Prognostic 18F-FDG Radiomic Features in Advanced High-Grade Serous Ovarian Cancer.

High-grade serous ovarian cancer (HGSOC) is an aggressive disease with different clinical outcomes and poor prognosis. This could be due to tumor heterogeneity. The 18F-FDG PET radiomic parameters permit addressing tumor heterogeneity. Nevertheless, this has been not well studied in ovarian cancer. The aim of our work was to assess the prognostic value of pretreatment 18F-FDG PET radiomic features in patients with HGSOC. A review of 36 patients diagnosed with advanced HGSOC between 2016 and 2020 in our center was performed. Radiomic features were obtained from pretreatment 18F-FDGPET. Disease-free survival (DFS) and overall survival (OS) were calculated. Optimal cutoff values with receiver operating characteristic curve/median values were used. A correlation between radiomic features and DFS/OS was made. The mean DFS was 19.6 months and OS was 37.1 months. Total Lesion Glycolysis (TLG), GLSZM_ Zone Size Non-Uniformity (GLSZM_ZSNU), and GLRLM_Run Length Non-Uniformity (GLRLM_RLNU) were significantly associated with DFS. The survival-curves analysis showed a significant difference of DSF in patients with GLRLM_RLNU > 7388.3 versus patients with lower values (19.7 months vs. 31.7 months, p = 0.035), maintaining signification in the multivariate analysis (p = 0.048). Moreover, Intensity-based Kurtosis was associated with OS (p = 0.027). Pretreatment 18F-FDG PET radiomic features GLRLM_RLNU, GLSZM_ZSNU, and Kurtosis may have prognostic value in patients with advanced HGSOC.

Soft Tissue Aneurysmal Bone Cyst in the Sartorius Muscle of a 13-Year-Old Boy Mimicking Myositis Ossificans: Case Report.

INTRODUCTION: A soft tissue aneurysmal bone cyst is an extremely rare tumor. The objective of the article is to present the clinical, radiological, and histopathological features of a very unusual neoplasm of soft tissues. CASE REPORT: A 13-year-old male patient presented a painful, mobile, and rapidly growing mass on the posteromedial aspect of his left knee. Imaging studies revealed a mass that arose from the medial surface of the distal sartorius muscle, with extension to the subcutaneous fat tissue. It was a well-circumscribed solid tumor with a peripheral rim calcification on plain film, computerized tomography, and ultrasound (zonal phenomenon). On magnetic resonance imaging, a heterogenous mass on T1-weighted images (WI) and T2-WI was seen, with a peripheral hypointense rim in both sequences. An outstanding edema on T2-WI extending to the soft tissue and muscles of the medial compartment of the knee was detected. The mass was resected, and the "tumoral mimickers" histopathological and molecular (next-generation sequencing) diagnoses confirmed a soft tissue aneurysmal bone cyst. A follow-up showed that the patient was free of disease 12 months after surgery. CONCLUSION: Soft tissue aneurysmal bone cyst is a rare tumor. Appropriate clinical and radiological correlation should be performed to differentiate it from other tumor mimickers.

Failure of scintigraphy lymphatic mapping in endometrial cancer. Causes and solutions.

AIM: To evaluate the effect of technical problems and patient characteristics on sentinel lymph node (SLN) scintigraphic detection and mapping success in early stages of endometrial cancer (EC). METHODS: Patients with clinical early stage EC (IA-IB) underwent SLN mapping using technetium-99m-nanocolloid, between September 2011 and February 2020 were included. There were excluded cases with technical problems, 92 patients were included for the analysis of the diagnostic performance and the relation of mapping failure (pelvic unilateral or not detected SLN) with patient (age, body mass index, previous pelvic disease or surgery) and disease characteristics (histology, grade, myometrial invasion, lymphovascular space infiltration, tumor size, and lymphatic infiltration risk). RESULTS: The overall detection rate was 79%. Lymph node metastases were diagnosed in 7 patients. Age (P = .01), depth of myometrial invasion ≥50% (P = .04) and high risk of lymphatic infiltration (P = .02) were positively associated with mapping failure. In multivariate analysis, age was significantly associated with mapping failure [odds ratio = 1.63, 95%CI: 1.06-2.50; P = .027]. CONCLUSIONS: Age, depth of myometrial invasion and high risk of lymphatic infiltration were the factors associated with higher mapping failure. An individualized injection technique, optimizing the methodology, could minimize the detection failures.

