Detection of alternative subpleural lymph flow pathways using indocyanine green fluorescence

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

Research output: Contribution to journalArticlepeer-review

14 Citations (Scopus)


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.

Original languageEnglish
Pages (from-to)640-648
Number of pages9
JournalSurgery Today
Issue number6
Publication statusPublished - 2018 Jan 30


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


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