Chinese expert consensus on preoperative assisted positioning technology of small pulmonary nodules (2025 edition)_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 GU Chundong ¹ ,  LIU Baodong ² , Lung Cancer Medical Education Committee of Chinese Medicine Education Association , Thoracic Surgery Professional Committee of the Cross-Strait Medical and Health Exchange Association

1. The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning, P. R. China;
2. Xuanwu Hospital, Capital Medical University, Beijing, 100053, P. R. China;

Corresponding?author：

GU Chundong, Email: guchundong@dmu.edu.cn; LIU Baodong, Email: liubaodongxw@aliyun.com

Keywords：

Small pulmonary nodule; preoperative assisted localization; expert consensus

DOI：

10.7507/1007-4848.202505036

Video：

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Abstract Full text Figures/Tables Video References Cited by

How to accurately locate pulmonary nodules in thoracic surgery is a key challenge in surgery. "Chinese expert consensus on preoperative assisted positioning technology of small pulmonary nodules (2025 edition)" (hereafter referred to as the consensus) is an update version incorporating the latest evidence and clinical practice based on the 2019 edition, aiming to provide reference for clinical practice. The consensus summarizes commonly used preoperative assisted positioning technologies, such as percutaneous lung puncture positioning (Hookwire positioning needles, metal spring coils, etc.), transbronchial puncture positioning (electromagnetic navigation bronchoscopes, etc.), and virtual reality and 3D printing positioning, and introduces the application indications, operating specifications and potential complications of different positioning technologies, analyzes the existing technical advantages and shortcomings, and emphasizes the selection of the most appropriate positioning method according to the specific situation of the patient, so as to improve the success rate and safety of the surgery, and promotes the minimally invasive and precise development of thoracic surgery.

Citation： GU Chundong, LIU Baodong, Lung Cancer Medical Education Committee of Chinese Medicine Education Association, Thoracic Surgery Professional Committee of the Cross-Strait Medical and Health Exchange Association. Chinese expert consensus on preoperative assisted positioning technology of small pulmonary nodules (2025 edition). Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(8): 1047-1055. doi: 10.7507/1007-4848.202505036 Copy