Low-Grade Versus High-Grade Glioma That Is the Question. 18F-Fluorocholine PET in the Detection of Anaplastic Focus.

Gliomas are characterized by intratumoral histological heterogeneity, coexisting foci of low and high grade. First, in low-grade gliomas, neoangiogenesis has not yet developed and cellularity is low, so alterations on perfusion MRI may not be present. Second, a non-negligible number of high-grade gliomas show none, patchy, or weak contrast enhancement on MRI, so they can be misdiagnosed as low-grade glioma, preventing their correct management. We present 4 cases of patients in which F-fluorocholine PET defined the anaplastic tumor component and therefore the tumor aggressiveness, solving the limitations of MRI.

Usefulness of CA125 and its kinetic parameters and positron emission tomography/computed tomography (PET/CT) with fluorodeoxyglucose ([18F] FDG) in the detection of recurrent ovarian cancer / Utilidad del CA125 y sus parámetros cinéticos y de la tomografía por emisión de positrones/tomografía computarizada (PET/TC) con fluorodesoxiglucosa ([18F]FDG) en la detección de la recidiva del cáncer de ovario

Background and objective: To assess the usefulness of cancer antigen 125 (CA125) serum levels and kinetic values, velocity (CA125vel) and doubling time (CA125dt), as well as fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT), in the detection of ovarian cancer recurrence. To assess the optimal cut-off for CA125, CA125vel and CA125dt to detect relapse with [18F]FDG-PET/CT. Material and methods: A retrospective analysis was performed of 59 [18F]FDG-PET/CT (48 patients) for suspected recurrence of ovarian cancer. Receiver operating characteristic (ROC) curves were plotted and area-under-the curve (AUC) statistics were computed for CA125, CA125vel and CA125dt. The results obtained in the group with normal and high (>35U/ml) CA125 levels were compared. Results: Forty-four cases of recurrence were diagnosed (7 had CA125 ≤35U/ml), whereas 15 showed no disease. All of them were correctly catalogued by PET/CT. In ROC analysis, the discriminatory power of CA125 was relatively high (AUC 0.835) and the optimal cut-off point to reflect active disease was 23.9U/ml. The ROC analyses for the CA125vel and CA125dt showed an AUC of 0.849 and 0.728, respectively, with an optimal cut-off point of 1.96U/ml/month and 0.76 months, respectively. In patients with normal CA125 and recurrence of ovarian cancer, the CA125vel was significantly higher than in patients without recurrence (p=0.029). Conclusion: [18F]FDG-PET/CT is more accurate than CA125 parameters in the detection of ovarian cancer recurrence. CA125 serum levels are essential; nevertheless, CA125 kinetic values must be considered to detect relapse. Particularly in patients with CA125 within normal values, in which a higher CA125vel is indicative of recurrence

Fundamento y objetivo: Valorar en la recidiva del cáncer de ovario la utilidad del CA125 y sus parámetros cinéticos, velocidad (CA125vel) y tiempo de duplicación (CA125td), y de la tomografía por emisión de positrones/tomografía computarizada (PET/TC) con fluorodesoxiglucosa ([18F]FDG). Determinar el valour óptimo del CA125, CA125vel y CA125td para detectar recidiva con [18F]FDG-PET/TC. Material y métodos: Análisis retrospectivo de 59 estudios [18F]FDG-PET/TC en 48 pacientes con sospecha de recidiva de cáncer de ovario platino-sensible. Realizamos un análisis ROC (Receiver operating characteristic) y el área bajo la curva (AUC) para el CA125, CA125vel, CA125td. Comparamos los resultados entre los grupos con CA125 dentro de la normalidad y CA125 patológico (>35U/ml). Resultados: Fueron diagnosticados de recidiva 44 casos (7 con CA125 ≤35U/ml), mientras que 15 no mostraron recurrencia. Todos ellos fueron correctamente catalogados mediante la PET/TC. La curva ROC demostró una capacidad discriminatoria del CA125 relativamente alta (AUC 0.835), con un valour óptimo de referencia de 23.9U/ml. El análisis ROC para la CA125vel y el CA125td mostró un AUC de 0.849 y 0.728, con un valour de referencia de 1.96U/ml/mes y 0.76 meses, respectivamente. En las pacientes con CA125 en límites normales la CA125vel fue significativamente mayor en las pacientes con recidiva que en aquellas sin enfermedad (p=0.029). Conclusión: La [18F]FDG-PET/TC es más exacta que los parámetros de CA125 en la detección de recurrencia de cáncer de ovario. Los niveles séricos de CA125 resultan esenciales, no obstante, los parámetros cinéticos deben ser tenidos en cuenta en la detección de la recidiva

Value of [18F]FDG-PET/CT and CA125, serum levels and kinetic parameters, in early detection of ovarian cancer recurrence: Influence of histological subtypes and tumor stages.

To assess the diagnostic accuracy of CA125, its kinetic values and positron emission tomography/computed tomography with 2-deoxy-2-[F]fluoro-D-glucose ([F]FDG-PET/CT), in relation with tumor characteristics for suspected recurrence of ovarian cancer. To evaluate the performance of CA125-related parameters as a selection criteria to perform a [F]FDG-PET/CT.A retrospective analysis of 69 [F]FDG-PET/CT for suspected recurrence of ovarian cancer was performed. All patients had 2 measurements of CA125, before PET/CT, to calculate kinetic values, as CA125vel (CA125vel = [CA125a - CA125b]/time) and CA125dt (CA125dt = [log2 × time]/[logCA125a - CA125b]). Maximum standard uptake value (SUVmax) was calculated. The diagnostic accuracy was calculated for all the variables and the optimal cut-off value of each of them by the receiver-operating characteristics (ROC) analysis. All the tests were compared with tumor characteristics and clinical-radiological evolution during follow-up of at least 6 months.Fifty-five cases were diagnosed of recurrence (11 with CA125 <35 U/mL), while 14 showed no disease (11 with CA125 < 35 U/mL). All of them were correctly cataloged by PET/CT. CA125, CA125vel, and SUVmax showed higher levels in recurrent patients (mean 129.54 U/mL, 24.58 U/mL per mo, and 8.69 g/mL, respectively) than in nonrecurrent (mean 20.35 U/mL, 0.60 U/mL per mo, and 0.64 g/mL, respectively). No statistical differences in CA125dt were found. Patients with recurrence of high-grade serous carcinoma (HGSC) showed higher CA125 and CA125vel, without differences in the rest of subtypes and International Federation of Gynecology and Obstetrics stages. The ROC analyses for CA125, CA125vel, and CA125dt showed an area under the curve (AUC) of 0.873 (95% confidence interval [CI] 0.77-0.969), 0.903 (95% CI 0.813-0.994), and 0.727 (95% CI 0.542-0.913), respectively, with an optimal cut-off point of 23.95 U/mL, 4.49 U/mL per mo, and 3.36 months, respectively, while for the SUVmax the AUC was of 0.982 (95% CI 0.948-1.000), and the cut-off point of 2. Multivariate regression analysis identified CA125 and CA125vel as predictors of recurrence.[F]FDG-PET/CT is more accurate than the parameters obtained from the CA125 to detect early recurrence. CA125vel is the most suitable parameter, mainly in HGSC. Levels of CA125vel ≥ 4.49 U/mL per mo facilitate earlier detection by the execution of a [F]FDG-PET/CT. The calculation of these parameters is independent of tumor stage at diagnosis.

Usefulness of CA125 and its kinetic parameters and positron emission tomography/computed tomography (PET/CT) with fluorodeoxyglucose ([18F] FDG) in the detection of recurrent ovarian cancer.

