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Invited Commentary
June 24, 2020

Inhalational Indocyanine Green to Visualize Lung Tumors—Defining the Margin of Error

Author Affiliations
  • 1Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
JAMA Surg. Published online June 24, 2020. doi:10.1001/jamasurg.2020.1348

The adoption of video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery has allowed for improved perioperative outcomes with equivalent long-term oncologic results for non–small cell lung cancer compared with traditional thoracotomy.1 One potential limitation of minimally invasive techniques is a decreased ability to palpate smaller lung nodules and determine an adequate margin of healthy tissue in patients who require lung-preserving resections. Robotic-assisted thoracoscopic surgery also has an absence of haptic feedback, and surgeons must learn to “feel with their eyes.” To improve tumor detection, some surgeons have attempted to use intraoperative fluorescence imaging.2 While previous reports have focused on the intravenous administration of fluorescent dyes, such as indocyanine green (ICG), Quan et al3 investigated the use of inhalational ICG for intraoperative visualization of tumor margins in mouse, rabbit, and human lungs. In this issue of JAMA Surgery, they provide evidence suggesting that ICG delivered via the endotracheal tube and negative contrast imaging can be used to detect subcentimeter nodules in the pulmonary periphery. Inhaled delivery has the benefits of direct delivery to the lungs, significantly less preparation time, and much lower doses than is required for intravenous use.

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