Clinical use of near-infrared fluorescence imaging with indocyanine green in thoracic surgery: a literature review

Indocyanine Green Ureteral Mapping in Complex Pelvic Surgery

INTRODUCTION AND HYPOTHESIS

Visual feedback using retrograde ureteral indocyanine green (ICG) instillation and near-infrared (NIR) fluorescence is an effective and reproducible option for ureteral identification in robotic pelvic surgeries. The purpose of this video is to discuss risks for intraoperative ureteral injury, demonstrate ICG ureteral mapping, review pelvic and ureteral anatomy, and common sites of ureteral injury during complex hysterectomies and reconstructive surgeries.

METHODS

Three robotic pelvic surgeries are presented with ICG and NIR fluorescent live ureteral mapping. Steps for ICG ureteral mapping and surgical technique are demonstrated.

RESULTS

Cases included a 51-year-old with enlarged uterine leiomyomata and adhesive disease undergoing a total robotic hysterectomy (TRH), a 54-year-old with leiomyomata and stage 2 uterovaginal prolapse undergoing TRH with uterosacral ligament suspension, and a 61-year-old with stage 2 post-hysterectomy prolapse undergoing a robotic sacrocolpopexy. Procedure duration ranged from 116 to 183 min. Patients were discharged home the day of surgery and remained complication-free at their 6-week postoperative appointment.

CONCLUSION

Bilateral ureters were demonstrated via ICG with NIR fluorescence throughout the duration of all cases. ICG ureteral mapping complements careful surgical techniques to reduce iatrogenic ureteral injury. More data with larger prospective studies are needed to determine if ICG ureteral mapping significantly reduces iatrogenic ureteral injury.

Advantages and rational application of indocyanine green fluorescence in pulmonary nodule surgery: a narrative review

Background and Objective

The early detection and early treatment of high-risk pulmonary nodules directly affect the long-term survival rate of patients. However, conventional nodule localization methods, such as hook-wire, technetium-99m, and methylene blue are associated with issues such as a high-frequency of complications, low patient tolerance, serious side effects, and inability to identify pigmented lungs. For patients who require segmentectomy, there is often a lack of effective path planning, resulting in insufficient resection margins or excessive loss of lung function. Therefore, effective and rational nodule localization and surgical approaches are crucial. This narrative review aimed to evaluate the advantages of indocyanine green (ICG) fluorescence in pulmonary nodule surgery and clarify its application in various types of patients.

Methods

We searched the PubMed and Web of Science databases from January 2010 to January 2024 using the terms "localization of pulmonary nodules", "localization of pulmonary nodules AND indocyanine green", "localization of pulmonary nodules AND complication", "localization of pulmonary nodules AND surgical planning", and "localization of pulmonary nodules AND underlying lung disease". Information used to write this narrative review was from clinical phenomena, statistical data, and authors' conclusions.

Key Content and Findings

The commonly used localization methods of pulmonary nodule such as computed tomography (CT)-guided percutaneous placement of hook-wire are accompanied with serious complications: including hemopneumothorax and ache. Meanwhile, routine dye commonly fails to localize the nodules in patients with anthracosis. ICG with the enhanced permeability and retention (EPR) effect can be used effectively for preoperative and intraoperative localization of pulmonary nodules and its nature of allowing the observance of the condition of pulmonary blood vessels has gradually become a hotspot of research in this field.

Conclusions

For nodules with a depth of less than 1 cm, no penetration depth problem is encountered when ICG fluorescence is used. Percutaneous puncture can effectively identify the location of nodules at low cost. Compared with other localization methods, it can effectively avoid problems such as pain, radiation exposure, marker displacement, and the existence of anthrax lesions in the lungs. For patients on whom it is difficult to locate nodules due to tissue results, virtual bronchoscopy or electromagnetic navigation bronchoscopy can effectively identify nodules and reduce complications such as pneumothorax. For patients whose operation is postponed due to fever, sudden cardiovascular and cerebrovascular diseases, there is no risk of nodule localization material detachment by using ICG. ICG can also be used in patients with pulmonary physiological or pathological diseases. Meanwhile, in patients with deep pulmonary nodules, ICG fluorescence can help plan the surgical path, ensure the margin of resection, reduce lung function damage, and prevent bronchial fistula. Therefore, the rational use of ICG fluorescence technology can effectively locate nodules, assist surgeons in planning surgical methods, potentially reducing complications and ultimately improving patient prognosis.

