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

: 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.