BACKGROUND AND OBJECTIVE: To assess the usefulness of cancer antigen 125 (CA125) serum levels and kinetic values, velocity (CA125vel) and doubling time (CA125dt), as well as fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT), in the detection of ovarian cancer recurrence. To assess the optimal cut-off for CA125, CA125vel and CA125dt to detect relapse with [18F]FDG-PET/CT. MATERIAL AND METHODS: A retrospective analysis was performed of 59 [18F]FDG-PET/CT (48 patients) for suspected recurrence of ovarian cancer. Receiver operating characteristic (ROC) curves were plotted and area-under-the curve (AUC) statistics were computed for CA125, CA125vel and CA125dt. The results obtained in the group with normal and high (>35U/ml) CA125 levels were compared. RESULTS: Forty-four cases of recurrence were diagnosed (7 had CA125 ≤35U/ml), whereas 15 showed no disease. All of them were correctly catalogued by PET/CT. In ROC analysis, the discriminatory power of CA125 was relatively high (AUC 0.835) and the optimal cut-off point to reflect active disease was 23.9U/ml. The ROC analyses for the CA125vel and CA125dt showed an AUC of 0.849 and 0.728, respectively, with an optimal cut-off point of 1.96U/ml/month and 0.76 months, respectively. In patients with normal CA125 and recurrence of ovarian cancer, the CA125vel was significantly higher than in patients without recurrence (p=0.029). CONCLUSION: [18F]FDG-PET/CT is more accurate than CA125 parameters in the detection of ovarian cancer recurrence. CA125 serum levels are essential; nevertheless, CA125 kinetic values must be considered to detect relapse. Particularly in patients with CA125 within normal values, in which a higher CA125vel is indicative of recurrence.

Role of 99mTc-HYNIC-Tyr3-octreotide scintigraphy in neuroendocrine tumors based on localization of the primary tumor.

BACKGROUND: The aim of our work was to determine the accuracy of 99mTc-HYNIC Tyr3 octreotide scintigraphy (TcOS) in detecting active disease in neuroendocrine tumors (NETs) based on embryological origin of the primary tumor (foregut, midgut or hindgut). METHODS: We analyzed retrospectively 45 studies (12 staging, 26 suspicion of recurrence, and 7 treatment response) belonging to 33 patients with histological confirmation of NETs. Whole body scan and a SPECT-CT were acquired 4 hours post-injection of 740 MBq of 99mTc-HYNIC Tyr3 octreotide. The studies were divided into 3 groups based on the embryological origin of primary tumor (foregut [group 1], midgut [group 2] and hindgut [group 3]). The accuracy of TcOS in each group was assessed, included chi-square analyses. The final diagnosis was established by histopathology or clinical/radiological follow-up greater than 6 months. RESULTS: The localization of the primary tumor per patient revealed that 58% were from the foregut, 30% from the midgut and 12% from the hindgut. In study-based analysis (45 studies), TcOS showed an overall sensitivity, specificity and accuracy of 95%, 92% and 93% respectively. The accuracy per studies for the groups 1, 2 and 3 were: 100%, 92% and 66% respectively, demonstrating a better detection of active disease in primary tumors from foregut and midgut compared to hindgut (P=0.02). CONCLUSIONS: The accuracy of TcOS in the assessment of NETs seems to be better in tumors with foregut and midgut origin, showing a possible relationship between the embryological origin of NETs and detection of active disease by TcOS.

Comparison of different predictive tools of axillary status in breast cancer with micrometastatic sentinel node.

AIM: To compare the performance of six different nomograms and one score in the prediction of non-sentinel lymph node status in a subset of women with breast cancer and micrometastatic sentinel nodes (SN). MATERIAL AND METHODS: Twenty-five patients were included in the study. Five different nomograms not specifically designed for micrometastatic SN, one recently published nomogram specially developed for this type of patients and one score were analyzed, and the corresponding receiver operating characteristic curves were obtained. The area under the curve (AUC) was calculated, as well as the false negative and false positive results and their corresponding rates (FNR and FPR) for a cutoff of ≤10% or ≤4 points. RESULTS: The Memorial Sloan Kettering Cancer Center (MSKCC) nomogram showed the best performance in this low-risk group of patients (AUC 0.900, FPR 64%, FNR 0%), followed by the French nomogram. CONCLUSIONS: The MSKCC nomogram seems to have the highest accuracy in the identification of patients with low risk of further axillary disease in the subgroup of women with micrometastatic SN.

Semi-quantitative lymph node assessment of (18)F-FDG PET/CT in locally advanced breast cancer: correlation with biological prognostic factors.