Study protocol for Near-infrared molecular imaging for lung cancer detection and treatment during mini-invasive surgery (phase II Trial) - (the RECOGNISE study)

INTRODUCTION

To date, radical surgery remains the best curative option in patients with early-stage lung cancer. In patients with small lung lesions, video-assisted thoracic surgery (VATS) should be increasingly chosen as a fundamental alternative to thoracotomy as it is associated with less postoperative pain and better quality of life. This scenario necessarily increases the need for thoracic surgeons to implement new localization techniques. The conventional near-infrared (NIR) indocyanine green (ICG) method demonstrated a significant limitation in deep cancer recognition, principally due to its intrinsic low-depth tissue penetration. Similarly, the lymph-node sentinel approach conducted by the ICG method was demonstrated to be inefficient, mainly due to the non-specificity of the tracker and the irregular pathway of pulmonary lymph node drainage. Our study aims to evaluate the effectiveness of Cetuximab- IRDye800CW in marking lung nodules and mediastinal lymph nodes.

METHODS AND ANALYSIS

This study is defined as an open-label, single-arm, single-stage phase II trial evaluating the effectiveness of Cetuximab-IRDye800CW in detecting tumors and lymph-node metastases in patients with lung cancer who are undergoing video-assisted thoracic surgery (VATS). Cetuximab is a monoclonal antibody that binds, inhibits, and degrade the EGFR. The IRDye® 800CW, an indocyanine-type NIR fluorophore, demonstrated enhanced tissue penetration compared to other NIR dyes. The combination with the clinical approved monoclonal antibody anti-epidermal growth factor EGFR Cetuximab (Cetuximab-IRDye800) has shown promising results as a specific tracker in different cancer types (i.e., brain, pancreas, head, and neck). The study's primary outcome is focused on the proportion of patients with lung nodules detected during surgery using an NIR camera. The secondary outcomes include a broad spectrum of items, including the proportion of patients with detection of unexpected cancer localization during surgery by NIR camera and the proportion of patients with negative surgical margins, the evaluation of the time spawns between the insertion of the NIR camera and the visualization of the nodule and the possible morbidity of the drug assessed during and after the drug infusion.

ETHICS AND DISSEMINATION

This trial has been approved by the Ethical Committee of Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino (Torino, Italy) and by the Italian Medicines Agency (AIFA). Findings will be written as methodology papers for conference presentations and published in peer-reviewed journals. The Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, the University of Torino, and the AIRC Public Engagement Divisions will help identify how best to publicize the findings.Trial registration EudraCT 202,100,645,430.

CLINICALTRIALS

gov NCT06101394 (October 23, 2023).

A Green Lantern for the Surgeon: A Review on the Use of Indocyanine Green (ICG) in Minimally Invasive Surgery

Indocyanine green (ICG) fluorescence imaging has revolutionized surgical practice across various medical and surgical specialties. This article reviews the clinical applications of ICG in abdominal, urological, thoracic, and gynecological surgery. ICG fluorescence imaging has been widely adopted in general surgery for various applications, including perfusion assessment, intraoperative visualization of the ureter, and tumor localization. It is particularly valuable in evaluating anastomotic leaks and aiding in precise tumor resection during minimally invasive surgeries. Studies have shown mixed results on its effectiveness in reducing anastomotic leak rates, highlighting the need for further research. In thoracic surgery, ICG facilitates the identification and resection of pulmonary bullae, as well as the precise localization of pulmonary nodules during video-assisted surgery. In urology, ICG aids in localizing renal tumors and guiding selective arterial occlusion during partial nephrectomy. Its role in identifying the lymphatic pathway in prostate cancer and sentinel lymph node biopsy in gynecological cancer is also discussed. Despite its benefits, the use of ICG fluorescence faces challenges such as limited tissue penetration, the potential for false results, a lack of standardized protocols, and high equipment costs. Nonetheless, it remains a powerful tool that could improve surgical outcomes.

