Equipo multidisciplinar de cirugía radioguiada: Alternativa de cambio al paradigma actual / Multidisciplinary radio-guided surgery team: Alternative to change the current paradigm

IntroducciónAnte el aumento constante de la demanda asistencial de exploraciones relacionadas con cirugía radioguiada (CRG), nuestro hospital adoptó incluir en el equipo de CRG nuevos perfiles profesionales con el fin de reducir parcialmente el tiempo de dedicación de los médicos nucleares a esta tarea.Objetivos: Analizar el proceso de incorporación de los perfiles de Técnico Superior en Imagen para el Diagnóstico (TSID) y Enfermera Referente de Ganglio Centinela (ERGC), evaluando su despliegue en los procedimientos ligados a la técnica. Material y métodos: Análisis de la actividad de CRG durante el periodo 2018-2022, centrándolo en los procedimientos prequirúrgicos y quirúrgicos relativos a cáncer de mama (CaM) y melanoma maligno (MM), por ser aquellas patologías en las que se concentró la transferencia de competencias asistenciales. Evolución cronológica de las competencias asumidas por los diferentes perfiles durante su integración en el equipo de CRG. Resultados: La actividad asistencial de CRG durante el periodo analizado experimentó un incremento del 109%. CaM y MM son las patologías que aglutinaron con diferencia una mayor demanda asistencial. La transferencia de competencias en estas dos patologías se ha producido de manera progresiva, asumiendo en 2022 el 74% (460/622) de la fase de administración el ERGC y el 64% (333/519) de las cirugías el TSID. Conclusiones: La creación de un equipo multidisciplinar de CRG, que incluye distintos perfiles profesionales (MN, ERGC y TSID), es una eficaz estrategia para dar respuesta al incremento de la complejidad y número de todos los procedimientos relacionados con la CRG.(AU)

Introduction: Given the constant increase in the healthcare demand for examinations related to radio-guided surgery (RGS), our hospital adopted new professional profiles in the RGS team, in order to partially reduce the time spent by nuclear medicine physicians on this task. Aim: To analyze the process of incorporating the profiles of Superior Diagnostic Imaging Technician (TSID) and Sentinel Node Referent Nurse (ERGC), evaluating their deployment in the procedures linked to the technique. Material and methods: Analysis of RGS activity during the period 2018-2022, focusing on pre-surgical and surgical procedures related to breast cancer (BC) and malignant melanoma (MM), as they are those pathologies on which the transfer of care competencies was concentrated. Chronological evolution of the competencies assumed by the different profiles during their integration into the RGS team. Results: RGS's healthcare activity during the analyzed period experienced an increase of 109%. BC and MM were the pathologies that accounted for by far the greatest demand for care. The transfer of competencies in these two pathologies occurred in a progressive and staggered manner, with 74% (460/622) of the administration phase being carried out by the ERGC and 64% (333/519) of the surgeries by the TSID in 2022. Conclusions: The creation of a multidisciplinary RGS team that includes different professional profiles (NM, ERGC and TSID) is an effective strategy to respond to the increase in the complexity and number of all procedures related to RGS.(AU)

Multidisciplinary radio-guided surgery team: Alternative to change the current paradigm.

INTRODUCTION: Given the constant increase in the healthcare demand for examinations related to radio-guided surgery (RGS), our hospital adopted new professional profiles in the RGS team, in order to partially reduce the time spent by nuclear medicine physicians on this task. AIM: To analyze the process of incorporating the profiles of Diagnostic Imaging Technician (DIT) and Sentinel Node Referent Nurse (SNRN), evaluating their deployment in the procedures linked to the technique. MATERIAL AND METHODS: Analysis of RGS activity during the period 2018-2022, focusing on pre-surgical and surgical procedures related to breast cancer (BC) and malignant melanoma (MM), as they are those pathologies on which the transfer of care competencies was concentrated. Chronological evolution of the competencies assumed by the different profiles during their integration into the RGS team. RESULTS: RGS's healthcare activity during the analyzed period experienced an increase of 109%. BC and MM were the pathologies that accounted for by far the greatest demand for care. The transfer of competencies in these two pathologies occurred in a progressive and staggered manner, with 74% (460/622) of the administration phase being carried out by the SNRN and 64% (333/519) of the surgeries by the DIT in 2022. CONCLUSIONS: The creation of a multidisciplinary RGS team that includes different professional profiles (nuclear medicine physician [MN], ERGC and TSID) is an effective strategy to respond to the increase in the complexity and number of all procedures related to RGS.

Perfil enfermera referente de ganglio centinela: descripción, validación y aplicación en la práctica asistencial / Sentinal lymph node reference nurse model: description, validation, and application in clinical practice

Introducción En 2019 se genera la oportunidad de integrar un enfermero en el equipo de cirugía radioguiada (CRG), adaptando el modelo de enfermera referente a las exploraciones de ganglio centinela (GC). Objetivos Describir el procedimiento adoptado para definir el perfil enfermera referente de ganglio centinela (ERGC), validar su aplicación práctica y establecer su implementación asistencial. Material y métodos Metodología de análisis y mejora continua en gestión de procesos (ciclo PDCA): definición y planificación de las funciones de ERGC en el protocolo de cáncer de mama, realización prueba piloto con 20 pacientes y análisis de los datos de cara a validar el circuito y establecer su implementación asistencial. Resultados Se elaboraron flujos del procedimiento, integrando la figura de ERGC. En la prueba piloto, un 15% de las mujeres presentaron un resultado positivo de ansiedad frente a un 60% de valoración subjetiva positiva de ansiedad. Tras las intervenciones enfermeras realizadas, se obtuvo una reducción del 58,3% en valoración subjetiva de ansiedad, un 100% de conocimiento de la prueba y una valoración del dolor en la administración del radiotrazador aceptable en las pacientes. En el nivel de calidad técnica, 8/10 ítems valorados consiguieron el objetivo previamente establecido por el equipo de CRG. Conclusiones La creciente complejidad de la técnica de biopsia de GC ha creado la oportunidad de implementar cuidados enfermeros en el procedimiento de localización prequirúrgica del GC. El perfil ERGC es el idóneo para llevarlo a cabo y ha conllevado mejoras objetivas en los diagnósticos enfermeros e ítems evaluados (AU)

Introduction In 2019 the opportunity to add a nurse within the radioguided surgery (RGS) team was generated. The referent nurse model was adapted to, the sentinel node (SN) preoperative approaches. Objectives To describe the process performed to define the sentinel node referentnurse (SNRN) profile, to validate its practical application and to establish its clinical implementation. Material and methods Methodology of analysis and continuous improvement in the management of processes (cycle PDCA): Definition and planning of the SNRN functions in the breast cancer protocol, performance of a pilot test with 20 patients and analysis of the data in order to validate the circuit and establish its final clinical implementation. Results New procedure flows-charts were elaborated, adding the figure of the SNRN, its function and nursing interventions during the process. In the pilot test a 58.3% reduction in subjective anxiety, a 75% decrease of the overall anxiety level, a 100% knowledge of the test and an acceptable patient perception of pain's level during the radiotracer administration were obtained. Regarding technical quality, 8/10 items assessed reached the level previously established by the RGS team. Conclusions The increasing complexity of the SN biopsy technique has created the opportunity to implement nursing care in the presurgical SN localization process. The profile of the SNRN is ideal for carrying it out and has led to improvements in the nursing diagnoses and assessed items (AU)

Sentinel node referent nurse: Description, validation and application in clinical practice.

INTRODUCTION: In 2019 the opportunity to add a nurse within the radioguided surgery (RGS) team was generated. The referent nurse model was adapted to, the sentinel node (SN) preoperative approaches. OBJECTIVES: To describe the process performed to define the sentinel node referent nurse (SNRN) profile, to validate its practical application and to establish its clinical implementation. MATERIAL AND METHODS: Methodology of analysis and continuous improvement in the management of processes (cycle PDCA): definition and planning of the SNRN functions in the breast cancer protocol, performance of a pilot test with 20 patients and analysis of the data in order to validate the circuit and establish its final clinical implementation. RESULTS: New procedure flows-charts were elaborated, adding the figure of the SNRN, its function and nursing interventions during the process. In the pilot test a 58.3% reduction in subjective anxiety, a 75% decrease of the overall anxiety level, a 100% knowledge of the test and an acceptable patient perception of pain's level during the radiotracer administration were obtained. Regarding technical quality, 8/10 items assessed reached the level previously established by the RGS team. CONCLUSIONS: The increasing complexity of the SN biopsy technique has created the opportunity to implement nursing care in the presurgical SN localization process. The profile of the SNRN is ideal for carrying it out and has led to improvements in the nursing diagnoses and assessed items.

