deshayes sln & fluorescence imaging.ppt [mode de

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Emmanuel Deshayes

With the kind help of Pr Francesco Giammarile

IAEA WorkShop, November 2017

(radio)GuidedintraOperative

ScintigraphicTumor

Targeting

The GOSTT concept

GOSTT = Radioguided Surgery

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Radioguided Surgery

20052000199519901985

0

100

200

300 Medline-based searchAim: tailor surgical approaches to the different disease‐specific and patient‐specific conditions

Method: 1. preoperative “labeling” of target lesions;2. intraoperative guidance (detecting probe); 3. minimal surgical access and probe‐aided assessment of the completeness of excision. Synergistic collaboration of

different specialties involved

The GOSTT concept1. Methods

a. After interstitial injection • Lymphatic (Sentinel node)• Intra‐tumoral (ROLL)

b. After systemic administration (SPECT or PET specific tracers)c. Others (leakage measurement during isolated limb perfusion…)

2. Materialsa. Devices

• Preoperative imaging• Intraoperative gamma‐probe• Intraoperative imaging• Multimodality preoperative imaging ("mixed‐reality" surgery)

b. Tracers• Radiopharmaceuticals • Hybrid compounds

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Artery

Vein

TumorSentinel Lymph Node

Secondary Lymph Nodes

Lymphatic vessel

Particles diffuse into interstitial fluid, drains into lymphatic vessels and regional nodes

First node involved in metastatic spread of tumour

The sentinel node concept

: Hot

• Common (guidelines)

– Breast

– Melanoma

– Gynecological malignancies

• Rare (research)

– Head and neck

– Urological malignancies

– Others

Sentinel Lymph Node Indications

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Imaging modalities

Planar/dynamic

SPECT‐CT

Landmarks

No Consensus

Nothing!

SPECT/CT: General indications

• Planar images difficult to interpret: unexpected unusual drainage patterns no or poor visualization of drainage (low or no activity, injection closer

to nodes, depth, overweighed patients ...) SPECT/CT• Topographic localization and detection of additional SLNs areas of deep lymphatic drainage (pelvis, abdomen, or mediastinum) areas with complex anatomy (head and neck)

identification of number, size, depth, and exact localization

• AdvantagesSurgical planningSensitivity SpecificityAttenuation correction

• ProblemsCost and added time Additional radiationNon suitable for dynamic studies“too much” sensitive?

“Hybrid imaging with SPECT and CT including anatomical information improves the localization of SLNs and reduces misinterpretation of images.”

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SPECT/CT: Added Values

Sensitivity

Breast cancerLymph node clearly

shown only on SPECT-CT

Breast cancerAn intra-mamary lymph node is seen only in SPECT-CT


Sensitivity

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Specific location of the SLN

Breast cancerLevel I and Level II axillar lymph

nodes clearly shown on SPECT-CT


Breast cancerInternal mammary lymph nodes

Specific location of the SLN


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Breast cancer

Anatomic Information for surgical planning



F.Giammarile

Anatomic Information for surgical planning

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Injection methods

Injection method does not affect the identification of axillary SLN

4%

99%20%

9%

99%

Superficial injections

Deep injections

Superficial injections are easy to perform

Deep injections may require ultrasound or sterotaxic guidance but allow detection of extra‐axillary nodes


Pre-surgical imaging

Breast cancer

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Pre-surgical imaging Breast cancer

Radioguided Occult Lesion Localisation (ROLL)Intratumoral administration guided by ultrasound/stereotaxisFollowed by immediate surgical resection, guided by probe

In non‐palpable suspected breast lesion replace hooked wired localization

(SLN in separate occasion)

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Pre-surgical imaging Melanoma



Head and neck cancer

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Cervical cancer



Vulvarcancer

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Penilecancer



Testicularcancer

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Radiopharmaceuticals

Latest technological knowledge

Methods and instrumentation

Handle

Infrared localization

system

Optical camera

‐ 99mTc colloids (nano, sulfur) ‐ 99mTc phytates

‐ Better than colloids in breast cancer (533 patients, SurgToday, 2006)