Methods of bronchial stump buttressing in post-pneumonectomy bronchopleural fistula prevention: a systematic review

<b>Introduction:</b> The bronchopleural fistula (BPF) remains one of the most severe complications after pneumonectomy. Several surgical methods may enhance bronchial stump healing and reduce the occurrence of BPF. Usually, surgeons use tissue buttressing, such as intercostal muscle flap (IMF), parietal pleura, pericardium fat pad, or mediastinal fat, to reinforce the bronchial stump. This paper reviews the literature describing the impact of different buttressing tissues on the occurrence of early post-pneumonectomy BPF.<b>Material and methods:</b> We included all studies that described the use of bronchial stump buttressing in patients after pneumonectomy. Studies written in languages other than English were excluded. The search was performed using PubMed, Google Scholar, Embase, COCHRANE databases, and the clinical trial registry on December 1, 2023. We used the following search input: "lung cancer" AND "pneumonectomy" AND ("bronchopleural fistula" OR "BPF") AND ("tissue buttressing" OR "intercostal muscle flap" OR "mediastinal fat pad"). We analysed the types of studies, the numbers of patients, and the most important conclusions. We performed descriptive statistics.<b>Results:</b> Twenty-seven articles on the use of bronchial tissue buttressing were identified. Nine papers were rejected due to small sample size (< 20 patients), surgical operation other than pneumonectomy or lobectomy, or papers older than 30 years. Ultimately, 16 articles were included in the analysis. Among them, three papers highlighted the statistically significant influence of bronchial stump buttressing in reducing the risk of BPF formation. Descriptive statistics were reported in nine studies, and two papers included the assessment of the blood perfusion in the buttressing tissue. Only one study was a randomized trial featuring a control group for comparison.<b>Discussion:</b> Buttressing the bronchial stump remains a controversial issue in thoracic surgery. It could be beneficial for high-risk patients. Among different tissues, the ideal one has still not been identified. Future research should incorporate control groups and intraoperative assessments of the blood supply to the tissue employed for bronchial buttressing.

Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy

INTRODUCTION

Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue.

METHODS

Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group.

RESULTS

Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size.

CONCLUSIONS

This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.

Use of Indocyanine Green Fluorescence Imaging in Thoracic and Esophageal Surgery

BACKGROUND

Fluorescence imaging using indocyanine green in thoracic and esophageal surgery is gaining popularity because of the potential to facilitate surgical planning, to stage disease, and to reduce postoperative complications. To optimize use of fluorescence imaging in thoracic and esophageal surgery, an expert panel sought to establish a set of recommendations at a consensus meeting.

METHODS

The panel included 12 experts in thoracic and upper gastrointestinal surgery from Asia-Pacific countries. Before meeting, 7 focus areas were defined: intersegmental plane identification for sublobar resections; pulmonary nodule localization; lung tumor detection; bullous lesion detection; lymphatic mapping of lung tumors; evaluation of gastric conduit perfusion; and lymphatic mapping in esophageal surgical procedures. A literature search of the PubMed database was conducted using keywords indocyanine green, fluorescence, thoracic, surgery, and esophagectomy. At the meeting, panelists addressed each focus area by discussing the most relevant evidence and their clinical experiences. Consensus statements were derived from the proceedings, followed by further discussions, revisions, finalization, and unanimous agreement. Each statement was assigned a level of evidence and a grade of recommendation.

RESULTS

A total of 9 consensus recommendations were established. Identification of the intersegmental plane for sublobar resections, localization of pulmonary nodules, lymphatic mapping in lung tumors, and assessment of gastric conduit perfusion were applications of fluorescence imaging that have the most robust current evidence.

CONCLUSIONS

Based on best available evidence and expert opinions, these consensus recommendations may facilitate thoracic and esophageal surgery using fluorescence imaging.

