Inhaled Indocyanine Green Negative-contrast Fluorescence-guided Surgery for Pulmonary Metastasectomy

Indocyanine green fluorescence (ICG-F)-guided surgery has, in recent years, optimized the precision and safety of surgical procedures. Although its applications are increasingly widespread, in most cases, the dye is administered intravenously. We present a case of inhaled indocyanine green use for the identification and resection of pulmonary metastatic nodules. A 12-year-old female patient with a history of sternal Ewing sarcoma with bone and pulmonary metastases was treated with chemotherapy, proton therapy, partial sternal and costal cartilage resection, and reconstruction with mesh and absorbable plates. She later developed pulmonary relapse, with two subpleural metastases identified in segments 6 and 9 of the right lung. After initiating chemotherapy, thoracoscopic surgery was planned to resect the nodules. Before surgery, nebulization of indocyanine green was performed via an endotracheal tube at 0.2 mg/kg using an inhalation chamber for 5 minutes at 6 liters per minute. During surgery, fluorescence was observed in the insufflated lung parenchyma, allowing for clear differentiation of metastatic nodules from peripheral fibrotic or inflammatory tissue and enabling a safe wedge resection of both lesions. The postoperative period was uneventful, and the patient is currently completing postoperative chemotherapy cycles.