Preoperative localization of breast lesions with a hookwire has
become a standard radiologic practice (1-3). The technique is
advantageous because the needle is accurately positioned under
image guidance and once deployed, the hook maintains the
wire in position until the patient can undergo surgical resection
of the suspicious lesion (4). With the advent of video-assisted
thoracoscopic surgery (VATS), thoracotomy is no longer
required for the excision of peripheral lung nodules. However,
VATS is limited to lesions which can be seen or palpated by
the surgeon. Failure to visualize or palpate a lesion can lead to
conversion thoracotomy rates of up to 46% (5). Preoperative
localization of lung nodules which are too small to palpate or too
far from the pleural surface to see or palpate during thoracoscopy
was first described by Mack et al. (6).
This technique involves placement of a wire in or adjacent to
a pulmonary nodule using CT guidance. Currently there are no
localizing wires available specifically designed for lung tissue.
Previous reports of localization have described the use of the
nonmodified Kopans, Hawkins, and other innovative wires in
localizing solitary pulmonary nodules (7-9). The majority of
cases of wire localization have involved solid pulmonary nodules.
We present two cases of preoperative localization of ground glass
nodules (GGNs) using a modified Kopans wire. The modified
Kopans differs from the nonmodified in that it bears a thick
reinforced segment which is designed to be in or adjacent to
the lesion. This reinforced segment allows for better palpation
and visualization. To our knowledge, this is the first publication
describing localization with this form of wire and specifically for
A 46-year-old woman underwent a CT chest for evaluation
of chronic cough. The CT demonstrated a 1cm GGN in the
central portion of the left lower lobe (Figure 1). This nodule
was later biopsied and the final pathology documented atypical
cells suspicious for adenocarcioma in situ (formerly known as
bronchioalveolar carcinoma). Surgical resection through VATS
I mage o f th e I s s u e
Preoperative CT-Guided percutaneous wire localization of ground
glass pulmonary nodules with a modified Kopans wire
Maureen P . Kohi1, David M. Naeger1, Jasleen Kukreja2, Nicholas Fidelman1, Jeanne M. LaBerge1, Roy L. Gordon1,
Robert K. Kerlan Jr1
1University of California, San Francisco, Department of Radiology and Biomedical Imaging, 505 Parnassus Ave., M-391, San Francisco, CA
94143-0628, USA; 2University of California, San Francisco Department of Surgery, 505 Parnassus Ave., San Francisco, CA 94122, USA
Purpose: To report a technique of using a modified Kopans wire to localize ground glass pulmonary nodules prior to
Methods: CT-guided preoperative localization of ground glass nodules was performed using the modified Kopans wire.
Results: In both cases, the wire successfully localized the ground glass nodule and the surgeon was able to remove the
nodule during video-assisted thoracoscopic wedge resection.
Conclusions: Preoperative CT-guided insertion of the modified Kopans wire can result in successful wedge resection of
ground glass nodules. The reinforced segment of the modified Kopans wire serves as an excellent source of palpation and
localization for the surgeon.
CT-guided; modified Kopans wire; ground glass nodules
J Thorac Dis 2013;5(2):E31-E34. doi: 10.3978/j.issn.2072-1439.2012.07.05
Corresponding to: Maureen P . Kohi, MD. Department of Radiology and Biomedical
Imaging, 505 Parnassus Ave., M-391 Box 0628 San Francisco, CA 94143-0628, USA.
Submitted Apr 29, 2012. Accepted for publication Jul 01, 2012.
Available at www.jthoracdis.com
© Pioneer Bioscience Publishing Company. All rights reserved.
Kohi et al. Modified Kopans wire and ground glass nodules
was planned but because of the ground glass nature of the nodule
and its distance from the pleural surface, preoperative wire
localization was requested.
The wire localization was performed using a helical CT
scanner (HiSpeed Advantage; General Electric Medical Systems,
Milwaukee, WI). The optimal skin entry was determined
following consultation with the referring surgeon. Conscious
sedation was performed using a combination of Fentanyl and
Versed. Following informed consent, the patient was positioned
prone on the CT scanner table. An initial scan with 2.5 mm
sections through the area of the suspected nodule was performed
so that the entry skin site, depth, and angulation of the needle
could be planned. The skin entry site was marked and prepped
with chlorhexidine and draped in the usual sterile fashion. The
length of the hookwire (Modified Kopans; Cook, Bloomington,
IN) was determined by the depth required to reach the lesion
from the skin surface plus an additional 1.5 cm in order to
position the stiff portion of wire adjacent to or within the
nodule. Following local anesthesia of the soft tissues with 1%
lidocaine, using serial CT scans to confirm locations, a 20-gauge
spinal needle was positioned adjacent to the nodule. Once the
tip was placed at the desired location, the stylet was removed and
the hookwire was deployed by pulling back the spinal needle;
additional CT image confirmed final placement (Figure 2).
The portion of wire external to the patient was secured to the
patient’s skin in a sterile fashion with gauze and tape. The patient
was then transferred to the operating room for wedge resection.
A small pneumothorax was present at the completion of the
procedure. The patient underwent successful wedge resection of
the nodule and the localizing hookwire. Final pathology of the
nodule confirmed adenocarcioma in situ.
A 71-year-old male who underwent a CT abdomen and pelvis in
June 2010 for work up of additional treatments for his Crohn's
disease, was found to have a 1.5 cm GGN in the right lower
lobe (Figure 3). He had a 6-month follow up PET/CT which
demonstrated slight interval increase in size of the nodule
without discernable hypermatebolism beyond background.
