Gamma Probe Detection Research Articles

Setting-up a training programme for intraoperative molecular imaging and sentinel node mapping: how to teach? How to learn?

The current expansion of image-guided surgery is closely related to the role played by radio-guided surgery in supporting the sentinel node (SN) procedure during more than three decades. The so-called triple approach (lymphoscintigraphy, gamma probe detection and blue dye) was not only essential in the seminal validation of the SN procedure but also a first collective learning effort based on skill transfer and outcome-related evaluation which laid the fundaments to delineate the field of intraoperative molecular imaging (IMI) based on a similar multimodality approach and multidisciplinary practice. These elements are also becoming valid in the current incorporation of SPECT/CT and PET/CT to existing and new protocols of IMI procedures and SN mapping concerning other clinical applications. On the other hand, there is a growing tendency to combine novel modern technologies in an allied role with gamma guidance in the operating room following the development of hybrid tracers and multimodal detection approaches. Against this background, learning initiatives are required for professionals working in this area. This objective has led to a group of European practitioners with large experience in SN mapping and IMI applications to give shape to a programme made up out of specific learning modules aimed to be used as a conductive thread in peripherical or centralised training instances concerning the topic. The presented work, written as a tutorial review, is placed in an available prior-art context and is primarily aimed at medical and paramedical practitioners as well as at hardware and software developers.

Multiple Metastases of Parathyroid and Papillary Thyroid Carcinoma in a Female Patient Treated with Long-Term Hemodialysis

Parathyroid cancer is a rare, clinically aggressive malignancy with a prevalence of approximately 0.005% relative to all carcinoma cases and 1-5% among patients with primary hyperparathyroidism. Prognosis largely depends on the extent of the primary surgery. Non-radical surgical treatment increases the risk of local and distant metastases of the parathyroid cancer associated with limited treatment options. The combination of thyroid and parathyroid disorders has been described rather well for the general population; however, cases of parathyroid and thyroid carcinoma in the same patient are extremely rare (1 case per 3000 patients with parathyroid disorders). We present a rare clinical case of combination of parathyroid and thyroid cancers with metastases of both tumors to the neck lymph nodes in a woman with a mutation in the MEN1 gene (NM_130799.2): c.658T > C p.Trp220Arg (W220R), who has been exposed to radiation for 20 years before diagnosis of thyroid cancer and received renal replacement therapy with long-term hemodialysis before the diagnosis of parathyroid cancer. The patient underwent several surgeries because of metastases of the parathyroid cancer in the neck lymph nodes. Surgeons used intraoperative navigation methods (single-channel gamma detection probe, Gamma Probe 2, and fluorescence angiography with indocyanine green (ICG)) to clarify the volume of surgery. Currently, the patient is still in laboratory remission, despite the structural recurrence of tumors.

A Prospective Double-Blinded Randomized Controlled Trial Comparing the Intraoperative Injection of Technetium Tc 99m Tilmanocept with Technetium Tc 99m Sulfur Colloid in Breast Cancer Lymphatic Mapping

Introduction. Technetium-labeled sulfur colloid (TSC) is a radiolabeled mapping agent commonly used for sentinel lymph node biopsy (SLNBx). Tilmanocept, a CD206 receptor-targeted mapping agent, has gained recent popularity due to potential advantages of rapid and quick uptake to the SLNs. The objectives of this study were to assess (1) the difference in the number of SLNs harvested using tilmanocept versus TSC and (2) the difference in time to transcutaneous localization when using an intraoperative injection approach. Methods. Patients undergoing breast conservation and SLNBx were consented and randomized to receive either 0.5 mCi of filtered TSC or 0.5 mCi of tilmanocept injected intradermally immediately after induction of anesthesia. Axillary transcutaneous gamma detector probe counts were taken at 1-minute intervals until a hot spot was identified. SLNs were then identified and excised. Additional nodes were excised if their counts per second (cps) were greater than 10% of the cps of the hottest SLN. The number of SLNs was based on both number of nodes collected intraoperatively and the number recorded in the final pathology report. Results. The study population consisted of 86 patients, 48 randomized to tilmanocept and 38 to TSC. There were no significant differences in patient or tumor characteristics between the two groups. Localization rates were 100% for both cohorts. The mean number of SLNs identified and removed was not significantly different ( p = 0.34 , intraoperatively; p = 0.57 , pathology reported). Time to transcutaneous localization was 3.3 ± 2.0 minutes for tilmanocept and 3.9 ± 2.3 minutes for TSC ( p = 0.19 ). The average cps for the hottest node was 2,180.0 ± 2,460.5 in the tilmanocept group compared to 2,679.3 ± 2,687.5 in the TSC group ( p = 0.94 ). Conclusion. There was no significant difference in the number of SLNs harvested or in the time to transcutaneous localization when using tilmanocept versus TSC as the radiolabeled mapping agents for intraoperative injection and mapping. Either agent can be used without any significant difference in performance.

