Real-time ultrasound virtual navigation in 3D PET/CT volumes for superficial lymph-node evaluation: innovative fusion examination

OBJECTIVE

To evaluate the feasibility and clinical application of fusion imaging with virtual navigation, combining ¹⁸ F-fluorodeoxyglucose (¹⁸ F-FDG) positron emission tomography/computed tomography (PET/CT) with real-time ultrasound imaging, in assessing superficial lymph nodes in breast-cancer and gynecological-cancer patients.

METHODS

This was a pilot study of breast- and gynecological-cancer patients with abnormal uptake of ¹⁸ F-FDG by axillary or groin lymph nodes on PET/CT scan, examined at our institution between January 2017 and May 2019. Fusion imaging was performed, uploading preacquired PET/CT DICOM images onto the ultrasound machine and synchronizing them with real-time ultrasound scanning performed at the lymph-node site. In the first phase, we assessed the feasibility and reliability of fusion imaging in a series of 10 patients with suspicious lymph nodes on both PET/CT and ultrasound, and with full correspondence between both techniques in terms of size, shape and morphology of the lymph nodes (Group A). In the second phase, we included 20 patients with non-corresponding findings between PET/CT and ultrasound: 10 patients with lymph nodes that were suspicious or pathological on PET/CT scan but not suspicious on ultrasound assessment (Group B), and 10 patients with suspicious or pathological lymph nodes on both PET/CT and ultrasound but with no correspondence between the two techniques in terms of number of affected lymph nodes (Group C).

RESULTS

In the 30 selected patients, fusion imaging was assessed at 30 lymph-node sites (22 inguinal and eight axillary nodes). In the first phase (Group A), the fusion technique was shown to be feasible in all 10 lymph-node sites evaluated. In the second phase, fusion imaging was completed successfully in nine of 10 cases in Group B and in all 10 cases in Group C. In all groups, fusion imaging was able to identify the target lymph node, guiding the examiner to perform a core-needle aspiration biopsy or to inject radiotracer for selective surgical nodal excision, according to the radio-guided occult lesion localization technique.

CONCLUSION

Fusion imaging with virtual navigation, combining PET/CT and real-time ultrasound imaging, is technically feasible and able to detect target lymph nodes even when PET/CT and ultrasound findings are inconsistent. Fusion imaging can also be used to guide the performance of core-needle aspiration biopsy, avoiding further surgical diagnostic procedures, or the injection of radiotracer for selective surgical nodal excision, enabling more sparing, selective surgery. This innovative technique could open up multiple diagnostic and therapeutic opportunities in breast and gynecological oncology. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound morphometric and cytologic preoperative assessment of inguinal lymph-node status in women with vulvar cancer: MorphoNode study

OBJECTIVE

To assess the accuracy of preoperative ultrasound examination for predicting lymph-node (LN) status in patients with vulvar cancer.

METHODS

This was a single-institution retrospective observational study of all women with a histological diagnosis of vulvar cancer triaged to inguinal surgery within 30 days following ultrasound evaluation between December 2010 and January 2016. For each groin examined, 15 morphological and dimensional sonographic parameters associated with suspicion for LN involvement were examined. A morphometric ultrasound pattern (MUP) was expressed for each groin, classifying the inguinal LN status into five groups (normal; reactive-but-negative; minimally suspicious/probably negative; moderately suspicious; and highly suspicious/positive) according to subjective judgment, followed by stratification as positive or negative for metastasis according to morphometric binomial assessment (MBA). In cases of positive MBA, fine-needle aspiration cytology was performed. Combining the information obtained from MUP and cytologic results, a binomial final overall assessment (FOA) was assigned for each groin. The final histology was considered as the reference standard. Comparison was performed between patients with negative and those with positive LNs on histology, and receiver-operating-characteristics curves were generated for statistically significant variables on univariate analysis, to evaluate their diagnostic ability to predict negative LN status.

RESULTS

Of 144 patients included in the analysis, 87 had negative inguinal LNs and 57 had positive LNs on histology. A total of 256 groins were analyzed, of which 171 were negative and 85 showed at least one metastatic LN on histology. The following parameters showed the greatest accuracy, with the best balance between specificity and sensitivity, in predicting negative LN status: cortical (C) thickness of the dominant LN (cut-off, 2.5 mm; sensitivity, 90.0%; specificity, 77.9%); short-axis (S) length of the dominant LN (cut-off, 8.4 mm; sensitivity, 63.9%; specificity, 90.6%); C/medulla (M) thickness ratio of the dominant LN (cut-off, 1.2 mm; sensitivity, 70.4%; specificity, 91.5%), the combination of S length and C/M thickness ratio (sensitivity, 88.9%; specificity, 82.4%); and the FOA analysis (sensitivity, 85.9%; specificity, 84.2%).

CONCLUSIONS

Preoperative ultrasound assessment, with or without the addition of cytology, has a high accuracy in assessing inguinal LN status in patients with vulvar cancer. In particular, the combination of two ultrasound parameters (S length and C/M thickness ratio) provided the greatest accuracy in discriminating between negative and positive LNs. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Fusion of ultrasound and 3D single-photon-emission computed tomography/computed tomography to identify sentinel lymph nodes in vulvar cancer: feasibility study

OBJECTIVE

To evaluate the feasibility of fusion of ultrasound imaging and three-dimensional (3D) single-photon-emission computed tomography/computed tomography (SPECT/CT) in detecting sentinel lymph nodes in women with vulvar cancer.

METHODS

This was a prospective pilot single-center study. Patients with vulvar cancer who were candidates for sentinel lymph-node biopsy were enrolled between December 2018 and February 2019. Fusion imaging virtual navigation using 3D SPECT/CT and ultrasound was performed to investigate the tumor-draining lymph node. All clinical, imaging, surgical and histological information was collected prospectively and entered into a dedicated Excel file. Feasibility and success of fusion imaging virtual navigation and time needed to perform the three steps of fusion imaging were evaluated.

RESULTS

Ten lymph-node sites were evaluated in five consecutive women with a histological diagnosis of vulvar cancer. Fusion imaging virtual navigation was feasible and completed successfully for all (10/10) draining sites. Median overall time to perform fusion imaging was 32 (range, 25-40) min and the time decreased from the first to the last examination.

CONCLUSIONS

The present study demonstrated that fusion imaging virtual navigation using 3D SPECT/CT and ultrasound is feasible and able to detect sentinel lymph nodes in women with vulvar carcinoma. Fusion imaging using ultrasound for detection of sentinel lymph nodes opens up multiple diagnostic and therapeutic opportunities in gynecological oncology. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Update on oncoplastic breast surgery

Oncoplastic surgery of the breast (OPS) has generated great excitement over the past years and has become an integrated component of the surgical treatment of breast cancer. Oncoplastic surgical procedures associate the best surgical oncologic principles to achieve wide tumor-free margins with the best principles of plastic surgery to optimize cosmetic outcomes. Thanks to oncoplastic techniques, the role of breast conserving surgery (BCS) has been extended to include a group of patients who would otherwise require mastectomy to achieve adequate tumor clearance. As OPS continues to gain acceptance and diffusion, an optimal and systematic approach to these techniques is becoming increasingly necessary. This article has the aim to review the essential principles and techniques associated with oncoplastic surgery, based on the data acquired through an extensive search of the PUBMED and MEDLINE database for articles published using the key words "breast cancer oncoplastic surgery". This review analyzes possible the advantages", classifications, indications, and the criteria for a proper selection of oncoplastic techniques to facilitate one's ability to master these procedures and make OPS a safe and an effective procedure.

Effect of angiotensin II on proximal tubular reabsorption in normal humans

The effects of angiotensin II (AII) on proximal tubular reabsorption have been evaluated in 6 healthy volunteers under normal salt and water balance. One-hour clearance periods were performed before, during and after the infusion of pressor doses of AII; in 3 of the 6 subjects, the study was repeated with lower doses of AII. Glomerular filtration rate (GFR) and renal plasma flow (RPF) were determined by the clearances of inulin and PAH, and the fractional excretion of lithium (FELi) was considered as an index of proximal sodium reabsorption. The effects of AII on the fractional excretion of beta 2 microglobulin (FE beta 2M) were also studied. Both doses of AII decreased GFR and RPF and increased the filtration fraction (FF); the modifications of these parameters, as well as the reduction of FELi and the fractional excretion of sodium (FENa) and the increase of plasma aldosterone and of plasma atrial natriuretic peptide (ANP), were more evident with pressor doses of AII, which increased the blood pressure from 129/83 to 142/95 mm Hg (p less than 0.01). AII did not modify FE beta 2M in either study. During AII, FELi decreased less than FENa and both were closely and inversely related to the variations of FF, whilst no relationship was present between FE beta 2M and FF. These results suggest that, in normal humans, the AII-induced rise of FF may be an important factor, even if not the only one, in enhancing the proximal reabsorption of lithium and thus of sodium, whilst it does not affect the absorption of beta 2M.

The effect of body weight compression on axillo-femoral by-pass patency

The influence of external compression on extra-anatomic bypass patency is still debated. The specific purpose of this study is the evaluation of ankle Pressure Index (P.I.) and Pulse Volume Recorder (P.V.R.) wave amplitude changes after 5 and 10 minutes of external bypass compression by body weight, lying on the side of the reconstruction. Eight patients with axillo-femoral bypass (mean follow-up 15.5 months) have been evaluated. The external body weight compression caused important changes of graft haemodynamics: (1) decrease in ankle Pressure Index at 5 min (p less than 0.005) or 10 min (p less than 0.0005); (2) decrease in P.V.R. wave amplitude at 5 min (p less than 0.005) and 10 min (p less than 0.025).

Specific B lymphocytes efficiently pick up, process and present antigen to T cells

To study the nature of the antigen bridge between specific B and T lymphocytes we have isolated from the same donor clones of human T cells and EBV-transformed B cells specific for tetanus toxoid (TT). We found that TT-specific B cells are extremely efficient in presenting TT (but not an unrelated antigen) to T cells, as they can trigger T cell proliferation in the presence of only 10(-12) M TT, a concentration that is approximately 10(4) times lower than that required for presentation by conventional antigen-presenting cells such as macrophages or non-specific B cells. The high avidity of the interaction between specific B and T cells is reflected by the resistance to inhibition by antibodies against the T4 antigen. Experiments with fixed and chloroquine-treated B cells show that the role of surface antibodies is limited to the uptake of antigen and that in order to obtain presentation, the antigen has to be internalized, processed and subsequently displayed on the cell surface, where it becomes available for T cell recognition in an MHC-restricted fashion.

Immunochemical mapping of alpha-2 interferon

A panel of five monoclonal antibodies, designated U1-U5, produced by murine hybridoma clones has been raised to recombinant interferon (IFN) alpha-2, and one monoclonal antibody, designated U6, has been raised to a mixture of cyanogen bromide fragments of IFN alpha-2. These antibodies have been characterized with respect to (1) neutralization of IFN antiviral and antiproliferative activities, (2) binding to four cloned IFN alpha subtypes (alpha-1, alpha-2, alpha-4, and alpha-7) that are naturally occurring and to two novel products of recombinant DNA technology (delta-4 alpha-1 and delta-4 alpha-2/alpha-1 hybrid), and (3) binding to three cyanogen bromide fragments of IFN alpha-2. Four of the six monoclonal antibodies inhibited IFN antiviral activity. In conjunction with the previously reported monoclonal antibodies III/21 [Arnheiter, H., Thomas, R. M., Leist, T., Fountoulakis, M., & Gutte, B. (1981) Nature (London) 294, 278-280] and NK-2 [Secher, D. S., & Burke, D. C. (1980) Nature (London) 285, 446-450], eight unique epitopes have been described. Analysis of cross-reactivity patterns with IFN alpha fragments and subtypes indicated that monoclonal antibodies U1 and NK-2, which neutralized both antiviral and antiproliferative activities, and U2, which was nonneutralizing in these assays, were directed to distinct epitopes located in a polypeptide consisting of the amino-terminal 15 amino acid residues linked to residues 60-110 by a disulfide bond. The epitope recognized by U1 was determined to reside, at least in part, between residues 5 and 15. Competitive binding studies indicated that neutralizing monoclonal antibody U3, which did not bind to any of the cyanogen bromide fragments, was directed to an epitope partially overlapping that of NK-2. Epitopes to which neutralizing monoclonal antibodies U3, U4, and U5 and nonneutralizing antibody U6 were directed were readily distinguished by cross-reactivity with IFN alpha subtypes. The nonneutralizing monoclonal antibody U6 was determined to be directed to an epitope between residues 22 and 58. The fact that delta-4 alpha-1 and the delta-4 alpha-2/alpha-1 hybrid were active in an antiviral assay indicated a lack of direct functional significance for the first four amino-terminal amino acid residues and the Cys1-Cys98 disulfide bond. However, reduction with 2-mercaptoethanol of IFN alpha-2 altered the integrity of four of the eight epitopes. These data support a critical role for disulfide linkages in maintaining the native conformation of IFN alpha-2 and provide a potential basis for predicting the location of functionally important domains.