Intraoperative gamma imaging of axillary sentinel lymph nodes in breast cancer patients

doi:10.1016/S1120-1797(06)80030-X

Physica Medica

Volume 21, Supplement 1, 2006, Pages 76-79

https://doi.org/10.1016/S1120-1797(06)80030-X Get rights and content

Abstract

Sentinel lymph node (SLN) biopsy is now standard practice in the management of many breast cancer patients. Localization protocols vary in complexity and rates of success. The least complex involve only intraoperative gamma counting of radiotracer uptake or intraoperative visualization of blue-dye uptake; the most complex involve preoperative gamma imaging, intraoperative counting and intraoperative dye visualization. Intraoperative gamma imaging may improve some protocols. This study was conducted to obtain preliminary experience and information regarding intraoperative imaging. Sixteen patients were enrolled: 8 in a protocol that included intraoperative counting and dye visualization (probe/dye), 8 in a protocol that involved intraoperative imaging, counting and dye visualization (camera/probe/dye). Preoperative imaging of all 16 patients was performed using a GE 500 gamma camera with a LEAP collimator (300 cpm/μCi). The results of this imaging were not, however, given to the surgeon until the surgeon had completed the procedures required for the study. A Care Wise C-Trak probe was used for intraoperative counting. A Gamma Medica Inc. GammaCAM/OR (12.5 × 12.5 cm FOV) with a LEHR collimator (135 cpm/μCi) was used for intraoperative imaging. Times from start of surgery to external detection of a radioactive focus and to completion of excision of SLNs were recorded. Foci were detected preoperatively via imaging in 16/16 patients. Intraoperative external detection using the probe was accomplished in less than 4 min (mean = 1.5 min) in 15/16 patients, and via intraoperative imaging in 6/8 patients. The average time for completion of excision of nodes was 19 min for probe/dye and 28 min for camera/probe/dye. In one probe/dye case, review of the preoperative images prompted the surgeon to resume axillary dissection and remove one additional SLN.

