Small Nodule Localization. Bernard Park, M.D. Attending Surgeon, Thoracic Service Memorial Sloan Kettering Cancer Center

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1 Small Nodule Localization Bernard Park, M.D. Attending Surgeon, Thoracic Service Memorial Sloan Kettering Cancer Center

2 Disclosures Intuitive Surgical: honoraria Medtronic: consulting

3 Image guidance in surgery Angioplasty 1964 Nuclear Medicine 1946 Ultrasound PET/CT 2001 Traditional radiology Roentgen 1895 CT scan Hounsfield 1971 Helical CT 1989 Multidetector CT 1999

4 The modern surgeon can do it all Visual Inspection Finger palpation Preoperative or intraoperative localization

5 Most common localization techniques Metallic hook wires and coils Percutaneous injection of methylene blue, autologous blood, radiotracer, other contrast materials (collagen, barium) Intraoperative ultrasound

6 Problems Coordination of procedures Dislodgement Dye diffusion Complications: Pain Cough Pneumothorax Hematoma/hemorrhage Air embolism

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9 Physiologic-guidance Optical imaging Molecular imaging Combination of above Dye or Fluorescent contrast agent injected systemically or locally Camera system that can detect and possibly quantify the agent visualize either tumor or other structures

10 Fluorescent dyes Optical imaging agents (organic fluorophores, metallic nanoparticles, and semiconductor quantum dots) poor tissue penetration Near-infrared fluorophores (NIRFs), which emit light at wave- lengths between 700 and 900 nm decreased scatter and blood absorption

11 Combined molecular and optical dyes

12 Near infrared camera SPY Elite Novadaq technologies Artemis NIR camera Quest Medical Imaging PINPOINT Novadaq technologies FIREFLY Intuitive Surgical

13 Clinical Indications Nodules localization Assessment of resection margins Guidance for segmental resections Lymph nodal mapping

14 Navigational Bronchoscopy

15 ENB and dye localization Author Year Pts/lesions Size Pleura GGO % Awais /33 10 (4-27) 13 (3-44) Marin o Success % Cancer % /72 8 (4-17) 6 (1-19) Awais O, Ann Thorac Surg 2016 Marino KA, Ann Thorac Surg 2016

16 ENB and NIR Anayama T, Ann Thorac Surg 2015

17 Lung nodule localization

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19 Lung metastasis* *Localization of nodules is a not indicated for use or approved by US FDA

20 Molecular Imaging Okusanya OT, JTCVS 2015

21 The Optical Biopsy: A Novel Technique for Rapid Intraoperative Diagnosis of Primary Pulmonary Adenocarcinomas Gregory T. Kennedy, BA,* Olugbenga T. Okusanya, MD,* Jane J. Keating, MD,* Daniel F. Heitjan, PhD,y Charuhas Deshpande, MD,z Leslie A. Litzky, MD,z Steven M. Albelda, MD, Jeffrey A. Drebin, MD, PhD,* Shuming Nie, PhD,-J Philip S. Low, PhD,jj and Sunil Singhal, MD* 30 patients Indeterminate nodules 19/30 fluorescent 18/19 cancers on frozen 19/19 cancers on path Average diagnosis 2.4 min (optical) vs 26.5 min (frozen)

22 Assessment of surgical margins Keating JJ, Mol Imaging Biol 2016 Sensitivity 80 % 30 % Specificity 100 % 90 % PPV 100 % 82 % NPV 83 % 56%

23 12 patients Sizes cm Distance from pleura cm 80% SLN detection rate 100% sensitive and specific 12.5% upstaging *Identification of lymphatic drainage is a not indicated for use or approved by US FDA

24 Nodal Mapping Gilmore et al. J Thorac Cardiovasc Surg. 2013

25 Segmental Anatomy

26 Conclusions Physiologic guidance is safe, easy to use and doesn t require special training It spares the patient additional procedures It has the potential of improving surgical precision while cutting operative time It may improve oncologic outcomes