RESUMO
PURPOSE: Diagnostic imaging modalities have moderate sensitivity for the identification of lymph node (LN) metastases in prostate cancer (PCa) patients. Mapping the lymphatic drainage from the prostate can help to identify the LNs directly draining from the tumour (sentinel nodes (SNs)); the LNs stated to have the highest chance of containing metastatic cancer cells. Although the lymphatic drainage may differ between segments within the prostate, the location of the primary tumour is not routinely taken into account during peripheral zone-aimed tracer administration. This study evaluates whether linking the SN procedure to the primary cancer deposits increases the identification accuracy of lymphatic metastases. METHODS: Sixty-seven PCa patients, scheduled for robot-assisted laparoscopic prostatectomy (RALP) and extended lymph node dissection (ePLND) with subsequent SN biopsy, were included in this retrospective study. After injection of the hybrid tracer ICG-99mTc-nanocolloid in the prostate, SN mapping was performed based on lymphoscintigraphy and SPECT/CT. SNs were resected using a combination of radio- and fluorescence guidance. Pathology was used to determine the primary tumour location and metastatic spread. Fluorescence imaging of paraffin-embedded prostate tissue was used to determine the location of the tracer deposits in the prostate. This deposition was related to the primary tumour location, the lymphatic drainage pattern of the injected tracer, and the metastatic spread. RESULTS: In total 265 radioactive LNs (211 SNs and 54 higher-echelon nodes in 64 patients; 4.3 LNs per patient; IQR: 2-6) were identified. In three patients (4%) preoperative imaging did not allow identification of SNs. Tumour-positive SN visualization within the pelvis was shown to be influenced by intraprostatic location of tracer administration. This could be concluded from (1) a clear correlation between lymphatic drainage to the right or left side of the body and tracer deposition on the right or left side of the prostate, (2) visualization of a higher number of LNs after dorsal tracer deposition compared with ventral tracer deposition, (3) different drainage patterns observed for tracer deposition into the base or apex of the prostate, and (4) the indication that intratumoural tracer deposition increases the chance of visualizing nodal metastases compared with extratumoural tracer deposition. CONCLUSIONS: The correlation between the location of the tracer deposits, the location of the primary tumour, and the visualization of the (tumour-positive) SNs indicated that placement of tracer deposits is of influence on the visualized lymphatic drainage pattern. This suggests that tracer injection near or into the primary tumour site is beneficial for the identification of metastatic spread.
Assuntos
Neoplasias da Próstata/patologia , Linfonodo Sentinela/cirurgia , Coloides , Humanos , Período Intraoperatório , Masculino , Metástase Neoplásica , Período Pré-Operatório , Neoplasias da Próstata/cirurgia , Traçadores Radioativos , Estudos Retrospectivos , Linfonodo Sentinela/patologiaRESUMO
PURPOSE: Hybrid image-guided surgery technologies such as combined radio- and fluorescence-guidance are increasingly gaining interest, but their added value still needs to be proven. In order to evaluate if and how fluorescence-guidance can help realize improvements beyond the current state-of-the-art in sentinel node (SN) biopsy procedures, use of the hybrid tracer indocyanine green (ICG)-99mTc-nancolloid was evaluated in a large cohort of patients. PATIENTS AND METHODS: A prospective trial was conducted (n = 501 procedures) in a heterogeneous cohort of 495 patients with different malignancies (skin malignancies, oral cavity cancer, penile cancer, prostate cancer and vulva cancer). After injection of ICG-99mTc-nanocolloid, SNs were preoperatively identified based on lymphoscintigraphy and SPECT/CT. Intraoperatively, SNs were pursued via gamma tracing, visual identification (blue dye) and/or near-infrared fluorescence imaging during either open surgical procedures (head and neck, penile, vulvar cancer and melanoma) or robot assisted laparoscopic surgery (prostate cancer). As the patients acted as their own control, use of hybrid guidance could be compared to conventional radioguidance and the use of blue dye (n = 300). This was based on reported surgical complications, overall survival, LN recurrence free survival, and false negative rates (FNR). RESULTS: A total of 1,327 SN-related hotspots were identified on 501 preoperative SPECT/CT scans. Intraoperatively, a total number of 1,643 SNs were identified based on the combination of gamma-tracing (>98%) and fluorescence-guidance (>95%). In patients wherein blue dye was used (n = 300) fluorescence-based SN detection was superior over visual blue dye-based detection (22-78%). No adverse effects related to the use of the hybrid tracer or the fluorescence-guidance procedure were found and outcome values were not negatively influenced. CONCLUSION: With ICG-99mTc-nanocolloid, the SN biopsy procedure has become more accurate and independent of the use of blue dye. With that, the procedure has evolved to be universal for different malignancies and anatomical locations.