Abstract P1-01-08: Axillary surgery after neoadjuvant chemotherapy in breast cancer - Survey among Argentinian breast surgeons

Abstract Background: Over the last years, decreasing invasiveness to achieve less morbidity has been the trend for surgical procedure but axillary management after neoadjuvant chemotherapy (NAC) remains controversial. Different authors have shown the efficacy of sentinel lymph node biopsy (SLNB) to assess axillary response in patients who underwent NAC encouraging the use of these techniques instead of axillary lymph node dissection (ALND) in breast cancer patients. Argentinian surgeons don’t have a consensus guideline on the management of the axilla in patients after NAC, therefore the treatment of the axilla widely varies. This survey has been developed to assess the management of the axilla after NAC among argentinian breast surgeons. Methods: Members of the Argentinian Society of Breast Surgeons were invited by e-mail to complete an anonymous online survey between April 1st and May 31th of 2021. The survey consisted in 17 single-answer multiple choice questions (each question having 4 options). The surgeons had the option to write their own custom response on a comment field. Results: Of the 731 members, 263 answered the survey. 71% treated less than 50 neoadjuvant breast cancer patients last year. Axillary ultrasound is considered a standard tool in the initial evaluation of the axilla by 81% of participants and 73% performed core needle biopsy in case of suspicious node before NAC. 78% marked suspicious nodes before NAC (the majority with charcoal). 24% supported that ALND could be omitted only in cN0 patients, 55% in cN0- cN1, 9% in cN0-cN1-cN2 and 15% in any initial stage with a favorable response to NAC. 75% of the respondents evaluated axillary response after NAC using axillary ultrasound prior surgery. 15% performed ALND when there were any suspicious node by ultrasound. Most of the surgeons (76%) considered that double method (blue dye and radioisotope) allows better identification rate. 77% considered that at least three nodes and resection of the marked node is mandatory to reduce the false negative rate of the sentinel lymph node biopsy (SLNB) after NAC. 63% considered that pathologic complete response in the axilla is necessary to omit ALND and 37% omitted the ALND in the presence of positive sentinel node after NAC. 131 of the interviewed work in a public hospital and private practice, 27 of them (20%) can’t manage the axilla in the same way in both places because the lack of technology (gamma detection probe technology for example) at public hospitals. Discussion: The management of the axilla after NAC is a challenge for breast surgeons and forces them to personalize treatments and stay informed regarding changes in the scientific evidence. Axillary ultrasound is a widely-used method by argentine surgeons, it allows them to identify suspicious lymph nodes, perform core needle biopsies, and mark them, but an excessive use can also lead to unnecessary ALND. There is not consensus about the importance of pre- and post-NAC stage in deciding to perform only SLNB or ALND. Twenty percent of the surgeons perform SNLB only in cN0 patients, and on the other hand, 37% will omit the ALND even in the presence of positive sentinel node after NAC, extrapolating results from trials that may not fit in these patients. The high fragmentation and decentralization in the provision of health care services that characterizes Argentina’s health system is an obstacle to manage the complexity of neoadjuvant breast cancer patients. Conclusions: There is no standard management of the axilla in patients that undergo NAC in Argentina. Breast surgeons should gathered together to develop clinical practice guidelines in this matter and design strategies to improve the management of the neoadjuvant breast cancer patients in Argentina. Citation Format: M. Eugenia Azar, M. Dolores Mansilla F., Jorgelina Cavallero, Ornella Sturla, Hernan Ursino, Gaston Berman, Martin Ipiña, Andrea Aguilar, Valeria Caceres, Eduardo Gonzalez. Axillary surgery after neoadjuvant chemotherapy in breast cancer - Survey among Argentinian breast surgeons [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-01-08.

The efficacy of 99mTc-rituximab as a tracer for sentinel lymph node biopsy in cutaneous melanoma patients.