The patient reported no respiratory symptoms. This nodule
was suspicious for adenocarcinoma in situ based on its imaging
characteristics and surgical resection was planned. Due to the
ground glass nature of the nodule, preoperative wire localization
The procedure was performed with a similar technique to
case 1. Following local anesthesia of the soft tissues with 1%
lidocaine, using serial CT images for guidance, a 20-gauge spinal
needle was advanced into the nodule. Once the tip was placed at
the desired location, the stylet was removed and the hookwire
was deployed by pulling back the Chiba needle; additional
CT images confirmed placement (Figure 4). The portion of
the wire external to the patient was secure to the patient’s skin
in a sterile fashion with gauze and tape. The patient was then
transferred to the operating room for wedge resection. A small
pneumothorax was present at the completion of the procedure.
The patient underwent successful wedge resection of the nodule
and the localizing hookwire. Final pathology of the nodule was
adenocarcinoma in situ.
VATS is a minimally invasive surgical solution for resection of
solitary pulmonary nodules. However, VATS-assisted wedge
resection can be challenging in cases where the nodule is too
small or too far from the pleural surface, or lacks sufficient
Figure 1. Supine transaxial CT chest image demonstrates 1 cm
ground glass nodule in the central portion of the left lower lobe
Figure 2. Prone transaxial CT chest image after placement demonstrates
the hookwire (white arrow) adjacent to the ground glass nodule (black
arrow). Note the positioning of the reinforced portion of the wire is
adjacent to the ground glass opacification.
Journal of Thoracic Disease, Vol 5, No 2 April 2013
Figure 3. Supine transaxial CT chest image demonstrates 1.5 cm
ground glass nodule in the peripheral right lower lobe (arrow).
density such as GGNs to be palpable by the surgeon.
Several preoperative and intraoperative nodule localization
techniques have been reported in the literature. CT-guided
methylene blue or colored collagen injection has been described
though is limited by the rapid spread of the dye through the lung
Intraoperative tattooing of lung lesions has also been
described, though this technique requires palpation of the lesion,
much like resection without pre-operative localization (12).
Intraoperative endoscopic ultrasound has also been used to
identify peripheral nodules, but with a high false negative rate up
to 40% (13).
Hookwire needle localization of pulmonary nodules was first
described by Mack et al. (6), using the principles and techniques
used for years to locate breast lesions prior to surgery. Several
reports have described modifications to this technique. Plunkett
et al. (14) described the use of the Hawkins III breast lesion
localization system (Angiotech Pharmaceuticals Inc; Vancouver,
BC, Canada), though wire dislodgement occurred in 2 of 20
patients. Surgical time was prolonged in these two cases, but
without having to convert to open thoracotomy.
Shah et al. (7) used the nonmodified Kopans wire to localize
seventeen nodules in fourteen patients. Only 1 case of wire
dislodgement was reported; local pulmonary hemorrhage was
detected on post-localization CT in six patients. All nodules
were successfully resected. Shepard et al. (15) also used the
nonmodified Kopans wire; dislodgement occurred in 2 of 10
patients and small pneumothoraces occurred in three patients.
Successful nodule resection was performed in all ten patients
There is no commercially available hookwire specifically
designed for localizing lung nodules. Additionally, there is no
consensus with regards to which wire to use for cases of GGNs.
We favor the use of the modified Kopans wires; the reinforced
segment of the wire allows for an additional tool in visualizing
or palpating the nodule. We prefer to deploy the wire through
either a spinal needle which bears a stylet. The stylet protects
against introduction of air into the pleural space. Once in proper
position, the stylet can be quickly removed and the hookwire can
Previous reports describe wire localization of solid pulmonary
nodules, with only a few reported cases of GGNs. We believe
GGN smay be localized with the same ease, and indeed may
become a more common indication for localization given GGNs
often lack the density to be easily palpated.
Both our patients experienced a small pneumothorax
following wire deployment. This did not affect the patient’s
status, and were ultimately inconsequential as the patients went
immediately to the operating room to undergo VATS. According
to the literature asymptomatic pneumothorax may occur in
30% of the patients (16). Additional complications include
parenchymal hemorrhages which rarely affect the outcome of the
procedure, and potential wire dislodgement following placement.
The latter is of particular concern because if the procedure is not
salvaged through wide excision, conversion to open thoracotomy
may be required.
In both of our cases, the wires successfully localized the lesion
for the surgeon and were removed in the operating room. This
may be due to the use of the modified Kopans wire, which has a
sturdier portion proximal to the hook. In addition, the distance
between the hookwire tip and the pleura was always greater than
3 cm, a factor demonstrated to correlate with successful wire
In summary, we have described preoperative wire localization
Figure 4. Left lateral decubitus transaxial CT chest image
demonstrates placement of the hookwire (white arrow) adjacent to
the ground glass nodule (black arrow). Note the precise positioning
of the stiff portion of the wire adjacent to the ground glass
Kohi et al. Modified Kopans wire and ground glass nodules
of GGNs with a modified Kopans wire resulting in successful
surgical resection. The modified Kopans wire, secondary to its
reinforced segment is an excellent and effective tool in facilitating
thoracoscopic surgery for wedge resection of pulmonary nodules
that are too small, too far from the pleural surface, or not dense
enough to see or palpate. However, further research is required
to determine the optimal pulmonary nodule pre-resection
Disclosure: The authors declare no conflict of interest.
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Cite this article as: Kohi MP, Naeger DM, Kukreja J,
Fidelman N, LaBerge JM, Gordon RL, Kerlan RK Jr.
Preoperative CT-Guided percutaneous wire localization
of ground glass pulmonary nodules with a modified
kopans wire. J Thorac Dis 2013;5(2):E31-E34. doi: