CT-guided indocyanine green fluorescence localization demonstrates superior reliability over hook-wire for pulmonary ground-glass nodules: a retrospective cohort study

Introduction

Lung cancer is the leading cause of cancer-related death in many regions worldwide (1). A recent clinical study showed that low-dose computed tomography (CT) screening can effectively detect early-stage lung cancer in high-risk individuals, potentially improving the likelihood of early detection (2). The early detection of lung cancer provides more treatment options, results in less invasive surgeries, and improves patient survival rates. High-resolution CT (HRCT) is commonly used in daily practice and screening, leading to the frequent identification of ground-glass opacity (GGO) in asymptomatic patients (3,4). A GGO is characterized by an area of indistinct dense opacity on HRCT scans, where bronchial or pulmonary vascular structures remain visible and has a maximum diameter of less than 3 cm (5). GGO can result from various medical conditions, including infections, interstitial diseases, acute alveolar diseases, and neoplasms (6). ground-glass nodules (GGNs) frequently manifest as multiple lesions, and there has been a recent increase in the occurrence of multiple primary lung cancers accompanied by GGO (7,8). GGNs affect the quality of life and mental health of patients (9). The negative impact of GGNs on quality of life is primarily psychological. In cases of indeterminate nature and requiring long-term follow-up, they cause significant “scanxiety”, anxiety, depression, and impair social functioning. The follow-up process itself adds burden through waiting, cost, and radiation concerns. In contrast, direct physiological impact is usually minimal due to their indolent nature (9-12).

With the development of video-assisted thoracoscopic surgery (VATS), wedge resection of the lung is not only minimally invasive and safe, but is also able to completely remove lesions, and has a diagnostic accuracy rate of nearly 100%. It is now widely used in the diagnosis and treatment of GGNs (13). Segmentectomy is also considered based on lesion location, number, and multidisciplinary evaluation—especially for peripheral GGO-dominant lung cancers ≤2 cm with solid component/total diameter ratio (CTR) >0.5. High-quality studies confirm its oncological non-inferiority to lobectomy while preserving lung function. Lobectomy remains standard for mixed GGOs with large solid components or aggressive pathology (14). Sublobectomy combined with subsegmentectomy/conization may be used for multiple or anatomically special GGOs (15). However, intraoperative localization of GGN during VATS is challenging when the lesion does not induce pleural changes (13,16). The inadequate localization of nodules can prolong the operative time as surgeons take time to search for nodules, and it can even lead to unplanned conversions to an open thoracotomy (13,16,17).

To address this, preoperative CT-guided localization techniques have been developed. Among these, hook-wire placement is often considered a reference standard. However, meta-analyses have quantified its limitations: dislodgement or migration occurs in approximately 6–10% of procedures, pneumothorax requiring intervention is reported in up to 10% of cases, and parenchymal hemorrhage is also common. Rare but severe complications, such as systemic air embolism or migration into the heart or great vessels, have been documented (17-21). These risks, coupled with patient discomfort and the logistical challenge of scheduling surgery immediately after wire placement, highlight the need for improved techniques. Therefore, developing and validating improved localization techniques is of significant clinical importance.

Fluorescence-guided surgery with indocyanine green (ICG) has been investigated as an alternative for over a decade. ICG is a safe, near-infrared (NIR) fluorescent dye that allows real-time intraoperative visualization. Previous studies have demonstrated the feasibility of CT-guided or hybrid operating room-guided ICG injection for pulmonary nodule localization (22,23). While conceptually established, its performance merits rigorous evaluation in specific cohorts, such as patients with small, peripheral GGNs. Furthermore, a direct comparison of its practical advantages—particularly for localizing multiple nodules and avoiding risks associated with retained metallic devices—against the established hook-wire benchmark remains clinically relevant.

To address these points, the aim of the study was to evaluate the feasibility and safety of the ICG fluorescence localization technique for the resection of GGNs under NIR fluorescence thoracoscopy. We present this article in accordance with the STROBE reporting checklist (24) (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0050/rc).