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2.	Larscheid RC, Thorpe PE, Scott WJ. Percutaneous transthoracic needle aspiration biopsy: a comprehensive review of its current role in the diagnosis and treatment of lung tumors. Chest, 1998, 114(3): 704-709.
3.	Tan BB, Flaherty KR, Kazerooni EA, et al. The solitary pulmonary nodule. Chest, 2003, 123(1 Suppl): 89S-96S.
4.	Congregado M, Merchan RJ, Gallardo G, et al. Video-assisted thoracic surgery (VATS) lobectomy: 13 years' experience. Surg Endosc, 2008, 22(8): 1852-1857.
5.	肺小結節術前輔助定位技術專家共識(2019 版)專家組. 肺小結節術前輔助定位技術專家共識. 中國胸心血管外科臨床雜志, 2019, 26(2): 109-113.The Expert Group of Expert Consensus for Localization Technique of Subcentimeter Pulmonary Small Nodule Prior to Video-assisted Thoracoscopic Surgery (version 2019). Expert consensus for localization technique of subcentimeter pulmonary small nodule prior to video-assisted thoracoscopic surgery (version 2019). Chin J Clin Thorac Cardiovasc Surg, 2019, 26(2): 109-113.
6.	Suzuki K, Nagai K, Yoshida J, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest, 1999, 115(2): 563-568.
7.	Miyoshi K, Toyooka S, Gobara H, et al. Clinical outcomes of short hook wire and suture marking system in thoracoscopic resection for pulmonary nodules. Eur J Cardiothorac Surg, 2009, 36(2): 378-382.
8.	Ciriaco P, Negri G, Puglisi A, et al. Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization. Eur J Cardiothorac Surg, 2004, 25(3): 429-433.
9.	黃威, 周逸鳴, 姜格寧. CT引導下Hookwire定位肺部小病灶的臨床應用及改進. 中華胸心血管外科雜志, 2015, 31(6): 366-367.Huang W, Zhou YM, Jiang GN. Clinical application and improvement of Hookwire positioning small lung lesions under CT guidance. Chin J Thorac Cardiovasc Surg, 2015, 31(6): 366-367.
10.	Dendo S, Kanazawa S, Ando A, et al. Preoperative localization of small pulmonary lesions with a short hook wire and suture system: experience with 168 procedures. Radiol, 2002, 225(2): 511-518.
11.	Chang SH, Geraci TC, Johnson KR, et al. Narrative review: preoperative localization techniques for small lung nodules. Curr Chall Thorac Surg, 2022, 4: 36.
12.	Yanagiya M, Sato M, Ueda K, et al. Preoperative lung surface localization for pulmonary wedge resection: a single-center experience. J Thorac Dis, 2020, 12(5): 2129-2136.
13.	Wang JL, Ding BZ, Xia FF. Preoperative computed tomography-guided localization for multiple lung nodules: a meta-analysis. Minim Invasive Ther Allied Technol, 2022, 31(8): 1123-1130.
14.	Pickering EM, Kalchiem-Dekel O, Sachdeva A. Electromagnetic navigation bronchoscopy: a comprehensive review. AME Med J, 2018, 3: 117.
15.	Chiu CH, Chao YK, Liu YH, et al. Clinical use of near-infrared fluorescence imaging with indocyanine green in thoracic surgery: a literature review. J Thorac Dis, 2016, 8(Suppl 9): S744-S748.
16.	Park CH, Han K, Hur J, et al. Comparative effectiveness and safety of preoperative lung localization for pulmonary nodules: a systematic review and meta-analysis. Chest, 2017, 151(2): 316-328.
17.	Chen S, Zhou J, Zhang J, et al. Video-assisted thoracoscopic solitary pulmonary nodule resection after CT-guided hookwire localization: 43 cases report and literature review. Surg Endosc, 2011, 25(6): 1723-1729.
18.	周建華, 李文濤, 陳海泉, 等. 孤立性肺小結節在CT引導下帶鉤鋼絲術前定位. 中華胸心血管外科雜志, 2011, 27(5): 257-261.Zhou JH, Li WT, Chen HQ, et al. Preoperative positioning of isolated pulmonary nodules under CT guidance. Chin J Thorac Cardiovasc Surg, 2011, 27(5): 257-261.
19.	Feng Q, Zhou J, Dong N, et al. Factors influencing the accuracy and safety of preoperative computed tomography (CT)-guided soft hook-wire localization for pulmonary nodules: a comprehensive analysis. Quant Imaging Med Surg, 2024, 14(3): 2309-2323.
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21.	Zhao L, Lv C, Wang Z, et al. Mobile 3-dimensional C-arm system-assisted localization and resection of pulmonary nodules: a case description. Quant Imaging Med Surg, 2023, 13(5): 3378-3382.
22.	Liu L, Zhang L J, Chen B, et al. Novel CT-guided coil localization of peripheral pulmonary nodules prior to video-assisted thoracoscopic surgery: a pilot study. Acta Radiol, 2014, 55(6): 699-706.
23.	Mayo JR, Clifton JC, Powell TI, et al. Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection. Radiol, 2009, 250(2): 576-585.
24.	Liang Q, Liu H, Liu L, et al. Comparison of hook wire and microcoil preoperative localisation in subsolid pulmonary nodules: a retrospective analysis. Clin Radiol, 2025, 82: 106794.