[Peri-ictal SPECT in temporal lobe epilepsy: post-surgical evaluation]. / SPECT periictal en la epilepsia del lóbulo temporal: valoración tras cirugía.

INTRODUCTION: our aim was to evaluate the usefulness of peri-ictal SPECT in localising the epileptogenic region (ER) in candidates for temporal lobectomy to treat medically refractory complex partial seizures (CPS). Interictal and ictal SPECT, MRI and video-EEG results were compared and the positive predictive value (PPV) was calculated in those patients with good surgical outcome. MATERIALS AND METHODS: 37 patients who had a minimum of 3 years follow-up after surgery were studied retrospectively. Pre-surgical evaluation had included video-EEG monitoring, MRI and interictal and ictal SPECT. These results were compared to the surgically treated ER and successful outcome confirmed by post-surgical clinical follow-up. 29/37 patients remained seizure-free in the post-surgical follow-up. Interictal and peri-ictal SPECT were performed using 740 MBq of 99mTc-HMPAO. Peri-ictal SPECT was ictal in 25 patients and postictal in 12. RESULTS: ER concordance with video-EEG and peri-ictal SPECT was 86% (32/37 patients). It was 84% (31/37) for MRI and 54% (20/37 patients) for interictal SPECT. Peri-ictal SPECT localised the ER in 8/11 patients with discordant MRI and video-EEG results. Ictal SPECT localised the ER in the correct temporal lobe in 23/25 patients (92% concordance). In the 29 patients with a good surgical outcome, the PPV of video-EEG was 95% (27/29) and it was 90% (26/29) for both MRI and peri-ictal SPECT. CONCLUSIONS: peri-ictal brain SPECT is well able to localize ER in patients with temporal lobe epilepsy. Periictal SPECT concordance with ER was as good as video-EEG and MRI and its PPV was as good as that of MRI. We strongly recommend its use in the pre-surgical evaluation of temporal lobe epilepsy, especially when MRI and EEG are discordant.

SPECT periictal en la epilepsia del lóbulo temporal: valoración tras cirugía / Peri-ictal SPECT in temporal lobe epilepsy: post-surgical evaluation

Introducción: el objetivo de este trabajo fue valorar la utilidad de la tomografía computarizada por emisión monofotónica (SPECT) periictal para localizar la región epileptógena (RE) en pacientes con crisis parciales complejas (CPC) del lóbulo temporal. Material y métodos: de forma retrospectiva se ha evaluado a 37 pacientes con CPC del lóbulo temporal a quienes se realizó una lobectomía temporal completa o selectiva. Para ello, se comparó la concordancia de la RE quirúrgica con los hallazgos de la resonancia magnética (RM), el videoelectroencefalograma (vídeo-EEG) y las SPECT cerebrales interictal y periictal. En segundo lugar, se valoró el valor predictivo positivo (VPP) de estas exploraciones en los 29 pacientes que presentaron un buen control de las crisis tras la cirugía. La SPECT se realizó tras la inyección de 740 MBq de 99mTc-HMPAO. Resultados: la concordancia de la RE quirúrgica con el vídeo-EEG, la RM, la SPECT icterictal y la SPECT periictal fue del 86% (32/37 pacientes), el 84% (31/37 pacientes), el 54% (20/37 pacientes) y el 86% (32/37 pacientes), respectivamente. En los 11 casos con RM y vídeo-EEG discordante o normal, la SPECT periictal fue decisivo en 8 (73%). En los 29 pacientes con evolución favorable tras la cirugía, el VPP del vídeo-EEG fue del 95% (27/29) y el de la RM y la SPECT periictal fue del 90% (26/29). Conclusiones: la concordancia de la RE quirúrgica con la SPECT periictal fue similar al del vídeo-EEG y la RM y tuvo el mismo VPP que la RM. Por ello, creemos que la SPECT periictal debe emplearse de forma sistemática en la evaluación prequirúrgica de la epilepsia del lóbulo temporal, especialmente cuando vídeo-EEG y RM son discordantes o normales(AU)

