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Surgery Today

, Volume 48, Issue 6, pp 640–648 | Cite as

Detection of alternative subpleural lymph flow pathways using indocyanine green fluorescence

  • Aya Harada Takeda
  • Yui WatanabeEmail author
  • Toshiyuki Nagata
  • Masaya Aoki
  • Tadashi Umehara
  • Soichi Suzuki
  • Go Kamimura
  • Kazuhiro Wakida
  • Tsunayuki Otsuka
  • Naoya Yokomakura
  • Kota Kariatsumari
  • Koichi Sakasegawa
  • Yoshihiro Nakamura
  • Masami Sato
Original Article

Abstract

Purpose

Pulmonary lymphatic fluid predominately flows along the bronchi. However, there are reports suggesting that an alternative lymphatic pathway exist, which may result in skip metastases. The aim of this study was to evaluate the subpleural lymph flow in vivo using indocyanine green (ICG) fluorescence.

Methods

One hundred cases were enrolled. ICG was injected into the macroscopically healthy subpleural space. Intraoperative fluorescence images were then observed in real time.

Results

ICG fluorescence was observed moving through subpleural channels in 58/100 cases. ICG flowed into adjacent lobes over interlobar lines in 18 cases and flowed from the visceral pleura directly into the mediastinum in 5 cases. The frequency of mediastinal detection without hilar lymph node detection was significantly higher in the left lung compared to the right (p < 0.05). The subpleural lymph flow detection rates were significantly lower in patients with smoking pack-years ≥ 40 than those with < 40 (p < 0.05).

Conclusions

The flow of lymphatic fluid directly into the mediastinum suggests one mechanism of skip metastasis. In addition, the reduction of the subpleural lymph flows in smokers with ≥ 40 pack-years suggests that smoking might modify lymph flow patterns. These findings may assist in selecting the optimal therapy for patients with possible skip metastasis.

Keywords

Subpleural lymph flow Indocyanine green fluorescence Lung cancer Skip metastasis Lung remodeling 

Notes

Acknowledgements

The authors would like to express their gratitude to Dr. Robert Qaqish and Ms. Cara Summers from University Health Network, Toronto, Canada, for their English editing.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Supplementary material

Video 1. (a) The ICG flowed through the subpleural space forming obvious tracts, but stayed within the injected lobes (arrows). (b) The ICG flowed through the subpleural space to adjacent lobes over the interlobar lines (arrow). (c) The ICG flowed through the subpleural space directly into hilar LNs (arrow). (d) The ICG flowed through the subpleural space directly to the mediastinum (arrow). Abbreviations: UL: upper lobe, LL: lower lobe, PN: phrenic nerve, dAO: descending aorta, PA: pulmonary artery, AA: aortic arch (MP4 7265 KB)

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Copyright information

© Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  • Aya Harada Takeda
    • 1
  • Yui Watanabe
    • 1
    Email author
  • Toshiyuki Nagata
    • 1
  • Masaya Aoki
    • 1
  • Tadashi Umehara
    • 1
  • Soichi Suzuki
    • 1
  • Go Kamimura
    • 1
  • Kazuhiro Wakida
    • 1
  • Tsunayuki Otsuka
    • 1
  • Naoya Yokomakura
    • 1
  • Kota Kariatsumari
    • 1
  • Koichi Sakasegawa
    • 1
  • Yoshihiro Nakamura
    • 1
  • Masami Sato
    • 1
  1. 1.Department of General Thoracic Surgery, Graduate School of Medical and Dental SciencesKagoshima UniversityKagoshimaJapan

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