Assuntos
Período Pré-Operatório , Biópsia de Linfonodo Sentinela/métodos , Humanos , Período IntraoperatórioRESUMO
BACKGROUND: The treatment of axillary lymph node metastases after neoadjuvant systemic therapy (NST) remains debatable and axillary lymph node dissection (ALND) is still the standard of care. Marking axillary lymph nodes with radioactive iodine seeds (MARI procedure) is accurate in restaging the axilla after NST (false-negative rate 7 per cent). Here, the potential of tailored axillary treatment, determined by combining the results of PET-CT before NST with those of the MARI procedure after NST, was analysed. METHODS: A cohort of axillary node-positive patients was used to construct a hypothetical treatment algorithm based on a combination of PET-CT and the MARI procedure. In the algorithm, the number of fluorodeoxyglucose (FDG)-avid axillary lymph nodes (1-3 versus 4 or more) before NST and the tumour status of the MARI node (positive versus negative) after NST were used to tailor axillary treatment. All patients in the cohort underwent ALND, allowing estimation of potential overtreatment and undertreatment. RESULTS: A total of 93 patients were included in the study. Between one and three FDG-avid axillary lymph nodes were observed in 59 patients, and four or more in 34 patients. The MARI node was tumour-negative in 32 patients and showed residual disease in 61. Treatment according to the constructed algorithm would have resulted in 74 per cent of patients avoiding an ALND, with potential undertreatment in three patients (3 per cent) and overtreatment in 16 (17 per cent). CONCLUSION: Tailored axillary treatment after NST in node-positive patients, by combining PET-CT before NST and the MARI procedure after NST, has the potential for ALND to be avoided in 74 per cent of patients.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/diagnóstico por imagem , Radioisótopos do Iodo , Compostos Radiofarmacêuticos , Adulto , Idoso , Algoritmos , Axila/diagnóstico por imagem , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/cirurgia , Feminino , Fluordesoxiglucose F18 , Humanos , Excisão de Linfonodo/métodos , Linfonodos/diagnóstico por imagem , Metástase Linfática , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Procedimentos Desnecessários , Adulto JovemRESUMO
INTRODUCTION: Conventional sentinel node (SN) mapping is performed by injecting a radiocolloid followed by lymphoscintigraphy (and SPECT/CT imaging). An extra intraoperative injection with blue dye can then allow for optical identification of the SN. In order to improve the current clinical standard, the hybrid tracer indocyanine green (ICG)-(99m)Tc-nanocolloid was introduced, a tracer that is both radioactive and fluorescent. This feasibility study aimed to evaluate the value of a multimodal-based SN biopsy in vulvar cancer. MATERIALS AND METHODS: Fifteen patients with vulvar cancer (29 groins) scheduled for SN biopsy were peritumorally injected with ICG-(99m)Tc-nanocolloid followed by lymphoscintigraphy and SPECT/CT imaging to identify the SNs. In thirteen patients, shortly before the start of the operation, blue dye was intradermally injected around the lesion. SNs were harvested using a combination of radiotracing, fluorescence imaging, and optical blue dye detection. A portable gamma camera was used before and after SN excision to confirm excision of the preoperatively defined SNs. RESULTS: Preoperative lymphoscintigraphy and SPECT/CT imaging visualized drainage to 39 SNs in 28 groins. During the operation, 98% (ex vivo 100%) of the SNs were radioactive. With fluorescence imaging 96% of the SNs (ex vivo 100%) could be visualized. Only 65% of the SNs had stained blue at the time of excision. CONCLUSION: ICG-(99m)Tc-nanocolloid can be used for preoperative SN identification and enables multimodal (radioactive and fluorescent) surgical guidance in patients with vulvar cancer. The addition of fluorescence-based optical guidance offers more effective SN visualization compared to blue dye.
