Intraoperative probes and imaging probes

Smaller is better? Compact vs. Conventional gamma camera for sentinel lymph node localization in patients with breast cancer

PURPOSE

Sentinel lymph node biopsy (SLNB) has been recognized as "the gold standard" for axillary staging in early breast cancer patients with clinically negative lymph nodes, resulting in significant morbidity decrease and quality of life improvement. This study aims to validate the performance of a newly developed handheld portable gamma camera (PGC) produced by Imagensys (Italy), in detecting and locating sentinel lymph nodes (SLNs) during the preoperative and intraoperative phases in breast cancer patients compared to conventional lymphoscintigraphy.

METHODS

Adult female patients with histologically confirmed breast cancer, candidates for surgery and SLNB, were prospectively enrolled in this open-label, pre-marketing clinical trial. All patients underwent pre- operative assessment using both the PGC and conventional lymphoscintigraphy. The performance of the two devices was compared using the Poisson regression model for incidence rate ratios (IRRs). The intrinsic sensitivity of the devices was compared using the Wilcoxon Ranked Sign Test. The utility of PGC during intra-operative procedures was also evaluated. The manoeuvrability of the devices was evaluated using operator-satisfaction questioner.

RESULTS

Sixty-eight patients (median age 50 years, BMI 21.4) were enrolled, including two patients with bilateral breast cancer, who underwent SLNB on both axillae. The PGC demonstrated superior preoperative lymph node detection rate (IRR 8.01, 95% CI 6.11-10.50; p < 0.0001) and intrinsic device sensitivity (mean counts per second 409 ± 286 vs. 255 ± 1173 for conventional device, p = 0.0003) compared to the conventional gamma camera. Intra-operative assessment with PGC was performed in 62 patients and no additional lymph nodes were visualised. However, the conventional gamma camera demonstrated superior manoeuvrability (p < 0.0001).

CONCLUSION

The PGC handheld gamma camera showed promising results for preoperative SLN assessment in patients with breast cancer. The limited manoeuvrability may be related to the operator's experience leading to higher inter-operator variability. Appropriate training and frequent use of nuclear medicine and surgical equipment could overcome this limitation.

Development and performance evaluation of a novel scintillation-based active shielding gamma probe

The gamma probe is a commonly used detector for localizing sentinel lymph nodes after the injection of radiopharmaceuticals. In recent years, studies have focused on improving the features of gamma probes to achieve more consistent localization of the radiotracer uptake. As part of this effort, a novel gamma probe prototype based on an active shielding was developed, and its characteristics, including sensitivity, resolution and shielding effectiveness, were determined. The prototype integrates trapezoidal-shaped bismuth germanate (BGO) array coupled with a silicon photomultiplier (SiPM) array, accompanied by dedicated electronics and software for stand alone usage. We conducted a thorough characterization, validating experimental observations through Monte Carlo simulations using the GEANT4 simulation package. In scattering environment, with a probe-source distance of 30 mm, the experimental results show that the detector sensitivity is 120 ± 5 cps/MBq, and the spatial and angular resolutions, in terms of full width at half maximum (FWHM), are 44.8 ± 1.3 mm and 87.3 ± 1 . 5 ∘ , respectively. The shielding effectiveness of the probe was determined to be greater than 95 % . The prototype with active shielding was found to have comparable performance to conventional gamma probes.

Deep Learning Signal Discrimination for Improved Sensitivity at High Specificity for CMOS Intraoperative Probes

The challenge in delineating the boundary between cancerous and healthy tissue during cancer resection surgeries can be addressed with the use of intraoperative probes to detect cancer cells labeled with radiotracers to facilitate excision. In this study, deep learning algorithms for background gamma ray signal rejection were explored for an intraoperative probe utilizing CMOS monolithic active pixel sensors optimized toward the detection of internal conversion electrons from [Formula: see text]Tc. Two methods utilizing convolutional neural networks (CNNs) were explored for beta-gamma discrimination: 1) classification of event clusters isolated from the sensor array outputs (SAOs) from the probe and 2) semantic segmentation of event clusters within an acquisition frame of an SAO which provides spatial information on the classification. The feasibility of the methods in this study was explored with several radionuclides including 14C, 57Co, and [Formula: see text]Tc. Overall, the classification deep network is able to achieve an improved area under the curve (AUC) of the receiver operating characteristic (ROC), giving 0.93 for 14C beta and [Formula: see text]Tc gamma clusters, compared to 0.88 for a more conventional feature-based discriminator. Further optimization of the lower left region of the ROC by using a customized AUC loss function during training led to an improvement of 31% in sensitivity at low false positive rates compared to the conventional method. The segmentation deep network is able to achieve a mean dice score of 0.93. Through the direct comparison of all methods, the classification method was found to have a better performance in terms of the AUC.

