed percutaneously with CT guidance, radioisotopes are detected using a counter that can be positioned in multiple angles around the targeted lesion to identify it during surgical resection (52). Similarly to MB, timing of the subsequent surgical resection is important as it should be coordinated to occur within 24 hours to maximize the effect of the isotope (30,31,52-56). Limitations to this localization approach include the additional equipment required and associated cost as well radiation exposure (52-56).

ICG marking of PPLs utilizes near-infrared fluorescence during surgical resection to visualize the target area. The procedure can be performed bronchoscopically (57,58) or percutaneously (58-60) using a mixture of ICG with another vehicle such as lipiodol (58,59) or MB (57). Although it can also be utilized to mark lesions through systemic injection, this approach is limited by potential for accumulation of ICG in other organs (61). Recent studies have also utilized an inhalational route for ICG to mark tumors and facilitate surgical resection with promising results (62,63).


Targeted optical imaging agents

In addition to the above non-targeted PPL marking modalities, other localization techniques exist including intraoperative molecular imaging utilizing targeted optical imaging agents. Targeted tracers are composed of a carrier molecule, such as an antibody, peptide or small molecule, with a fluorescent probe attached to it and are directed at a specific disease biomarker to allow for increased specificity in accumulating in the target tissue (64,65). In a preliminary validation study, the use of pafolacianine has revealed promising results, showing its quick binding to the target receptor and swift clearance from healthy non-cancerous tissues, making it suitable for infusion either the day before or on the day of the surgery (66). Other similarly designed agents are in different stages of development. It will be interesting to see the impact of these agents on the field as more data emerges in the future.


Percutaneous versus bronchoscopic guided localization

Once a decision on a dye or metallic marker is confirmed, the modality used to deploy the marker must be chosen. Although percutaneous localization with CT guidance has traditionally been the norm, there is mounting evidence supporting the adoption of bronchoscopic approaches. CT-guided lung biopsies offer superior diagnostic yield compared to traditional bronchoscopic modalities (67). However, this approach is limited by an increased risk for complications. Meta analyses have shown that the incidence of pneumothorax post CT-guided biopsy ranges from 15% to 25% with ~7% requiring chest tube drainage (68-70). The incidence of hemorrhage ranged from 3% to 7% (64,65). Additionally, biopsy of smaller lung nodules is also more likely to result in pneumothorax (70) and less likely to be diagnostically accurate (71,72).

Recent advances in bronchoscopic technology utilizing robotic-assisted bronchoscopy with shape sensing technology (73-77) and electromagnetic navigation with digital tomosynthesis (78-81) have allowed for improved diagnostic yield compared to prior bronchoscopic approaches with minimal procedural complications. Additionally, studies have shown that bronchoscopic marking has a favorable safety profile compared to CT-guided biopsy with comparable effectiveness (17,82). Because it can be performed in the operating room, bronchoscopic marking may also reduce the time between localization and surgery (83).

An additional advantage of bronchoscopic marking is the ability to access several anatomic locations that are often not amenable to the percutaneous approach, including the apex and interlobar (17). Multiple nodules or deeper nodules (more than 3 cm from the pleural surface) may be marked during the same procedure without substantially increasing the procedural complication risks (17,70). Finally, there is the ability to biopsy and mark the target lesion while also staging the mediastinal and hilar lymph nodes in one procedure, thus negating the need for a second anesthetic event.


Consideration of which nodules should be marked

Presently, there are no clear consensus guidelines or recommendations on which nodules should be marked. Suzuki et al. suggested that nodules less than 1cm in diameter and at a depth of >5 mm from the pleural surface should be preoperatively marked based on the failure rate to detect these types of lesions intraoperatively was 63% (33). Similarly, Tamura et al. recommended that solid lung nodules <15 mm in diameter and at a depth to the nearest pleural surface >10 mm should be preoperatively marked (84). Interestingly, these authors also noted that there is almost no possibility to detect non-solid nodules at a pleural depth greater than 3 mm, independent of size or diameter, suggesting that, potentially, all ground-glass nodules should be marked prior to resection (84).

Based on the above literature, combined with our own institutional experience performing marking procedures, we recommend considering the following criteria for the evaluation of PPLs for localization and their subsequent marking procedure.