Indocyanine-enhanced mouse model of bleomycin-induced lung fibrosis with hallmarks of progressive emphysema

The development of new drugs for idiopathic pulmonary fibrosis strongly relies on preclinical experimentation, which requires the continuous improvement of animal models and integration with in vivo imaging data. Here, we investigated the lung distribution of bleomycin (BLM) associated with the indocyanine green (ICG) dye by fluorescence imaging. A long-lasting lung retention (up to 21 days) was observed upon oropharyngeal aspiration (OA) of either ICG or BLM + ICG, with significantly more severe pulmonary fibrosis, accompanied by the progressive appearance of emphysema-like features, uniquely associated with the latter combination. More severe and persistent lung fibrosis, together with a progressive air space enlargement uniquely associated with the BLM + ICG group, was confirmed by longitudinal micro-computed tomography (CT) and histological analyses. Multiple inflammation and fibrosis biomarkers were found to be increased in the bronchoalveolar lavage fluid of BLM- and BLM + ICG-treated animals, but with a clear trend toward a much stronger increase in the latter group. Similarly, in vitro assays performed on macrophage and epithelial cell lines revealed a significantly more marked cytotoxicity in the case of BLM + ICG-treated mice. Also unique to this group was the synergistic upregulation of apoptotic markers both in lung sections and cell lines. Although the exact mechanism underlying the more intense lung fibrosis phenotype with emphysema-like features induced by BLM + ICG remains to be elucidated, we believe that this combination treatment, whose overall effects more closely resemble the human disease, represents a valuable alternative model for studying fibrosis development and for the identification of new antifibrotic compounds.

Fluorescence probes for lung carcinoma diagnosis and clinical application

This review provides an overview of the most recent developments in fluorescence probe technology for the accurate detection and clinical therapy of lung carcinoma.

In vivo molecular and single cell imaging

Molecular imaging is used to improve the disease diagnosis, prognosis, monitoring of treatment in living subjects. Numerous molecular targets have been developed for various cellular and molecular processes in genetic, metabolic, proteomic, and cellular biologic level. Molecular imaging modalities such as Optical Imaging, Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), Single Photon Emission Computed Tomography (SPECT), and Computed Tomography (CT) can be used to visualize anatomic, genetic, biochemical, and physiologic changes in vivo. For in vivo cell imaging, certain cells such as cancer cells, immune cells, stem cells could be labeled by direct and indirect labeling methods to monitor cell migration, cell activity, and cell effects in cell-based therapy. In case of cancer, it could be used to investigate biological processes such as cancer metastasis and to analyze the drug treatment process. In addition, transplanted stem cells and immune cells in cell-based therapy could be visualized and tracked to confirm the fate, activity, and function of cells. In conventional molecular imaging, cells can be monitored in vivo in bulk non-invasively with optical imaging, MRI, PET, and SPECT imaging. However, single cell imaging in vivo has been a great challenge due to an extremely high sensitive detection of single cell. Recently, there has been great attention for in vivo single cell imaging due to the development of single cell study. In vivo single imaging could analyze the survival or death, movement direction, and characteristics of a single cell in live subjects. In this article, we reviewed basic principle of in vivo molecular imaging and introduced recent studies for in vivo single cell imaging based on the concept of in vivo molecular imaging.

Intraoperative uses of near-infrared fluorescence spectroscopy in pediatric surgery: A systematic review

BACKGROUND

The application of near infrared spectroscopy (NIRS) imaging in surgery is growing. This study aimed to systematically review the literature to summarize the intraoperative uses of NIRS in pediatric surgery.

METHODS

A PRISMA-compliant literature search was conducted in PubMed, Embase, Scopus, and Web of Science from inception to February 2020. Title/abstract and then full-text screening were performed. The Oxford centre for Evidence Based Medicine tool (OCEBM) was used to evaluate the level of evidence of included studies.

RESULTS

Reviewers identified 53 articles. Of which, 34 studies (64.2%) were case-series and 11 (20.8%) were case reports. Most of the studies (n = 45, 84.9%) were level 4 on the OCEBM tool. The most common uses of NIRS were to visualize the biliary tree and to identify primary and metastatic malignant tissues. Other applications include assessment of perfusion of tissues including bowel anastomoses, and lymphatic surgery. Several advantages of the introduction of NIRS in pediatric surgery exist including having the potential to reduce operative time and intra/post-operative complications. Moreover, NIRS helps in detecting malignant tissues that can be missed by conventional imaging. However, NIRS has important limitations such as difficulty in identification of the biliary tree in obese patients or inflamed gallbladder, detection of small deeply localized malignant tissues, as well as the high cost.