How molecular imaging will enable robotic precision surgery : The role of artificial intelligence, augmented reality, and navigation

Molecular imaging is one of the pillars of precision surgery. Its applications range from early diagnostics to therapy planning, execution, and the accurate assessment of outcomes. In particular, molecular imaging solutions are in high demand in minimally invasive surgical strategies, such as the substantially increasing field of robotic surgery. This review aims at connecting the molecular imaging and nuclear medicine community to the rapidly expanding armory of surgical medical devices. Such devices entail technologies ranging from artificial intelligence and computer-aided visualization technologies (software) to innovative molecular imaging modalities and surgical navigation (hardware). We discuss technologies based on their role at different steps of the surgical workflow, i.e., from surgical decision and planning, over to target localization and excision guidance, all the way to (back table) surgical verification. This provides a glimpse of how innovations from the technology fields can realize an exciting future for the molecular imaging and surgery communities.

Tumor-non-tumor discrimination by a β- detector for Radio Guided Surgery on ex-vivo neuroendocrine tumors samples

This paper provides a first insight of the potential of the β^- Radio Guided Surgery (β^--RGS) in a complex surgical environment like the abdomen, where multiple sources of background concur to the signal at the tumor site. This case is well reproduced by ex-vivo samples of 90^Y-marked Gastro-Entero-Pancreatic Neuroendocrine Tumors (GEP NET) in the bowel. These specimens indeed include at least three wide independent sources of background associated to three anatomical districts (mesentery, intestine, mucose). The study is based on the analysis of 37 lesions found on 5 samples belonging to 5 different patients. We show that the use of electrons, a short range particle, instead of γ particles, allows to limit counts read on a lesion to the sum of the tumor signal plus the background generated by the sole hosting district.The background on adjacent districts in the same specimen/patient is found to differ up to a factor 4, showing how the specificity and sensitivity of the β^--RGS technique can be fully exploited only upon a correct measurement of the contributing background. This locality has been used to set a site-specific cut-off algorithm to discriminate tumor and healthy tissue with a specificity of 100% and a sensitivity, on this test data sample, close to 100%. Factors influencing the sensitivity are also discussed. One of the specimens set allowed us evaluate the volume of the lesions, thus concluding that the probe was able to detect lesions as small as 0.04 mL in that particular case.

Feasibility study of a point-of-care positron emission tomography system with interactive imaging capability

PURPOSE

We investigated the feasibility of a novel positron emission tomography (PET) system that provides near real-time feedback to an operator who can interactively scan a patient to optimize image quality. The system should be compact and mobile to support point-of-care (POC) molecular imaging applications. In this study, we present the key technologies required and discuss the potential benefits of such new capability.

METHODS

The core of this novel PET technology includes trackable PET detectors and a fully three-dimensional, fast image reconstruction engine implemented on multiple graphics processing units (GPUs) to support dynamically changing geometry by calculating the system matrix on-the-fly using a tube-of-response approach. With near real-time image reconstruction capability, a POC-PET system may comprise a maneuverable front PET detector and a second detector panel which can be stationary or moved synchronously with the front detector such that both panels face the region-of-interest (ROI) with the detector trajectory contoured around a patient's body. We built a proof-of-concept prototype using two planar detectors each consisting of a photomultiplier tube (PMT) optically coupled to an array of 48 × 48 lutetium-yttrium oxyorthosilicate (LYSO) crystals (1.0 × 1.0 × 10.0 mm³ each). Only 38 × 38 crystals in each arrays can be clearly re-solved and used for coincidence detection. One detector was mounted to a robotic arm which can position it at arbitrary locations, and the other detector was mounted on a rotational stage. A cylindrical phantom (102 mm in diameter, 150 mm long) with nine spherical lesions (8:1 tumor-to-background activity concentration ratio) was imaged from 27 sampling angles. List-mode events were reconstructed to form images without or with time-of-flight (TOF) information. We conducted two Monte Carlo simulations using two POC-PET systems. The first one uses the same phantom and detector setup as our experiment, with the detector coincidence re-solving time (CRT) ranging from 100 to 700 ps full-width-at-half-maximum (FWHM). The second study simulates a body-size phantom (316 × 228 × 160 mm³ ) imaged by a larger POC-PET system that has 4 × 6 modules (32 × 32 LYSO crystals/module, four in axial and six in transaxial directions) in the front panel and 3 × 8 modules (16 × 16 LYSO crystals/module, three in axial and eight in transaxial directions) in the back panel. We also evaluated an interactive scanning strategy by progressively increasing the number of data sets used for image reconstruction. The updated images were analyzed based on the number of data sets and the detector CRT.

RESULTS

The proof-of-concept prototype re-solves most of the spherical lesions despite a limited number of coincidence events and incomplete sampling. TOF information reduces artifacts in the reconstructed images. Systems with better timing resolution exhibit improved image quality and reduced artifacts. We observed a reconstruction speed of 0.96 × 10⁶ events/s/iteration for 600 × 600 × 224 voxel rectilinear space using four GPUs. A POC-PET system with significantly higher sensitivity can interactively image a body-size object from four angles in less than 7 min.

CONCLUSIONS

We have developed GPU-based fast image reconstruction capability to support a PET system with arbitrary and dynamically changing geometry. Using TOF PET detectors, we demonstrated the feasibility of a PET system that can provide timely visual feedback to an operator who can scan a patient interactively to support POC imaging applications.