Assuntos
Linfonodos/patologia , Linfonodos/cirurgia , Neoplasias Vulvares/patologia , Neoplasias Vulvares/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Verde de Indocianina , Linfonodos/diagnóstico por imagem , Pessoa de Meia-Idade , Imagem Multimodal , Estadiamento de Neoplasias , Compostos Radiofarmacêuticos , Biópsia de Linfonodo Sentinela/métodos , Agregado de Albumina Marcado com Tecnécio Tc 99m , Tomografia Computadorizada de Emissão de Fóton Único , Tomografia Computadorizada por Raios X , Neoplasias Vulvares/diagnóstico por imagem , Adulto JovemRESUMO
PURPOSE: The aim of this study was to evaluate the association of primary tumour (18)F-fluorodeoxyglucose (FDG) uptake with clinical, histopathological and molecular characteristics of breast cancer patients scheduled for neoadjuvant chemotherapy. Second, we wished to establish for which patients pretreatment positron emission tomography (PET)/CT could safely be omitted because of low FDG uptake. METHODS: PET/CT was performed in 214 primary stage II or III breast cancer patients in the prone position with hanging breasts. Tumour FDG uptake was qualitatively evaluated to determine the possibility of response monitoring with PET/CT and was quantitatively assessed using maximum standardized uptake values (SUV(max)). FDG uptake was compared with age, TNM stage, histology, hormone and human epidermal growth factor receptor 2 status, grade, Ki-67 and molecular subtype in univariable and multivariable analyses. RESULTS: In 203 tumours (95 %) FDG uptake was considered sufficient for response monitoring. No subgroup of patients with consistently low tumour FDG uptake could be identified. In a univariable analysis, SUV(max) was significantly higher in patients with distant metastases at staging examination, non-lobular carcinomas, tumours with negative hormone receptors, triple negative tumours, grade 3 tumours, and in tumours with a high proliferation index (Ki-67 expression). After multiple linear regression analysis, triple negative and grade 3 tumours were significantly associated with a higher SUV(max). CONCLUSION: Primary tumour FDG uptake in breast cancer patients scheduled for neoadjuvant chemotherapy is significantly higher in tumours with prognostically unfavourable characteristics. Based on tumour characteristics associated with low tumour FDG uptake, this study was unable to identify a subgroup of patients unlikely to benefit from pretreatment PET/CT.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Carcinoma/diagnóstico por imagem , Fluordesoxiglucose F18 , Compostos Radiofarmacêuticos , Adulto , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/tratamento farmacológico , Carcinoma/diagnóstico , Carcinoma/tratamento farmacológico , Quimioterapia Adjuvante , Feminino , Fluordesoxiglucose F18/farmacocinética , Humanos , Pessoa de Meia-Idade , Imagem Multimodal , Tomografia por Emissão de Pósitrons , Prognóstico , Compostos Radiofarmacêuticos/farmacocinética , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: To investigate whether lymphoscintigraphy and SPECT/CT after intralesional injection of radiopharmaceutical into each tumour separately in patients with multiple malignancies in one breast yields additional sentinel nodes compared to intralesional injection of the largest tumour only. METHODS: Patients were included prospectively at four centres in The Netherlands. Lymphatic flow was studied using planar lymphoscintigraphy and SPECT/CT until 4 h after administration of (99m)Tc-nanocolloid in the largest tumour. Subsequently, the smaller tumour(s) was injected intratumorally followed by the same imaging sequence. Sentinel nodes were intraoperatively localized using a gamma ray detection probe and vital blue dye. RESULTS: Included in the study were 50 patients. Additional lymphatic drainage was depicted after the second and/or third injection in 32 patients (64%). Comparison of planar images and SPECT/CT images after consecutive injections enabled visualization of the number and location of additional sentinel nodes (32 axillary, 11 internal mammary chain, 2 intramammary, and 1 interpectoral. A sentinel node contained metastases in 17 patients (34%). In five patients with a tumour-positive node in the axilla that was visualized after the first injection, an additional involved axillary node was found after the second injection. In two patients, isolated tumour cells were found in sentinel nodes that were only visualized after the second injection, whilst the sentinel nodes identified after the first injection were tumour-negative. CONCLUSION: Lymphoscintigraphy and SPECT/CT after consecutive intratumoral injections of tracer enable lymphatic mapping of each tumour separately in patients with multiple malignancies within one breast. The high incidence of additional sentinel nodes draining from tumours other than the largest one suggests that separate tumour-related tracer injections may be a more accurate approach to mapping and sampling of sentinel nodes in patients with multicentric or multifocal breast cancer.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Linfonodos/diagnóstico por imagem , Agregado de Albumina Marcado com Tecnécio Tc 99m , Tomografia Computadorizada por Raios X/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/metabolismo , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Drenagem , Feminino , Humanos , Excisão de Linfonodo , Linfonodos/metabolismo , Linfonodos/cirurgia , Metástase Linfática , Linfocintigrafia/métodos , Pessoa de Meia-Idade , Compostos Radiofarmacêuticos/administração & dosagem , Biópsia de Linfonodo Sentinela/métodos , Agregado de Albumina Marcado com Tecnécio Tc 99m/administração & dosagem , Tomografia Computadorizada de Emissão de Fóton Único/métodosRESUMO
PURPOSE: To apply single-photon emission computed tomography (SPECT) in combination with computed tomography (CT) for preoperative identification of sentinel lymph nodes (SNs) and to investigate surgical feasibility and safety of intraoperative sampling. METHODS: A retrospective combined interim analysis of 20 patients from two prospective trials who underwent injection of 99mTc-nanocolloid into the renal tumour for preoperative identification of SN with SPECT/CT and subsequent removal of the tumour and intraoperative sampling using a gamma probe and portable camera. Lymphadenectomy was completed locoregionally. Surgical approach, time, blood loss, intraoperative yield, Clavien complications and anatomical location of SN in correlation with preoperative imaging were evaluated. RESULTS: SPECT/CT detected SN in 14/20 patients (70%), including 4 patients with non-visualisation on planar lymphoscintigraphy. Twenty-six SNs were seen: 17 para-aortic (including interaorto-caval), 4 retrocaval, 1 hilar, 1 celiac trunc, 1 internal mammary and 2 mediastinal and pleural. These latter 4 nodes were not harvested according to protocol. All other SNs, except for 2 weakly radioactive interaorto-caval nodes, were identified and excised with a mean additional time of 20 min. None of the removed SN and locoregional nodes was tumour-bearing. CONCLUSIONS: Intraoperative SN identification and sampling in RCC with preoperative detection on SPECT/CT is surgically safe and feasible. SN from the kidney are mainly localised in the para-aortic region, but aberrant nodes receive direct drainage. Non-visualisation of SN appears in almost a third of the patients. Further studies are required to demonstrate whether accurate mapping of lymphatic drainage and extent of lymphatic spread may have diagnostic and therapeutic implications.
