Edward G. Soltesz, MD, MPH, Sungjee Kim, PhD, Rita G

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Intraoperative Sentinel Lymph Node Mapping of the Lung Using Near-Infrared Fluorescent Quantum Dots Edward G. Soltesz, MD, MPH, Sungjee Kim, PhD, Rita G. Laurence, BS, Alec M. DeGrand, BS, Cherie P. Parungo, MD, Delphine M. Dor, BA, Lawrence H. Cohn, MD, Moungi G. Bawendi, PhD, John V. Frangioni, MD, PhD, Tomislav Mihaljevic, MD The Annals of Thoracic Surgery Volume 79, Issue 1, Pages 269-277 (January 2005) DOI: 10.1016/j.athoracsur.2004.06.055 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Intraoperative invisible near-infrared (NIR) fluorescence imaging system. View of the NIR fluorescence imaging system deployed in the operating room. The Annals of Thoracic Surgery 2005 79, 269-277DOI: (10.1016/j.athoracsur.2004.06.055) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Sentinel lymph node (SLN) mapping of the right upper lung lobe in a pig using invisible near-infrared (NIR) fluorescent quantum dots (QDs). (A) Depicted from top to bottom are NIR fluorescence images of the surgical field before QD injection (autofluorescence), during QD injection, 45 seconds after injection (lung retracted), 1 minute after injection, and after SLN resection. For each time point, color video (left), NIR fluorescence (middle), and color-NIR merge (right) images are presented. Fluorescence images exhibit identical exposure times and normalization. QDs rapidly localize to the SLN (white arrow). Lack of fluorescence in the nodal basin after resection confirms complete removal of the sentinel nodal tissue. (B) NIR QD retention in the resected SLN compared with regional negative controls. (C) Histologic analysis of frozen sections of the SLN (B). Photomicrographs (×20 and ×40) illustrating the same field with representative hematoxylin and eosin (H+E)-stained sections and consecutive unstained sections photographed on a NIR fluorescence microscope. The Annals of Thoracic Surgery 2005 79, 269-277DOI: (10.1016/j.athoracsur.2004.06.055) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Sentinel lymph node (SLN) mapping of the right upper lung lobe in a pig using invisible near-infrared (NIR) fluorescent quantum dots (QDs). (A) Depicted from top to bottom are NIR fluorescence images of the surgical field before QD injection (autofluorescence), during QD injection, 45 seconds after injection (lung retracted), 1 minute after injection, and after SLN resection. For each time point, color video (left), NIR fluorescence (middle), and color-NIR merge (right) images are presented. Fluorescence images exhibit identical exposure times and normalization. QDs rapidly localize to the SLN (white arrow). Lack of fluorescence in the nodal basin after resection confirms complete removal of the sentinel nodal tissue. (B) NIR QD retention in the resected SLN compared with regional negative controls. (C) Histologic analysis of frozen sections of the SLN (B). Photomicrographs (×20 and ×40) illustrating the same field with representative hematoxylin and eosin (H+E)-stained sections and consecutive unstained sections photographed on a NIR fluorescence microscope. The Annals of Thoracic Surgery 2005 79, 269-277DOI: (10.1016/j.athoracsur.2004.06.055) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Modified lung schematic. Mapping of sentinel lymph nodes (SLNs) in the pig lung. Invisible near-infrared quantum dots were injected into the right and left upper and lower lobes. A mediastinal SLN was identified after 14 injections (X), whereas an intraparenchymal hilar SLN was identified after 2 injections (Y). (Reprinted with modification from [1] by permission of The C. V. Mosby Co.) The Annals of Thoracic Surgery 2005 79, 269-277DOI: (10.1016/j.athoracsur.2004.06.055) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Isosulfan blue colocalization. (A) Depicted from top to bottom are invisible near-infrared (NIR) fluorescence images of the surgical field during quantum dot (QD) injection, 1 minute after QD injection (just before isosulfan blue injection), and 5 minutes after QD injection (ie, 4 minutes after isosulfan blue injection). For each time point, color video (left), NIR fluorescence (middle), and color-NIR merge (right) images are presented. Fluorescence images exhibit identical exposure times and normalization. QDs rapidly localize to the sentinel lymph node (S) from their injection site (I). Coinjection of isosulfan blue (90 seconds after QD injection) quenches the QD fluorescence as evidenced by the loss of QD fluorescence at 5 minutes. Isosulfan blue colocalizes to the same lymph node as the QDs (S). (B) NIR QD and isosulfan blue retention (arrow) in the resected sentinel lymph node. The Annals of Thoracic Surgery 2005 79, 269-277DOI: (10.1016/j.athoracsur.2004.06.055) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions