How Doctors Find and Remove Tiny Lung Nodules

Finding tiny lung nodules is becoming more common

As lung cancer screening expands and CT imaging continues to improve, clinicians are detecting increasing numbers of small pulmonary nodules. Many are found during screening programmes, while others are discovered incidentally during scans carried out for unrelated reasons.

Most of these nodules are not cancer. They may represent previous infections, inflammation or other benign changes. Others, however, are an early lung cancer, where timely treatment offers the best chance of cure.

For clinicians, the challenge is not simply detecting these nodules, but working out which ones need action and how best to treat them.

Not every lung nodule needs to be removed. Decisions are based on several factors, including the size and appearance of the nodule, whether it changes over time, the person’s overall health and the likelihood of cancer.

Where surgery is recommended, the aim is often to remove the suspicious area while preserving as much healthy lung tissue as possible.

This has become increasingly important following landmark clinical trials showing that, for carefully selected people with very early-stage non-small cell lung cancer, sublobar resection, such as a segmentectomy or wedge resection, can achieve outcomes comparable to removing an entire lobe of the lung. These studies have helped change surgical practice for small, peripheral tumours.

The challenge most people never see

Although a lung nodule may be clearly visible on a CT scan, finding exactly the same lesion during minimally invasive surgery is not always straightforward.

Many early-stage lung cancers are now only a few millimetres in size. They may sit deep within the lung and cannot always be seen or felt during video-assisted or robotic surgery.

At the same time, surgeons need to remove enough healthy tissue around the nodule to achieve a clear surgical margin while avoiding unnecessary removal of healthy lung.

Accurately locating these tiny lesions has therefore become an increasingly important part of modern thoracic surgery.

How localisation works today

To overcome this challenge, many hospitals perform a separate localisation procedure before surgery.

This is usually carried out in the CT department, where a radiologist uses CT guidance to place a small marker, such as a hook wire or dye, close to the lung nodule.

The patient is then transferred to the operating theatre for surgery.

The approach is well established and highly effective, but it also creates a fragmented pathway. It requires an additional procedure, exposes patients to further CT imaging and can cause discomfort while they wait for surgery. Because the lung is punctured before the operation, complications such as pneumothorax can also occur.

Researchers have therefore been exploring whether this step could be simplified without compromising the operation itself.

Could augmented reality offer an alternative?

A new randomised clinical trial, published in JAMA Surgery, investigated whether augmented reality (AR) could replace conventional CT-guided localisation for people undergoing surgery for CT-detected pulmonary nodules suspicious for early-stage lung cancer.

Rather than carrying out localisation in the radiology department before surgery, the researchers used an AR-guided system in the operating theatre after the patient had received a general anaesthetic.

Using a three-dimensional digital model created from the patient’s CT scan, surgeons were guided to the correct location before immediately proceeding with thoracoscopic surgery during the same anaesthetic.

The idea was not to change the operation itself, but to simplify everything leading up to it.

What did the study find?

The trial included 270 participants treated across five hospitals in China.

The researchers found that AR-guided localisation achieved successful sublobar resection in 98.5% of cases, compared with 99.3% using conventional CT-guided localisation, meeting the study’s predefined criterion for non-inferiority. In other words, the new approach performed just as well at helping surgeons remove the target nodule successfully.

There were also several important practical differences.

Compared with the conventional approach, AR-guided localisation was associated with:

• lower radiation exposure

• lower preoperative pain scores

• shorter localisation procedures

• a much shorter interval between localisation and surgery.

Pneumothorax occurred in almost 30% of people undergoing conventional CT-guided localisation before surgery, while no clinically significant complications related to AR-guided localisation were reported.

Why does this matter?

The study does not change who should undergo surgery, nor does it introduce a new treatment for lung cancer.

Instead, it focuses on improving one part of an established surgical pathway.

As screening programmes identify increasing numbers of very small lung nodules, thoracic surgeons are performing more lung-sparing operations than ever before. That makes accurate localisation increasingly important.

The accompanying editorial argues that the real significance of the study lies in improving the overall patient experience. By bringing localisation and surgery together into a single encounter, the approach has the potential to reduce discomfort, simplify hospital workflows and avoid some of the logistical challenges associated with transferring patients between departments before surgery.

Looking ahead

The findings are encouraging, but they should also be interpreted carefully.

This was a well-designed randomised trial conducted across five centres in China. Further research will be needed to determine how readily this approach can be adopted in other healthcare systems, how it performs in routine clinical practice and whether it offers similar benefits across different surgical teams and patient populations.

Even so, the study highlights an important point.

Innovation in lung cancer care is not limited to new medicines or new screening programmes. Sometimes, it comes from improving the processes that support existing treatment. As more lung cancers are diagnosed at an earlier stage, advances that make surgery more accurate, more efficient and less burdensome could make a meaningful difference to the people who need it.

Core sources

Song Z, Wang Z, Yao H, et al. Single-Encounter Augmented Reality–Guided Localization for Resection of Suspected Early-Stage Lung Cancer: A Randomized Clinical Trial. JAMA Surgery. https://jamanetwork.com/journals/jamasurgery/fullarticle/2851476

Sihag S. Augmented Reality, Thoracic Surgery, and Improving the Patient Experience. JAMA Surgery. https://jamanetwork.com/journals/jamasurgery/article-abstract/2851481

MacMahon H, Naidich DP, Goo JM, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology. https://pubs.rsna.org/doi/10.1148/radiol.2017161659

American Thoracic Society. What is a Lung Nodule? https://www.thoracic.org/patients/patient-resources/resources/lung-nodules-online.pdf

Altorki NK, Wang X, Wigle D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non–Small-Cell Lung Cancer. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMoa2212083

Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L). The Lancet. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01439-6/fulltext

ESMO Clinical Practice Guideline. Early and locally advanced non-metastatic non-small-cell lung cancer. https://www.esmo.org/guidelines/lung-and-chest-tumours/early-and-locally-advanced-non-metastatic-non-small-cell-lung-cancer

D'Amico TA, Casiraghi M, et al. Sublobar resection for early-stage non-small cell lung cancer. Video-Assisted Thoracic Surgery. https://vats.amegroups.org/article/view/12984/html

Xu S, et al. Augmented reality navigation for pulmonary nodule localisation: a feasibility study. https://pmc.ncbi.nlm.nih.gov/articles/PMC8674605/

Further reading from Lung Cancer Europe:

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Early-onset lung cancer: why are more younger adults being diagnosed?

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