Introduction: our aim was to evaluate the usefulness of peri-ictal SPECT in localising the epileptogenic region (ER) in candidates for temporal lobectomy to treat medically refractory complex partial seizures (CPS). Interictal and ictal SPECT, MRI and video-EEG results were compared and the positive predictive value (PPV) was calculated in those patients with good surgical outcome. Materials and methods: 37 patients who had a minimum of 3 years follow-up after surgery were studied retrospectively. Pre-surgical evaluation had included video-EEG monitoring, MRI and interictal and ictal SPECT. These results were compared to the surgically treated ER and successful outcome confirmed by post-surgical clinical follow-up. 29/37 patients remained seizure-free in the post-surgical follow-up. Interictal and peri-ictal SPECT were performed using 740 MBq of 99mTc-HMPAO. Peri-ictal SPECT was ictal in 25 patients and postictal in 12. Results: ER concordance with video-EEG and peri-ictal SPECT was 86% (32/37 patients). It was 84% (31/37) for MRI and 54% (20/37 patients) for interictal SPECT. Peri-ictal SPECT localised the ER in 8/11 patients with discordant MRI and video-EEG results. Ictal SPECT localised the ER in the correct temporal lobe in 23/25 patients (92% concordance). In the 29 patients with a good surgical outcome, the PPV of video-EEG was 95% (27/29) and it was 90% (26/29) for both MRI and peri-ictal SPECT. Conclusions: peri-ictal brain SPECT is well able to localize ER in patients with temporal lobe epilepsy. Periictal SPECT concordance with ER was as good as video-EEG and MRI and its PPV was as good as that of MRI. We strongly recommend its use in the pre-surgical evaluation of temporal lobe epilepsy, especially when MRI and EEG are discordant(AU)

[Usefulness of bone scintigraphy for staging in a case of histiocytosis of the temporal bone]. / La gammagrafía ósea demuestra ser útil para el diagnóstico de extensión en un caso de histiocitosis X del hueso temporal.

We present the case of a 43-year-old man diagnosed of insipid diabetes and hypogonadotropic hypogonadism in whom a right temporal bone lesion was observed in the control MRI, thus leading to his admission. A bone scintigraphy with 99mTc-HMDP showed increased uptake in the right temporal region with sphenoidal extension, coinciding with the MRI. In addition, increased uptake having less intensity and size was observed in the left temporal region. A biopsy on the newly appearing mouth ulcers in the jugal mucous was performed and showed Langerhan's cells, the diagnosis of histiocytosis X being confirmed. Six months later a new MRI indicated disease progression with bilateral temporal involvement. The bone scan findings in this case provided a more exact extension diagnosis of the disease than the MRI.

La gammagrafía ósea demuestra ser útil para el diagnóstico de extensión en un caso de histiocitosis X del hueso temporal / Usefulness of bone scintigraphy for staging in a case of histiocytosis od the temporal bone

Exponemos el caso de un varón de 43 años diagnosticado de diabetes insípida e hipogonadismo hipogonadotropo, que en la RM craneal de control se objetivó una lesión extraaxial temporal derecha, motivo por el que fue ingresado. Se realizó una gammagrafía ósea que describió un aumento de captación de Tc99m-HMDP en región temporal derecha con extensión esfenoidal, coincidente con la RM. Además, en región temporal izquierda se observó una hipercaptación de menor intensidad y tamaño. Se realizó biopsia sobre úlceras bucales de nueva aparición en mucosa yugal que mostró células de Langerhans, estableciéndose el diagnóstico de histiocitosis X. Al cabo de 6 meses se realizó una nueva RM que demostró progresión de la enfermedad, con afectación temporal bilateral. Los hallazgos de la gammagrafía ósea, dieron lugar en este caso a un diagnóstico de extensión de la enfermedad más preciso que la RM

