Principles, technical specifications, and clinical application of lung watershed topography map 2.0: A thoracic surgery expert consensus (2024 version)_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 ZHONG Wenzhao ¹ , YANG Fan ² , HU Jian ³ , TAN Fengwei ⁴ , YANG Xuening ¹ , PU Qiang ⁵ , JIANG Wei ⁶ , ZHAO Deping ⁷ , LI Hecheng ⁸ , YAN Xiaolong ⁹ , TAN Lijie ⁶ , FAN Junqiang ¹⁰ , QIAO Guibin ¹¹ , NIE Qiang ¹ , KANG Mingqiang ¹² , WU Weibing ¹³ , ZHANG Hao ¹⁴ , LI Zhigang ¹⁵ , CHEN Zihao ¹ , GAO Shugeng ⁴ , WU Yilong ¹ , Chinese Medical Doctor Association Thoracic Surgeons Branch , China Anti-Cancer Association, The Society of Non-small Cell Lung Cancer , Chinese Research Hospital Association, The Society of Thoracic Surgery , Guangdong Medical Association Lung Tumor Branch

1. Department of Thoracic Surgery, Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, P. R. China;
2. Department of Thoracic Surgery, Peking University People's Hospital, Beijing, 100044, P. R. China;
3. Department of Thoracic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, P. R. China;
4. Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, 100021, P. R. China;
5. Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
6. Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, P. R. China;
7. Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Shanghai, 200433, P. R. China;
8. Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, P. R. China;
9. Department of Thoracic Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, 710038, P. R. China;
10. Department of Thoracic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, P. R. China;
11. Department of Thoracic Surgery, Zhujiang Hospital of Southern Medical University, Guangzhou, 510280, P. R. China;
12. Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, P. R. China;
13. Department of Thoracic Surgery, Jiangsu Province Hospital, Nanjing, 210029, P. R. China;
14. Department of Thoracic Surgery, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, P. R. China;
15. Department of Thoracic Surgery, Shanghai Chest Hospital, Shagnhai, 200030, P. R. China;

Corresponding author：

ZHONG Wenzhao, Email: zhongwenzhao@gdph.org.cn

Keywords：

Pulmonary nodules; watershed topography map; three-dimensional reconstruction; artificial intelligence; indocyanine green; expert consensus

DOI：

10.7507/1007-4848.202412023

Video：

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Abstract Full text Figures/Tables Video References Cited by

With the widespread adoption of low-dose CT screening and the extensive application of high-resolution CT, the detection rate of sub-centimeter lung nodules has significantly increased. How to scientifically manage these nodules while avoiding overtreatment and diagnostic delays has become an important clinical issue. Among them, lung nodules with a consolidation tumor ratio less than 0.25, dominated by ground-glass shadows, are particularly worthy of attention. The therapeutic challenge for this group is how to achieve precise and complete resection of nodules during surgery while maximizing the preservation of the patient's lung function. The "watershed topography map" is a new technology based on big data and artificial intelligence algorithms. This method uses Dicom data from conventional dose CT scans, combined with microscopic (22-24 levels) capillary network anatomical watershed features, to generate high-precision simulated natural segmentation planes of lung sub-segments through specific textures and forms. This technology forms fluorescent watershed boundaries on the lung surface, which highly fit the actual lung anatomical structure. By analyzing the adjacent relationship between the nodule and the watershed boundary, real-time, visually accurate positioning of the nodule can be achieved. This innovative technology provides a new solution for the intraoperative positioning and resection of lung nodules. This consensus was led by four major domestic societies, jointly with expert teams in related fields, oriented to clinical practical needs, referring to domestic and foreign guidelines and consensus, and finally formed after multiple rounds of consultation, discussion, and voting. The main content covers the theoretical basis of the "watershed topography map" technology, indications, operation procedures, surgical planning details, and postoperative evaluation standards, aiming to provide scientific guidance and exploration directions for clinical peers who are currently or plan to carry out lung nodule resection using the fluorescent microscope watershed analysis method.

Citation： ZHONG Wenzhao, YANG Fan, HU Jian, TAN Fengwei, YANG Xuening, PU Qiang, JIANG Wei, ZHAO Deping, LI Hecheng, YAN Xiaolong, TAN Lijie, FAN Junqiang, QIAO Guibin, NIE Qiang, KANG Mingqiang, WU Weibing, ZHANG Hao, LI Zhigang, CHEN Zihao, GAO Shugeng, WU Yilong, Chinese Medical Doctor Association Thoracic Surgeons Branch, China Anti-Cancer Association, The Society of Non-small Cell Lung Cancer, Chinese Research Hospital Association, The Society of Thoracic Surgery, Guangdong Medical Association Lung Tumor Branch. Principles, technical specifications, and clinical application of lung watershed topography map 2.0: A thoracic surgery expert consensus (2024 version). Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(2): 141-152. doi: 10.7507/1007-4848.202412023 Copy