– 198Au‐colloïd ‐ Uniformity of size (20 nm):

high lymph node uptake (15% vs 5%) (Nuc Med Biol, 2011)

‐ 99mTc‐Tilmanocept ‐ Receptor imaging

(Radio) pharmaceuticals for SLN

‐Diameter < 1nm

‐Coloration of urines (12‐24 hours) and teguments (24‐48 hours)

‐Long term tatooing effect

‐Anaphylactic shock 0.4‐1%

Eckert et al, 2013

Radiopharmaceuticals Blue Dyes

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99mTc‐Tilmanocept

Receptor targeting agent

Lymphoseek ® • High affinity for CD 206 receptor

• Small size: 7nm, 19kDa

• Accumulation on macrophages and dendritic cells

• Internalized in lymphatic tissue

• High uptake and fast clearance from injection site

• Two phase III study in breast cancer (Baker el al. 2015 & Wallace et al. 2013):

• excellent concordance with blue and less surgically removed SLN. Sensitivity equal to colloids

“The advantages of this tracer include rapid clearance from the injection depot and low accumulation in second‐echelon nodes. This novel radiopharmaceutical might be of particular utility in patients with head and neck melanoma.”

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Bimodal (hybrid) agents

Perspectives in Imaging Agents for Lymphatic Mapping

Assembled nanoparticulecontaining ICG

Fluorescent agent (ICG)

Simultaneous scintigraphic and optical imaging (near‐infrared fluorescence):

Tissue penetration signals Brouwer OR, Ann

Surg Oncol (2012)

Intrumentation

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Endoscopic detection

Laparoscopic Gamma-Probe

Prostate carcinoma

Small field of view portable imaging devices

Portable gamma camera:Sentinella ®

Laser pointer centers targets on the screen

ANT

ANT axilar

OBLIQUE axilar

LATERAL Axilar

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Portable gamma camera: breast

57 year old patient with a breast cancer in left upper outer

quadrant

Images obtained with the portable gamma camera before and after SLN

excision:completeness of the SLN removal


Portable gamma camera: melanoma

No SLN on pre‐operative imaging

Portable gamma camera: SLN is depicted

Increased resolution and sensitivity

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Frontal melanoma with drainage to several nodes at different neck’s

level in right cervical basin

Images obtained with the portable gamma camera before and after

resection of 2 nodes:one more node is depicted

added value for close monitoring of the surgical procedure


Portable gamma camera: melanoma

3D/2D tracking assisted probes

3‐D volume rendering SPECT

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"Mixed‐Reality" Surgery(better 3D perception)


3‐D volume rendering SPECT

SPECT‐CT: sentinel node near the left testicular vessels

SLN localized in the operation room guided by SPECT/CT information

and using a portable gamma camera for real time display

testicular cancer


Portable gamma camera and laparoscopic Gamma-Probe

125I seed pointer (on the collimator)

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Radioguided Surgery today

• Multimodality preoperative molecular imaging

Intraoperative imaging

Non‐imaging procedures

• are essential for optimizing surgical approaches in patient‐ and

disease‐specific conditions

• to reduce the invasiveness of procedures (positively impact health

economy)

• providing the standardization of the methods (guidelines)

Take‐home messages

Radioguided Surgery tomorrow

• Develop more specific tumor markers to delineate more precisely

the extent of damage (bimodal radioactive and fluorescent agents)

• Develop more sensitive detectors, miniaturized and ergonomic

• Integrate different surgical methods (imaging modalities, resection,

navigation)

Robot‐assisted endoscopic surgery

Virtual reality (mostly for training purposes), mixed reality and

augmented reality

Take‐home messages

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Historical: “open and see”Passed: “open and listen”Present: “see, open and listen”Future: “see, open, listen and see with new eyes”

Conclusion: Evolution of Oncologic Surgery

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