Radioguided Techniques Research Articles

Imaging adjuvants in pediatric surgical oncology.

Surgery is a crucial component of pediatric cancer treatment, but conventional methods may lack precision. Image-guided surgery, including fluorescent and radioguided techniques, offers promise for enhancing tumor localization and facilitating precise resection. Intraoperative molecular imaging utilizes agents like indocyanine green to direct surgeons to occult deposits of tumor and to delineate tumor margins. Next-generation agents target tumors directly to improve specificity. Radioguided surgery, employing tracers like metaiodobenzylguanidine (MIBG), complements fluorescent techniques by allowing for detection of tumors at a greater depth. Dual-labeled agents combining both modalities are under development. Three-dimensional modeling and virtual/augmented reality aid in preoperative planning and intraoperative guidance. The above techniques show great promise to benefit patients with pediatric tumors, and their continued development will almost certainly improve surgical outcomes.

Intra-Articular Osteoid Osteoma of the Hip: An Observation and the Review of the Literature

Osteoid osteoma is a common benign bone tumor that affects young adults and has a typical clinical and radiographic presentation in long bones. However, when it appears in unusual intra-articular locations, the clinical symptomatology is then atypical and can lead to misdiagnosis constituting a diagnostic challenge for clinicians and causing delay in management. We present the case of a girl of 16 years with an osteoma osteoid intra-articular right hip involving the femoral head. This unusual location was the cause of unexplained pain and a delay in diagnosis of 20 months after the onset of symptoms, as the initial Magnetic Resonance Imaging (MRI) examination could not identify the lesion. The tomodensitometry is in this indication the most specific examination which made it possible to evoke the diagnosis of osteoid osteoma. Once the diagnosis is made, given the complexity of the location, it makes it difficult to access radio-guided techniques. The open surgical excision allowed healing with complete disappearance of pain. After complete surgical excision of the tumor, histopathological examination confirmed the final diagnosis of intra-articular osteoid osteoma. No recurrence was observed.

Implementation of radioguided surgery in prostate cancer.

With the development of new imaging technologies and tracers, the applications of radioguided surgery for prostate cancer are growing rapidly. The current paper aims to give an overview of the recent advances of radioguided surgery in the management of prostate cancer. We performed a literature search to give an overview of the current status of radioguided surgery for prostate cancer. Three modalities of radioguided surgery, the sentinel node procedure, Cerenkov Luminescence / beta-radio-guided surgery and radio-guided salvage surgery in recurrent prostate cancer, were reviewed in detail. Radioguided surgery for prostate cancer has shown promising value in the treatment of primary diagnosed prostate cancer and recurrent loco-regional lymph node positive prostate cancer. Advances have been made into minimal invasive (robot-assisted) laparoscopic surgery. The sentinel node procedure for prostate cancer has been further developed and is currently performed with high diagnostic sensitivity. Cerenkov luminescence imaging is a feasible and encouraging technique for intraoperative margin assessment in prostate cancer. Radioguided surgery in recurrent prostate cancer has shown to be feasible, yielding high sensitivity and specificity for detecting small local recurrences and metastases. With the availability of different new tracers, the road has been paved towards clinically feasible radioguided surgery for prostate cancer. Novel technologies now being developed for minimal invasive surgery are speeding up clinical research. Currently, none of the radioguided surgery techniques mentioned have been accepted as standard of care.

Sentinel lymph node biopsy in oral–oropharyngeal squamous cell carcinoma: standards, new technical procedures, and clinical advances

To provide substantial coverage and critical appraisal of standards as well as new technical procedures and clinical advances concerning sentinel lymph node biopsy (SNB) in oral squamous cell carcinoma (OSCC). The MEDLINE database was searched via the PubMed interface up to January 2019 for the following MeSH heading: “sentinel lymph node biopsy” and “squamous cell carcinoma of head and neck”. SNB exists as an alternative to elective neck dissection (END) in OSCC. Pre-surgical planar lymphoscintigraphy with intra-operative hand-held gamma probe allows using SNB. Furthermore, the contribution of pre-surgical SPECT/CT improves the sentinel lymph node (SLN) roadmap in sites that are closer to the injection site. Portable gamma camera and freehand SPECT are not yet routine clinical practice, but can further improve intra-operative SLN detection. However, the difficulty in detecting SLNs located closer to the injection site persists. SNB with combined radioactive and near-infrared fluorescence guidance is an attractive option for improving spatial resolution of radio-guided techniques while maintaining depth penetration. Numerous studies have demonstrated that SNB can be proposed for accurate histopathological staging of the neck and the guidelines support the introduction of SNB as an alternative to END in T1/T2 N0 OSCC patients. New hybrid imaging techniques, which are offering new possibilities to assist clinicians and surgeons in localizing the site of uptake in sentinel node detection, need to be confirmed in ongoing and future clinical trials. In the future, the integration of new PET tracers could continue along the route mapped out in SNB.