PURPOSE: The aim of this study was to analyse the correlation between dual-time-point (18)F-2-deoxy-2-fluoro-D-glucose (FDG) uptakes in lymph nodes assessed by positron emission tomography (PET)/CT and histopathological and immunohistochemical prognostic factors. METHODS: Seventy-five women with locally advanced breast cancer were prospectively evaluated. PET/CT was requested in the initial staging previous to adjuvant chemotherapy (multicentre study). All of the patients underwent (18)F-FDG PET/CT with a dual-time-point acquisition. Both examinations were evaluated qualitatively and semi-quantitatively with calculation of maximum standardized uptake values (SUV(max)) in PET-1 (SUV-1) and in PET-2 (SUV-2) and the percentage variation of the SUV or retention index (RI) between PET-1 and PET-2 in lymph nodes with the greater (18)F-FDG uptake. The biological prognostic parameters such as the steroid receptor status, p53 and HER2 expression, proliferation rate (Ki-67) and grading were determined from tissue of the primary tumour. Metabolic and biological parameters were correlated using Spearman's rank-order correlation coefficient and Mann-Whitney U and Kruskal-Wallis tests. RESULTS: Negative receptor status was correlated with higher SUV-1, SUV-2 and RI in lymph nodes. The results were significant for progesterone receptor status. p53 over-expression and triple-negative status were associated with greater semi-quantitative parameters in lymph nodes. Higher tumoural grades were related with greater semi-quantitative parameters (p > 0.05). CONCLUSION: Biological factors of bad prognosis were correlated with higher semi-quantitative metabolic values in lymph nodes. Therefore these results appear to reveal biological significance of lymph node (18)F-FDG accumulation.

18F-FDG retention index and biologic prognostic parameters in breast cancer.

AIM: To analyze the correlation between [(18)F]-fluoro-2-deoxy-D-glucose (F-FDG) uptake assessed by positron emission tomography/computed tomography (PET/CT) in breast tumors and histopathologic and immunohistochemical prognostic factors. MATERIAL AND METHODS: Sixty-eight women with breast cancer were prospectively evaluated. PET/CT was requested in the initial staging previous to neoadjuvant chemotherapy (multicentric study).All the patients underwent a standard (18)F-FDG PET/CT followed by a delayed acquisition, 1 hour (PET-1) and 3 hours (PET-2) after FDG administration. Both examinations were evaluated qualitatively and semiquantitatively (SUV(max) values) in PET-1 (SUV-1) and in PET-2 (SUV-2). The percentage variation of the standard uptake values (retention index) between PET-1 and PET-2 was calculated.Clinical and metabolic stages were assessed according to TNM classification. All biologic prognostic parameters, such as the receptor status, p53 and c-erbB-2 expression, proliferation rate (Ki-67), and grading were determined from tissue of the primary tumor. Metabolic, clinical, and biologic parameters were correlated. RESULTS: A positive relationship was found between the SUV(max), tumor size, clinical, and metabolic stages. SUV-1 and SUV-2 values showed significant statistical correlation (P < 0.05) with PET stage and tumor size assessed by PET. On the contrary, the retention index showed relation with clinical stage (P < 0.05).When related to the biologic parameters, retention index showed the best results, with positive and significant relation (P < 0.05), with histologic grade, and Ki-67 and c-erbB-2 expression. Isolated SUV values only showed significant relation to Ki-67 expression. CONCLUSION: The retention index showed the best relation with biologic and clinical parameters compared with isolated SUVmax values for what could be a predictive marker of tumor biologic behavior.

Impact of radioguided occult lesion localization on the correct excision of malignant breast lesions: effect of histology and tumor size.

AIM: To evaluate the impact of radioguided occult lesion localization (ROLL) in the correct location and excision of malignant breast lesions, and analyze if these results are affected by the histology and tumor size. MATERIALS AND METHODS: A total of 105 patients with occult breast lesions were studied. The mean age was 55 years. An intralesional dose of 18.5 MBq of 99mTc-labeled macroaggregated human albumin (AMA) was administered using stereotaxic mammography or ultrasound. Surgical resection was carried out with the help of a gammadetector probe. In the histological study, disease-free margin was defined by a distance between the tumor lesion and the surgical margin of more than 1 mm. The possible influence of tumor histology and lesion diameter with respect to free/affected margins was analyzed. RESULTS: Correct radiotracer placement was achieved in 100/105 of the cases (95.2%). In the remaining 5 cases (4.8%), radiotracer placement was incorrect, with 2 of them being malignant lesions that were found by macroscopic inspection, and the other 3 having benign pathology. Among the malignant lesions (44 cases), correct placement of the radiotracer was achieved in 42 cases (95.5%). Of these 42 malignant lesions, in which the ROLL was correctly performed, free surgical margins were obtained in 24 cases (57.1%), while the other 18 (42.9%) had infiltrated surgical margins. The most common histological type among the malignant lesions was invasive ductal carcinoma (71.4%). The histological types with an increased frequency of infiltration of surgical margins were invasive and microinvasive cancer (94.4%). All the affected margins were in lesions greater than 10 mm, and the highest incidence was in those between 20 and 30 mm (55.5%). CONCLUSION: In our experience, the advantages of the ROLL technique are a precise localization of malignant breast lesions (95.5%) and an increased probability of a complete excision with free margins in more than one half of them. Nevertheless, special consideration should be taken when dealing with invasive and microinvasive cancers and in those exceeding 10 mm because of their higher incidence of infiltrated margins.

