Image-guided pulmonary metastasectomy in the hybrid operating room

Surgical radicality is the main prognostic factor in patients who have undergone pulmonary metastasectomy, despite potential differences in underlying primary cancer biology. Current localization techniques place fiducial markers into the lung parenchyma to facilitate detection and guide resection of pulmonary nodules during minimally invasive thoracoscopic surgery. Markers include metal, dye, radiopaque agents, fluorescent contrast, and radiolabeled agents. Traditional marker-guided pulmonary resection comprises a two-stage workflow: (I) preoperative computed tomography (CT)-guided transthoracic implantation of a fiducial marker in the interventional CT suite followed by (II) patient transfer to the operation room for surgical removal. However, the patient is at risk for procedural adverse effects or dislodgement of the marker during the interval period between localization completion and surgery start. The development of a hybrid operating room allows for a one-stage approach to localization, as well as the integration of new imaging modalities and localization methods to pulmonary metastasectomy. In this review, we will explore several current and novel technologies in development relevant for image-guided pulmonary metastasectomy, informed by studies in the setting of hybrid operating room as well as our own experience with the Guided Therapeutics operating room at Toronto General Hospital.