We aimed to assess the additional value of SPECT/CT over planar lymphoscintigraphy (PI) in sentinel node (SN) detection in malignancies with different lymphatic drainage such as breast cancer, melanoma, and pelvic tumors. Methods: From 2010 to 2013, 1,508 patients were recruited in a multicenter study: 1,182 breast cancer, 262 melanoma, and 64 pelvic malignancies (prostate, cervix, penis, vulva). PI was followed by SPECT/CT 1-3 h after injection of 99m Tccolloid particles. Surgery was performed the same or next day. Results: Significantly more SNs were detected by SPECT/CT for breast cancer (2,165 vs. 1,892), melanoma (602 vs. 532), and pelvic cancer (195 vs. 138), all P , 0.001. The drainage basin mismatch between PI and SPECT/CT was 16.5% for breast cancer, 11.1% for melanoma, and 51.6% for pelvic cancers. Surgical adjustment was 17% for breast cancer, 37% for melanoma, and 65.6% for pelvic cancer. Conclusion: SPECT/CT detected more SNs and changed the drainage territory, leading to surgical adjustments in a considerable number of patients in all malignancies studied but especially in the pelvic cancer group because of this group's deep lymphatic drainage. We recommend SPECT/CT in all breast cancer patients with no SN visualized on PI, all patients with melanoma of the head and neck or trunk, all patients with pelvic malignancies, and those breast cancer and melanoma patients with unexpected drainage on PI. The status of regional lymph nodes is a major prognostic factor in many malignant tumors. Sentinel lymph node (SN) biopsy in patients with clinically node-negative tumors is a validated technique for accurate staging of nodal disease in breast cancer (1,2) and melanoma (3,4) and is being used with promising results in other solid tumors including pelvic malignancies (5,6). The use of SN mapping in an increasing list of tumors shows a variety of lymphatic drainage basins containing the SN (7). SNs are the lymph nodes draining the primary tumor and therefore the most likely to contain tumor cells spreading to the drainage basin (8). Assuming an orderly progression of lymph flow, the tumor status of the SN predicts the status of the regional draining basin (1). Selective SN biopsy enables the detection of metastatic and occult micrometastatic nodal involvement by thorough histopathologic examination in the intraoperative setting, sparing patients a systematic regional lymphadenectomy when the node is negative.Planar lymphoscintigraphy (PI) after local injection of radiocolloid is well suited for the mapping of regional lymph nodes, but occasionally no SNs are visualized, for instance, in obese patients or when SNs are located too close to the injection site. In addition, the anatomic information provided by planar scintigraphy is limited and the exact SN location is difficult to define in deeply located nodes (9,10). Unexpected basin drainage sites and unpredictable pathways also hinder interpretation of planar images. Because of its superior contrast, resolution, and display of exact anatomic landmarks, SPECT...
Hybrid tracers that are both radioactive and fluorescent help extend the use of fluorescence-guided surgery to deeper structures. Such hybrid tracers facilitate preoperative surgical planning using (3D) scintigraphic images and enable synchronous intraoperative radio- and fluorescence guidance. Nevertheless, we previously found that improved orientation during laparoscopic surgery remains desirable. Here we illustrate how intraoperative navigation based on optical tracking of a fluorescence endoscope may help further improve the accuracy of hybrid surgical guidance. After feeding SPECT/CT images with an optical fiducial as a reference target to the navigation system, optical tracking could be used to position the tip of the fluorescence endoscope relative to the preoperative 3D imaging data. This hybrid navigation approach allowed us to accurately identify marker seeds in a phantom setup. The multispectral nature of the fluorescence endoscope enabled stepwise visualization of the two clinically approved fluorescent dyes, fluorescein and indocyanine green. In addition, the approach was used to navigate toward the prostate in a patient undergoing robot-assisted prostatectomy. Navigation of the tracked fluorescence endoscope toward the target identified on SPECT/CT resulted in real-time gradual visualization of the fluorescent signal in the prostate, thus providing an intraoperative confirmation of the navigation accuracy.