Methods

Patients

The data of patients who underwent pulmonary GGN resection at the Department of Thoracic Surgery, The First Affiliated Hospital of Ningbo University from July 2022 to September 2022 were retrospectively analyzed. To ensure the accuracy of nodule localization, all enrolled patients underwent a diagnostic HRCT scan within 4 weeks prior to the scheduled surgery. Clear and uniform inclusion and exclusion criteria were established. The inclusion criteria were as follows: (I) age >18 years; (II) GGN with a diameter <2 cm confirmed by HRCT; and (III) adequate cardiopulmonary function to tolerate surgery. The exclusion criteria were as follows: (I) GGN with a diameter ≥2 cm; (II) lesion located in the inner one-third of the lung field (adjacent to critical anatomical structures such as the main bronchi and major blood vessels); (III) solid nodule or solid component >50%; (IV) inadequate cardiopulmonary function to tolerate surgery; and/or (V) allergy to iodine contrast agent. To evaluate the relative safety and efficacy, a historical control group was established using data from our previously published cohort of patients who underwent CT-guided hook-wire localization for GGNs at the same institution between January and July 2015 (17). Notably, the exclusion criteria for the historical control group, as defined in our previous study (17), differed from those used in the current ICG study. The primary exclusion criteria in the historical study were: (I) GGO diameter >1 cm; (II) lesions located in the inner two-thirds of the lung field; (III) solid nodules or solid component >70%. In contrast, the present study employed stricter inclusion criteria to ensure that lesions were more suitable for wedge resection and fluorescence localization. All consecutive patients meeting the criteria during the study period were included to minimize bias in patient selection. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Regional Ethics Review Board of The First Affiliated Hospital of Ningbo University (No. 20190375) and informed consent was obtained from all the patients.

Materials and procedures

A disposable puncture needle (AS-E/SII 1.6/0.5, Shanghai SA MEDICAL & Plastic Instruments Co., Ltd., Shanghai, China) was used for the procedure. For localization, ICG (25 mg per vial, Dandong Yichuang Pharmaceutical Co., Ltd., Dandong, China) was diluted with sterile water to a concentration of approximately 2.5 mg/mL. Under CT guidance, 0.5 to 1 mL of this solution was injected percutaneously in close proximity to the target nodule. This dose and concentration regimen was selected based on established protocols for CT-guided ICG localization, which aim to provide a strong fluorescent signal while minimizing tissue dispersion (22). The patient was positioned on the CT examination bed in the supine, prone, or lateral position. A low-resolution CT scan (5-mm slice thickness) was first used to locate the nodules, and a self-made positioning needle was placed on the patient’s body surface (Figure 1A). The scanning range was then narrowed, and an HRCT scan (1-mm slice thickness) was used to determine the crossing point of the lesion and positioning needle, which served as the puncture point. The puncture angle was determined based on the relationship between the ribs and the lesion, selecting a direction as close to perpendicular to the body surface as possible, and the puncture depth was measured. After routine disinfection and draping, the physician administered local anesthesia using 2% lidocaine, and then performed the puncture. Post-puncture CT was used to confirm that the puncture needle was adjacent to the lesion, after which the pre-prepared ICG solution (0.5–1 mL) was injected. Following another CT scan to ensure that there were no severe complications, the patient was transferred directly to the operating room. Intraoperatively, the localized area exhibited focal fluorescence (Figure 1B-1D, Figure 2A). All the CT-guided localization procedures were performed by a fixed team of experienced physicians, using uniform equipment to minimize variability introduced by different operators or devices.

Figure 1 Site and process for puncture localization. (A) Body surface markers; (B,C) puncture localization process; (D) computed tomography examination room in the operating room.

Figure 2 Localization diagram under the computed tomography and video-assisted thoracoscopic surgery pulmonary wedge resection process. (A) Computed tomography scan image of puncture needle positioned around the lesion; (B) indocyanine green localization points observed under near-infrared fluorescence thoracoscopy; (C) pulmonary wedge resection under fluorescence thoracoscopy; (D) lesions in the lung tissue after resection.

VATS was typically performed using a single- or two-incision method. The surgeon used an NIR fluorescence thoracoscope (Stryker) to locate the GGN (Figure 2B), followed by wedge resection with a linear cutting and suturing device (Figure 2C). The resected specimen was then sent for intraoperative frozen section analysis (Figure 2D).