We present the case of a 43-year-old man diagnosed of insipid diabetes and hypogonadotropic hypogonadism in whom a right temporal bone lesion was observed in the control MRI, thus leading to his admission. A bone scintigraphy with 99mTc-HMDP showed increased uptake in the right temporal region with sphenoidal extension, coinciding with the MRI. In addition, increased uptake having less intensity and size was observed in the left temporal region. A biopsy on the newly appearing mouth ulcers in the jugal mucous was performed and showed Langerhan's cells, the diagnosis of Histiocytosis X being confirmed. Six months later a new MRI indicated disease progression with bilateral temporal involvement. The bone scan findings in this case provided a more exact extension diagnosis of the disease than the MRIWe present the case of a 43-year-old man diagnosed of insipid diabetes and hypogonadotropic hypogonadism in whom a right temporal bone lesion was observed in the control MRI, thus leading to his admission. A bone scintigraphy with 99mTc-HMDP showed increased uptake in the right temporal region with sphenoidal extension, coinciding with the MRI. In addition, increased uptake having less intensity and size was observed in the left temporal region. A biopsy on the newly appearing mouth ulcers in the jugal mucous was performed and showed Langerhan's cells, the diagnosis of Histiocytosis X being confirmed. Six months later a new MRI indicated disease progression with bilateral temporal involvement. The bone scan findings in this case provided a more exact extension diagnosis of the disease than the MRI

[Usefulness of pilocarpine in the prevention of xerostomia in patients with head and neck cancer treated with radiotherapy. Assessment with gammagraphy and salivary flow]. / Utilidad de la pilocarpina como profiláctico de xerostomía en pacientes con cáncer de cabeza y cuello tratados con radioterapia. Valoración mediante gammagrafía y flujo salivar.

AIM: To assess the utility of salivary gland scintigraphy and salivary flow to quantify salivary function and to evaluate the usefulness of pilocarpine in the treatment of radiation-induced xerestomia in head and neck cancer patients. METHOD: Thirty two patients with head and neck tumor treated with radiotherapy (RDT) were studied. Patients were classified into two groups: pilocarpine group (P), that received prophylactic pilocarpine before RDT and during the first year after treatment. No pilocarpine group (NP) that received RDT without pilocarpine. Salivary gland scintigraphy and salivary flow were performed before RDT and during one year after treatment. Parotid and submaxillary uptake and excretion were calculated. Salivary flow after stimulation during five minutes was also obtained. RESULTS: Uptake and excretion in both salivary glands decreased after RDT. There were no statistical differences comparing P and NP groups (p < 0.001). However, in group P a trend to recovery was observed in parotid uptake values at 12 months after treatment, but it was not statistically significant. In both groups the salivary flow decreased after RDT and a good correlation (r = 0.8) between salivary flow and submaxillary excretion and parotid excretion was found. CONCLUSIONS: Salivary gland scintigraphy and salivary flow could be useful to evaluate salivary gland function in patients with head and neck irradiated tumors. Although better results on the salivary uptake at 12 months were noted, pilocarpine did not significantly improve salivary gland function.

[111In-pentetreotide in the study of tumors expressing somatostatin receptors]. / 111In-pentetreótida en el estudio de tumores que expresan receptores para la somatostatina.

UNLABELLED: The usefulness of 111In-pentetreotide scintigraphy in the diagnosis of neuroendocrine tumors was evaluated. MATERIAL AND METHOD: 39 patients with clinical or biochemical suspicion of neuroendocrine tumors were studied. 29 patients underwent surgery and diagnosis was confirmed by anatomopathology findings (7 mixed tumors, 6 carcinoids, 3 insulinomas, 3 pheocromocytomas, 2 glucagonomas, 2 medullary thyroid carcinomas, 1 gastrinoma and 5 metastatic lesions). In 10 patients who did not undergo surgery, the diagnostic criteria were based on a 6 month follow-up. 111In-pentetreotide scintigraphy and computed tomography (CT) were performed in all of the patients. RESULTS: The scintigraphy correctly detected 58% of the primary tumors while the CT was positive in only 45% of the cases. Both techniques detected metastasis in 5 patients. CONCLUSION: 111In-pentetreotide scintigraphy is a useful technique to diagnose those tumors that have somatostatin receptors. In our series, the sensitivity of this method was higher than the CT.