CONCLUSIONS

NIRS is a promising modality that can be used intraoperatively to augment different pediatric surgical procedures. NIRS has important advantages and limitations compared to conventional surgery, however, more studies are required to evaluate its outcomes and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

In vivo molecular and single cell imaging

Molecular imaging is used to improve the disease diagnosis, prognosis, monitoring of treatment in living subjects. Numerous molecular targets have been developed for various cellular and molecular processes in genetic, metabolic, proteomic, and cellular biologic level. Molecular imaging modalities such as Optical Imaging, Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), Single Photon Emission Computed Tomography (SPECT), and Computed Tomography (CT) can be used to visualize anatomic, genetic, biochemical, and physiologic changes in vivo. For in vivo cell imaging, certain cells such as cancer cells, immune cells, stem cells could be labeled by direct and indirect labeling methods to monitor cell migration, cell activity, and cell effects in cell-based therapy. In case of cancer, it could be used to investigate biological processes such as cancer metastasis and to analyze the drug treatment process. In addition, transplanted stem cells and immune cells in cell-based therapy could be visualized and tracked to confirm the fate, activity, and function of cells. In conventional molecular imaging, cells can be monitored in vivo in bulk non-invasively with optical imaging, MRI, PET, and SPECT imaging. However, single cell imaging in vivo has been a great challenge due to an extremely high sensitive detection of single cell. Recently, there has been great attention for in vivo single cell imaging due to the development of single cell study. In vivo single imaging could analyze the survival or death, movement direction, and characteristics of a single cell in live subjects. In this article, we reviewed basic principle of in vivo molecular imaging and introduced recent studies for in vivo single cell imaging based on the concept of in vivo molecular imaging. [BMB Reports 2022; 55(6): 267-274].

Safety and Efficacy of Cone-Beam Computed Tomography-Guided Lung Tumor Localization with a Near-Infrared Marker: A Retrospective Study of 175 Patients

Preoperative localization holds promise for overcoming the limitations of video-assisted thoracoscopic surgery (VATS) in the treatment of impalpable lung nodules. The purpose of this study was to assess the safety and efficacy of cone-beam computed tomography (CBCT)-guided localization using near-infrared (NIR) marking. Between 2017 and 2021, patients presenting with a solitary pulmonary nodule (SPN) who had undergone CBCT-guided lesion localization with indocyanine green (ICG) in a hybrid operating room were included. The primary outcomes were the efficacy of localization and the occurrence of complications. The study cohort consisted of 175 patients with the mean age of 58.76 years. The mean size and depth of the 175 SPNs were 8.34 mm and 5.3 mm, respectively. The mean time required for lesion marking was 14.71 min. Upon thoracoscopic inspection, the NIR tattoo was detected in the vast majority of the study participants (98.3%). An utility thoracotomy to allow digital palpation was required in two of the three patients in whom the tattoo was not identifiable. The perioperative survival rate was 100%, and the mean length of hospital stay was 3.09 days. We conclude that needle localization with ICG injection is a safe and feasible technique to localize SPNs prior to resection.

A novel TMTP1-modified theranostic nanoplatform for targeted in vivo NIR-II fluorescence imaging-guided chemotherapy for cervical cancer