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics (version 26.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize patient and nodule characteristics. Continuous variables were presented as mean ± standard deviation (SD) or as median (range) and categorical variables were reported as numbers (percentages). To address the precision of our estimates for the primary feasibility and safety outcomes, we reported 95% CI for key proportions (e.g., successful identification rate, complication rate) using the Clopper-Pearson (exact) method. For comparisons between the ICG and historical control groups, continuous variables were compared using the Mann-Whitney U test or independent t-test, and categorical variables were compared using the chi-squared test or Fisher’s exact test. Data completeness was ensured as all key outcome variables (localization success, complications, pathological diagnosis) were mandatorily recorded in the operative and pathological reports. Therefore, there were no missing data for the primary and secondary outcomes analyzed in this study, and no specific data imputation or handling techniques were required.

Results

A total of 104 lung GGNs were identified from 94 patients who underwent VATS wedge resection following preoperative CT-guided ICG localization. The baseline demographic, clinical, and nodule characteristics of the study cohort are summarized in Table 1. Briefly, the cohort was predominantly female (76.6%), and the most common nodule location was at the right upper lobe (27.9%). The median diameter of the nodules was 6 mm (range, 2–16 mm), and the median distance from the pleura was 9 mm (range, 2–28 mm). The historical control (hook-wire) group consisted of 29 GGOs from 23 patients who underwent localization between January and July 2015 (17). The two groups were comparable in terms of age, nodule size, and depth from the pleura (Table 2).

In this cohort of 94 patients, a total of 104 GGNs were identified, with ICG fluorescence clearly identified in 87 nodules (92.6%; 95% CI: 85.3–96.5%), and ICG dispersion observed intraoperatively in 7 (7.4%; 95% CI: 3.6–14.6%). All nodules were successfully resected via VATS wedge resection. Importantly, no procedures required conversion to thoracotomy for nodule localization or removal. The median localization time under CT guidance was 15 min (range, 8–28 min). Complications occurred in 15 cases (16.0%; 95% CI: 9.9–24.5%) following puncture, including pneumothorax in 12 cases (12.8%) and minimal hemoptysis in 3 cases (3.2%), none of which required further treatment. No instances of severe anaphylactic shock or other serious complications were observed. Among the seven patients with ICG dispersion intraoperatively, all the lesions were able to be successfully located by identifying the dye aggregation points without the need for conversion to open chest surgery, and all the specimen margins were greater than 2 cm from the lesions. The pathological results of the 104 GGNs postoperatively showed 30 nodules of in situ adenocarcinoma (28.8%), 53 nodules of microinvasive adenocarcinoma (51.0%), 6 of invasive adenocarcinoma (5.8%), and 15 of benign nodules (14.4%), with a 100% surgical success rate (Table 1).

The ICG group (n=94) was compared with a historical control group (n=23, derived from our prior study) (17) undergoing hook-wire localization. The baseline characteristics (age, gender, nodule size, and depth) were comparable between groups (Table 2). The success rate of initial localization was 100% in both groups. The overall complication rate associated with the localization procedure was comparable between the ICG group and the hook-wire group (16.0% vs. 26.1%; P=0.26). Notably, no patient in the ICG group required conversion to lobectomy due to localization failure, whereas this occurred in 8.7% of the hook-wire group (P=0.04) (Table 2).

Discussion

Since GGO was first identified by CT scans in the 1990s, the prevalence of pulmonary GGO has been increasing, particularly with the widespread adoption of HRCT for lung cancer screening (25). Some subpleural nodules, particularly pure GGO, may be inaccessible during surgery. Surgery is the standard treatment for these patients, and sublobar resection is the preferred approach for these small lung nodules (26). Traditional localization techniques, including coil spring, hook-wire, and methylene blue, are commonly used to locate lung nodules. In a previous study, we confirmed that preoperative CT-guided hook-wire localization significantly increased the feasibility of wedge resection under VATS for GGO, and had a low complication rate and good clinical utility (17). However, there are still some limitations and potential complications with these localization techniques, including dislocation, pain, diffusion, and bleeding.