Assuntos
Carcinoma de Células Renais/diagnóstico por imagem , Carcinoma de Células Renais/cirurgia , Neoplasias Renais/diagnóstico por imagem , Neoplasias Renais/cirurgia , Imagem Multimodal , Tomografia por Emissão de Pósitrons , Biópsia de Linfonodo Sentinela/métodos , Tomografia Computadorizada por Raios X , Adulto , Idoso , Perda Sanguínea Cirúrgica , Feminino , Humanos , Período Intraoperatório , Rim/diagnóstico por imagem , Rim/cirurgia , Linfonodos/diagnóstico por imagem , Linfonodos/cirurgia , Metástase Linfática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Imagem Multimodal/efeitos adversos , Estudos Retrospectivos , Tecnécio , Fatores de TempoRESUMO
INTRODUCTION AND OBJECTIVES: To evaluate the migration of 99mTc-tilmanocept from the injection site (IS) as well as the uptake in sentinel nodes (SNs) and non-SNs for lymphatic mapping in patients with breast cancer and melanoma, scheduled for SN biopsy after interstitial tracer administration. MATERIALS AND METHODS: For 29 primary tumours in 28 patients (mean age: 62y, range: 45-81y) scheduled for SN biopsy planar images were acquired 10 and 120min after administration of 74MBq 99mTc-tilmanocept, in order to evaluate lymphatic drainage as well as uptake ratios between injection site (IS), SN and non-SN. SPECT-CT was performed immediately after delayed planar images to enable anatomical lymph node localization. RESULTS: SNs were visualized in all patients (100%) with drainage to 34 basins. Uptake in non-SNs was perceived in 16 basins (47%). Number of SNs was concordant between early and delayed images in all basins excepting five (86%). In 24 patients tracer migrated to one lymph node basin (LNB), in three to 2 and in one to 4. When IS was included (N=29) on image, IS/SN ratio could be measured per LNB. The IS/SN ratio at 2h compared to 15min decreased with an average of 66% (range: 15-96%). SN/non-SN 2h ratio in LNBs with visible non-SNs averaged 6.6 (range: 2.3-15.6). In 9 patients with two SNs SN1/SN2 ratio averaged 1.9 on delayed images. At histopathology, SNs were found to be tumour positive in 7 basins (20%). CONCLUSION: 99mTc-tilmanocept appears to meet the requirements for improved SN imaging in breast cancer and melanoma on the basis of early and persistent SN visualization frequently accompanied by no or markedly less non-SN uptake. This is associated to rapid migration from the injection site together with increasing SN uptake and retention as expressed by decreasing IS/SN and persistently high SN/non-SN ratios. Further head-to-head comparison of 99mTc-tilmanocept with standard SN radiotracers in larger series of patients is necessary.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Dextranos/farmacocinética , Mananas/farmacocinética , Melanoma/diagnóstico por imagem , Compostos Radiofarmacêuticos/farmacocinética , Linfonodo Sentinela/diagnóstico por imagem , Neoplasias Cutâneas/diagnóstico por imagem , Pentetato de Tecnécio Tc 99m/análogos & derivados , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Dextranos/administração & dosagem , Feminino , Humanos , Linfonodos/diagnóstico por imagem , Masculino , Mananas/administração & dosagem , Melanoma/patologia , Pessoa de Meia-Idade , Compostos Radiofarmacêuticos/administração & dosagem , Linfonodo Sentinela/metabolismo , Biópsia de Linfonodo Sentinela , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton Único , Neoplasias Cutâneas/patologia , Pentetato de Tecnécio Tc 99m/administração & dosagem , Pentetato de Tecnécio Tc 99m/farmacocinética , Fatores de TempoRESUMO
AIM: This study has aimed to assess if the prone position shows significant differences in regards to the supine position in PET/CT studies in breast cancer patients and to determine which modality offers better evaluation of the images. METHOD: A total of 30 patients were included from October 2009 to February 2010 prior to beginning neoadjuvant chemotherapy. An intravenous (18)F-FDG dose ranging from 180 to 240 MBq was administered. Image acquisition was begun 60 ± 10 min after injection. First of all, a thorax scan was performed with the patient in prone position, followed by a whole body study with the patient in supine position. RESULTS: Uptake in tumor lesions was observed in all of the patients. Twenty-four patients (80%) had the same number of lesions with both techniques. Five patients (17%) had a different amount of axillary lymph nodes. One patient (3.3%) had a different number of lesions. The prone position lesions had a mean SUVmax 8.89 ± 4.18 compared to 7.67 ± 4.34 in supine position. The areas of the primary breast lesions were higher in the prone position (8.59 ± 7.80 compared with 7.81 ± 7.39). Mean SUVmax of axillary nodes was 5.97 ± 4.02 in prone and 4.41 ± 3.10 in supine. CONCLUSION: The hanging breast technique can achieve higher lesion visualization as well as higher semiquantitative values in comparison with standard procedure. This supports its inclusion in acquisition guidelines of PET/CT imaging in breast cancer patients.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Tomografia por Emissão de Pósitrons/métodos , Decúbito Ventral , Tomografia Computadorizada por Raios X/métodos , Adulto , Feminino , Radioisótopos de Flúor , Fluordesoxiglucose F18 , Humanos , Metástase Linfática/diagnóstico por imagem , Pessoa de Meia-Idade , Compostos Radiofarmacêuticos , Sensibilidade e EspecificidadeRESUMO
PURPOSE: Our aim was to assess the feasibility of intraoperative radioguidance with a portable gamma camera during laparoscopic sentinel node (SN) procedures in urological malignancies. METHODS: We evaluated the use of the intraoperative portable gamma camera in 20 patients: 16 patients with prostate carcinoma (PCC), 2 patients with renal cell carcinoma (RC) and 2 patients with testicular cancer (TC). Intra/peritumoural injection of (99m)Tc-nanocolloid ((99m)Tc) was followed by planar lymphoscintigraphy, SPECT/CT and marking of SN levels. Before laparoscopy a (125)I seed was fixed on the laparoscopic gamma probe as a pointer of SN seeking. The portable gamma camera was set to display the (99m)Tc signal for SN localisation and the (125)I signal for SN seeking. Matching of these signals on screen indicated exact SN localisation, and consequently this SN was removed. RESULTS: The mean injected dose was 218 MBq in PCC, 228 MBq in RC and 88 MBq in TC. Pelvic SN were visualised in all PCC patients, with uncommonly located SN in seven patients. SN metastases were found in seven patients (one in a uncommonly located SN). Both RC patients and TC patients had para-aortic SN, which were all tumour free. A total of 59 SN were removed. The portable gamma camera enabled real-time SN display/identification in 18 patients (90%). CONCLUSION: The use of a portable gamma camera in combination with a laparoscopic gamma probe incorporates intraoperative real-time imaging with improved SN identification in urological malignancies. This procedure might also be useful for SN identification of other deep draining malignancies.
Assuntos
Câmaras gama , Laparoscopia/métodos , Linfonodos/patologia , Cirurgia Assistida por Computador/instrumentação , Neoplasias Urológicas/patologia , Neoplasias Urológicas/cirurgia , Idoso , Estudos de Viabilidade , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada de Emissão de Fóton Único , Tomografia Computadorizada por Raios X , Neoplasias Urológicas/diagnóstico por imagemRESUMO
PURPOSE: To assess the feasibility of using freehand Single Photon Emission Computed Tomography (freehandSPECT) for the identification of technetium-99m-hydroxydiphosphonate (99mTc-HDP) positive bone lesions and to evaluate the possibility of using these imaging data-sets for augmented- and virtual-reality based navigation approaches. MATERIAL AND METHODS: In 20 consecutive patients referred for scintigraphy with 99mTc-HDP, 21 three-dimensional freehandSPECT-images were generated using a handheld gamma camera. Concordance of the two different data sets was ranked. Furthermore, feasibility of segmenting the hotspot of tracer accumulation for navigation purposes was assessed. RESULTS: In 86% of the cases freehandSPECT images showed good concordance with the corresponding part of the scintigraphic images. In lesions with a signal to background ratio (SBR) >1.36, freehandSPECT provided an automatically segmented reference point for navigation purposes. In 14% of the cases (average SBR 1.82, range 1.0-3.4) freehandSPECT images showed intermediate concordance due to difficult anatomical area or negative bone scintigraphy and could not be used as navigation targets. CONCLUSION: In this pilot study, in 86% of the cases freehandSPECT demonstrated good concordance with traditional scintigraphy. A lesion with a SBR of 1.36 or more was suitable for navigation. These high-quality freehandSPECT images supported the future exploration navigation strategies, e.g. guided needle biopsies.