Quantitative assessment of Cerenkov luminescence for radioguided brain tumor resection surgery

Cerenkov luminescence imaging (CLI) is a developing imaging modality that detects radiolabeled molecules via visible light emitted during the radioactive decay process. We used a Monte Carlo based computer simulation to quantitatively investigate CLI compared to direct detection of the ionizing radiation itself as an intraoperative imaging tool for assessment of brain tumor margins. Our brain tumor model consisted of a 1 mm spherical tumor remnant embedded up to 5 mm in depth below the surface of normal brain tissue. Tumor to background contrast ranging from 2:1 to 10:1 were considered. We quantified all decay signals (e^±, gamma photon, Cerenkov photons) reaching the brain volume surface. CLI proved to be the most sensitive method for detecting the tumor volume in both imaging and non-imaging strategies as assessed by contrast-to-noise ratio and by receiver operating characteristic output of a channelized Hotelling observer.

A novel radioguided surgery technique exploiting β(-) decays

The background induced by the high penetration power of the radiation is the main limiting factor of the current radio-guided surgery (RGS). To partially mitigate it, a RGS with β⁺-emitting radio-tracers has been suggested in literature. Here we propose the use of β⁻-emitting radio-tracers and β⁻ probes and discuss the advantage of this method with respect to the previously explored ones: the electron low penetration power allows for simple and versatile probes and could extend RGS to tumours for which background originating from nearby healthy tissue makes probes less effective. We developed a β⁻ probe prototype and studied its performances on phantoms. By means of a detailed simulation we have also extrapolated the results to estimate the performances in a realistic case of meningioma, pathology which is going to be our first in-vivo test case. A good sensitivity to residuals down to 0.1 ml can be reached within 1 s with an administered activity smaller than those for PET-scans thus making the radiation exposure to medical personnel negligible.

A GSO tweezers-type coincidence detector for tumor detection

A Gd2SiO5 (GSO) tweezers-type coincidence detector was developed and tested for tumor detection in procedures such as (18)F-fluorodeoxyglucose (FDG)-guided surgery. The detector consists of a pair of GSO scintillators, a pair of metal-packaged small-sized photomultiplier tubes (PMTs), and a coincidence circuit. Because the GSO scintillators are located on the tips of tweezers, a target organ such as a lymph node or the colon can be easily positioned between them. The size of a single GSO was 8 × 14 × 14 mm. The results show that the energy resolution was 30 % full-width at half-maximum (FWHM) and the timing resolution was 6 ns FWHM for 511-keV gamma photons. The point-spread function perpendicular to the detector was 4.5 mm FWHM, and the point-spread function parallel to the detector was 7.5 mm FWHM. The absolute sensitivity of the coincidence detector was 0.6% at the center of the detector when the two GSOs were 5 mm apart. Background counts due to the accidental and scatter coincidence were 2 cps up to 48 MBq from the positron source contained in a 20-cm-diameter, 20-cm-high cylindrical phantom. From these results, we conclude that the proposed tweezers-type coincidence detector is useful for tumor detection by the use of FDG, such as that in radio-guided surgery.

Feasibility evaluation of radioimmunoguided surgery of breast cancer

Breast-conserving surgery involves completely excising the tumour while limiting the amount of normal tissue removed, which is technically challenging to achieve, especially given the limited intraoperative guidance available to the surgeon. This study evaluates the feasibility of radioimmunoguided surgery (RIGS) to guide the detection and delineation of tumours intraoperatively. The 3D point-response function of a commercial gamma-ray-detecting probe (GDP) was determined as a function of radionuclide (¹³¹I, ¹¹¹In, ^99mTc), energy-window threshold, and collimator length (0.0–3.0-cm). This function was used to calculate the minimum detectable tumour volumes (MDTVs) and the minimum tumour-to-background activity concentration ratio (T:B) for effective delineation of a breast tumour model. The GDP had larger MDTVs and a higher minimum required T:B for tumour delineation with ¹³¹I than with ¹¹¹In or ^99mTc. It was shown that for ¹¹¹In there was a benefit to using a collimator length of 0.5-cm. For the model used, the minimum required T:B required for effective tumour delineation was 5.2 ± 0.4. RIGS has the potential to significantly improve the accuracy of breast-conserving surgery; however, before these benefits can be realized, novel radiopharmaceuticals need to be developed that have a higher specificity for cancerous tissue in vivo than what is currently available.

Multifunctionalized gold nanoparticles with peptides targeted to gastrin-releasing peptide receptor of a tumor cell line

Functionalization of gold nanoparticles (AuNPs) with both a targeting peptide (an analogue of the peptide Bombesin) and a drug peptide ligand (an analogue of the RAF peptide) with the aim of improving selectivity in the delivery of the conjugates as well as the antitumor activity is described. Studies on the internalization mechanism of peptide-AuNP conjugates and viability of cells were carried out. An enhancement of the activity and selectivity of the peptide multifunctionalized conjugates was observed.

Immunotherapy of malignant disease with tumor antigen-specific monoclonal antibodies

A few tumor antigen (TA)-specific monoclonal antibodies (mAb) have been approved by the Food and Drug Administration for the treatment of several major malignant diseases and are commercially available. Once in the clinic, mAbs have an average success rate of approximately 30% and are well tolerated. These results have changed the face of cancer therapy, bringing us closer to more specific and more effective biological therapy of cancer. The challenge facing tumor immunologists at present is represented by the identification of the mechanism(s) underlying the patients' differential clinical response to mAb-based immunotherapy. This information is expected to lead to the development of criteria to select patients to be treated with mAb-based immunotherapy. In the past, in vitro and in vivo evidence has shown that TA-specific mAbs can mediate their therapeutic effect by inducing tumor cell apoptosis, inhibiting the targeted antigen function, blocking tumor cell signaling, and/or mediating complement- or cell-dependent lysis of tumor cells. More recent evidence suggests that TA-specific mAb can induce TA-specific cytotoxic T-cell responses by enhancing TA uptake by dendritic cells and cross-priming of T cells. In this review, we briefly summarize the TA-specific mAbs that have received Food and Drug Administration approval. Next, we review the potential mechanisms underlying the therapeutic efficacy of TA-specific mAbs with emphasis on the induction of TA-specific cellular immune responses and their potential to contribute to the clinical efficacy of TA-specific mAb-based immunotherapy. Lastly, we discuss the potential negative effect of immune escape mechanisms on the clinical efficacy of TA-specific mAb-based immunotherapy.

A prototype hybrid intraoperative probe for ovarian cancer detection

A novel prototype intraoperative system combining positron detection and optical coherence tomography (OCT) imaging has been developed for early ovarian cancer detection. The probe employs eight plastic scintillating fiber tips for preferential detection of local positron activity surrounding a central scanning OCT fiber providing volumetric imaging of tissue structure in regions of high radiotracer uptake. Characterization measurements of positron sensitivity, spatial response, and position mapping are presented for Tl(204)/Cs(137) sources as well as 18F-FDG. In conjunction with co-registered frequency domain OCT measurements the results demonstrate the potential for a miniaturized laparoscopic probe offering simultaneous functional localization and structural imaging for improved early cancer detection.

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.

Radiation dose to surgical staff from positron-emitter-based localization and radiosurgery of tumors

Surgical tissue characterization based on radiotracer uptake has become much more common in recent years, particularly due to the advent of the sentinel lymph node biopsy technique. Radiolabeled pharmaceuticals are used with hand-held gamma-sensitive probes, which are capable of localizing small tumors and lymph nodes that are first identified via scintigraphy. The radiation safety of such radioguided procedures, which typically employ 99mTc, has been well established. Now, with the emergence of 18F-fluorodeoxyglucose (18FDG) as a widely used tracer for PET imaging of cancer patients, there is increasing interest in the possibility of utilizing 18FDG for intraoperative tumor detection. First, though, the exposure to operating room personnel must be shown to be at a safe level. Due to the short half-life of 18F, the exposure rate will vary significantly with the start time post-injection as well as the duration of the procedure. The aim of this investigation is to determine empirically an exposure rate equation that can be integrated to estimate the exposure to a surgeon and assistants, from patients injected with 18FDG, over an arbitrarily chosen time interval. The study was conducted by measuring the radiation exposure rate from hospital in-patients receiving 18FDG-PET scans at various times from one to seven hours post injection; the empirical equation was determined from the plot of exposure rate vs. time for all patients. The resulting effective dose equivalent for the surgeon for typical values of injected activity, delay time and procedure duration was approximately 60 microSv.

Development of a tweezers-type coincidence imaging detector

OBJECTIVE

When employing F-18-fluorodeoxyglucose (FDG)-guided surgery to detect positron accumulation in isolated small organs, sampling these organs from opposite directions is a useful way of determining a tumor's position, similar to sampling a small organ with tweezers. The coincidence method is suitable for this purpose because only the positrons between two detectors can be detected. For this purpose, we developed a tweezers-type coincidence imaging detector.

METHODS

The detector employs two depth-of-interaction (DOI) detectors positioned at the tip of the tweezers and images the positron distribution between them using the coincidence method. The DOI detector consists of a 4 x 3 Gd(2)SiO(5):Ce (GSO) array optically coupled to a one-dimensionally arranged quad-photomultiplier tube. These GSOs were arranged to form a DOI detector using the Anger principle. The useful field of view is 20 mm x 15 mm. With these configurations, we could resolve 4 x 3 GSO arrays on a position histogram.

RESULTS

Because the imaging detectors were positioned at the tip of the tweezers, one could easily sample the target part manually from opposed sides. A real-time image in coincidence between these two DOI detectors could be obtained. The point spread functions were approximately 3-mm full width at half-maximum (FWHM) parallel to the tweezers and 4-mm FWHM perpendicular to them. The sensitivity was approximately 1% when the two imaging detectors were 10 mm apart.

CONCLUSIONS

With these results, we conclude that the developed tweezers-type imaging detector has a potential to be a new instrument in nuclear medicine.