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Intraoperative nuclear imaging is an important technical advance in radioguided surgery. Adult studies enumerate the benefits including better visualization of nodes particularly near the injection site and determination of postexcision radioactivity [9–14]. These adult studies show precise and reproducible localization including depth of the nodes [10–13].
Lymphatic mapping to guide sentinel lymph node biopsy (SLNB) typically requires lymphoscintigraphy prior to surgery. In young pediatric patients, this process often requires intubation in the nuclear medicine suite followed by transport to the operating room (OR).
We reviewed 14 pediatric cases in which a portable nuclear imaging camera was utilized to perform the entirety of the SLNB in the OR.
This method, utilizing intraoperative nuclear imaging, helped to confirm removal of the sentinel lymph node in real time, decreased anesthesia time, and avoided transport of a sedated or intubated child.
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Time constraints can be dictators in this context. There are efforts to develop devices with various sizes of fields of view: small, ~5 cm × 5 cm; relatively small, ~10 cm × 10 cm; moderate, ~20 cm × 20 cm; moderately large ~30 cm × 40 cm.131-139 Note that the field of view of a conventional gamma camera is ~40 cm × 50 cm.
Accurate staging of many cancers with no clinical evidence of lymph node involvement is often a critical component of the management of such cancers and is generally and historically accomplished by accurate pathological assessment of multiple nodes. Unfortunately, such assessment usually involves excision of the multiple nodes and can result in significant morbidities. Over the past half century, and particularly over the last quarter century, investigators have defined and refined the “sentinel lymph node(s)” concept and have developed and investigated sentinel lymph node biopsy (SLNB) procedures. Such procedures are designed to stage cancers primarily via assessment of the sentinel nodes of the cancers and to do so with limited risk of morbidities. For some cancers (e.g., breast, melanoma, head and neck, penile), there are SLNB procedures that are used routinely. For other cancers, there are SLNB procedures being investigated that will yet prove successful and practical or successful but not practical or neither practical nor successful. In this review, SLNB procedures for breast, melanoma (adult and pediatric), head-and-neck, gastrointestinal (gastric, esophageal, colon), genitourinary (penile, prostate), and gynecological (uterine, cervical, vulvar, ovarian) cancers are discussed, including results of significant clinical trials performed using such in the management of these various cancers.
Portable gamma camera guidance in sentinel lymph node biopsy: Prospective observational study of consecutive cases
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La biopsia selectiva del ganglio centinela representa la herramienta más importante para determinar el estatus ganglionar en el paciente con melanoma.
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Estudio observacional sobre una serie de casos incluidos prospectivamente y de forma consecutiva de pacientes a los cuales se les realizó la técnica de biopsia selectiva de ganglio centinela radioguiada mediante gammacámara portátil. Se realizó un análisis de concordancia entre los ganglios detectados entre la linfografía prequirúrgica, la gammagrafía portátil y los ganglios disecados.
Durante el período de estudio se incluyeron 29 pacientes diagnosticados de melanoma cutáneo. Eran 17 mujeres (62,5%) y 12 varones (37,5%) y la edad media fue de 52,6 años (rango: 26-82). Se realizó disección del ganglio centinela en el 100% de los pacientes; además se obtuvieron en algunos casos ganglios secundarios.
En el número detectado de ganglios mediante linfografía preoperatoria hubo concordancia con respecto a la gammagrafía portátil y a los ganglios disecados finalmente en 16 de los pacientes (55,2%). Respecto a las complicaciones se observaron solo seromas en un 3,64% de los casos, no presentando en ningún caso dehiscencia de la herida, infección, hematoma o hemorragia.
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Sentinel lymph node biopsy is the most important tool available for node staging in patients with melanoma.
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Prospective observational study of a consecutive series of patients undergoing radioguided sentinel lymph node biopsy. We analyzed agreement between nodes detected by presurgical lymphography, those detected by the gamma camera, and those finally dissected.
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In 16 cases (55.2%), there was agreement between the number of nodes detected by lymphography, those detected by the gamma camera, and those finally dissected. The only complications observed were seromas (3.64%). No cases of wound dehiscence, infection, hematoma, or hemorrhage were observed.
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Currently, due to progress in detection and to extended screening, surgeons have to deal with increasing numbers of non-palpable lesions in breast cancer. These lesions can be treated by radio-guided surgery in the lumpectomy associated with sentinel lymph node (SLN) procedures. Thanks to advances in detector technology, mini gamma cameras are now available, that can perform real-time lymphoscintigraphy during surgery, or at bedside.
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We conducted our search on MEDLINE and EMBASE databases. We performed a comprehensive review to identify clinical studies or cases using mobile gamma cameras in breast cancer surgery.
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Mobile gamma cameras seem to be useful imaging tools either used pre-operatively or during surgery. They assist surgeons with accurate localization of SLNs and/or radio-labelled tumours, and in verification that all radioactive nodes have been excised.
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In many cases, a single hot spot on preoperative imaging represented 2 or more sentinel lymph nodes adjacent to each other. Though Scopinaro et al. measured a significant decrease of biopsy time in breast cancer sentinel node biopsy with the use of SGC, other authors report that the detection using SGC combined with gamma probe and dye method requires a longer procedure time [12,79]. Although one of the principal advantages of SCG in sentinel lymph node biopsies is real-time imaging, a longer acquisition time may be needed to detect and localize low levels of activity.
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Intraoperative gamma imaging of axillary sentinel lymph nodes in breast cancer patients

Abstract

Sentinel node detection with imaging probe

Tumori

Evaluation of hand-held gamma camera with 1-mm NaI(Tl) pixels

SPIE Proc

A hand-held imaging probe for radioguided surgery: Physical performance and preliminary clinical experience

Eur J Nucl Med Mol Imaging

Performance evaluation of a hand-held semiconductor (CdZnTe)-based gamma camera

Eur J Nucl Med Mol Imaging