BackgroundThe sentinel lymph node (SLN) status is a vital prognostic factor for malignant melanoma (MM) patients. There is increasing evidence that a radioactive agent, rather than its combination with blue dye, is sufficient for a SLN biopsy (SLNB). Thus, we discussed the efficacy of 99mTc-rituximab as a tracer in MM patients.MethodsA total of 502 consecutive patients with MM who underwent SLNB were enrolled in this study. All participants were peritumorally injected with 99mTc-rituximab before imaging, and scanned with single-photon emission computed tomography-computed tomography (SPECT-CT) to detect the number and location of the SLN. A gamma detection probe was employed to detect radioactive SLNs in operation. Follow up was conducted to observe whether nodal or distant recurrence occurred.ResultsThe SLNs were successfully imaged via SPECT-CT and harvested from all 502 participants. No drainage tube was indwelled and 32 (6.3%) participants experienced the following complications: seroma (n=26, 5.2%), wound infections or lymphangitis (n=6, 1.2%), sensory nerve injuries (n=4, 0.8%). There were 380 patients who were diagnosed as SLN-negative and 122 (24.2%) were SLN-positive. A total of 85 SLN-positive patients received complete lymph node dissection, and 28 (32.9%) had additional positive lymph nodes. During a median follow-up of 24 months, 28 participants were found to have a false negative (FN) SLN. The FN rate was 18.7%. A higher T stage was a predictive factor for FN [odds ratio (OR) 1.77; P<0.05]. There was no significant difference in the positive or FN rate between the acral and cutaneous groups.ConclusionsThe radiopharmaceutical 99mTc-rituximab could be employed as a simple and safe tracer in acral and cutaneous melanoma SLN biopsies.

Study on intraoperative localization of sentinel lymph nodes using freehand SPECT in breast cancer patients.

The diagnostic and therapeutic approach to axillary lymph nodes is considered indispensable in the treatment of breast cancer patients. To investigate the effectiveness of 3D freehand SPECT (fhSPECT) in sentinel lymph node (SLN) mapping in breast cancer, compared with the use of a conventional gamma probe. We retrospectively compared the fhSPECT lymph node mapping modality, with gamma probe detection in early-stage, clinically node-negative breast cancer patients, with biopsy-confirmed malignancy. The two techniques were compared based on the average number of LNs excised per axilla. The duration of SLN mapping was also compared between the two groups. The performance of the two methods on obese and post-systemic therapy patients was evaluated. FhSPECT was used in 150 cases, while the gamma probe was employed in 50 cases. FhSPECT detected at least 3 nodes in 83.3% of the patients vs. 72.0% with the γ-probe (p = 0.107). The mean number of SLNs excised per axilla was 3.66 using the γ-probe and 4.18 with fhSPECT (p = 0.03). The average surgical time was 39 ±7 min with the γ-probe and 37.54 ±17 min with fhSPECT (p = 0.228). Sentinel lymph node biopsy (SLNB) mean surgical time evolved from 40.2 ±20.77 min to 32.35 ±10.46 min (p = 0.033). In obese patients, a reduction in surgical times was noted from 45.5 ±3.09 min to 44.04 ±20.9 (p = 0.27), in addition to a significant increase in average LN detection in the fhSPECT group (4.26 ±1.44) compared to the γ-probe group (3.2 ±1.65) (p = 0.043). The use of the fhSPECT modality is effective and safe, and, when compared to the γ-probe, has significant advantages in SLN mapping.

Preoperative Axillary Ultrasound-guided Wire Localization and Lymphoscintigraphy for Sentinel Lymph Node Biopsy in Breast Cancer Patients

Background: Breast cancer has the highest incidence and mortality among female malignant tumors. Breast cancer with negative axillary lymph nodes has been diag- nosed mainly at an early stage. Sentinel lymph node biopsy (SLNB) is a standard screening technique for patients with early-stage breast cancer and clinically nega- tive lymph nodes. Lymphoscintigraphy (sentinel lymph node mapping) has been reg- ularly used as the standard method for SLNB. Today, ultrasound-guided wire locali- zation (USGWL) is a well-established technique with superior outcomes. Therefore, we attempted to determine whether preoperative UGWL and lymphoscintigraphy (blue dye and isotope injection) improve SLN detection and false-negative rate in breast cancer patients undergoing SLNB and identify clinical factors that may affect the diagnostic accuracy of axillary ultrasound (AUS). Methods: Between December 2018 and June 2019, 55 patients with clinical T1- 3N0 breast cancer eligible for an SLNB at Imam Khomeini Hospital in Tehran were included in our study. Tumor characteristics and demographic data were collect- ed by reviewing medical records and questionnaires prepared by our surgical team. The day before SLNB, all patients underwent ultrasound-guided wire localization of SLN. Lymphoscintigraphy was performed with an unfiltered 99mTc-labelled sulfur colloid peritumoral injection followed by methylene blue dye injection. The results were analyzed based on the permanent pathology report. Results: Among the 55 patients, 71.8% of SLNs were detected by wire localization, while 57.8% were found by methylene blue mapping and 59.6% by gamma probe detection. Compared with wire localization and isotope injection, the methylene blue dye technique had a low sensitivity (72.2%), while both wire localization and isotope injection reached 77.8%. The sensitivity, specificity, and accuracy of UGWL were 77.8%, 42.1%, and 65.4%, respectively. Otherwise, methylene blue dye and isotope injection accuracy was 47.3% and 50.1%, respectively. Furthermore, there was a significant relationship between BMI, tumor size, laterality, reactive ALN, and the accuracy of preoperative AUS. But there was no significant correlation between age, weight, height, tumor biopsy, tumor location, the time interval between methylene blue dye and isotope injection to surgery, and also the type of surgery to the accuracy of preoperative AUS. Conclusion: Preoperative UGWL can effectively identify SLNs compared to lym- phoscintigraphy (blue dye and isotope injection) in early breast cancer patients un- dergoing SLNB.

Survival Advantage Following TAG-72 Antigen-Directed Cancer Surgery in Patients With Colorectal Carcinoma: Proposed Mechanisms of Action.

Patients with colorectal carcinoma (CRC) continue to have variable clinical outcomes despite undergoing the same surgical procedure with curative intent and having the same pathologic and clinical stage. This problem suggests the need for better techniques to assess the extent of disease during surgery. We began to address this problem 35 years ago by injecting patients with either primary or recurrent CRC with 125I-labeled murine monoclonal antibodies against the tumor-associated glycoprotein-72 (TAG-72) and using a handheld gamma-detecting probe (HGDP) for intraoperative detection and removal of radioactive, i.e., TAG-72-positive, tissue. Data from these studies demonstrated a significant difference in overall survival data (p < 0.005 or better) when no TAG-72-positive tissue remained compared to when TAG-72-positive tissue remained at the completion of surgery. Recent publications indicate that aberrant glycosylation of mucins and their critical role in suppressing tumor-associated immune response help to explain the cellular mechanisms underlying our results. We propose that monoclonal antibodies to TAG-72 recognize and bind to antigenic epitopes on mucins that suppress the tumor-associated immune response in both the tumor and tumor-draining lymph nodes. Complete surgical removal of all TAG-72-positive tissue serves to reverse the escape phase of immunoediting, allowing a resetting of this response that leads to improved overall survival of the patients with either primary or recurrent CRC. Thus, the status of TAG-72 positivity after resection has a significant impact on patient survival.

A Novel Sentinel Lymph Node Approach in Oral Squamous Cell Carcinoma.

Occult metastases are common in patients with oral squamous cell carcinoma (OSCC) which is why elective neck dissection, adjuvant radiotherapy or watchful waiting have been treatment options after surgical removal of the primary tumour. Sentinel lymph node biopsy (SLNB) has lately emerged as a novel possibility in treatment planning. To establish a reliable and clinically useful protocol for SLNB in staging/elective neck dissection in oral cancer. Fourteen consecutive patients with T1-T2 N0 oral cancer were enrolled when scheduled for elective neck dissection. This study outlines various techniques for improving SLNB in head and neck cancer. After evaluation, a combination of techniques was found to constitute a reliable, clinically adaptable work concept. The suggested procedure starts with the pre-surgical injection of radioactive technetium 99Tcm carried on tilmanocept (Lymphoseek ®) at the tumour site. The radioactivity in the lymph node is then visualized preoperatively with Single Photon Emission Computed Tomography (SPECT/CT). Intraoperatively, indocyanine green (ICG) is injected and a sentinel node is visualized with near-infrared light. To support the sentinel node detection, the surgeon uses a hand-held gamma detection probe. This approach results in a reproducible and reliable detection of sentinel nodes. This paper presents a novel protocol for the identification of the sentinel node in the head and neck region. The protocol additionally enables the use of flow cytometry analysis of resected lymph nodes.