In this study, we evaluated a localization technique by performing percutaneous ICG injection under CT-guidance and displaying GGN under NIR fluorescence thoracoscopy. A total of 104 lung GGNs from 94 patients were successfully localized with a success rate of 92.6% (95% CI: 85.3–96.5%). The median localization time was 15 min, and the procedure-related complication rate was 16.0% (95% CI: 9.9–24.5%), primarily comprising self-limited pneumothorax or minor hemoptysis; no serious complications were observed. While this complication rate is not negligible, it appears numerically lower than the pooled rates reported for hook-wire localization in meta-analyses (e.g., pneumothorax requiring intervention of up to ~10%, with overall complication rates often exceeding 20%) (18). Furthermore, in this study, when compared to a historical cohort undergoing hook-wire localization, the CT-guided ICG fluorescence technique also achieved a comparable safety profile in terms of overall procedural complications, with a rate of 16.0% vs. 26.1% (P=0.26). Most complications in both groups were minor and self-limited, such as asymptomatic pneumothorax. The most salient finding, however, lies in the marked improvement in procedural reliability. The hook-wire technique carries an inherent risk of dislodgement, which in our historical cohort led to conversion to a more extensive lobectomy in 8.7% of cases intraoperatively. In stark contrast, the ICG fluorescence technique completely avoided this serious scenario (0% conversion rate, P=0.04). This represents a critical clinical advantage, as it ensures that the planned minimally invasive wedge resection can proceed without interruption, preserving lung parenchyma and avoiding unplanned escalation of surgical intervention. Beyond reliability, the ICG technique offers several practical advantages over the hook-wire method.

ICG is a biologically safe dye with low toxicity and an extremely low allergy rate (0.01%) (27). It is a water-soluble molecule that binds to plasma proteins after entering the bloodstream, is quickly captured by hepatocytes and excreted into the bile ducts via biliary secretion, and is ultimately excreted from the body through the gastrointestinal tract. Compared with the traditional hook-wire localization technique, after ICG localization, patients have no obvious accompanying pain with breathing, and multiple lesions can simultaneously be located. In this study, nine patients underwent localization of two or more GGNs, with no significant adverse reactions. This approach may help minimize the risk of severe or potentially fatal complications associated with metal tags such as hook-wire (20,21).

A study has reported mild adverse reactions to ICG in 0.15% of cases, moderate reactions in 0.2%, and severe adverse reactions in 0.05%, with no mortality documented (28). Compared with traditional positioning techniques, the second advantage of ICG positioning is that it is not affected by the surgery time. After traditional positioning techniques, patients need to undergo surgery as soon as possible after the puncture to reduce the occurrence of potential complications. With ICG positioning, the dye can generally be retained in the patient’s body for up to 24 hours, with the longest reported retention time in the literature being 6 days (29), allowing for a more reasonable scheduling of the time interval between ICG positioning and surgery.

Furthermore, in addition to the aforementioned advantages in reliability and scheduling compared to hook-wire localization, ICG also exhibits unique physicochemical advantages over other traditional localization agents, such as methylene blue. ICG has a significantly larger molecular weight (~775 Da) than methylene blue (~320 Da). When bound to plasma proteins such as albumin, ICG forms macromolecular complexes (~80 kDa). This property allows ICG to remain in the extravascular space for extended periods under pathological conditions with increased vascular permeability (e.g., pulmonary edema), effectively reducing rapid clearance by the lymphatic system compared to traditional methylene blue (30). Carbon particles (e.g., pulmonary carbon deposits in smokers or patients with pneumoconiosis) may absorb visible light wavelengths (e.g., the blue light spectrum of methylene blue). However, NIR light, which corresponds to ICG’s excitation wavelength of 800 nm, exhibits superior tissue penetration and is less affected by carbon particle interference (31). Compared with traditional methylene blue and other localization techniques, ICG is less affected by factors such as pulmonary edema or the deposition of carbon particles in the lungs due to its superior tissue penetration.

However, ICG also has the limitation of intraoperative diffusion, which occurred in 7.4% (95% CI: 3.6–14.6%) of our cases. Diffusion mainly occurs when the injection site is too close to the pleura or when ICG is mistakenly injected into the pleural space. Furthermore, the time interval between ICG injection and surgical visualization may influence dispersion; a longer delay could potentially allow for broader dye migration within the pulmonary parenchyma. Unlike methylene blue, ICG diffusion can be localized by identifying the fluorescent accumulation point, as the injection site typically exhibits the brightest NIR fluorescence, minimally affecting the surgery. In this study, all seven nodules with dispersion were successfully localized using this strategy. Thus, ICG fluorescence-guided localization under CT guidance is more feasible than traditional methods.

