Second-generation ICG fusion fluorescence endoscopy in pituitary neuroendocrine tumor surgery
- 1Department of Neurosurgery, Binzhou Medical University Hospital, Binzhou, Shandong, China
Abstract
Objective: This study investigated the clinical feasibility of integrating second-generation real-time indocyanine green (ICG) fusion fluorescence endoscopy into routine transsphenoidal surgical workflow for pituitary neuroendocrine tumors (PitNETs). Our focus was on describing the qualitative fluorescence patterns of PitNETs observed within the procedure-embedded 15–18 min delay window following administration of ICG, and evaluating the reproducibility of image interpretation.
Methods: This retrospective single-center descriptive feasibility study included 26 patients with PitNETs who underwent endoscopic transsphenoidal surgery. ICG was intravenously injected before sellar floor drilling, then after the tumor-pituitary interface was fully exposed, real-time fusion mode fluorescence endoscopy was maintained for continuous observation. Two independent observers retrospectively assessed fluorescence intensity and contrast patterns on video clips of intraoperative fusion fluorescence imaging. Interobserver agreement for binary fluorescence intensity grading and three-category contrast pattern classification (tumor-dominant, equivalent, and pituitary-dominant) was evaluated using Cohen's kappa coefficient (weighted kappa for ordinal pattern categories).
Results: Surgery under fluorescence guidance was successfully completed for all 26 patients, with no ICG-related adverse events. No intraoperative mode switching was required, and fluorescence signals remained stable within the delay window. The contrast pattern classifications were: tumor-dominant n = 8 (all clinically functioning PRL-PitNETs), equivalent n = 15 (multiple subtypes), and pituitary-dominant n = 3 (all elderly patients ≥65 years with non-functioning PitNETs). Interobserver agreement was excellent, with Cohen's kappa of 0.91 (95% CI: 0.85–0.97, P < 0.001) for binary fluorescence intensity grading and a weighted Cohen's kappa of 0.89 (95% CI: 0.82–0.96, P < 0.001) for contrast pattern classification. All postoperative adverse events were mild and resolved conservatively, with no permanent pituitary dysfunction.
Conclusion: Second-generation ICG fusion fluorescence endoscopy demonstrated preliminary technical feasibility and short-term safety for integration into transsphenoidal surgical workflow. The three fluorescence contrast patterns within the 15–18 min window show good interobserver agreement. The clinical utility of these patterns for tumor-pituitary interface assessment remains unproven and requires prospective validation.
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BibTeX
@article{gao2026secondgeneration,
title = {{Second-generation ICG fusion fluorescence endoscopy in pituitary neuroendocrine tumor surgery}},
author = {Huidong Gao and Haoyu Song and Yuyuan Fan and Yongqiang Xu and Zhuoqun Li and Pengfei Liu and Wenbo Gao and Ke Guo and Mengyang Xing},
journal = {Frontiers in Surgery},
year = {2026},
month = oct,
doi = {10.3389/fsurg.2026.1938360},
url = {https://doi.org/10.3389/fsurg.2026.1938360},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Second-generation ICG fusion fluorescence endoscopy in pituitary neuroendocrine tumor surgery
AU - Huidong Gao
AU - Haoyu Song
AU - Yuyuan Fan
AU - Yongqiang Xu
AU - Zhuoqun Li
AU - Pengfei Liu
AU - Wenbo Gao
AU - Ke Guo
AU - Mengyang Xing
PY - 2026
DA - 2026/10/21
JO - Frontiers in Surgery
DO - 10.3389/fsurg.2026.1938360
UR - https://doi.org/10.3389/fsurg.2026.1938360
AB - Objective: This study investigated the clinical feasibility of integrating second-generation real-time indocyanine green (ICG) fusion fluorescence endoscopy into routine transsphenoidal surgical workflow for pituitary neuroendocrine tumors (PitNETs). Our focus was on describing the qualitative fluorescence patterns of PitNETs observed within the procedure-embedded 15–18 min delay window following administration of ICG, and evaluating the reproducibility of image interpretation. Methods: This retrospective single-center descriptive feasibility study included 26 patients with PitNETs who underwent endoscopic transsphenoidal surgery. ICG was intravenously injected before sellar floor drilling, then after the tumor-pituitary interface was fully exposed, real-time fusion mode fluorescence endoscopy was maintained for continuous observation. Two independent observers retrospectively assessed fluorescence intensity and contrast patterns on video clips of intraoperative fusion fluorescence imaging. Interobserver agreement for binary fluorescence intensity grading and three-category contrast pattern classification (tumor-dominant, equivalent, and pituitary-dominant) was evaluated using Cohen's kappa coefficient (weighted kappa for ordinal pattern categories). Results: Surgery under fluorescence guidance was successfully completed for all 26 patients, with no ICG-related adverse events. No intraoperative mode switching was required, and fluorescence signals remained stable within the delay window. The contrast pattern classifications were: tumor-dominant n = 8 (all clinically functioning PRL-PitNETs), equivalent n = 15 (multiple subtypes), and pituitary-dominant n = 3 (all elderly patients ≥65 years with non-functioning PitNETs). Interobserver agreement was excellent, with Cohen's kappa of 0.91 (95% CI: 0.85–0.97, P < 0.001) for binary fluorescence intensity grading and a weighted Cohen's kappa of 0.89 (95% CI: 0.82–0.96, P < 0.001) for contrast pattern classification. All postoperative adverse events were mild and resolved conservatively, with no permanent pituitary dysfunction. Conclusion: Second-generation ICG fusion fluorescence endoscopy demonstrated preliminary technical feasibility and short-term safety for integration into transsphenoidal surgical workflow. The three fluorescence contrast patterns within the 15–18 min window show good interobserver agreement. The clinical utility of these patterns for tumor-pituitary interface assessment remains unproven and requires prospective validation.
SN - 2296-875X
ER -