The Formulation of Methylene Blue Encapsulated, Tc-99m Labeled Multifunctional Liposomes for Sentinel Lymph Node Imaging and Therapy.

Methylene blue (MB) is a commonly used dye that can be used for near-infrared (NIR) imaging and photodynamic therapy (PDT) by producing reactive oxygen species after light exposure, inducing apoptosis. The limiting factor of MB is its poor penetration through cell membranes. Its decreased cellular uptake can be prevented by encapsulation in drug delivery systems such as liposomes. Additionally, the enhanced permeability and retention effect of tumors enables enhanced accumulation of nanocarriers at the target site. Nanosized, MB encapsulated, Tc-99m radiolabeled Lipoid S PC:PEG2000-PE:Chol: DTPA-PE and DPPC:PEG2000-PE:Chol:DTPA-PE liposomes were formulated to design multifunctional theranostic nanocarriers for: 1) NIR imaging, 2) gamma probe detection of sentinel lymph nodes (SLNs), and 3) PDT, which can provide accurate imaging and therapy helping surgery with a single liposomal system. The characterization of liposomes was performed by measuring particle size, zeta potential, phospholipid content, and encapsulation efficiency. Additionally, the in vitro release profile of MB and physical stability were also evaluated over 6 months at determined time intervals by measuring the mean particle size, zeta potential, encapsulation efficiency, and phospholipid content of liposomes kept at room temperature (25°C) and 4°C. Tc-99m radiolabeled, nanosized Lipoid S PC:PEG2000-PE:Chol:DTPA-PE and DPPC:PEG2000-PE:Chol:DTPA-PE liposomes showed suitable particle size (around 100 nm), zeta potential (-9 to -13 mV), encapsulation efficiency (around 10%), phospholipid efficiency (around 85-90%), and release profiles. Additionally, the liposomes found stable for 3 months especially when kept at 4°C. MB encapsulated, Tc-99m radiolabeled, nanosized Lipoid S PC:PEG2000-PE:Chol:DTPA-PE and DPPC:PEG2000-PE:Chol:DTPA-PE liposomes were found to have potential for SLN imaging by gamma probe detection, NIR imaging, and PDT. In vitro and in vivo imaging and therapeutic efficiency should be definitely evaluated to enable a final decision and our studies on this research topic are continuing.

Asking Another Way: One Health System's Experience with Assessing Ultrasound Probe Reprocessing Risks

<h3>Background</h3> It is vital to understand the range of use for an instrument before asking how it is reprocessed. During a mock survey at an ambulatory surgery center (ASC), it was discovered that a gamma-detection probe used on intact skin was also used in conjunction with a sterile sheath on sterile tissue during invasive procedures. Low-level disinfection (LLD) was performed in between use. Although LLD was appropriate after use on intact skin according to the Spaulding Classification, the end user incorrectly perceived, and was reinforced by the vendor, that a sterile sheath negated the need for sterilization after use on sterile tissue. <h3>Methods</h3> To understand the scope of the issue, 81 areas that order sterile ultrasound probe covers were specifically asked how probes were used and reprocessed to assess whether appropriate reprocessing was occurring. A multidisciplinary group was formed to review the probes' instructions for use (IFU), identify solutions to correct inappropriate reprocessing techniques including education and resource procurement, and formulate a plan to implement the standard of care across the health system. <h3>Results</h3> A risk assessment was created outlining the reprocessing method required for ultrasound probes based on its intended use in addition to its previous use. Reprocessing changes were made to 9 ultrasound probe types used in 2 hospitals and 2 ASCs. <h3>Conclusions</h3> Asking whether an ultrasound probe "touched" mucous membranes or sterile tissue to assess compliance with reprocessing was incomplete due to end-users' misunderstanding of the effect a sterile sheath had on reprocessing requirements. End-users' believed the device was not "touching" mucous membranes or sterile tissue if a sterile sheath was used. By changing the phrasing of the question to include how the probe is used, our health system was able to successfully identify probes that required a higher level of reprocessing based on the intended use of the probe.

