title: First demonstration of 3-D lymphatic mapping in breast cancer using freehand SPECT.
abstract: OBJECTIVE
  Freehand SPECT is a 3-D tomographic imaging modality based on data acquisition with a hand-held detector that is moved freely, in contrast to conventional, fixed gamma camera systems. In this pilot study, the feasibility of freehand SPECT for 3-D lymphatic mapping in breast cancer was evaluated.
  
  
  METHODS
  A total of 85 patients (age: 29-88 years) with an initial diagnosis of invasive breast cancer and no clinical evidence of nodal involvement prospectively underwent sentinel lymph node (SLN) biopsy. Preoperative lymphatic mapping (35-87 MBq (99m)Tc-Nanocoll) included tomographic imaging with a SPECT/CT device (Siemens Symbia T6) serving as reference. Initially, the freehand SPECT approach was assessed in a pilot study consisting of 50 patients. The quality of each freehand SPECT acquisition was assessed and ranked as good, intermediate or poor. In another series comprising a further 35 patients (validation study), a guidance system for the acquisition was implemented based on the results of the pilot study, ensuring acquisitions with good quality. For 3-D tomographic image reconstruction, ad hoc models and iterative reconstruction algorithms were used in all 85 patients. To allow for adequate comparison, SPECT/CT data and freehand SPECT data were registered within the same coordinate system.
  
  
  RESULTS
  In the pilot study, freehand SPECT enabled mapping of 24 of 83 SLNs in 20 of 44 patients (3 dropouts, 3 patients without SLN either in SPECT/CT or in freehand SPECT). Using SPECT/CT as reference, the accuracy of freehand SPECT was 77.8% (7/9 nodes) in scans with good quality, while for intermediate and poor quality scans, the accuracy was reduced to 34.3 and 12.8%, respectively. In the validation study, quality feedback improved the results significantly and freehand SPECT enabled the mapping of at least one SLN in 87.5% of the patients (28/32 - 3 dropouts). Compared to the reference method, freehand SPECT showed a sensitivity of 83.3% (35/42 nodes). False-negative findings were related to insufficient scanning time, insufficient coverage of the axillary region, close proximity of the SLN to the injection site and low tracer uptake in the SLNs.
  
  
  CONCLUSIONS
  In this preliminary study, we could demonstrate that 3-D localization of SLNs is feasible using freehand SPECT technology. Prerequisites for acquisition of a good scan quality, most likely allowing precise SLN mapping, have been defined. This approach has high potential to allow image-guided biopsy and further standardization of SLN dissection, thus bringing 3-D nuclear imaging into the operating room.
authors.affiliation: Technische Universität München, Boltzmannstr. 3, 85748 Garching bei Muenchen, Germany. wendler@tum.de
authors.forename: Thomas
authors.initials: T
authors.lastname: Wendler
authors.forename: Ken
authors.initials: K
authors.lastname: Herrmann
authors.forename: Andreas
authors.initials: A
authors.lastname: Schnelzer
authors.forename: Tobias
authors.initials: T
authors.lastname: Lasser
authors.forename: Joerg
authors.initials: J
authors.lastname: Traub
authors.forename: Olivier
authors.initials: O
authors.lastname: Kutter
authors.forename: Alexandra
authors.initials: A
authors.lastname: Ehlerding
authors.forename: Klemens
authors.initials: K
authors.lastname: Scheidhauer
authors.forename: Tibor
authors.initials: T
authors.lastname: Schuster
authors.forename: Marion
authors.initials: M
authors.lastname: Kiechle
authors.forename: Markus
authors.initials: M
authors.lastname: Schwaiger
authors.forename: Nassir
authors.initials: N
authors.lastname: Navab
authors.forename: Sibylle I
authors.initials: SI
authors.lastname: Ziegler
authors.forename: Andreas K
authors.initials: AK
authors.lastname: Buck
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery*; D005240:Feasibility Studies; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D007432:Intraoperative Period; D008875:Middle Aged; D011786:Quality Control; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*; D014057:Tomography, X-Ray Computed