39. First implementation in France of nonpalpable breast lesions localization using an 125I-seed (radioactive)

Introduction For the excision of nonpalpable breast lesions, the surgeon needs a landmark previously placed under radiological or ultrasound imaging control. The current technique consists in implanting a metal wire from the lesion to the skin, which presents some constraints in terms of patient comfort, surgery precision (potential wire migration) and medical organization. Here is presented the implementation of breast lesion localization using an 125I radioactive seed as part of a mononoclinical trial comparing the wire-guided and radioguided techniques. Today, a feedback over 18 patients enables a first report on this technique. Methods In order to insure the feasibility of the iodine seed (IsoSeed® - Eckert & Ziegler) technique, the radiopaque and echogenic seed’s features were checked. In the surgery room, the iodine seed (A Results The seed is visible under X-Ray and ultrasound imaging. Thus this localization technique is possible, as well as the control of the seed presence into the lesion using Faxitron imaging (X-Ray). The 11 mm diameter probe was approved by the surgeons. With a 1.5 cm focalization (FWHM of the radial sensitivity curve), it offers the best compromise sensitivity/focalization. In light of the clinical activities, the scattered radiation of 99mTc does not trouble the 125I seed detection. For a seed implanted at 1, 2 and 3 cm depth, the breast skin dose was respectively evaluated at 2.2, 0.5 and 0.2 mGy/MBq/day. The highest activity and implantation duration being 10 MBq and 10 days, there is no contraindication to this technique due to radioprotection. The simulation using the piece of meat led to validate every step of the protocol with the different operators and thus resolve every major difficulty in relation to this technique. Conclusions The 18 iodine seed localizations (activity: 4.4 ± 1.5 MBq (1 σ ) , presence duration in the breast: 4.6 ± 3 days (1 σ ) ) were successful and enabled to optimize the established protocol. They confirm that this technique brings the solution to the constraints linked to the wire-guided localization: the seed positioning and the surgery gesture are made easier, the patient comfort is unquestionably improved and the medical organization flows better. Today, no seed migration has been observed, which may also promise a gain in precision.

Systematic review and meta-analysis of radio-guided versus wire-guided localization in the treatment of non-palpable breast cancers

Background: One-third of breast cancers present as non-palpable lesions. The current gold standard surgical treatment for these cancers is wide local excision using wire-guided localization (WGL). WGL has drawbacks including technical and scheduling issues, which resulted in the development of alternative radio-guided techniques (RGL).

Systematic review of radioguided versus wire-guided localization in the treatment of non-palpable breast cancers

One-third of breast cancers present as non-palpable lesions. The current gold standard treatment for these cancers is localized wide local excision using wire-guided localization (WGL). WGL has drawbacks including technical and scheduling issues resulting in the development of alternative radioguided techniques (RGL). A systematic review was performed to identify studies comparing RGL and WGL. The outcomes of surgical margin status, re-operation rates, surgical operative time, volume and excised specimen weight and successful sentinel lymph node biopsy (SLNB) rates were evaluated. Pooled odds ratios (ORs) and 95% confidence intervals were estimated using fixed-effects analyses and random-effects analyses in case of statistically significant heterogeneity (p<0.05). Seven randomized controlled trials (RCTs) matching the inclusion criteria were identified. The pooled ORs for involved surgical margin status were 0.78 (95% CI, 0.52-1.17); for re-operations 0.74 (95% CI, 0.49-1.11) and for successful SLNB 1.29 (95% CI, 0.66-2.53). There was a significant difference in surgical operating time in favour of RGL (mean difference (MD), -2.95; 95% CI, -4.43, -1.47) and a significant difference in excised specimen volume, favouring WGL (MD, 6.79; 95% CI, 0.03, 13.56). The MD for a specimen weight of -3.00 (95% CI, -15.15, 9.15) showed no significant difference between RGL and WGL. RGL has a reduced operating time, but larger volume excisions compared to WGL. There is insufficient evidence to support the uptake of RGL over WGL, and larger, adequately powered, multi-centre RCTs are required.