Osteoid Osteoma in Talus: Our Experience in Radioguided Surgery

The osteoid osteoma (OO) is the third most frequent benign bone tumor, whose location is more frequent in long bones of lower limbs. Its presence in the distal lower limb is uncommon, with the talus the most common reported location. Surgical treatments with radioguided surgery of OO of foot and ankle in our hospital were reviewed. We present a retrospective cohort study of 4 patients with clinical and radiologic findings suspicious OO with at least 1 year of follow-up. We used radioguided surgery for surgical resection after the injection of a dose of 99mTc-hydroxydiphosphonate. The nidus was located with the help of a portable gamma camera and gamma detection probe, concluding the surgical resection when its activity decreased to the levels present in healthy tissues. Samples were sent for pathologic anatomy for further examination. Lesions were localized in all patients. The cure rate, based on the absence of relapse of symptoms, was 100%. On the basis of our experience and on the available literature, we suggest that radioguided surgery is an effective and safe method for the treatment of OO in the foot and ankle. Although radiofrequency ablation is the first choice treatment for OO, radioguided surgery offers a number of advantages: an accurate delimitation of the nidus, allowing a more precise excision of the lesion; a decrease in postoperative complications; and the possibility of confirmation in histopathologic studies. Because of the small number of cases, a multicenter study could be useful to increase the number of cases and therefore provide more evidence to this type of treatment. Level of Evidence: Level V. See Instructions for Authors for a complete description of levels of evidence.

The ratio and size of positive sentinel lymph nodes predicts the involvement of non-sentinel lymph nodes following completion axillary lymph node dissection

Background: The role of completion axillary lymph node dissection (CALND) following positive sentinel lymph node biopsy (SLNB) is being actively debated. The involvement of our unit in the POSNOC trial (which has a no-treatment arm), has prompted a review of our unit’s CALND results, in order to examine predictors of involvement of non-sentinel lymph nodes (n-SLN). Methods: We retrospectively analyzed our experience of SLNB between July 2008 to 2013. A total of 1,152 breast cancer patients underwent SLNB based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99mTc-nanocolloid and Patent Blue V injected peri-areola. Results: Out of 1,152 SLNB performed, 224 were positive for metastatic disease; 203 patients were anesthetically capable of progressing to CALND. On univariate analysis, involved n-SLN on CALND could not be predicted by age, size of tumor, procedure performed, lymph vascular invasion, number of positive SLN, receptor status; ER, PR, HER2 or triple negative. There was a trend toward higher incidence of positive n-SLN with increasing grade, and extracapsular spread, but these did not reach statistical significance. Positive n-SLN on CALND was however predicted by macrometastases in SLN and ratio of positive nodes on SLNB. Conclusions: In our series of more than 200 SLNB, a ratio of >0.5 positive SLN yield and presence of macrometastases in positive SLN, were associated with positive n-SLN on CALND.

In patients with micrometastases in sentinel lymph node biopsies, involvement of the non-sentinel lymph nodes cannot be predicted by clinicopathological variables

Background: The sentinel lymph node biopsy (SLNB) procedure is long considered as an accurate method of staging the axilla for axillary involvement in early stage breast cancer. The question remains as to whether patients with micrometastases should undergo axillary clearance. We aimed to assess the indicators for positive non-sentinel lymph nodes (SLN) following completion axillary lymph node dissection (CALND). Methods: We retrospectively analysed our experience of SLNB between July 2008 and July 2013. A total of 1,152 breast cancer patients underwent SLNB based on lymphoscintigraphy, intra-operative gamma probe detection, and blue dye mapping using 99m Tc-nanocolloid and Patent Blue V injected peri-areola. Statistical analysis was performed using Fisher’s exact and χ 2 for categorical data. Results: Out of 1,152 SLNBs performed, 224 (19.4%) were positive for metastatic disease; macrometastases in 150 (67.0%), micrometastases in 72 (32.1%) and isolated tumour cells (ITC) in 2 (0.9%). CALND was not performed in 20 cases (9 macrometastases, 10 micrometastases, and 1 ITC), largely due to concerns regarding fitness for anaesthesia. On univariate analysis, positive non-SLN in CALND for patients with micrometastases on SLNB was not predicted by grade (G0–G2, 6/43; G3; 3/19; P=0.565), size of primary breast tumour (&lt;40 mm, 8/58; ≥40 mm, 1/4; P=0.475), lymph vascular invasion (5/30 vs. 4/31; P=0.503), age (&lt;50 years, 3/24 vs. ≥50 years, 6/38; P=0.496), or number of positive SLNB. Conclusions: In our series, 14.5% (9/62) of patients with micrometastases had positive non-SLN on CALND, which was not predicted by any clinicopathological characteristics. However, it is important to inform our patients that 14.5% of patients with micrometastases on SLNB may have positive non-SLN.