Near-infrared II (NIR-II, 900-1700 nm) fluorescence bioimaging with advantages of good biosafety, excellent spatial resolution, high sensitivity, and contrast has attracted great attention in biomedical research fields. However, most of the nanoprobes used for NIR-II fluorescence imaging have poor tumor-targeting ability and therapeutic efficiency. To overcome these limitations, a novel NIR-II-emissive theranostic nanoplatform for fluorescence imaging and treatment of cervical cancer was designed and prepared. The NIR-II-emissive dye IR-783 and chemotherapy drug doxorubicin (DOX) were encapsulated into liposomes, and the tumor-targeting peptide TMTP1 (a polypeptide with a sequence of cyclic ASN Val Val Arg Gln Cys) was conjugated to the surface of the liposomes to form IR-783-DOX-TMTP1 nanoparticles (NPs) via self-assembly methods. The IR-783-DOX-TMTP1 NPs showed strong NIR-II emission, excellent biocompatibility and a long lifetime in vivo. Furthermore, high-definition NIR-II fluorescence microscopy images of ear blood vessels and intratumoral blood vessels were obtained from IR-783-DOX-TMTP1 NP-stained mice with high spatial resolution under 808 nm laser excitation. Moreover, IR-783-DOX-TMTP1 NPs showed strong tumor-targeting ability and highly efficient chemotherapeutic characteristics towards cervical tumors. The novel targeting and NIR-II-emissive IR-783-DOX-TMTP1 NPs have great potential in diagnosis and therapy for cervical cancer.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Current and Future Applications of Virtual, Augmented, and Mixed Reality in Cardiothoracic Surgery

BACKGROUND

This review aims to examine the existing literature to address currently used virtual, augmented, and mixed reality modalities in the areas of preoperative surgical planning, intraoperative guidance, and postoperative management in the field of cardiothoracic surgery. In addition, this innovative technology provides future perspectives and potential benefits for cardiothoracic surgeons, trainees, and patients.

METHODS

A targeted, non-systematic literature assessment was performed within the Medline and Google Scholar databases to help identify current trends and to provide better understanding of the current state-of-the-art extended reality (XR) modalities in cardiothoracic surgery. Related articles published up to July 2020, are included in the review.

RESULTS

XR is a novel technique gaining increasing application in cardiothoracic surgery. It provides a three-dimensional (3D) and realistic view of structures and environments and offers the user the ability to interact with digital projections of surgical targets. Recent studies showed the validity and benefits of XR applications in cardiothoracic surgery. Examples include XR-guided pre-operative planning, intraoperative guidance and navigation, post-operative pain and rehabilitation management, surgical simulation, and patient education.

CONCLUSIONS

XR is gaining interest in the field of cardiothoracic surgery. In particular, there are promising roles for XR applications in televirtuality, surgical planning, surgical simulation, and perioperative management. However, future refinement and research is needed to further implement XR in the aforementioned settings within cardiothoracic surgery.

Near-Infrared-Guided Pulmonary Segmentectomy After Endobronchial Indocyanine Green Injection

BACKGROUND

The aim of this study is to prospectively determine the feasibility and safety of near-infrared fluorescence-guided pulmonary segmentectomy after endobronchial indocyanine green (ICG) injection using virtual bronchoscopy.

METHODS

Fifteen patients who underwent pulmonary segmentectomy were prospectively enrolled. Using preoperative computed tomography datasets a bronchial road map was created to determine the bronchus for ICG injection. Immediately after intubation ICG was injected into the target bronchi using an ultrathin bronchoscope. During the operation a near-infrared thoracoscope was used to detect ICG fluorescence and determine the intersegmental plane. The assessment points were (1) whether the ICG demarcation lines corresponded to the intersegmental lines expected from the pulmonary veins, (2) whether it was possible for the planned segmentectomy to be completed by electrocautery and 1 or fewer uses of an automated suturing device according to the demarcation plane, (3) whether any surgical complications occurred intraoperatively or (4) in the 1 month after surgery, and (5) whether the target lesion was removed completely with sufficient surgical margin to evaluate the feasibility and safety of this procedure.

RESULTS

In 13 cases (87%) a segmentectomy was completed in the planned way with sufficient surgical margins. The failure in 2 cases was due to a technical issue in the bronchial injection. No complications developed intraoperatively. Recurrent air leakage occurred in 1 case. No procedure-related adverse event was noted postoperatively.

CONCLUSIONS

Near-infrared-guided pulmonary segmentectomy with endobronchial ICG injection using virtual bronchoscopy was safe and feasible, and minor technical revision can make this procedure more reliable.

TMTP1-modified Indocyanine Green-loaded Polymeric Micelles for Targeted Imaging of Cervical Cancer and Metastasis Sentinel Lymph Node in vivo

Metastasis is one of the most threatening aspects of cervical cancer. We developed a method to intraoperatively map the primary tumor, metastasis and metastatic sentinel lymph nodes (SLNs), providing real-time intraoperative guidance in cervical cancer.