  • Selection:
    • Newly identified solid pulmonary nodules <1 cm in size and/or >0.5 cm from the pleural surface;
    • Pure ground-glass opacity (GGO) pulmonary nodules regardless of size;
  • Procedure:
    • Injection of 0.5 mL of biocompatible fluorescent and optically visible dyes no more than 1 cm from the pleural surface after traversing the nodule with the needle;
    • Placement of a single, large fiducial marker near and medial to the nodule;
  • Assessment:
    • Marking procedure:
      • Utilization of cross-sectional imaging [CT, cone-beam CT, or three-dimensional (3D) mobile fluoroscopy] to ensure appropriate placement of radiopaque markers (if used) in relation to the target lesion;
    • Surgery:
      • Visualization of the visceral pleural surface without broad dye dispersion or dye on the parietal pleural surface;
      • Palpation and/or radiographic/ultrasonographic visualization of fiducial marker placed in and around the nodule;
      • At least 1 cm margins on final pathology.

Formal guidelines will also be needed to assess PPL localization success. Traditionally, PPL localization has been judged subjectively by the operator or by the surgeon at the time of resection. Additional metrics may include a post-localization CT chest or intraoperative 3D imaging afforded by cone beam CT or mobile 3D fluoroscopy units.

A clear follow up plan to evaluate if minimal lung tissue was resected after PPL marking would also be informative. Because a minimally invasive surgical approach leads to less impaired pulmonary function tests (PFTs) values and improved 6-minute walk distances (85,86), we suggest a comparison of baseline and post-resection PFTs be routinely performed to further understand if lesion marking facilitates improved patient outcomes. This evaluation may allow for a rough extrapolation of how much lung function and tissue may be saved by preventing a larger surgical resection. Efforts to characterize this potential benefit will require dedicated future research studies to determine if there are meaningful improvements in both objective, based on PFTs and walk test values, and subjective, based on patient quality of life surveys, measures.


Combination marking: a new approach

As discussed, bronchosocpic PPL marking has a favorable risk profile and comparable efficacy to percutaneous approaches. Available evidence suggests that both dye and fiducial markers are reasonable choices for preoperative localization prior to surgery. Data also suggests that utilizing both techniques together may have a positive impact on the marking process by allowing them to act together in an almost synergistic fashion. Previous studies utilizing a dual localization of a hook wire combined with a radiotracer (87), with lipiodol (88), or with ICG and lipiodol (89) have shown excellent results in terms of ability to successfully mark the PPL and facilitate surgical resection without significant increase in procedural time.

A recent study showed that placing an ICG soaked fiducial marker to localize PPLs allowed for appropriate localization of the lesion and a delayed surgical excision up to 9 days after marker placement (90) (Figure 1). The fiducial marker operates both as a fluoroscopic marker while also acting as a local binder, holding the dye hyperlocal and preventing unwanted peri-lesional leak. This composite effect allows both for increased time between PPL localization and surgery and also provides the thoracic surgeon more options intraoperatively to locate the target lesion. While more research is needed, bronchoscopic placement of dye-soaked fiducial markers may be an important contributor in facilitating a minimally invasive lung sparing surgery.

Figure 1 Representative images from a bronchoscopic procedure using an ICG-soaked fiducial marker to localize a PPL. (A) Cross-sectional mobile 3D fluoroscopy images showing Cook Tornado embolization coil soaked with ICG (red arrows) placed near a right upper lobe solid nodule (blue arrows). (B) Visualization of the ICG dye-soaked coil as a neon green target on the pleural surface during surgical resection. ICG, indocyanine green; PPL, peripheral pulmonary lesion; 3D, three-dimensional.

Conclusions

With the advent of lung cancer screening and increased CT chest utilization, the incidence of PPLs being detected and referred for surgical resection will continue to increase. While emerging data has been helpful in identifying and selecting the appropriate patients and lung nodules for different types of surgical approaches, this field will continue to evolve as more data becomes available. Due to the decreased morbidity and recovery time with minimally invasive thoracic surgery, this approach will continue to be used to simultaneously establish a diagnosis and definitive treatment in many cases. Localization of PPLs, whether with metallic or liquid markers or both together via CT guidance or bronchoscopic modalities, has been shown via numerous single-center studies and meta-analyses to be a safe and successful method to facilitate lung sparing surgery. No specific approach to marking PPLs has been shown to be superior at this time, although this may reflect a lack of randomized data and multiple products or modalities being available at institutions. Similarly, standardized definitions of successful PPL marking are lacking. Further studies and development of guidelines are needed to identify appropriate patients with PPLs for localization procedure, to develop criteria for successful marking procedures, and to ensure procedures are done in a standardized fashion to optimize patient care.


Acknowledgments

Funding: None.


Footnote

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-23-25/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-23-25/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


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doi: 10.21037/ccts-23-25
Cite this article as: Marakini AB, Satterfield M, Stockdale GG, Benn BS. Localization approaches to improve surgical resection of peripheral pulmonary lesions: a clinical practice review. Curr Chall Thorac Surg 2024;6:12.

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