Indocyanine Green and Technetium-99m: CT-Guided Marking of Lung Nodules Before Robotic-Assisted Lung Resection

Background/Objectives: For stage I non-small cell lung cancer, surgery remains the cornerstone of treatment and the use of minimally invasive techniques is desirable. The lack of tactile feedback in RATS is a well-known drawback of this approach, so precise identification of the disease is crucial for performing lung resection. Methods: We present our retrospective case history, accounting for 83 patients, which were divided into two groups based on marking technique: 99mTc-MAA (99mTechnetium Albumin Macroaggregates) only (Tech group) (22 cases, 26.5%) and 99mTc-MAA + Indocyanine Green (Tech + ICG group) (61 cases, 73.49%). Results: In the Tech group, there were 11 males (50%) ad 11 females (50%), the median nodule diameter was 21.5 mm (IQR 16), and the median distance of the nodule from the visceral pleura was 18 mm (IQR 21). Eighteen out of 22 nodules (81.82%) were subsolid. Three conversions were reported, all due to failure to identify the nodule (13.63%). The mean operative time was 111.6 ± 45.6 min. The histopathological examination resulted in 13 lung adenocarcinomas, one squamous cell carcinoma, two minimally invasive lung adenocarcinomas, two lung adenocarcinomas in situ, three metastases from another tumor, and one benign nodule. In the Tech + ICG group, there were 27 males (44.26%) and 34 females (55.73%), the median nodule diameter was 18 mm (IQR 14), and the median distance of the nodule from the visceral pleura was 24 mm (IQR 15). Forty-six out of 61 nodules were subsolid (75.4%). Four conversions were reported, due to failure in nodule identification (6.55%). The operative time was 105.6 ± 36.8 min. The histopathological examination resulted in 12 lung adenocarcinomas, seven squamous cell carcinomas, nine minimally invasive lung adenocarcinomas, 12 lung adenocarcinomas in situ, one typical carcinoid, seven atypical adenomatous hyperplasias, seven metastases from another tumor, and six benign nodules. The two groups are homogeneous in terms of median nodule diameter (p = 0.676), the median distance from visceral pleura (p = 0.114), SUV max (p = 0.894), operative time (p = 0.512), and nodule characteristics (solid vs. subsolid) (p = 0.724). The conversion rate was lower in the Tech + ICG group (6.55% vs. 13.63%), but the difference was not statistically significant (p = 0.375). Conclusions: Both techniques appear to be safe and reproducible. Further standardized studies are needed to validate and confirm the results obtained from our case series.