Assuntos
Biópsia por Agulha/métodos , Doenças Ósseas/diagnóstico por imagem , Câmaras gama , Biópsia Guiada por Imagem/métodos , Medronato de Tecnécio Tc 99m/análogos & derivados , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Doenças Ósseas/patologia , Neoplasias Ósseas/diagnóstico por imagem , Neoplasias Ósseas/secundário , Método Duplo-Cego , Desenho de Equipamento , Humanos , Biópsia Guiada por Imagem/instrumentação , Especificidade de Órgãos , Imagens de Fantasmas , Projetos Piloto , Compostos Radiofarmacêuticos/farmacocinética , Software , Medronato de Tecnécio Tc 99m/farmacocinética , Tomografia Computadorizada de Emissão de Fóton Único/instrumentação , Imagem Corporal TotalRESUMO
In 3 patients, two men aged 22 years and 38 years with melanoma, and one woman aged 46 years with breast cancer, local tumour growth recurred following regional lymph node dissection. All three developed metastasis in new distant regional basins, which were once more dissected. The first melanoma patient died from haematogenous metastasis, 2 years after the excision of his primary melanoma. The other melanoma patient was alive, without evidence of disease, 8 years after the treatment of his primary tumour. The breast cancer patient, who underwent contralateral axillary lymph node dissection, was also alive, without evidence of disease, 27 years after the treatment of her primary tumour. Diversion of lymphatic flow as a result of regional lymph node dissection for cancer may lead to metastasis to a distant lymph node basin if tumour growth recurs in the original area. Knowledge of this usually unknown phenomenon is important since metastasis to these new regional basins can still be treated curatively, in the form of another lymph node dissection. These distant lymph node basins must therefore be carefully checked during follow-up monitoring.
Assuntos
Neoplasias da Mama/patologia , Excisão de Linfonodo , Metástase Linfática , Melanoma/patologia , Neoplasias Cutâneas/patologia , Adulto , Neoplasias da Mama/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Melanoma/cirurgia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/prevenção & controle , Medição de Risco , Neoplasias Cutâneas/cirurgia , Fatores de TempoRESUMO
Sentinel lymph node (SLN) biopsy is now the standard of care for regional staging in several solid tumors. The interstitial administration of a radiotracer around the primary tumor provide the possibility to sequentially obtain images with a gamma camera and visualize lymphatic mapping and the SLN. There is, however, a large geographical variability in those radiotracers and nanocolloids ranging from 15-100nm which are most widely employed in Europe, while filtered and unfiltered 99mTc-sulfur colloid (range 20-1000nm) is usually used in the USA with different drawbacks in its use. The new radiotracer 99mTc-Tilmanocept, designed specifically for the identification of SLNs and recently becoming commercially available in USA and Europe, appears to have the potency to overcome the shortcomings described for the conventional radiotracers used until now for SLN biopsy and at the same time to transform current imaging paradigms. After delineating the challenges for the next generation of radiotracers, this paper discusses the properties of 99mTc-Tilmanocept, its validation process for SLN biopsy and its emerging clinical applications in various malignancies.
Assuntos
Dextranos , Mananas , Neoplasias/diagnóstico por imagem , Neoplasias/patologia , Cintilografia , Biópsia de Linfonodo Sentinela/normas , Pentetato de Tecnécio Tc 99m/análogos & derivados , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/patologia , Carcinoma de Células Escamosas/diagnóstico por imagem , Carcinoma de Células Escamosas/patologia , Humanos , Melanoma/diagnóstico por imagem , Melanoma/patologia , Neoplasias Bucais/diagnóstico por imagem , Neoplasias Bucais/patologiaRESUMO
AIM: The purpose of this study was to determine the predictive value of lymphatic mapping with selective lymphadenectomy in patients with Merkel's cell carcinoma. METHODS: Eight patients with biopsy proven Merkel's cell carcinoma underwent sentinel node biopsy. Lymphoscintigraphy was performed the day before surgery following intradermal injection of 74-111MBq of 99mTc-nanocolloid divided into four doses around the biopsy scar. Dynamic and static images were obtained. RESULTS: At least one sentinel node was visualized in all patients. The sentinel node was intra-operatively identified with the aid of a hand-held gamma probe in all cases and patent blue dye in six out of eight cases. During surgery, all sentinel nodes were successfully harvested. Metastatic cell deposits were subsequently identified in three patients (37.5%) and they underwent regional lymphadenectomy. No additional involved lymph nodes were identified. No recurrence has been reported in a median follow-up of 4.6 years (range: 8 months-10 years). CONCLUSIONS: In conclusion, sentinel node biopsy in patients with Merkel's cell carcinoma appears to be a reliable staging technique.
