REVIEW   

The Quarterly Journal of Nuclear Medicine and Molecular Imaging 2017 September;61(3):247-70

DOI: 10.23736/S1824-4785.17.02995-8

Copyright © 2017 EDIZIONI MINERVA MEDICA

language: English

Advances in radioguided surgery in oncology

Renato A. VALDÉS OLMOS ^{1, 2}, Sergi VIDAL-SICART ³, Gianpiero MANCA ⁴, Giuliano MARIANI ⁴, Luisa F. LEÓN-RAMÍREZ ^{3, 5}, Domenico RUBELLO ⁶, Francesco GIAMMARILE ⁷ ✉

¹ Interventional Molecular Imaging Laboratory, Nuclear Medicine Section, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands; ² Division of Diagnostic Oncology, Department of Nuclear Medicine, Netherlands Cancer Institute, Amsterdam, The Netherlands; ³ Department of Nuclear Medicine, Hospital Clínic, Barcelona, Spain; ⁴ Regional Center of Nuclear Medicine, Pisa University Hospital, Pisa, Italy; ⁵ Department of Nuclear Medicine, San Carlos Hospital, Madrid, Spain; ⁶ Department of Nuclear Medicine, Santa Maria della Misericordia Hospital, Rovigo, Italy; ⁷ Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria

The sentinel lymph node (SLN) biopsy is probably the most well-known radioguided technique in surgical oncology. Today SLN biopsy reduces the morbidity associated with lymphadenectomy and increases the identification rate of occult lymphatic metastases by offering the pathologist the lymph nodes with the highest probability of containing metastatic cells. These advantages may result in a change in clinical management both in melanoma and breast cancer patients. The SLN evaluation by pathology currently implies tumor burden stratification for further prognostic information. The concept of SLN biopsy includes pre-surgical lymphoscintigraphy as a “roadmap” to guide the surgeon toward the SLNs and to localize unpredictable lymphatic drainage patterns. In addition to planar images, SPECT/CT improves SLN detection, especially in sites closer to the injection site, providing anatomic landmarks which are helpful in localizing SLNs in difficult to interpret studies. The use of intraoperative imaging devices allows a better surgical approach and SLN localization. Several studies report the value of such devices for excision of additional sentinel nodes and for monitoring the whole procedure. The combination of preoperative imaging and radioguided localization constitutes the basis for a whole spectrum of basic and advanced nuclear medicine procedures, which recently have been encompassed under the term “guided intraoperative scintigraphic tumor targeting” (GOSTT). Excepting SLN biopsy, GOSTT includes procedures based on the detection of target lesions with visible uptake of tumor-seeking radiotracers on SPECT/CT or PET/CT enabling their subsequent radioguided excisional biopsy for diagnostic of therapeutic purposes. The incorporation of new PET-tracers into nuclear medicine has reinforced this field delineating new strategies for radioguided excision. In cases with insufficient lesion uptake after systemic radiotracer administration, intralesional injection of a tracer without migration may enable subsequent excision of the targeted tissue. This approach has been helpful in non-palpable breast cancer and in solitary pulmonary nodules. The introduction of allied technologies like fluorescence constitutes a recent advance aimed to refine the search for SLNs and tracer-avid lesions in the operation theatre in combination with radioguidance.

KEY WORDS: Lymphoscintigraphy - Radionuclide imaging - Sentinel lymph node - Intraoperative neurophysiological monitoring - Radioactive tracers