Surgery of nonpalpable breast cancer: First step to a virtual per-operative localization? First step to virtual breast cancer localization.

Preoperative localization procedures of occult breast cancer (radioisotopic and wire localization) are invasive and uncomfortable. We have evaluated a novel technique which allows a virtual localization. Our retrospective study focused on patients treated for occult and unifocal breast cancer from September 2016 to June 2017. All patients had radioisotopic preoperative localization. We included patients who had a preoperative prone Magnetic Resonance Imaging (MRI) and an intraoperative 3D optical scan. During surgery, the surgeon localized the tumor thanks to a gamma detection probe and marked the localization on the skin with a black marker. The breast was then optically scanned. MRI was adjusted to the optical surface to match the exact breast position in the Operating Room. The virtual localization provided by the 3D breast modeling tool was retrospectively compared with the radioisotopic localization, defined as the pen mark visible in the optical scan. Nine patients were included in this feasibility study. Tumors were successfully localized in the respective breast quadrant. The mean cutaneous distance between virtual and radioisotopic localization was 1.4cm in patients with low breast volume (5/9) and 2.8cm in those with large breast volume (4/9). We developed a research prototype which enables virtual preoperative localization of nonpalpable breast lesions using MRI images and intraoperative optical scanning. Parameter optimization is required and will lead to a precise and noninvasive tool. By adding augmented reality, it will be possible to initiate a prospective study to compare this tool with the traditional localizations.

Sentinel lymph node detection using fluorescein and blue light-emitting diodes in patients with breast carcinoma: A single-center prospective study

Sentinel lymph node (SLN) biopsy is an essential procedure for lymph node staging in patients with breast carcinoma. Technetium-99m-labelled nanocolloid (99mTc) is the most accurate and widely used lymphatic mapping agent; however, there are concerns pertaining to the associated exposure to radiation. Studies focusing on new agents are required. We aimed to evaluate the feasibility and safety of SLN detection using fluorescein and blue light-emitting diodes (LEDs) in breast carcinoma patients. In this prospective study, a total of 61 patients with breast carcinoma, requiring SLN biopsy, were enrolled. Both fluorescein and 99mTc were intradermally injected into the areola of the affected breast of each patient. SLNs stained with fluorescein were detected using blue LED light first, and then, any remaining SLNs were detected using a gamma detection probe. The detection rate was analyzed, and the presence of complications was investigated. SLNs dyed with fluorescein using blue LED light were visualized in 57 of 61 patients (93.4%). None of the patients experienced complications related to the use of fluorescein or blue LED light. The detection of SLNs using fluorescein and blue LED light was feasible and safe in patients with breast carcinoma. This technique involves the use of visible light, allowing for SLNs to be viewed with the naked eye, and is quantifiable, easy to use, and economical.

A feasibility study of sentinel lymph node mapping by cervical injection of a tracer in Japanese women with early stage endometrial cancer

ObjectiveThe aim of this study was to investigate the feasibility of sentinel lymph node mapping characterized by a cervical tracer injection in endometrial cancer. Materials and methodsThis retrospective study was carried out using data for 57 patients with endometrial carcinoma who had undergone intraoperative sentinel lymph node mapping and subsequent surgical staging. Technetium colloid and/or indocyanine green was injected into the uterine cervix and a gamma-detecting probe and/or photodynamic eye camera system was used intraoperatively to locate hot spots. ResultsOf the 57 patients, 52 (91.2%) had FIGO Stage I disease. Successful unilateral or bilateral mapping occurred in 54 patients (94.7%) and 46 (80.7%), respectively. The median number of sentinel lymph nodes detected was two (range, 0–5). Following sentinel lymph node mapping, 41 patients (71.9%) underwent pelvic lymphadenectomy alone and 16 (28.1%) full lymphadenectomy. The median number of lymph nodes resected was 17 (range, 8–110). Sentinel lymph nodes were involved in four patients (7.0%), two with macrometastases and two with low-volume metastases. The sensitivity and negative predictive value for detecting lymph node metastasis were both 100%. ConclusionSentinel lymph node mapping with the use of cervical tracer injection is highly feasible in Japanese women with early stage endometrial cancer.