1.	Carr SR, Schuchert MJ, Pennathur A, et al. Impact of tumor size on outcomes after anatomic lung resection for stage 1A non-small cell lung cancer based on the current staging system. J Thorac Cardiovasc Surg, 2012, 143(2): 390-397.
2.	Plunkett MB, Peterson MS, Landreneau RJ, et al. Peripheral pulmonary nodules: Preoperative percutaneous needle localization with CT guidance. Radiology, 1992, 185(1): 274-276.
3.	Li X, Xu K, Cen R, et al. Preoperative computer tomography-guided indocyanine green injection is associated with successful localization of small pulmonary nodules. Transl Lung Cancer Res, 2021, 10(5): 2229-2236.
4.	Schuchert MJ, Abbas G, Awais O, et al. Anatomic segmentectomy for the solitary pulmonary nodule and early-stage lung cancer. Ann Thorac Surg, 2012, 93(6): 1780-1785.
5.	吴阶平医学基金会模拟医学部胸外科专委会. 人工智能在肺结节诊治中的应用专家共识(2022年版). 中国肺癌杂志, 2022, 25(4): 219-225.Thoracic Surgery Committee, Department of Simulated Medicine, Wu Jieping Medical Foundation. Chinese experts consensus on artificial intelligence assisted management for pulmonary nodule (2022 version). Chin J Lung Cancer, 2022, 25(4): 219-225.
6.	马永富, 李云婧, 张彤, 等. 混合现实技术辅助下肺小结节精准定位切除. 中华腔镜外科杂志(电子版), 2019, 12(3): 179-181.Ma YF, Li YJ, Zhang T, et al. Accurate localization and resection of small pulmonary nodules assisted by mixed reality technique. Chin J Laparoscop Surg (Electron Ed), 2019, 12(3): 179-181.
7.	孙云刚, 张强, 王朝, 等. 荧光法在单孔胸腔镜解剖性肺段切除术中识别段间交界线的可行性研究. 中国肺癌杂志, 2021, 24(11): 756-763.Sun YG, Zhang Q, Wang Z, et al. Feasibility investigation of fluorescence method in uniport thoracoscopic anatomical segmentectomy for identifying the intersegmental boundary line. Chin J Lung Cancer, 2021, 24(11): 756-763.
8.	Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg, 2011, 12(3): 514-515.
9.	孙琦, 翁建武. 肺癌患者采用3D单孔胸腔镜与三孔胸腔镜的手术效果及免疫功能与肿瘤标志物水平变化. 国际呼吸杂志, 2022, 42(12): 928-933.Sun Q, Weng JW. Surgical effects comparison of 3D single-port thoracoscopy and three-port thoracoscopy in patients with lung cancer and changes in immune function and tumor marker levels. Int J Respir, 2022, 42(12): 928-933.
10.	曾维华, 杨志峰, 程声通. 流域水资源集成管理. 中国环境科学, 2001, 21(2): 173-176.Zeng WH, Yang ZF, Cheng ST. Integrated water resources management on river basin. China Environ Sci, 2001, 21(2): 173-176.
11.	张楠, 陈树兴, 林铿强, 等. 基于"流域分析"的解剖性部分肺切除术在早期周围型肺癌中的应用. 中国微创外科杂志, 2023, 23(1): 20-24.Zhang N, Chen SX, Lin KQ, et al. Application of the anatomical partial lobectomy based on "watershed analysis" in the treatment of early-stage peripheral lung cancer. Chin J Minim Invasive Surg, 2023, 23(1): 20-24.
12.	Ito A, Takao M, Shimamoto A, et al. Prolonged intravenous indocyanine green visualization by temporary pulmonary vein clamping: Real-time intraoperative fluorescence image guide for thoracoscopic anatomical segmentectomy. Eur J Cardiothorac Surg, 2017, 52(6): 1225-1226.
13.	巨少龙, 高禹舜. 胸腔镜肺段切除术对肺功能影响的研究进展. 中国肺癌杂志, 2019, 22(8): 537-540.Ju SL, Gao YS. Advances in the study of the effects of video-assisted thoracoscopic segmentectomy on pulmonary function. Chin J Lung Cancer, 2019, 22(8): 537-540.
14.	Qiu B, Gao S, He J, et al. Outcomes and experience of anatomical partial lobectomy. J Thorac Cardiovasc Surg, 2022, 164(3): 637-647.
15.	Qiu B, Ji Y, He H, et al. Three-dimensional reconstruction/personalized three-dimensional printed model for thoracoscopic anatomical partial-lobectomy in stageⅠlung cancer: A retrospective study. Transl Lung Cancer Res, 2020, 9(4): 1235-1246.
16.	张楠, 陈星, 韩振中. 基于流域分析的解剖性部分肺切除术在早期周围型肺癌治疗中的应用. 中华实验外科杂志, 2024, 41(3): 586-589.Zhang N, Chen X, Han ZZ. Application of the anatomical partial lobectomy based on "watershed analysis" in the treatment of early-stage peripheral lung cancer. Chin J Exp Surg, 2024, 41(3): 586-589.