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30.	Ambrogi MC, Melfi F, Zirafa C, et al. Radio-guided thoracoscopic surgery (RGTS) of small pulmonary nodules. Surg Endosc, 2012, 26(4): 914-919.
31.	Sato T, Yutaka Y, Nakamura T, et al. First clinical application of radiofrequency identification (RFID) marking system-Precise localization of a small lung nodule. JTCVS Tech, 2020, 4: 301-304.
32.	Luo K, Lin Y, Lin X, et al. Localization of peripheral pulmonary lesions to aid surgical resection: a novel approach for electromagnetic navigation bronchoscopic dye marking. Eur J Cardiothorac Surg, 2017, 52(3): 516-521.
33.	Zhang J, He J, Chen J, et al. Application of indocyanine green injection guided by electromagnetic navigation bronchoscopy in localization of pulmonary nodules. Transl Lung Cancer Res, 2021, 10(12): 4414-4424.
34.	Folch E E, Labarca G, Ospina-Delgado D, et al. Sensitivity and safety of electromagnetic navigation bronchoscopy for lung cancer diagnosis: systematic review and meta-analysis. Chest, 2020, 158(4): 1753-1769.
35.	Sato M, Omasa M, Chen F, et al. Use of virtual assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection. J Thorac Cardiovasc Surg, 2014, 147(6): 1813-1819.
36.	Sato M, Nagayama K, Kuwano H, et al. Role of post-mapping computed tomography in virtual-assisted lung mapping. Asian Cardiovasc Thorac Ann, 2017, 25(2): 123-130.
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39.	Sato M, Aoyama A, Yamada T, et al. Thoracoscopic wedge lung resection using virtual-assisted lung mapping. Asian Cardiovasc Thorac Ann, 2015, 23(1): 46-54.
40.	Nakao K, Sato M, Nitadori J I, et al. Bilateral segmentectomies using virtual-assisted lung mapping (VAL-MAP) for metastatic lung tumors. Surg Case Rep, 2017, 3(1): 104.
41.	Sato M, Kuwata T, Yamanashi K, et al. Safety and reproducibility of virtual-assisted lung mapping: a multicentre study in Japan. Eur J Cardiothorac Surg, 2017, 51(5): 861-868.
42.	Sato M, Yamada T, Menju T, et al. Virtual-assisted lung mapping: outcome of 100 consecutive cases in a single institute. Eur J Cardiothorac Surg, 2015, 47(4): e131-e139.
43.	Zhang L, Li M, Li Z, et al. Three-dimensional printing of navigational template in localization of pulmonary nodule: a pilot study. J Thorac Cardiovasc Surg, 2017, 154(6): 2113-2119. e7.
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1. Aberle DR, Abtin F, Brown K. Computed tomography screening for lung cancer: has it finally arrived? Implications of the national lung screening trial. J Clin Oncol, 2013, 31(8): 1002-1008.
2. Larscheid RC, Thorpe PE, Scott WJ. Percutaneous transthoracic needle aspiration biopsy: a comprehensive review of its current role in the diagnosis and treatment of lung tumors. Chest, 1998, 114(3): 704-709.
3. Tan BB, Flaherty KR, Kazerooni EA, et al. The solitary pulmonary nodule. Chest, 2003, 123(1 Suppl): 89S-96S.
4. Congregado M, Merchan RJ, Gallardo G, et al. Video-assisted thoracic surgery (VATS) lobectomy: 13 years' experience. Surg Endosc, 2008, 22(8): 1852-1857.
5. 肺小結節術前輔助定位技術專家共識(2019 版)專家組. 肺小結節術前輔助定位技術專家共識. 中國胸心血管外科臨床雜志, 2019, 26(2): 109-113.The Expert Group of Expert Consensus for Localization Technique of Subcentimeter Pulmonary Small Nodule Prior to Video-assisted Thoracoscopic Surgery (version 2019). Expert consensus for localization technique of subcentimeter pulmonary small nodule prior to video-assisted thoracoscopic surgery (version 2019). Chin J Clin Thorac Cardiovasc Surg, 2019, 26(2): 109-113.
6. Suzuki K, Nagai K, Yoshida J, et al. Video-assisted thoracoscopic surgery for small indeterminate pulmonary nodules: indications for preoperative marking. Chest, 1999, 115(2): 563-568.
7. Miyoshi K, Toyooka S, Gobara H, et al. Clinical outcomes of short hook wire and suture marking system in thoracoscopic resection for pulmonary nodules. Eur J Cardiothorac Surg, 2009, 36(2): 378-382.
8. Ciriaco P, Negri G, Puglisi A, et al. Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization. Eur J Cardiothorac Surg, 2004, 25(3): 429-433.
9. 黃威, 周逸鳴, 姜格寧. CT引導下Hookwire定位肺部小病灶的臨床應用及改進. 中華胸心血管外科雜志, 2015, 31(6): 366-367.Huang W, Zhou YM, Jiang GN. Clinical application and improvement of Hookwire positioning small lung lesions under CT guidance. Chin J Thorac Cardiovasc Surg, 2015, 31(6): 366-367.