Evaluation of the efficacy of a small CdTe gamma-camera for sentinel lymph node biopsy

We previously reported the basic performance of a prototype small cadmium telluride (CdTe) gamma-camera (SSGC) intended for use in radioguided surgeries. In this study, we sought to confirm the favorable previous results and to extend the preliminary findings to examine the efficacy of the SSGC in an animal study and a clinical setting for sentinel lymph node biopsy.

METHODS

The prototype SSGC (1,024 pixels; field of view, 44.8 x 44.8 mm), equipped with a parallel-hole collimator, was used in both animal and clinical studies. 99mTc-phytate (18.5 MBq) was injected into the tongues and legs of 6 rabbits. In the clinical study, 74 MBq of 99mTc-phytate was injected into peritumoral regions in 8 patients with oral cancer. The detection of hot nodes by the SSGC was compared with that by a conventional scintillation gamma-camera (CGC).

RESULTS

The SSGC detected 29 hot nodes in images of 6 rabbits after injection. The number of hot nodes was the same as the number seen in CGC studies, but the CGC required a longer acquisition time to produce comparable images. There were no differences between the SSGC and the CGC in terms of activity ratios and hot node-to-background ratios. The biodistribution of 99mTc-phytate in removed tissues was evaluated by contact radiography, and radioactivity was assayed with a gamma-well counter. The mean +/- SD radioactivity in specimens was 0.15% +/- 0.15%, with a range of 0.01%-0.62%. In the clinical study, the SSGC detected 30 hot nodes with a 5- to 60-s acquisition time at 4 h after injection. The SSGC documented all hot nodes depicted by the CGC at 4 h after injection.

CONCLUSION

The SSGC showed significant potential for the detection of sentinel lymph nodes in lymphoscintigraphy. The results of the studies suggested that the SSGC facilitates the exploration of hot nodes in sentinel lymph node biopsy.

Towards intra-operative 3D nuclear imaging: reconstruction of 3D radioactive distributions using tracked gamma probes

Nuclear medicine imaging modalities assist commonly in surgical guidance given their functional nature. However, when used in the operating room they present limitations. Pre-operative tomographic 3D imaging can only serve as a vague guidance intra-operatively, due to movement, deformation and changes in anatomy since the time of imaging, while standard intra-operative nuclear measurements are limited to 1D or (in some cases) 2D images with no depth information. To resolve this problem we propose the synchronized acquisition of position, orientation and readings of gamma probes intra-operatively to reconstruct a 3D activity volume. In contrast to conventional emission tomography, here, in a first proof-of-concept, the reconstruction succeeds without requiring symmetry in the positions and angles of acquisition, which allows greater flexibility. We present our results in phantom experiments for sentinel node lymph node localization. The results indicate that 3D intra-operative nuclear images can be generated in such a setup up to an accuracy equivalent to conventional SPECT systems. This technology has the potential to advance standard procedures towards intra-operative 3D nuclear imaging and offers a novel approach for robust and precise localization of functional information to facilitate less invasive, image-guided surgery.

Positron detection for the intraoperative localisation of cancer deposits

Purpose

The study investigated the feasibility of a positron-sensitive hand-held detector system for the intraoperative localisation of tumour deposits resulting from intravenous [¹⁸F]FDG administration.

Methods

A total of 17 patients (12 receiving preoperative [¹⁸F]FDG PET imaging) with various histologically proven malignancies were included. Radioactivity from tumours and surrounding normal tissue was measured on average 3 h after administration of 36–110 MBq [¹⁸F]FDG and the tumour-to-background (T/B) ratio was calculated. In addition, phantom studies were performed to evaluate the spatial resolution and sensitivity of the probe.

Results

All known targeted tumour sites were identified by the positron probe. T/B ratios were generally high, with a mean T/B ratio of 6.6, allowing easy identification of most tumour sites. In one case of a hepatic metastasis, the T/B ratio of 1.34 was below expectations, since the preoperative [¹⁸F]FDG PET scan was positive. The probe was instrumental in the localisation of three additional tumour lesions (two lymph nodes, one anastomotic ring) that were not immediately apparent at surgery. Phantom studies revealed that [¹⁸F]FDG-containing gel (simulating tumour tissue), having 10 times more [¹⁸F]FDG than surrounding “normal” background gel, was clearly detectable in quantities as low as 15 mg. As measured in two cases, the absorbed radiation doses ranged from 2.5 to 8.6 μSv/h for the surgical team to 0.8 μSv/h for the aesthetician.

Conclusion

[¹⁸F]FDG-accumulating tumour tissues can be localised with positron probes intraoperatively with a low radiation burden to the patient and medical personnel. The methodology holds promise for further clinical testing.

Development of a positron-imaging detector with background rejection capability

OBJECTIVE

Intra-operative probes have recently become important instruments in nuclear medicine. In such an application, the radiopharmaceutical F-18-fluorodeoxyglucose (FDG) is promising. For the FDG-guided surgery, we developed and tested a positron-imaging detector with background rejection capability.

METHODS

The detector consists of an array of phoswich scintillators, a multi-channel position-sensitive photo-multiplier tube (PSPMT) and an electronic circuit. The scintillators and the PSPMT are encased in a tungsten shield and replaceable collimators are mounted on the top of the detector. Positrons are detected by the plastic scintillators while annihilation photons are detected by the BGOs. By employing a pulse-shape analysis, we can distinguish the true events (positrons) from background gamma events. The dimensions of each plastic scintillator are 2 mm x 2 mm x 3 mm and those of the BGO are 2 mm x 2 mm x 15 mm. These scintillators are optically coupled to each other and combined in an 8 x 8 array, which is optically coupled to a 1-inch square 8 x 8 multi-channel PSPMT via optical fibers. Position determination of the positrons is performed by 64-channel threshold circuits while the pulse shape analysis is applied for the summing signal.

RESULTS

The spatial resolution was measured by positioning an F-18 point source onto one pixel of the detector and found than the spillover to the neighbor pixel was less than 20%. The background count rate was less than 2 cps for a 20-cm diameter, 20-cm long cylinder phantom containing 3.7 MBq of F-18.

CONCLUSION

These results indicated that the developed positron-imaging detector will be useful for FDG-guided surgery.

Molecular imaging and radioimmunoguided surgery

Molecular imaging comprises a series of diagnostic modalities that provide information on the physiology and molecular composition of cells and tissues. One of these modalities, radioimmunodetection, uses radiolabeled monoclonal antibodies (mAbs) to image tissues. Two radioimmunodetection modalities are described in this article: immunoscintigraphy and radioimmunoguided surgery (RIGS). In immunoscintigraphy, the radioactivity is measured with the use of an external gamma camera and used to create images. In RIGS, the radioactivity is detected intraoperatively with the use of a handheld gamma probe to help the surgeon detect foci of otherwise occult disease. Both techniques have the potential to improve the preoperative and intraoperative localization of cancer. Multiple studies have been performed on the efficacy of RIGS on different malignancies, especially colorectal cancer. Despite the good sensitivity of the technique, some concerns revolve around the high rate of false positives and the real significance of leaving RIGS-positive tissue behind in terms of long-term outcomes and survival. More studies are warranted to further develop the technique and determine the specific role it will play on the diagnosis and management of surgical disease. Surgeons should actively participate in these studies and in expanding the applications of this promising technology.

PET-Probe: Evaluation of Technical Performance and Clinical Utility of a Handheld High-Energy Gamma Probe in Oncologic Surgery

BACKGROUND

Positron emission tomography (PET) has become an invaluable part of patient evaluation in surgical oncology. PET is less than optimal for detecting lesions <1 cm, and the intraoperative localization of small PET-positive lesions can be challenging as a result of difficulties in surgical exposure. We undertook this investigation to assess the utility of a handheld high-energy gamma probe (PET-Probe) for intraoperative identification of ¹⁸F-deoxyglucose (FDG)-avid tumors.

METHODS

Forty patients underwent a diagnostic whole-body FDG-PET scan for consideration for surgical exploration and resection. Before surgery, all patients received an intravenous injection of 7 to 10 mCi of FDG. At surgery, the PET-Probe was used to determine absolute counts per second at the known tumor site(s) demonstrated by whole-body PET and at adjacent normal tissue (at least 4 cm away from tumor-bearing sites). Tumor-to-background ratios were calculated.

RESULTS

Thirty-two patients (80%) underwent PET-Probe-guided surgery with therapeutic intent in a recurrent or metastatic disease setting. Eight patients underwent surgery for diagnostic exploration. Anatomical locations of the PET-identified lesions were neck and supraclavicular (n = 8), axilla (n = 5), groin and deep iliac (n = 4), trunk and extremity soft tissue (n = 3), abdominal and retroperitoneal (n = 19), and lung (n = 2). PET-Probe detected all PET-positive lesions. The PET-Probe was instrumental in localization of lesions in 15 patients that were not immediately apparent by surgical exploration.

CONCLUSIONS

The PET-Probe identified all lesions demonstrated by PET scanning and, in selected cases, was useful in localizing FDG-avid disease not seen with conventional PET scanning.

Novel Imaging Techniques in Melanoma

Cutaneous melanoma is one of the most deadly malignancies. Although it accounts for approximately 4% of all cancer cases, it ac-counts for approximately 79% of skin cancer-related deaths. In the past few years, the nuclear medicine platform used in the management of melanoma has extended to biochemical and structural imaging. In clinical practice, integrated positron emission tomography/CT devices allow anatomic and metabolic characterization of meta-static disease in a single study. Similarly, more accurate localization of sentinel nodes in a 3-D space now is feasible with hybrid single photon emission CT/CT system. In translational research, [18F]fluorodeoxyglucose probes have been designed to optimize the detection of melanoma tumor sites in vivo.

Hybrid positron detection and optical coherence tomography system: design, calibration, and experimental validation with rabbit atherosclerotic models

We evaluate the performance of our novel hybrid optical coherence tomography (OCT) and scintillating probe, demonstrate simultaneous OCT imaging and scintillating detection, and validate the system using an atherosclerotic rabbit model. Preliminary data obtained from the rabbit model suggest that our prototype positron probe detects local uptake of fluorodeoxyglucose (FDG) labeled with 18F positron (beta) radionuclide emitter, and the high-uptake regions correlate with sites of injury and extensive atherosclerosis areas. Preliminary data also suggest that coregistered high-resolution OCT images provide imaging of detailed plaque microstructures, which cannot be resolved by positron detection.

Update on detection of sentinel lymph nodes in patients with breast cancer

Sentinel lymph node biopsy is now the practice of choice for the management of many patients with breast cancer. This was not true in the early 1990s, when the first such procedures were performed and protocols for such were refined often. This was also not true in the first years of the 21st century, when a decade of collective experience and information acquired from numerous clinical investigations dictated additional subtle and not-so-subtle refinements of the procedures. However, it is true today; reports of the latest round of clinical investigations indicate that there are several breast cancer sentinel node procedures that result in successful identification of potential sentinel nodes in nearly all patients who are eligible for such procedures. A significant component of many of these successful sentinel node procedures is a detection and localization protocol that involves radiotracer methodologies, including radiopharmaceutical administration, preoperative nuclear medicine imaging, and intraoperative gamma counting. The present state and roles of nuclear medicine protocols used in breast cancer sentinel lymph node biopsy procedures is reviewed with emphasis on discussion of recent results, unresolved issues, and future considerations. Included are brief reviews of present radiotracer and blue-dye techniques for node localization, including remarks about injection strategies, counting probe technology, and radiation safety. Included also are discussions of on-going investigations of the implications of the presence of micrometastases; of the management value of detection, localization, and excision of extra-axillary nodes such as internal mammary nodes; and of the broad range of recurrence rates presently being reported. Remarks on the present and possible near- and long-term roles for nuclear medicine in the staging of breast cancer patients including comments on positron emission tomography and intraoperative imaging conclude the article.

[Use of intraoperative lymphoscintigraphy in doubtful cases of sentinel node detection]

Lymphoscintigraphy is a widely accepted method used to detect selectively the sentinel node in malignant melanoma. This is the case report of a patient who was operated on for an inguinal melanoma and who was referred to the Nuclear Medicine Section for preoperative lymphoscintigraphy. There were technical problems for sentinel node detection due to the proximity of injection points. We aimed to know the possibility to perform an intraoperative lymphoscintigraphy as a valid and useful technique in cases as this one.

Wiederholungseingriffe beim Schilddr�senkarzinom

Reoperation for thyroid cancer needs to consider patient-, tumor- and therapy-related aspects as well as present diagnostic results. Reoperation because of thyroid remnants, persistence of the primary tumor and lymph node metastasis (completion surgery) has to be distinguished from reoperation due to locoregional recurrence (primary tumor, lymph nodes). The primary surgical strategy should avoid the need for reoperation. The extent of reoperation is related to the extent of primary surgery, stage, and distant metastasis. The timing and indication of reoperation for differentiated thyroid carcinoma in an interdisciplinary multimodal treatment setting depends on diagnostic radioiodine scans and radioiodine therapy. Long-term, recurrence-free survival is achieved by sufficiently radical surgery with acceptable morbidity, including all additive or adjuvant treatment options.

An intra-operative positron probe with background rejection capability for FDG-guided surgery

For radio-guided surgery on tumors using F-18-FDG, detection of annihilation gamma photons emanating from other parts of the body produces background radiation counts and limits its use in clinical situations. To overcome this limitation, we have developed an intra-operative positron probe with background-rejection capability. The positron probe uses a phoswich detector composed of a plastic scintillator and a bismuth germinate (BGO). A positron from a positron emitter such as F-18 is detected by the plastic scintillator and emits annihilation photons. The BGO detects one of the annihilation photons while a photo-multiplier tube (PMT) detects scintillation photons from both scintillators. The decay time differences of these two scintillators are used to distinguish whether the event is a true event where a positron and a following annihilation photon are detected simultaneously, or a background event. In this configuration, only positrons can be selectively detected, even in an environment of high background gamma photon flux. Spatial resolution was 11-mm full width at half maximum (FWHM) 5 mm from the detector surface. Measured sensitivity for the F-18 point source was 2.6 cps/kBq 5 mm from the detector surface. The background count rate was less than 0.5 cps for a 20-cm diameter cylindrical phantom containing 37 MBq of F-18 solution measured on the phantom surface, while the positron count rate was almost linear over a range of approximately 6 kcps. These results indicate that our developed intra-operative positron probe is valuable for radio-guided surgery on tumors using F-18-FDG in a high flux of background annihilation gamma photons.

Optimum threshold setting for a positron-sensitive probe with background rejection capability

In a positron-sensitive probe composed of a plastic scintillator and a bismuth germanate (BGO), scattered annihilation photons in the plastic scintillator become background counts. Although these scattered annihilation photons can be rejected by higher threshold level settings for the scintillation pulse of the plastic scintillator and for that of the BGO, the system sensitivity is reduced. We have theoretically and experimentally optimized the threshold levels for both the plastic scintillator and the BGO. After calculating the energy loss in the plastic scintillator and the BGO for the scattered annihilation photons, we measured the background counts of a positron-sensitive probe by changing these threshold levels. Results revealed that one optimum threshold setting of the positron-sensitive probe was 0.3 of the peak level of the pulse for the plastic scintillator and 0.7 of that for the BGO. With these threshold levels, the background counts could be decreased to less than 0.2% of the true positron counts.

Development of an MR-compatible gamma probe for combined MR/RI guided surgery

We have developed and tested an MR-compatible gamma probe to simultaneously obtain anatomical information and functional information during surgery. The probe consists of a probe head, an optical fibre bundle and a photo-multiplier tube (PMT). The NaI(T1) scintillator contained in the probe head is connected to a 7 m optical fibre bundle that transfers the scintillation photons produced in the NaI(T1) to an area of low magnetic field or out of the MR-scanner's magnetic shielded room. Although the light loss due to the optical fibre bundle was more than 90%, the photo-peak of the gamma for Co-57 (122 keV) could be observed. The point spread function was 4.5 mm full width at half maximum (FWHM) at 5 mm from the collimator surface for 122 keV gamma photons. Furthermore, there was no sensitivity change outside the MR-scanner, inside the MR-scanner without scanning and inside the MR-scanner with scanning. The probe produced a small artefact on the phantom image of the MR-scanner due to the susceptibility difference of the alloy used for the collimator and the shield. However, the artefact was only limited to area surrounding the probe. These results indicate that the developed MR-compatible gamma probe will make it possible to realize the combined MR/RI guided surgery that provides surgeons with anatomical and RI distribution information simultaneously.

A hand-held imaging probe for radio-guided surgery: physical performance and preliminary clinical experience

Improvements in the specificity of radiopharmaceutical compounds have been paralleled by an upsurge of interest in developing small detectors to assist surgeons in localizing tumour tissue during surgery. This study reports the main technical features and physical characteristics of a new hand-held gamma camera dedicated to accurate and real-time intra-operative imaging. First clinical experience is also reported. The POCI (Per-operative Compact Imager) camera consists of a head module composed of a high-resolution interchangeable lead collimator and a CsI(Na) crystal plate optically coupled to an intensified position-sensitive diode. The current prototype has a 40-mm diameter field of view, an outer diameter of 9.5 cm, a length of 9 cm and a weight of 1.2 kg. Overall detector imaging characteristics were evaluated by technetium-99m phantom measurements. Three patients with breast cancer previously scheduled to undergo sentinel lymph node detection were selected for the preliminary clinical experience. Preoperative images of the lymphatic basin obtained using the POCI camera were compared with conventional transcutaneous explorations using a non-imaging gamma probe. The full-width at half-maximum (FWHM) spatial resolution was investigated in both air and scattering medium; when the phantom was placed in contact with the collimator, the POCI camera exhibited a 3.2 mm FWHM. The corresponding sensitivity was 290 cps/MBq. The preliminary clinical results showed that POCI was able to predict the number and location of all SLNs. In one case, two deep radioactive nodes missed by the gamma probe were detected on the intra-operative images. This very initial experience demonstrates that the physical performance of the POCI camera is adequate for radio-guided surgery. These results are sufficiently encouraging to prompt further evaluation studies designed to determine the specific and optimal clinical role of intra-operative imaging devices.

A novel silicon array designed for intraoperative charged particle imaging

A novel Si-PIN imaging array is under investigation for a charged particle (beta, positron, or alpha) sensitive intraoperative camera to be used for (residual) tumor identification during surgery. This class of collimator-less nuclear imaging device has a higher signal response for direct interactions than its scintillator-optical detector-based counterparts. Monte Carlo simulations with 635 keV betas were performed, yielding maximum and projected ranges of 1.64 and 0.55 mm in Si. Up to 90% of these betas were completely absorbed in the first 0.30 mm. Based on these results, 300 microm thick prototype Si detector arrays were designed in a 16 x 16 crossed-grid arrangement with 0.8 mm wide orthogonal strips on 1.0 mm pitch. A NIM- and CAMAC-based high-density data acquisition and processing system was used to collect the list mode data. The system was calibrated by comparisons of measured spectra to energy deposition simulations or by direct measurement of various >100 keV conversion electron or beta emitters. Mean electronic noise per strip was <3.6 keV FWHM at room temperature. When detecting positrons, which have an accompanying 511 keV annihilation background, the flood irradiated beta/gamma ratio was approximately 40, indicating that beta images could be made without the use of background rejection techniques. The intrinsic spatial resolution corresponds to the 1 x 1 mm2 pixel size, and measurements of beta emitting point and line sources yielded FWHM resolutions of 1.5 (lateral) and 2.5 mm (diagonal), respectively, with the larger widths due to particle range blurting effects. Deconvolution of the finite source size yielded intrinsic resolutions that corresponded to the image pixel size. Transmission images of circle and line phantoms with various hole sizes and pitch were resolved with either pure beta or positron irradiation without a background correction. This novel semiconductor imaging device facilitates high charged particle and low gamma sensitivity, high signal/noise ratio, and allows for compact design to potentially aid surgical guidance by providing in situ images of clinical relevance.