1. Carr SR, Schuchert MJ, Pennathur A, et al. Impact of tumor size on outcomes after anatomic lung resection for stage 1A non-small cell lung cancer based on the current staging system. J Thorac Cardiovasc Surg, 2012, 143(2): 390-397.
2. Plunkett MB, Peterson MS, Landreneau RJ, et al. Peripheral pulmonary nodules: Preoperative percutaneous needle localization with CT guidance. Radiology, 1992, 185(1): 274-276.
3. Li X, Xu K, Cen R, et al. Preoperative computer tomography-guided indocyanine green injection is associated with successful localization of small pulmonary nodules. Transl Lung Cancer Res, 2021, 10(5): 2229-2236.
4. Schuchert MJ, Abbas G, Awais O, et al. Anatomic segmentectomy for the solitary pulmonary nodule and early-stage lung cancer. Ann Thorac Surg, 2012, 93(6): 1780-1785.
5. 吴阶平医学基金会模拟医学部胸外科专委会. 人工智能在肺结节诊治中的应用专家共识(2022年版). 中国肺癌杂志, 2022, 25(4): 219-225.Thoracic Surgery Committee, Department of Simulated Medicine, Wu Jieping Medical Foundation. Chinese experts consensus on artificial intelligence assisted management for pulmonary nodule (2022 version). Chin J Lung Cancer, 2022, 25(4): 219-225.
6. 马永富, 李云婧, 张彤, 等. 混合现实技术辅助下肺小结节精准定位切除. 中华腔镜外科杂志(电子版), 2019, 12(3): 179-181.Ma YF, Li YJ, Zhang T, et al. Accurate localization and resection of small pulmonary nodules assisted by mixed reality technique. Chin J Laparoscop Surg (Electron Ed), 2019, 12(3): 179-181.
7. 孙云刚, 张强, 王朝, 等. 荧光法在单孔胸腔镜解剖性肺段切除术中识别段间交界线的可行性研究. 中国肺癌杂志, 2021, 24(11): 756-763.Sun YG, Zhang Q, Wang Z, et al. Feasibility investigation of fluorescence method in uniport thoracoscopic anatomical segmentectomy for identifying the intersegmental boundary line. Chin J Lung Cancer, 2021, 24(11): 756-763.
8. Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg, 2011, 12(3): 514-515.
9. 孙琦, 翁建武. 肺癌患者采用3D单孔胸腔镜与三孔胸腔镜的手术效果及免疫功能与肿瘤标志物水平变化. 国际呼吸杂志, 2022, 42(12): 928-933.Sun Q, Weng JW. Surgical effects comparison of 3D single-port thoracoscopy and three-port thoracoscopy in patients with lung cancer and changes in immune function and tumor marker levels. Int J Respir, 2022, 42(12): 928-933.
10. 曾维华, 杨志峰, 程声通. 流域水资源集成管理. 中国环境科学, 2001, 21(2): 173-176.Zeng WH, Yang ZF, Cheng ST. Integrated water resources management on river basin. China Environ Sci, 2001, 21(2): 173-176.
11. 张楠, 陈树兴, 林铿强, 等. 基于"流域分析"的解剖性部分肺切除术在早期周围型肺癌中的应用. 中国微创外科杂志, 2023, 23(1): 20-24.Zhang N, Chen SX, Lin KQ, et al. Application of the anatomical partial lobectomy based on "watershed analysis" in the treatment of early-stage peripheral lung cancer. Chin J Minim Invasive Surg, 2023, 23(1): 20-24.
12. Ito A, Takao M, Shimamoto A, et al. Prolonged intravenous indocyanine green visualization by temporary pulmonary vein clamping: Real-time intraoperative fluorescence image guide for thoracoscopic anatomical segmentectomy. Eur J Cardiothorac Surg, 2017, 52(6): 1225-1226.
13. 巨少龙, 高禹舜. 胸腔镜肺段切除术对肺功能影响的研究进展. 中国肺癌杂志, 2019, 22(8): 537-540.Ju SL, Gao YS. Advances in the study of the effects of video-assisted thoracoscopic segmentectomy on pulmonary function. Chin J Lung Cancer, 2019, 22(8): 537-540.
14. Qiu B, Gao S, He J, et al. Outcomes and experience of anatomical partial lobectomy. J Thorac Cardiovasc Surg, 2022, 164(3): 637-647.
15. Qiu B, Ji Y, He H, et al. Three-dimensional reconstruction/personalized three-dimensional printed model for thoracoscopic anatomical partial-lobectomy in stageⅠlung cancer: A retrospective study. Transl Lung Cancer Res, 2020, 9(4): 1235-1246.
16. 张楠, 陈星, 韩振中. 基于流域分析的解剖性部分肺切除术在早期周围型肺癌治疗中的应用. 中华实验外科杂志, 2024, 41(3): 586-589.Zhang N, Chen X, Han ZZ. Application of the anatomical partial lobectomy based on "watershed analysis" in the treatment of early-stage peripheral lung cancer. Chin J Exp Surg, 2024, 41(3): 586-589.

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