Video-axillaroscopy: a new mini-invasive technique for surgical exploration of the axillary region

Subclavicular lymph nodes are one of the deeper lymph node groups of the lymphatic network located in the axillary region. As its location is surrounded by vessels and nerves, biopsy of subclavicular lymph nodes is not possible without eye control. We describe a new, mini-invasive technique for accessing the thoracic outlet region. Video-axillaroscopy is a reliable mini-invasive technique for targeting biopsies of lymph nodes in the axillary region. It is safer and more accurate than radio-guided techniques. Exploration of this region might benefit treatment of lymphoma and breast cancer and applications might emerge for thoracic outlet syndromes.

Intra-articular osteoid osteoma of the hip misdiagnosed by MRI: An unusual cause of unexplained hip pain

Osteoid osteoma is a common benign bone tumor affecting the young adult with typical clinical and radiographic presentation in its most common locations. However, when arising in unusual intra-articular locations, diagnosis may appear confusing and lead to delayed management. We present the case of a 24-year-old man with intra-articular osteoid osteoma of the hip involving the posteroinferior quarter of the femoral head. This unusual location was at the origin of unexplained pain and delayed diagnosis made 18 months after the onset of symptoms since the initial magnetic resonance imaging (MRI) examination could not identify the lesion whereas it was detected on bone scintigraphy and thin slice CT imaging. Due to the complex location providing difficult access for radioguided techniques, an open surgical management was suggested and performed through a limited posterolateral approach with no hip dislocation, after identification of the circumflex pedicle. Following complete surgical excision of the tumor, the diagnosis could be confirmed after histopathologic analysis. No recurrence was observed.

The Effectiveness of Radioguided Parathyroidectomy in Patients With Negative Technetium Tc 99m–Sestamibi Scans

Many surgeons have shown that radio-guided resection of parathyroid glands can facilitate intraoperative localization in selected patients with primary hyperparathyroidism, especially in the reoperative setting. However, in patients with negative technetium Tc 99m-sestamibi (hereafter referred to as "sestamibi") scans, the usefulness of the gamma probe is unclear. Thus, we were interested in determining the role of radio-guided techniques in patients with primary hyperparathyroidism and negative or nonlocalizing sestamibi scans. Retrospective analysis of a prospective parathyroid database. Academic medical center. Seven hundred sixty-nine patients with primary hyperparathyroidism who had a sestamibi scan and underwent surgical invention by a single surgeon. All patients had radioguided parathyroidectomy using a handheld gamma probe. Radioactive counts, eucalcemia rate, and complications were compared between patients with positive and patients with negative sestamibi scans. All enlarged parathyroid glands were localized with the gamma probe in patients with a negative or with a positive sestamibi scan with similar sensitivities. This occurred despite the fact that smaller parathryoid glands were present, on average, in patients with negative sestamibi scans (428 mg vs 828 mg, P = .001). Equivalent high postoperative eucalcemia rates (>98%) and low complication rates (0.5%) were achieved with radioguided techniques in both patient populations. Radioguided techniques are equally effective in patients with negative (nonlocalizing) sestamibi scans undergoing parathyroidectomy for primary hyperparathyroidism. Moreover, use of the gamma probe led to the detection of all parathyroid glands, including ectopically located ones. These data suggest that the gamma probe has an important role for localization of parathyroid glands in patients with negative preoperative sestamibi scans.

The Negative Sestamibi Scan: Is a Minimally Invasive Parathyroidectomy Still Possible?

Tc-99-sestamibi scanning is utilized to determine whether patients with primary hyperparathyroidism (HPT) are candidates for minimally invasive parathyroidectomy (MIP). However, if the result of this scan is negative, many surgeons recommend bilateral parathyroid exploration because of possible multi-gland disease. The objectives of this study were to determine whether patients with primary HPT and negative sestamibi scans can benefit from additional imaging studies and are still potential candidates for MIP. Between March 2001 and April 2006, 578 consecutive patients with HPT underwent parathyroidectomy by a single surgeon. Pre-operative sestamibi scans had been done in 458 (79%) of these patients, 90 (20%) of which had negative results. These patients formed our study cohort. Of the 90 patients, 60 (67%) had a single adenoma, 17 (19%) double adenomas and 13 (14%) 3- to 4-gland hyperplasias. In 74 (82%) patients, localization was further investigated with one or more studies including thallium subtraction scans (n = 30), ultrasound (n = 15) and intra-operative internal jugular venous sampling (n = 49). Additionally, the use of radio-guided techniques intra-operatively facilitated minimally invasive techniques. Of these 90 patients, 47 had positive results from preoperative studies, including 12 positive thallium, 5 positive ultrasound and 13 positive internal jugular sampling results. In addition, positive results were observed for 17 patients using radio-probe techniques in the operating room. Accordingly, minimally invasive techniques were attempted in these 47 patients; 42 (89%) had single adenomas and in 5 the technique was converted to bilateral exploration for double adenoma/hyperplasia. In the setting of a negative sestamibi, the sensitivities of thallium scans and ultrasound were 30% and 27%, respectively. The overall cure rate in the 90 patients with negative sestamibi scans was 99%. In patients with primary HPT and a negative sestamibi scan, most patients (67%) will have a single adenoma. These patients benefitted from additional localization tests, which yielded a positive result in 52% of patients. Therefore, even in the setting of a negative sestamibi scan, the majority of patients with primary HPT are still candidates for MIP.

