title: Concomitant radio- and fluorescence-guided sentinel lymph node biopsy in squamous cell carcinoma of the oral cavity using ICG-(99m)Tc-nanocolloid.
abstract: OBJECTIVE
  For oral cavity malignancies, sentinel lymph node (SLN) mapping is performed by injecting a radiocolloid around the primary tumour followed by lymphoscintigraphy. Surgically, SLNs can then be localized using a handheld gamma ray detection probe. The aim of this study was to evaluate the added value of intraoperative fluorescence imaging to the conventional radioguided procedure. For this we used indocyanine green (ICG)-(99m)Tc-nanocolloid, a hybrid tracer that is both radioactive and fluorescent.
  
  
  METHODS
  Fourteen patients with oral cavity squamous cell carcinoma were peritumourally injected with ICG-(99m)Tc-nanocolloid. SLNs were preoperatively identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT)/CT for anatomical localization. During surgery, SLNs were detected with a handheld gamma ray detection probe and a handheld near-infrared fluorescence camera. Pre-incision and post-excision imaging with a portable gamma camera was performed to confirm complete removal of all SLNs.
  
  
  RESULTS
  SLNs were preoperatively identified using the radioactive signature of ICG-(99m)Tc-nanocolloid. Intraoperatively, 43 SLNs could be localized and excised with combined radio- and fluorescence guidance. Additionally, in four patients, an SLN located close to the primary injection site (in three patients this SLN was located in level I) could only be intraoperatively localized using fluorescence imaging. Pathological analysis of the SLNs revealed a metastasis in one patient.
  
  
  CONCLUSIONS
  Combined preoperative SLN identification and intraoperative radio- and fluorescence guidance during SLN biopsies for oral cavity cancer proved feasible using ICG-(99m)Tc-nanocolloid. The addition of fluorescence imaging was shown to be of particular value when SLNs were located in close proximity to the primary tumour.
authors.affiliation: Department of Nuclear Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
authors.forename: Nynke S
authors.initials: NS
authors.lastname: van den Berg
authors.forename: Oscar R
authors.initials: OR
authors.lastname: Brouwer
authors.forename: W Martin C
authors.initials: WM
authors.lastname: Klop
authors.forename: Bariş
authors.initials: B
authors.lastname: Karakullukcu
authors.forename: Charlotte L
authors.initials: CL
authors.lastname: Zuur
authors.forename: I Bing
authors.initials: IB
authors.lastname: Tan
authors.forename: Alfons J M
authors.initials: AJ
authors.lastname: Balm
authors.forename: Michiel W M
authors.initials: MW
authors.lastname: van den Brekel
authors.forename: Renato A
authors.initials: RA
authors.lastname: Valdés Olmos
authors.forename: Fijs W B
authors.initials: FW
authors.lastname: van Leeuwen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D005260:Female; D005456:Fluorescent Dyes; D005720:Gamma Rays; D006801:Humans; D007208:Indocyanine Green; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000000981:diagnostic imaging* / Q000601:surgery; D008207:Lymphatic Metastasis; D061305:Lymphoscintigraphy; D008297:Male; D008875:Middle Aged; D009062:Mouth Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D011859:Radiography; D019275:Radiopharmaceuticals; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D025321:Surgery, Computer-Assisted / Q000379:methods; D013668:Technetium Tc 99m Aggregated Albumin; D015899:Tomography, Emission-Computed, Single-Photon
chemical_list: D005456:Fluorescent Dyes; D019275:Radiopharmaceuticals; D013668:Technetium Tc 99m Aggregated Albumin; C083602:technetium Tc 99m nanocolloid; D007208:Indocyanine Green