Dual indocyanine green fluorescence imaging for segmentectomy in pulmonary metastasis of hepatocellular carcinoma: a case report

Background: When indocyanine green (ICG) is administered before surgery, it accumulates in lung metastases of hepatocellular carcinoma (HCC), causing the tumor to fluoresce. Additionally, during pulmonary segmentectomy, the intersegmental plane can be made fluorescent by administering ICG intraoperatively. We here report segmentectomy for pulmonary metastasis of HCC using "dual ICG fluorescence imaging", in which we combined tumor fluorescence by preoperative ICG administration and intersegmental plane fluorescence by intraoperative ICG administration. Case Description: A 62-year-old male with suspected pulmonary metastasis of HCC underwent right ventral segment (S3) segmentectomy for lesion resection. ICG was injected intravenously at a dose of 0.5 mg/kg body weight 3 days before surgery. ICG fluorescence of the tumor was visible through the pleura throughout surgery. After cutting all blood vessels and bronchi involved in S3, 0.1 mg/kg body weight of ICG was injected intravenously. The lung regions to be preserved were fluorescent, while the segment to be resected (S3) was seen as a deficit in fluorescence. S3 segmentectomy was completed while simultaneously checking the intersegmental and tumor fluorescence. Conclusions: In segmentectomy for pulmonary metastasis of HCC, "dual ICG fluorescence imaging", i.e., the combination of tumor fluorescence by preoperative ICG administration and intersegmental fluorescence by intraoperative ICG administration, results in excellent visibility and contributes to reliable segmentectomy for tumor resection.