Cirugía mamaria radioguiada. Evolución del uso de técnicas miniinvasivas y situación actual / Radioguided breast surgery. Evolution of the use of minimal-invasive technologies and current situation

El aumento en la detección de lesiones no palpables de mama ha permitido el desarrollo de métodos de localización mediante el uso de radiofármacos que nos permiten una óptima cirugía de extirpación “ahorradora” y, simultáneamente, la biopsia del ganglio centinela en los casos de cáncer mamario. Revisamos la bibliografía actual acerca del tema y se aprecia una eclosión de artículos sobre cirugía radioguiada en numerosos y destacados grupos de trabajo mundiales que reflejan la bondad del método, así como su eficacia y atractivo para unos cirujanos que apuestan cada vez más por la excelencia en su labor diaria. Aportamos también nuestra experiencia como grupo funcional que se extiende a 413 intervenciones sobre lesiones no palpables realizadas de forma radioguiada (ROLL) y en 229 casos de afección maligna (75%) ha sido posible simultanear con la biopsia del ganglio centinela (SNOLL). El interés que ha despertado la técnica no debe estar exento de un espíritu crítico pero innovador y reflexivo para poder analizar de forma correcta los resultados obtenidos por cada grupo, conscientes de que estamos ante métodos en que intervienen varias especialidades y cada una deberá aportar la máxima eficiencia (AU)

The increase in the detection of occult lesions has led to the development of new localisation methods using radiopharmaceutical products. The use of these products allows us to perform a “thrifty” (less-aggressive) surgical excision and, to simultaneously carry out the biopsy of the sentinel node in cases of breast cancer. On making a search for the most up to date references on this particular topic, we found many articles on radioguided surgery by many leading international work groups. These articles clearly show the advantages of the radioguided surgery method, its effectiveness and attractiveness to surgeons who are very much involved in the search for excellence in their daily work. We also contribute our experience as a functional group, with 413 interventions on occult lesions performed using the radioguided method (ROLL). In 229 cases out of these 413, we found a malignancy (75%); in all these 229 cases it was possible to perform the intervention simultaneously with the biopsy of the sentinel node (SNOLL), during the same surgical act. However the interest created by the new procedure, it is essential to keep a critical but innovative and reflexive mind on this issue, in order to accurately analyze the results obtained by each group. We must remember that these types of methods involve several clinical specialties and, therefore, each one will have to contribute with the highest efficiency

[Radioguided breast surgery. Evolution of the use of minimal-invasive technologies and current situation]. / Cirugía mamaria radioguiada. Evolución del uso de técnicas miniinvasivas y situación actual.

The increase in the detection of occult lesions has led to the development of new localisation methods using radiopharmaceutical products. The use of these products allows us to perform a "thrifty" (less-aggressive) surgical excision and, to simultaneously carry out the biopsy of the sentinel node in cases of breast cancer. On making a search for the most up to date references on this particular topic, we found many articles on radioguided surgery by many leading international work groups. These articles clearly show the advantages of the radioguided surgery method, its effectiveness and attractiveness to surgeons who are very much involved in the search for excellence in their daily work. We also contribute our experience as a functional group, with 413 interventions on occult lesions performed using the radioguided method (ROLL). In 229 cases out of these 413, we found a malignancy (75%); in all these 229 cases it was possible to perform the intervention simultaneously with the biopsy of the sentinel node (SNOLL), during the same surgical act. However the interest created by the new procedure, it is essential to keep a critical but innovative and reflexive mind on this issue, in order to accurately analyze the results obtained by each group. We must remember that these types of methods involve several clinical specialties and, therefore, each one will have to contribute with the highest efficiency.