Purpose This study aimed to update the clinical practice applications and technical procedures of sentinel lymph node (SLN) biopsy in vulvar cancer from European experts. Methods A systematic data search using PubMed/MEDLINE database was performed up to May 29, 2019. Only original studies focused on SLN biopsy in vulvar cancer, published in the English language and with a minimum of nine patients were selected. Results Among 280 citations, 65 studies fulfilled the inclusion criteria. On the basis of the published evidences and consensus of European experts, this study provides an updated overview on clinical applications and technical procedures of SLN biopsy in vulvar cancer. Conclusions SLN biopsy is nowadays the standard treatment for well-selected women with clinically negative lymph nodes. Negative SLN is associated with a low groin recurrence rate and a good 5-year disease-specific survival rate. SLN biopsy is the most cost-effective approach than lymphadenectomy in early-stage vulvar cancer. However, future trials should focus on the safe extension of the indication of SLN biopsy in vulvar cancer. Although radiotracers and optical agents are widely used in the clinical routine, there is an increasing interest for hybrid tracers like indocyanine-99m Tc-nanocolloid. Finally, it is essential to standardise the acquisition protocol including SPECT/CT images, and due to the low incidence of this type of malignancy to centralise this procedure in experienced centres for personalised approach.This article is part of the Topical Collection on Oncology -Genitourinary.
To provide surgeons with optimal guidance during interventions, it is crucial that the molecular imaging data generated in the diagnostic departments finds its way to the operating room. Sentinel lymph node (SLN) biopsy provides a textbook example in which molecular imaging data acquired in the department of nuclear medicine guides the surgical management of patients. For prostate cancer, in which SLNs are generally located deep in the pelvis, procedures are preferably performed via a (robotassisted) laparoscopic approach. Unfortunately, in the laparoscopic setting the senses of the surgeon are reduced. This topical review discusses technologic innovations that can help improve surgical guidance during SLN biopsy procedures. Metastasis in pelvic lymph nodes (LNs) is considered an important prognostic factor in prostate cancer. Prostatespecific antigen levels, pathologic stage, and Gleason score are predictors for LN involvement; the higher these factors are, the greater is the chance of nodal involvement. Postoperative (histo)pathologic examination of tissue samples obtained during (extended) pelvic lymphadenectomy is considered the gold standard in assessing metastatic spread. With an increasing LN dissection template, the prognosis of both N0 and N1 groups increases (Will Rogers phenomenon). Unfortunately, (extended) pelvic lymphadenectomy also increases the chance of postoperative complications such as lymphoceles, injuries to the obturator nerve or the ureter, and lymphedema of the lower extremity. Such complications can lead to a decrease in the patient's quality of life.Sentinel LN (SLN) biopsy focuses on the identification, subsequent minimally invasive excision, and pathologic and histopathologic evaluation of the LNs that drain directly from the primary tumor. Assuming the orderly spread of tumor cells through the lymphatic system, SLN biopsy can be used for LN staging. After staging, therapeutic follow-up can be decided on.The potential of SLN biopsy for detecting LN metastasis has been validated in several studies. The Augsburg group validated the SLN biopsy procedure in more than 2,000 patients with prostate cancer and reported a high sensitivity and an overall false-negative rate of 5.9% (1). Moreover, SLN biopsy allows the identification of SLNs outside the pelvic lymphadenectomy field (2-4). Recently, Joniau et al. showed that 44% of SLNs were located outside the extended pelvic lymphadenectomy field; in 6% of patients, a positive LN was located exclusively in the presacral or paraaortic region (2).Ideally, a surgeon is able to identify and excise the preoperatively identified SLNs in a minimally invasive manner, with a high sensitivity and specificity. This topical review discusses technologic improvements that may help improve the different aspects involved in (robot-assisted) laparoscopic SLN biopsy for prostate cancer; SLN biopsy for the prostate is often performed in combination with laparoscopic radical prostatectomy. Potential improvements can be found in (hybrid) tracers that are radioacti...
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