10. Dendo S, Kanazawa S, Ando A, et al. Preoperative localization of small pulmonary lesions with a short hook wire and suture system: experience with 168 procedures. Radiol, 2002, 225(2): 511-518.
11. Chang SH, Geraci TC, Johnson KR, et al. Narrative review: preoperative localization techniques for small lung nodules. Curr Chall Thorac Surg, 2022, 4: 36.
12. Yanagiya M, Sato M, Ueda K, et al. Preoperative lung surface localization for pulmonary wedge resection: a single-center experience. J Thorac Dis, 2020, 12(5): 2129-2136.
13. Wang JL, Ding BZ, Xia FF. Preoperative computed tomography-guided localization for multiple lung nodules: a meta-analysis. Minim Invasive Ther Allied Technol, 2022, 31(8): 1123-1130.
14. Pickering EM, Kalchiem-Dekel O, Sachdeva A. Electromagnetic navigation bronchoscopy: a comprehensive review. AME Med J, 2018, 3: 117.
15. Chiu CH, Chao YK, Liu YH, et al. Clinical use of near-infrared fluorescence imaging with indocyanine green in thoracic surgery: a literature review. J Thorac Dis, 2016, 8(Suppl 9): S744-S748.
16. Park CH, Han K, Hur J, et al. Comparative effectiveness and safety of preoperative lung localization for pulmonary nodules: a systematic review and meta-analysis. Chest, 2017, 151(2): 316-328.
17. Chen S, Zhou J, Zhang J, et al. Video-assisted thoracoscopic solitary pulmonary nodule resection after CT-guided hookwire localization: 43 cases report and literature review. Surg Endosc, 2011, 25(6): 1723-1729.
18. 周建華, 李文濤, 陳海泉, 等. 孤立性肺小結節在CT引導下帶鉤鋼絲術前定位. 中華胸心血管外科雜志, 2011, 27(5): 257-261.Zhou JH, Li WT, Chen HQ, et al. Preoperative positioning of isolated pulmonary nodules under CT guidance. Chin J Thorac Cardiovasc Surg, 2011, 27(5): 257-261.
19. Feng Q, Zhou J, Dong N, et al. Factors influencing the accuracy and safety of preoperative computed tomography (CT)-guided soft hook-wire localization for pulmonary nodules: a comprehensive analysis. Quant Imaging Med Surg, 2024, 14(3): 2309-2323.
20. Fan L, Yang H, Yu L, et al. Multicenter, prospective, observational study of a novel technique for preoperative pulmonary nodule localization. J Thorac Cardiovasc Surg, 2020, 160(2): 532-539. e2.
21. Zhao L, Lv C, Wang Z, et al. Mobile 3-dimensional C-arm system-assisted localization and resection of pulmonary nodules: a case description. Quant Imaging Med Surg, 2023, 13(5): 3378-3382.
22. Liu L, Zhang L J, Chen B, et al. Novel CT-guided coil localization of peripheral pulmonary nodules prior to video-assisted thoracoscopic surgery: a pilot study. Acta Radiol, 2014, 55(6): 699-706.
23. Mayo JR, Clifton JC, Powell TI, et al. Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection. Radiol, 2009, 250(2): 576-585.
24. Liang Q, Liu H, Liu L, et al. Comparison of hook wire and microcoil preoperative localisation in subsolid pulmonary nodules: a retrospective analysis. Clin Radiol, 2025, 82: 106794.
25. Wang Y, Yue Z, Shi X, et al. Comparison of safety and effectiveness of medical adhesive and metal spring coil in preoperative localization of peripheral pulmonary nodules. Front Med, 2025, 11: 1506254.
26. McDermott S, Fintelmann FJ, Bierhals AJ, et al. Image-guided preoperative localization of pulmonary nodules for video-assisted and robotically assisted surgery. Radiographics, 2019, 39(5): 1264-1279.
27. Sancheti MS, Lee R, Ahmed SU, et al. Percutaneous fiducial localization for thoracoscopic wedge resection of small pulmonary nodules. Ann Thorac Surg, 2014, 97(6): 1914-1918.
28. Park CH, Hur J, Lee SM, et al. Lipiodol localization for ground-glass opacity minimal surgery: rationale and design of the LOGIS trial. Contemp Clin Trials, 2015, 43: 194-199.
29. 單立梅, 翟榮, 吳澤宇, 等. 術前CT引導下氰基丙烯酸酯聯合亞甲藍定位肺小結節的臨床應用. 中國臨床研究, 2022, 2835(4): 503-506, 511.Dan LM, Zhe R, Wu ZY, et al. Preoperative CT-guided localization of small pulmonary nodules with cyanoacrylate and methylene blue. Chin J Clin Res, 2022, 2835(4): 503-506, 511.
30. Ambrogi MC, Melfi F, Zirafa C, et al. Radio-guided thoracoscopic surgery (RGTS) of small pulmonary nodules. Surg Endosc, 2012, 26(4): 914-919.
31. Sato T, Yutaka Y, Nakamura T, et al. First clinical application of radiofrequency identification (RFID) marking system-Precise localization of a small lung nodule. JTCVS Tech, 2020, 4: 301-304.
32. Luo K, Lin Y, Lin X, et al. Localization of peripheral pulmonary lesions to aid surgical resection: a novel approach for electromagnetic navigation bronchoscopic dye marking. Eur J Cardiothorac Surg, 2017, 52(3): 516-521.