Methods: TMTP1, a tumor metastasis targeting peptide, was employed to modify the indocyanine green (ICG)-loaded poly (ethylene glycol)- poly (lactic-co-glycolic acid) (PEG-PLGA) micelles. The cervical cancer subcutaneous tumor model and lung metastasis model were established to determine the active targeting of ICG-loaded TMTP1-PEG-PLGA micelles (ITM) for the primary tumor and occult metastasis of cervical cancer. Human cervical cancer HeLa cells engineered by firefly luciferase were injected into the right hocks of BALB/c nude mice to develop the SLN metastasis model. The ITM and control ICG-loaded PEG-PLGA micelles (IM) were injected into the right hind footpads in the SLN metastasis model, and the migration and retention of micelles were recorded under near-infrared fluorescence. K14-HPV16 transgenic mice were also used to detect the image capability of ITM to target cancerous lesions.

Results: ITM could actively target imaging of the primary tumor and cervical cancer metastasis. ITM quickly diffused from the injection site to SLNs along lymphatic capillaries and remained in the SLNs for 12 h. Moreover, ITM specifically accumulated in the tumor metastatic SLNs (T-SLNs), which could be successfully distinguished from normal SLNs (N-SLNs).

Conclusion: ITM could achieve active targeting of the primary tumor, metastasis and T-SLNs, providing precise and real-time intraoperative guidance for cervical cancer.

Placement of markers to assist minimally invasive resection of peripheral lung lesions

With development of lung cancer screening programs and increased utilization of radiographic imaging there is significantly higher detection of smaller lung nodules and subsolid lesions. These nodules could be malignant and pose a diagnostic challenge. Video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery (RATS) represent minimally invasive methods for tissue sampling. Intraoperative identification of these lesions maybe difficult, requiring marking prior to surgery. We review different techniques for the placement of markers to assist in the resection of peripheral lung lesions (PLL).

Indocyanine green fluorescence imaging for resection of pulmonary metastasis of hepatocellular carcinoma

Background

Indocyanine green (ICG) accumulates in hepatocellular carcinoma (HCC), and tumor fluorescence can be observed under irradiation with near infrared light (NIR). This study investigated the clinical utility of ICG fluorescence imaging during resection of pulmonary metastases of HCC.

Methods

From April 2010 to June 2018, six patients with suspected pulmonary metastasis of HCC were enrolled prospectively. Prior to surgery, all patients underwent the ICG hepatic function test following intravenous administration of ICG (0.5 mg/kg body weight). During surgery, metastatic HCC was identified by observation of ICG fluorescence, allowing assessment of the surgical margin. Tumor fluorescence was also evaluated on cut sections.

Results

A total of 11 metastatic HCCs were resected in six patients at nine operations. Eight lesions were removed by wedge resection and 3 lesions were managed by lobectomy. During surgery, tumor fluorescence could be confirmed through the visceral pleura in 6 out of 7 lesions treated by wedge resection, while NIR irradiation was difficult for 1 lesion. For these 6 lesions, the median distance from the tumor to the visceral pleura and the median surgical margin were 0 mm (range, 0-2 mm) and 14 mm (range, 11-17 mm), respectively. When cut sections were examined, all tumors emitted fluorescence. All lesions were histologically confirmed to be metastatic HCC.

Conclusions

In patients with pulmonary metastasis of HCC, ICG fluorescence imaging is useful for identifying the tumor and securing its margin when the lesion is peripheral and wedge resection is planned.