Assuntos
Carcinoma de Célula de Merkel/secundário , Biópsia de Linfonodo Sentinela/métodos , Neoplasias Cutâneas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Célula de Merkel/diagnóstico por imagem , Carcinoma de Célula de Merkel/cirurgia , Diagnóstico Diferencial , Feminino , Seguimentos , Humanos , Linfonodos/diagnóstico por imagem , Linfonodos/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias/métodos , Prognóstico , Cintilografia , Índice de Gravidade de Doença , Neoplasias Cutâneas/diagnóstico por imagem , Neoplasias Cutâneas/cirurgiaAssuntos
Arterite , Arterite de Células Gigantes , Fluordesoxiglucose F18 , Arterite de Células Gigantes/complicações , Arterite de Células Gigantes/diagnóstico por imagem , Humanos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Tomografia por Emissão de PósitronsRESUMO
Radio-guided surgery has been developed for application in those disease scheduled for surgical management, particularly in areas of complex anatomy. This is based on the use of pre-operative scintigraphic planar, tomographic and fused SPECT/CT images, and the possibility of 3D reconstruction for the subsequent intraoperative locating of active lesions using handheld devices (detection probes, gamma cameras, etc.). New tracers and technologies have also been incorporated into these surgical procedures. The combination of visual and acoustic signals during the intraoperative procedure has become possible with new portable imaging modalities. In daily practice, the images offered by these techniques and devices combine perioperative nuclear medicine imaging with the superior resolution of additional optical guidance in the operating room. In many ways they provide real-time images, allowing accurate guidance during surgery, a reduction in the time required for tissue location and an anatomical environment for surgical recognition. All these approaches have been included in the concept known as (radio) Guided intraOperative Scintigraphic Tumour Targeting (GOSTT). This article offers a general view of different nuclear medicine and allied technologies used for several GOSTT procedures, and illustrates the crossing of technological frontiers in radio-guided surgery.
Assuntos
Neoplasias/diagnóstico por imagem , Neoplasias/cirurgia , Cintilografia , Cirurgia Assistida por Computador , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Adulto JovemRESUMO
PURPOSE: To assess the 3D geometric sampling accuracy of a new PET-guided system for breast cancer biopsy (BCB) from areas within the tumour with high 18F-FDG uptake. MATERIALS AND METHODS: In the context of the European Union project MammoCare, a prototype semi-robotic stereotactic prototype BCB-device was incorporated into a dedicated high resolution PET-detector for breast imaging. The system consists of 2 stacked rings, each containing 12 plane detectors, forming a dodecagon with a 186mm aperture for 3D reconstruction (1mm3 voxel). A vacuum-assisted biopsy needle attached to a robot-controlled arm was used. To test the accuracy of needle placement, the needle tip was labelled with 18F-FDG and positioned at 78 target coordinates distributed over a 35mm×24mm×28mm volume within the PET-detector field-of-view. At each position images were acquired from which the needle positioning accuracy was calculated. Additionally, phantom-based biopsy proofs, as well as MammoCare images of 5 breast cancer patients, were evaluated for the 3D automated locating of 18F-FDG uptake areas within the tumour. RESULTS: Needle positioning tests revealed an average accuracy of 0.5mm (range 0-1mm), 0.6mm (range 0-2mm), and 0.4mm (range 0-2mm) for the x/y/z-axes, respectively. Furthermore, the MammoCare system was able to visualize and locate small (<10mm) regions with high 18F-FDG uptake within the tumour suitable for PET-guided biopsy after being located by the 3D automated application. CONCLUSIONS: Accuracy testing demonstrated high-precision of this semi-automatic 3D PET-guided system for breast cancer core needle biopsy. Its clinical feasibility evaluation in breast cancer patients scheduled for neo-adjuvant chemotherapy will follow.