33. Zhang J, He J, Chen J, et al. Application of indocyanine green injection guided by electromagnetic navigation bronchoscopy in localization of pulmonary nodules. Transl Lung Cancer Res, 2021, 10(12): 4414-4424.
34. Folch E E, Labarca G, Ospina-Delgado D, et al. Sensitivity and safety of electromagnetic navigation bronchoscopy for lung cancer diagnosis: systematic review and meta-analysis. Chest, 2020, 158(4): 1753-1769.
35. Sato M, Omasa M, Chen F, et al. Use of virtual assisted lung mapping (VAL-MAP), a bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection. J Thorac Cardiovasc Surg, 2014, 147(6): 1813-1819.
36. Sato M, Nagayama K, Kuwano H, et al. Role of post-mapping computed tomography in virtual-assisted lung mapping. Asian Cardiovasc Thorac Ann, 2017, 25(2): 123-130.
37. Kitano K, Sato M. Latest update about virtual-assisted lung mapping in thoracic surgery. Ann Transl Med, 2019, 7(2): 36.
38. Sato M, Murayama T, Nakajima J. Techniques of stapler-based navigational thoracoscopic segmentectomy using virtual assisted lung mapping (VAL-MAP). J Thorac Dis, 2016, 8(Suppl 9): S716-S730.
39. Sato M, Aoyama A, Yamada T, et al. Thoracoscopic wedge lung resection using virtual-assisted lung mapping. Asian Cardiovasc Thorac Ann, 2015, 23(1): 46-54.
40. Nakao K, Sato M, Nitadori J I, et al. Bilateral segmentectomies using virtual-assisted lung mapping (VAL-MAP) for metastatic lung tumors. Surg Case Rep, 2017, 3(1): 104.
41. Sato M, Kuwata T, Yamanashi K, et al. Safety and reproducibility of virtual-assisted lung mapping: a multicentre study in Japan. Eur J Cardiothorac Surg, 2017, 51(5): 861-868.
42. Sato M, Yamada T, Menju T, et al. Virtual-assisted lung mapping: outcome of 100 consecutive cases in a single institute. Eur J Cardiothorac Surg, 2015, 47(4): e131-e139.
43. Zhang L, Li M, Li Z, et al. Three-dimensional printing of navigational template in localization of pulmonary nodule: a pilot study. J Thorac Cardiovasc Surg, 2017, 154(6): 2113-2119. e7.
44. 劉宇健, 楊三虎, 黃立軍, 等. 基于體表網格與影像三維重建的肺小結節精準定位法. 中國胸心血管外科臨床雜志, 2020, 27(10): 1168-1172.Liu YJ, Yang SH, Huang LJ, et al. Accurate positioning method of lung nodules based on three-dimensional reconstruction of body surface mesh and image. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(10): 1168-1172.
45. Sun W, Zhang L, Wang L, et al. Three-dimensionally printed template for percutaneous localization of multiple lung nodules. Ann Thorac Surg, 2019, 108(3): 883-888.
46. Alsafadi HN, Uhl FE, Pineda RH, et al. Applications and approaches for three-dimensional precision-cut lung slices. disease modeling and drug discovery. Am J Respir Cell Mol Biol, 2020, 62(6): 681-691.
47. Chu XP, Chen ZH, Lin SM, et al. Watershed analysis of the target pulmonary artery for real-time localization of non-palpable pulmonary nodules. Transl Lung Cancer Res, 2021, 10(4): 1711-1719.
48. Chu XP, Chen ZH, Lin SM, et al. Precise resection of multiple pulmonary nodules using a three-dimensional reconstruction model: a case report. Thorac Cancer, 2021, 12(6): 970-973.
49. Sekimura A, Mizoguchi T, Ishikawa M, et al. Pulmonary nodule localization by pleural marking using virtual thoracoscopic imaging. Kyobu Geka, 2023, 76(1): 33-39.
50. Visentini-Scarzanella M, Sugiura T, Kaneko T, et al. Deep monocular 3D reconstruction for assisted navigation in bronchoscopy. Int J Comput Assist Radiol Surg, 2017, 12(7): 1089-1099.
51. Cornelis F H, Filippiadis D K, Wiggermann P, et al. Evaluation of navigation and robotic systems for percutaneous image-guided interventions: a novel metric for advanced imaging and artificial intelligence integration. Diagn Interv Imaging, 2025, 106(5): 157-168.
52. Gill RR, Zheng Y, Barlow JS, et al. Image-guided video assisted thoracoscopic surgery (iVATS) - phase Ⅰ-Ⅱ clinical trial. J Surg Oncol, 2015, 112(1): 18-25.
53. Gill RR, Barlow J, Jaklitsch MT, et al. Image-guided video-assisted thoracoscopic resection (iVATS): translation to clinical practice-real-world experience. J Surg Oncol, 2020, 121(8): 1225-1232.
54. Wu CC, Maher MM, Shepard JA. Complications of CT-guided percutaneous needle biopsy of the chest: prevention and management. AJR Am J Roentgenol, 2011, 196(6): W678-W682.
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