High sensitivity and negative predictive value of sentinel lymph node biopsy in a retrospective early stage oral cavity cancer cohort in the Northern Netherlands.

In cT1-2N0, oral squamous cell carcinoma (OSCC) occult metastases are detected in 23%-37% of cases. Sentinel lymph node biopsy (SLNB) was introduced in head and neck cancer as a minimally invasive alternative for an elective neck dissection in neck staging. Meta-analyses of SLNB accuracy show heterogeneity in the existing studies for reference standards, imaging techniques and pathological examination. The aim of this study was to assess the sensitivity and negative predictive value (NPV) of the SLNB in detecting occult metastases in cT1-2N0 OSCC in a well-defined cohort. Retrospective study. The SLNB procedure consisted of lymphoscintigraphy, SPECT/CT-scanning and gamma probe detection. Routine follow-up was the reference standard for the SLNB negative neck. Histopathological examination of sentinel lymph nodes (SLN) consisted of step serial sectioning, haematoxylin-eosin and cytokeratin AE1/3 staining. Two comprehensive oncology centres. A total of 91 consecutive patients with primary cT1-2N0 OSCC treated by primary resection and neck staging by SLNB procedure between 2008 and 2016. Sensitivity and negative predictive value. In all cases, SLNs were harvested. A total of 25 (27%) patients had tumour-positive SLNs. The median follow-up was 32months (range 2-104). Four patients were diagnosed with an isolated regional recurrence in the SLNB negative neck side resulting in an 85% sensitivity and a 94% NPV. In our cohort, the SLNB detected occult metastases in early OSCC with 85% sensitivity and 94% NPV. This supports that SLNB is a reliable procedure for surgical staging of the neck in case of oral cT1-2N0 SCC.

Eight Years' Experience of Sentinel Lymph Node Biopsy in Melanoma Using Lymphoscintigraphy and Gamma Probe Detection After Radiocolloid Mapping.

Isosulfan blue dye peripheral injection is used in preoperative sentinel lymph node (SLN) identification alone or, to increase sensitivity, in conjunction with radiocolloid mapping. However, isosulfan blue dye has certain drawbacks and limitations. This study assesses the authors' experience of SLN biopsy using only radiocolloid tracer. Between 2000 and 2008, 218 patients underwent SLN biopsy with radiocolloid mapping, preoperative localization by lymphoscintigraphy and intraoperative confirmation by gamma probe in primary malignant cutaneous melanoma. Mean Breslow index was 2.1 mm. The SLN biopsy success rate was above 98% at all sites and 87% in head and neck locations. The 5-year overall survival rate was 90% and that of 5-year disease-free survival was 80%. False-negative rate, with a mean follow-up time of 41 months, was 5.5%. Sentinel lymph node biopsy can be successfully performed in patients with melanoma using only radiocolloid tracer without blue dye staining. In circumstances where blue dye cannot be used such as head and neck tumors, allergic reactions and pregnancy, radiocolloid tracer mapping alone is not a loss of chance for patients with melanoma.

Radioguided Occult Lesion Localization in Deep Schwannomas of the Peripheral Nerves: Results of a Preliminary Case Series.

The detection of small deep schwannomas of the peripheral nerves has been increasing since the the use of precise neuroimaging techniques has become more widespread; however, although nonpalpable lesions can be well defined by images, it is often difficult to identify them during the surgical procedure. The authors report seven cases of nonpalpable small deep schwannomas surgically treated after their identification using the radioguided occult lesion localization (ROLL) technique. Seven men, whose ages ranged from 34 to 70 years (mean 52 years), presented with symptomatic nonpalpable peripheral nerve lesions; two cases involved the sciatic nerve, two the femoral nerve, two the radial nerve, and one the tibial nerve. Before the operation, all the patients were studied by ultrasonography and magnetic resonance imaging (MRI); 1 h before the surgery 3-5 MBq of 99mTc labeled with human albumin macroaggregates was injected into the lesion. A gamma detection probe permitted the preoperative and intraoperative detection of the nonpalpable schwannomas. The ROLL technique provides good support for identifying small lesions of the peripheral nerves both preoperatively and intraoperatively. This technique permits the use of minimally invasive approaches performed with local anesthesia, with good cosmetic results and acceptance by the patients.