A single-chip, dual-gain color–NIR camera for fluorescence-guided lung and breast cancer surgery

Near infrared (NIR) fluorescence guided surgery can highlight tumors and sentinel lymph nodes, but most clinical fluorescence imaging systems use multi-camera architectures in which residual color-NIR misregistration can mislocalize fluorescence relative to anatomy, and weak signals often require dimming operating room lights. We developed a single-chip dual-gain scientific CMOS (sCMOS) sensor with red, green, blue (RGB), and NIR channels that provides intrinsically coregistered color reflectance and NIR fluorescence under typical operating room illumination (50-80 kLux). A backside illuminated array with division of focal plane (DoFP) pixelated interference filters achieves an input-referred read noise of 2.25 electrons and a fused dynamic range >90 dB, enabling indocyanine green (ICG) detection at ~100 pM under dark-background conditions and ~500 pM under standard 50-80 kLux operating-room illumination, with quantification over four orders of magnitude. We integrated the sensor into a surgical camera and evaluated it in 20 patients with lung cancer receiving the cathepsin-activated ICG probe VGT-309 and 35 patients with breast cancer undergoing ICG-guided sentinel lymph node biopsy. In lung cancer, lesion level sensitivity was 0.90 (18/20) and positive predictive value was 0.78 (18/23), with at least one clinically significant event in 45% (9/20) of patients. In breast cancer (90 specimens), high-gain NIR imaging improved classification of gamma probe-designated sentinel lymph nodes by node-to-background ratio (ROC AUC 0.94 vs 0.60) while preserving a white light view. These results establish a single-chip route to lights-on color and NIR guidance in the operating room.