title: Multimodal Surgical Guidance during Sentinel Node Biopsy for Melanoma: Combined Gamma Tracing and Fluorescence Imaging of the Sentinel Node through Use of the Hybrid Tracer Indocyanine Green-(99m)Tc-Nanocolloid.
abstract: Purpose To evaluate the hybrid approach in a large population of patients with melanoma in the head and neck, on the trunk, or on an extremity who were scheduled for sentinel node (SN) biopsy. Materials and Methods This prospective study was approved by the institutional review board. Between March 2010 and March 2013, 104 patients with a melanoma, including 48 women (average age, 54.3 years; range, 18.5-87.4 years) and 56 men (average age, 55.2 years; range, 22.4-77.4 years) (P = .76) were enrolled after obtaining written informed consent. Following intradermal hybrid tracer administration, lymphoscintigraphy and single photon emission computed tomography/computed tomography were performed. Blue dye was intradermally injected prior to the start of the surgical operation (excluding patients with a facial melanoma). Intraoperatively, SNs were initially pursued by using gamma tracing followed by fluorescence imaging (FI) and, when applicable, blue-dye detection. A portable gamma camera was used to confirm SN removal. Collected data included number and location of the preoperatively and intraoperatively identified SNs and the intraoperative number of SNs that were radioactive, fluorescent, and blue. A two-sample test for equality of proportions was performed to evaluate differences in intraoperative SN visualization through FI and blue-dye detection. Results Preoperative imaging revealed 2.4 SNs (range, 1-6) per patient. Intraoperatively, 93.8% (286 of 305) of the SNs were radioactive, 96.7% (295 of 305) of the SNs were fluorescent, while only 61.7% (116 of 188) of the SNs stained blue (P < .0001). FI was of value for identification of near-injection-site SNs (two patients), SNs located in complex anatomic areas (head and neck [28 patients]), and SNs that failed to accumulate blue dye (19 patients). Conclusion The hybrid tracer enables both preoperative SN mapping and intraoperative SN identification in melanoma patients. In the setup of this study, optical identification of the SNs through the fluorescent signature of the hybrid tracer was superior compared with blue dye-based SN visualization.
authors.affiliation: From the Interventional Molecular Imaging Laboratory, Department of Radiology (N.S.v.d.B., O.R.B., F.W.B.v.L., R.A.V.O.) and Department of Surgery (B.E.S.), Leiden University Medical Center, Leiden, the Netherlands; Department of Nuclear Medicine (N.S.v.d.B., O.R.B., H.M.M., R.A.V.O.), Department of Head and Neck Surgery and Oncology (W.M.C.K., A.J.M.B., F.W.B.v.L.), Department of Biostatistics (H.v.T.), and Department of Surgery and Melanoma Center Amsterdam (O.E.N.), the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands; Department of Maxillofacial Surgery, Academic Medical Center, Amsterdam, the Netherlands (W.M.C.K., A.J.M.B.); Melanoma Institute Australia, Sydney, Australia (O.E.N.); Sydney Medical School, the University of Sydney, Sydney, NSW, Australia (O.E.N.); and Department of Melanoma and Surgical Oncology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (O.E.N.).
authors.forename: Nynke S
authors.initials: NS
authors.lastname: van den Berg
authors.forename: Oscar R
authors.initials: OR
authors.lastname: Brouwer
authors.forename: Boudewijn E
authors.initials: BE
authors.lastname: Schaafsma
authors.forename: Hanna M
authors.initials: HM
authors.lastname: Mathéron
authors.forename: W Martin C
authors.initials: WM
authors.lastname: Klop
authors.forename: Alfons J M
authors.initials: AJ
authors.lastname: Balm
authors.forename: Harm
authors.initials: H
authors.lastname: van Tinteren
authors.forename: Omgo E
authors.initials: OE
authors.lastname: Nieweg
authors.forename: Fijs W B
authors.initials: FW
authors.lastname: van Leeuwen
authors.forename: Renato A
authors.initials: RA
authors.lastname: Valdés Olmos
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007208:Indocyanine Green; D008297:Male; D008545:Melanoma / Q000000981:diagnostic imaging* / Q000473:pathology*; D008875:Middle Aged; D064847:Multimodal Imaging; D061848:Optical Imaging; D011446:Prospective Studies; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D012878:Skin Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology*; D025321:Surgery, Computer-Assisted; D013668:Technetium Tc 99m Aggregated Albumin; D055815:Young Adult
chemical_list: D019275:Radiopharmaceuticals; D013668:Technetium Tc 99m Aggregated Albumin; C083602:technetium Tc 99m nanocolloid; D007208:Indocyanine Green