February - 20209normal haptic feedback for the surgeon. If minimal invasive thoracic surgical techniques are utilized alone, more than half of the time the surgeon failed to palpate or visualize an indeterminate nodule such as a GGO.Minimally invasive thoracic surgery (da Vinci robotic or VATS) has demonstrated notable benefits in allowing a patient to recover and return to their preoperative quality of life at a faster rate. Various techniques have evolved to aid in localizing indeterminate nodules, facilitating a successful limited lung resection using minimally invasive surgery. Early experience required introduction of a wire hook, injectable dyes, coils, markers or radiotracers via a separate CT guided percutaneous process performed in radiology. With the advent of electromagnetic navigational bronchoscopy (ENB), indeterminate nodule dye marking could be offered in the operating room followed directly by minimally invasive surgical resection. The use of Indocyanine green (ICG) with intraoperative near-infrared imaging (Firefly) offers patients with a GGO the opportunity to benefit from a da Vinci robotic thoracic surgical intervention.Case Report:An elderly male with a former history of tobacco abuse and two prior malignancies was incidentally identified with a pure GGO in the right middle lobe. Over a course of surveillance, the GGO had doubled in size to 16 mm and demonstrated an 8 mm central solid component. The location of this GGO was not ideal for either a transthoracic needle biopsy or bronchoscopic approach. Considering the change in size and architecture, a concern was raised over malignancy. I recommended a single visit Monarch robotic bronchoscopy ICG dye marking followed by a da Vinci robotic exploration and resection of the GGO.Unlike current ENB bronchoscopy, the Monarch robotic bronchoscope provided an accurate platform that utilizes both optical recognition and navigational guidance. Once the ICG dye was delivered to the region of the GGO, the da Vinci robot utilizing Firefly near-infrared imaging was able to easily identify the right middle lobe GGO that was not visualized by the naked eye. A limited lung resection was performed and immediately interpreted by pathology as an adenocarcinoma lung cancer. The patient underwent a da Vinci robotic completion lobectomy and lymph node dissection. The patient's recovery was uneventful and only required a 2 day length of stay in a general ward bed. The final pathology demonstrated a pT1bN0 stage IA2 adenocarcinoma lung cancer. One week following surgery, the patient no longer was utilizing any narcotic pain medication. The patient was resuming an active lifestyle and was eager to return to playing golf.I am hopeful that lung cancer screening will follow the footsteps of other screening modalities. Being able to identify cancer at an earlier stage would be more amenable to curative resection. GGO is an increasingly frequent finding observed in lung cancer screening studies and, though it may represent a pulmonary inflammatory condition, a change in GGO size or development of a solid component could indicate malignancy. Conventional lung nodule diagnostic methods of needle biopsy or PET/CT may result in unacceptable false negative rates for a GGO. The combination of a Monarch robotic bronchoscopy ICG marking followed by immediate da Vinci® robotic lung exploration with Firefly can provide a "one-stop shop" to diagnose and treat a suspicious GGO. This combination of robotic technologies provides a highly accurate and efficient method of managing a GGO with minimal impact to patient quality of life. I believe that every multidisciplinary cancer program involved in lung cancer screening must be able to offer robotic minimal invasive options for GGO diagnosis and therapy. GGO is an increasingly frequent finding observed in lung cancer screening studies and, though it may represent a pulmonary inflammatory condition, a change in GGO size or development of a solid component could indicate malignancyPaul Chomiak
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