In addition to intraoperative diffusion, there are several other limitations with ICG localization technology. First, the tissue penetration depth of NIR fluorescence imaging is limited, and for some deeper nodules in the lung tissue, it may not be possible to inject ICG for localization under CT guidance. For these patients, bronchoscopy-guided ICG injection may be more appropriate (32). Second, it may be difficult to capture fluorescence in cases of severe lung emphysema or intraoperative lung collapse (33). Third, CT-guided localization inevitably results in excessive radiation exposure to the human body. The average radiation dose of a standard chest CT scan is 7.0 mSv, while the mean effective dose of low-dose CT ranges from 1.4 to 1.6 mSv, representing approximately one-fifth to one-sixth of that of conventional chest CT (34,35). Fourth, although ICG has fewer complications, vigilance remains necessary for severe adverse events such as anaphylactic shock (28,36).

These limitations will drive ongoing innovation in the field of fluorescence-guided thoracic surgery. To minimize excessive radiation exposure, a preliminary experimental study has reported a new localization technique using three-dimensional printing to simulate the chest wall surface. With the guidance of the model, percutaneous injection could prevent additional CT exposure (37). In addition, intraoperative ultrasound is another radiation-free, real-time localization technique. A recent prospective study has demonstrated that ultrahigh-frequency ultrasound is feasible for the intraoperative localization of GGNs (38). To overcome the limitations of non-specific biodistribution, the field is rapidly advancing toward targeted molecular imaging. This transition is evidenced by recent early-phase clinical trials. Notably, a phase 2 trial of VGT-309, a cathepsin-activated NIR probe, reported an enhanced tumor-to-background ratio and the ability to identify additional occult lesions during pulmonary resection (39), highlighting the potential of molecularly targeted probes to improve surgical precision beyond what is achievable with conventional dyes.

This study also reinforced the value of ICG as a versatile fluorescent agent in VATS. Beyond its established role in tumor localization, innovative administration routes are expanding its utility. Recent technical reports, such as the use of ICG nebulization to achieve clear fluorescence mapping of the bronchial tree during VATS (40), highlight its potential to solve adjacent surgical challenges. This bronchoscopic visualization technique can aid in precise anatomical dissection during complex segmentectomies, a common procedure for GGO resection. The parallel development of these complementary applications underscores the expanding range of applications of fluorescence-guided thoracic surgery.

There are limitations in this study inherent to its retrospective design with historical controls. First, although the inclusion of a historical control group enhances the comparative interpretation of our findings, non-randomized intervention allocation may introduce selection bias because the two patient groups were treated in different periods. While baseline characteristics were comparable, unmeasured confounding factors may still exist. Second, the use of a historical control implies that observed outcome differences could be influenced by temporal changes in surgical technique, perioperative care, or imaging protocols, rather than solely by the localization technique itself. Finally, although the sample size was sufficient for assessing feasibility and safety and for conducting the post-hoc analyses, it was not prospectively calculated for a superiority comparison and therefore may be underpowered to detect statistically significant differences in rare complications or secondary outcomes. Prospective randomized controlled trials are necessary to confirm the comparative efficacy and safety of ICG fluorescence localization and to provide higher-level evidence.

Conclusions

This study introduces a method for the localization and minimally invasive resection of pulmonary GGNs using NIR thoracoscopy with ICG. Our findings validate the safety and feasibility of this CT-guided fluorescence localization technique. As highlighted in a recent review, precise localization techniques for small pulmonary nodules are evolving toward diversification, minimally invasive approaches, and intelligent solutions. Future efforts should focus on developing novel targeted fluorescent probes and integrating them with radiation-free technologies such as three-dimensional reconstruction and electromagnetic navigation, ultimately aiming to achieve a radiation-free closed-loop precision diagnosis and treatment pathway (41).

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0050/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0050/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0050/prf

Funding: This work was supported by Zhejiang Provincial Medical, Health Science and Technology Project (No. 2024KY1541), and Ningbo Key R&D Program “Innovation Yongjiang 2035” (No. 2025Z173).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0050/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by Regional Ethics Review Board of The First Affiliated Hospital of Ningbo University (No. 20190375) and informed consent was obtained from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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