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Neoplasias da Mama/patologia , Mama/patologia , Fluordesoxiglucose F18 , Compostos Radiofarmacêuticos , Biópsia por Agulha/instrumentação , Desenho de Equipamento , Feminino , Humanos , Biópsia Guiada por Imagem/instrumentação , Procedimentos Cirúrgicos RobóticosRESUMO
INTRODUCTION: 18F-FDG PET/CT has high positive predictive value for the detection of avid lymph node metastases in breast cancer patients. We analysed the effect of upstaging lymph nodes by PET/CT on short-term outcome in stage II/III breast cancer patients. PATIENTS AND METHODS: A total of 278 stage II/III primary breast cancer patients (mean age 48.9 years, range 19-75 years) were re-staged with 18F-FDG PET/CT before start of pre-operative systemic treatment (PST). Patients were divided in three groups based on risk for local recurrence: a low - (T2N0), intermediate - (T0-2N1 and T3N0) and a high-risk group (T0-3N2-3, T3N1 and T4). Within these groups we looked at local recurrence-free survival (LRFS), recurrence-free survival (RFS) and overall survival (OS) within the first 3 years of follow-up. RESULTS: With a median follow-up (FU) of 50 months the RFS, LRFS and OS were 87%, 88% and 92% respectively for the whole group. PET/CT upstaged 43 patients from the low- and intermediate risk group to the high-risk group, based on detection of ≥4 avid axillary nodes or occult N2/3-disease. Patients upstaged with PET/CT had more events for all three analyses compared to the original risk groups, which resulted in a significantly worse RFS (69.8%; p = 0.03) a nearly significantly worse LRFS (p = 0.052) and no effect in OS (p = 0.433). DISCUSSION: Additional PET/CT staging allows breast cancer patients to be treated according to the true stage, still stage II/III breast cancer patients upstaged to N2/3 by PET/CT have worse short-term outcome, despite adjustment of treatment, than patients staged high-risk with conventional imaging.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Carcinoma Ductal de Mama/tratamento farmacológico , Carcinoma Lobular/tratamento farmacológico , Adulto , Idoso , Axila , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/patologia , Carboplatina/administração & dosagem , Carcinoma Ductal de Mama/diagnóstico por imagem , Carcinoma Ductal de Mama/patologia , Carcinoma Lobular/diagnóstico por imagem , Carcinoma Lobular/patologia , Ciclofosfamida/administração & dosagem , Intervalo Livre de Doença , Doxorrubicina/administração & dosagem , Feminino , Fluordesoxiglucose F18 , Humanos , Linfonodos/patologia , Metástase Linfática , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estadiamento de Neoplasias , Paclitaxel/administração & dosagem , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Prognóstico , Compostos Radiofarmacêuticos , Trastuzumab/administração & dosagem , Adulto JovemRESUMO
PURPOSE: This review aims to discuss the methodological aspects of dedicated molecular breast imaging (MBI) using 99mTc-sestamibi as radiotracer to guide biopsy of occult or unclear breast lesions on mammography (MG) and ultrasound (US) that are suspicious on MBI (BI-RADS criteria 4 and 5), including its advantages, limitations and future clinical applications. METHODS: Literature search was performed using the PubMed/MEDLINE database and "99mTc-sestamibi", "biopsy" and "breast cancer" as keywords. The search was restricted to English language. RESULTS: There are few studies on 99mTc-sestamibi guided biopsy methods; to our knowledge, no full studies have yet been reported on clinical validation of this new biopsy procedure. This review describes technical aspects of 99mTc-sestamibi guided biopsy and discusses the advantages and limitations of this procedure in comparison with MG, US and MRI-guided biopsy. CONCLUSIONS: MBI-guided biopsy appears to be a complementary modality and is principally indicated in the case of occult or unclear breast lesions on MG/US, that are suspicious on MBI. The future indication is in targeted biopsies in patients with large heterogeneous tumours. Further studies are needed to define the accuracy of this biopsy procedure.
RESUMO
INTRODUCTION: Lymphoscintigraphy with planar imaging is considered a helpful tool to depict lymph node drainage in patients with invasive breast cancer. Single Photon Emission Computed Tomography with integrated CT (SPECT/CT) is usually performed to detect sentinel nodes (SN)s in breast cancer patients showing non-visualisation on lymphoscintigraphy. Incorporation of new SN indications (recurrent surgery, previous radiotherapy, or neo-adjuvant chemotherapy) has led to an increase of non-visualisation rates. The present study evaluates the contribution of SPECT/CT and tracer reinjection for SN-visualisation in breast cancer patients without drainage on lymphoscintigraphy. METHODS: Between 1st of July 2008 and 6th of November 2014 in total 1968 patients underwent a SN breast procedure, using intra-tumoural tracer administration. SPECT/CT was performed in 284 breast cancer patients with non-visualisation of SNs on lymphoscintigraphy. If SN non-visualisation persisted, a second radiotracer injection with repeated imaging was performed when logistics allowed this. Univariate analysis was applied to evaluate SPECT/CT visualisation rates in specific subgroups. RESULTS: The SPECT/CT visualisation rate was 23.2% (66/284). Univariate analysis revealed no significant subgroups influencing SPECT/CT visualisation. In patients receiving reinjection after persistent SPECT/CT non-visualisation the SN-visualisation rate reached 62.1% (36/58). Intraoperatively, the SN-identification rate using a gamma probe and blue dye was 87.9% (175/199) and 32.9% (28/85) for, respectively, primary and recurrent surgery after non-visualisation on lymphoscintigraphy. CONCLUSION: In this evaluation including new breast cancer SN indications, SPECT/CT scored lower than reinjection to visualise SNs in patients with non-visualisation on lymphoscintigraphy. Consequently, our institutional protocol has been readjusted.