title: Localization of pulmonary nodules using navigation bronchoscope and a near-infrared fluorescence thoracoscope.
abstract: BACKGROUND
  Video-assisted thoracoscopic wedge resection of multiple small, non-visible, and nonpalpable pulmonary nodules is a clinical challenge. We propose an ultra-minimally invasive technique for localization of pulmonary nodules using the electromagnetic navigation bronchoscope (ENB)-guided transbronchial indocyanine green (ICG) injection and intraoperative fluorescence detection with a near-infrared (NIR) fluorescence thoracoscope.
  
  
  METHODS
  Fluorescence properties of ICG topically injected into the lung parenchyma were determined using a resected porcine lung. The combination of ENB-guided ICG injection and NIR fluorescence detection was tested using a live porcine model. An electromagnetic sensor integrated flexible bronchoscope was geometrically registered to the three-dimensional chest computed tomographic image data by way of a real-time electromagnetic tracking system. The ICG mixed with iopamidol was injected into the pulmonary nodules by ENB guidance; ICG fluorescence was visualized by a near-infrared (NIR) thoracoscope.
  
  
  RESULTS
  The ICG existing under 24-mm depth of inflated lung was detectable by the NIR fluorescence thoracoscope. The size of the fluorescence spot made by 0.1 mL of ICG was 10.4 ± 2.2 mm. An ICG or iopamidol spot remained at the injected point of the lung for more than 6 hours in vivo. The ICG fluorescence spot injected into the pulmonary nodule with ENB guidance was identified at the pulmonary nodule with the NIR thoracoscope.
  
  
  CONCLUSIONS
  The ENB-guided transbronchial ICG injection and intraoperative NIR thoracoscopic detection is a feasible method to localize multiple pulmonary nodules.
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Surgery II, Kochi Medical School, Kochi University, Kochi, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Anayama
authors.affiliation: Department of Radiation Medicine, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Jimmy
authors.initials: J
authors.lastname: Qiu
authors.affiliation: Department of Radiation Medicine, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Harley
authors.initials: H
authors.lastname: Chan
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Takahiro
authors.initials: T
authors.lastname: Nakajima
authors.affiliation: Department of Radiation Medicine, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Weersink
authors.affiliation: Department of Radiation Medicine, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Daly
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Judy
authors.initials: J
authors.lastname: McConnell
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Thomas
authors.initials: T
authors.lastname: Waddell
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Shaf
authors.initials: S
authors.lastname: Keshavjee
authors.affiliation: Department of Radiation Medicine, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Jaffray
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Irish
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Surgery II, Kochi Medical School, Kochi University, Kochi, Japan.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Hirohashi
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
authors.forename: Hironobu
authors.initials: H
authors.lastname: Wada
authors.affiliation: Department of Surgery II, Kochi Medical School, Kochi University, Kochi, Japan.
authors.forename: Kazumasa
authors.initials: K
authors.lastname: Orihashi
authors.affiliation: Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada. Electronic address: kazuhiro.yasufuku@uhn.ca.
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Yasufuku
mesh_terms: D000818:Animals; D020680:Bronchoscopes; D001999:Bronchoscopy / Q000379:methods; D004396:Coloring Agents; D005453:Fluorescence; D007208:Indocyanine Green; D055613:Multiple Pulmonary Nodules / Q000473:pathology*; D013552:Swine; D020708:Thoracoscopes; D013906:Thoracoscopy / Q000379:methods
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green