Thoracoscopic Localization Techniques for Patients With Solitary Pulmonary Nodule and History of Malignancy

Our aim was to evaluate the best intrathoracoscopic localization technique in patients with single pulmonary nodule and a history of malignancy. We divided 50 patients in two groups, well matched for diameter and depth of the pulmonary lesion. In 25 patients we performed intrathoracoscopic ultrasound to locate the pulmonary nodule (group A), whereas in the other 25 patients the radio-guided technique was adopted (group B). In both group A and group B, the localization techniques were compared with finger palpation. In group A, 12 nodules were in the left lung and 13 in the right one; in group B, 11 lesions were in the left and 14 in the right lung. In both groups, the distance of the nodule from the pleural surface was 2.6 +/- 0.5 cm (2 to 2.5 cm in 14 patients, and >2.5 cm for the remaining 11). The diameter of the nodule was 1.26 +/- 0.22 (< or =1 cm in 10 patients, and 1 to 1.5 cm in 15) in both groups. All patients underwent thoracoscopic wedge resection, and 10 patients with a primary pulmonary lesion underwent posterior-lateral thoracotomy for lobectomy and mediastinal lymphadenectomy. In group A, ultrasound localized the nodule in 24 of 25 patients (96%) whereas finger palpation localized it in 19 of 25 (76%; not significant). In group B, both the radio-guided and finger palpation techniques localized the nodule in 20 of 25 patients (80%; not significant). No complications were recorded with the ultrasound technique; however, 10 cases of pneumothorax were detected after the radio-guided technique (p < 0.01). Both the ultrasound and radio-guided techniques are accurate to detect solitary pulmonary nodules, but the radio-guided method yields complications as compared with the ultrasound.

Radioguided Parathyroidectomy Is Equally Effective for Both Adenomatous and Hyperplastic Glands

To determine the utility of radioguided parathyroidectomy for patients with hyperparathyroidism, we studied the properties of 180 resected, hyperfunctioning parathyroid glands. Radioguided resection of hyperfunctioning parathyroid glands has been shown to be technically feasible in patients with parathyroid adenomas. Radioguided excision may obviate the need for intraoperative frozen section because excised parathyroid adenomas uniformly have radionuclide ex vivo counts >20% of background. The feasibility and applicability of radioguided techniques for patients with parathyroid hyperplasia are unclear. Between March 2001 and September 2002, 102 patients underwent neck exploration for primary (n = 77) and secondary/tertiary (n = 25) hyperparathyroidism. All patients received an injection of 10 mCi of Tc-99m sestamibi the day of surgery. Using a gamma probe, intraoperative scanning was performed, looking for in vivo radionuclide counts > background to localize abnormal parathyroid glands. After excision, radionuclide counts of each ex vivo parathyroid gland were determined and expressed as a percentage of background counts.RESULTS Although patients with single adenomas had higher mean background radionuclide counts, the average in vivo counts of all enlarged glands were higher than background. Notably, in vivo counts did not differ between adenomatous and hyperplastic glands, suggesting equal sensitivity for intraoperative gamma detection. Ectopically located glands were identified in 22 cases and all were accurately localized using the gamma probe. Postresection, mean ex vivo radionuclide counts were highest in the single parathyroid adenomas and lowest in hyperplastic glands. Importantly, in all hyperplastic glands, the ex vivo counts were >20%. In patients with hyperparathyroidism, radioguided surgery is a sensitive adjunct for the intraoperative localization of both adenomatous and hyperplastic glands. In this series, all 180 enlarged parathyroids were located with the gamma probe. We have also shown that the ">20% rule" for ex vivo counts not only applies to parathyroid adenomas but also to hyperplastic glands. Therefore, radioguided resection is equally effective and informative for both adenomatous and hyperplastic glands.