Image-guided video-assisted thoracoscopic small lung tumor resection using near-infrared marking.

Abstract

Localization of non-visible, non-palpable small pulmonary nodules during video-assisted thoracoscopic surgery (VATS) remains challenging. We sought to investigate the feasibility and safety of image-guided video-assisted thoracoscopic surgery (iVATS) with near-infrared (NIR) marking in a hybrid operating room (OR). Both localization and surgery were performed by a single team of thoracic surgeons. Diluted indocyanine green (ICG; quantity: 0.3-0.5mL; dye concentration: 0.125mg/mL) was injected percutaneously to pinpoint the tumor's location under cone beam computed tomography (CBCT) guidance using a laser-guided navigation system. Real-time fluorescence images were intraoperatively obtained using a NIR thoracoscopic camera to guide subsequent resection. Between March and December 2017, 26 patients underwent NIR marking of small pulmonary nodules for iVATS. The median tumor size was 7mm (interquartile range [IQR] 5.3-10.8mm), whereas their median distance from the pleural surface was 5mm (IQR 0.3-10.5mm). Seven nodules (35%) were solid, whereas 17 (65%) were ground-glass opacities. All lesions were identifiable on intraoperative CBCT. The median time required for NIR localization was 13min. An NIR(+) "tattoo" was identified in all cases, and no intraoperative conversion to thoracotomy occurred. The final pathological diagnoses were primary lung cancer (n = 11), metastatic cancer (n = 6), and benign lung tumor (n = 9). Adverse events were not observed, and the median length of post-operative stay was 4days (IQR 3-4days). Our data show that iVATS with NIR marking is useful, has no adverse effects, and can successfully localize difficult-to-identify small pulmonary nodules.