Recent Advances in Tracking the Transplanted Stem Cells Using Near-Infrared Fluorescent Nanoprobes: Turning from the First to the Second Near-Infrared Window

Stem cell-based regenerative medicine has attracted tremendous attention for its great potential to treat numerous incurable diseases. Tracking and understanding the fate and regenerative capabilities of transplanted stem cells is vital for improving the safety and therapeutic efficacy of stem cell-based therapy, therefore accelerating the clinical application of stem cells. Fluorescent nanoparticles (NPs) have been widely used for in vivo tracking of the transplanted stem cells. Among these fluorescent NPs, near-infrared (NIR) NPs have greatly improved the sensitivity, tissue penetration depth, spatial and temporal resolutions of the fluorescence imaging-based stem cell tracking technologies due to the reduced absorption, scattering, and autofluorescence of NIR fluorescence in tissues. Here, this review summarizes the recent studies regarding the tracking of transplanted stem cells using NIR NPs and emphasizes the recent advances of fluorescence imaging in the second NIR window (NIR-II, 1000-1700 nm). Furthermore, the challenges and future prospects of the NIR NP-based technologies are also discussed.

Imaging techniques for minimally invasive thoracic surgery-Korea University Guro Hospital experiences

In this paper, we described our clinical experiences with respect to image-guided thoracic surgery, including procedures involving percutaneous injection of fluorescent dye, radiotracers, and hook wires, guided by preoperative computed tomography (CT); and transbronchial injection of fluorescent dye by using electromagnetic navigational bronchoscope technology. Our recent experience with the intravenous systemic injection of fluorescent dye for the intraoperative detection of pulmonary lesions and intersegmental planes are also described in this review.

Neutral merocyanine dyes: for in vivo NIR fluorescence imaging of amyloid-β plaques

Two neutral merocyanine-based near-infrared fluorescent probes were for the first time developed through rational engineering of the classical cationic cyanine scaffold IR-780 for in vivo imaging of amyloid-β plaques. In vivo NIRF imaging revealed that the probe could penetrate the blood-brain barrier and efficiently differentiate the living transgenic and wild-type mice.

Infrared fluorescence guided pleural biopsy during thoracoscopy

OBJECTIVE. The authors developed methods and assessment of efficacy of infrared fluorescence imaging of pleural carcinomatosis using indocyanine green (ICG). MATERIAL AND METHODS. The prospective study included 14 patients with malignant pleural carcinomatosis. All patients underwent standard thoracoscopy with pleural biopsy, then pleural cavity was examined under fluorescence control using ICG solution. Comparison of accuracy of biopsy materials obtained in white light and fluorescence was made. RESULTS. Signs of malignancy had 21 biopsy specimens out of 28, which were obtained in white light (in 12 patients out of 14). Research of biopsy specimens using fluorescence allowed doctors to make the precise diagnosis in all 14 patients, with 33 out of 34 biopsy materials being informative. CONCLUSIONS. Intraoperative application of infrared ICG fluorescence developed accuracy of biopsy and histological verification of the diagnosis.

The Application of Heptamethine Cyanine Dye DZ-1 and Indocyanine Green for Imaging and Targeting in Xenograft Models of Hepatocellular Carcinoma

Near infrared fluorescence (NIRF) imaging has strong potential for widespread use in noninvasive tumor imaging. Indocyanine green (ICG) is the only Food and Drug Administration (FDA) -approved NIRF dye for clinical diagnosis; however, it is unstable and poorly targets tumors. DZ-1 is a novel heptamethine cyanine NIRF dye, suitable for imaging and tumor targeting. Here, we compared the fluorescence intensity and metabolism of DZ-1 and ICG. Additionally, we assayed their specificities and abilities to target tumor cells, using cultured hepatocellular carcinoma (HCC) cell lines, a nude mouse subcutaneous xenograft model of liver cancer, and a rabbit orthotopic transplantation model. We found that DZ-1 accumulates in tumor tissue and specifically recognizes HCC in subcutaneous and orthotopic models. The NIRF intensity of DZ-1 was one order of magnitude stronger than that of ICG, and DZ-1 showed excellent intraoperative tumor targeting in the rabbit model. Importantly, ICG accumulated at tumor sites, as well as in the liver and kidney. Furthermore, DZ-1 analog-gemcitabine conjugate (NIRG) exhibited similar tumor-specific targeting and imaging properties, including inhibition of tumor growth, in HCC patient-derived xenograft (PDX) mice. DZ-1 and NIRG demonstrated superior tumor-targeting specificity, compared to ICG. We show that DZ-1 is an effective molecular probe for specific imaging, targeting, and therapy in HCC.