title: Microsurgery guided by sequential preoperative lymphography using68Ga-NEB PET and MRI in patients with lower-limb lymphedema.
abstract: OBJECTIVE
  The popularity of contemporary microsurgical techniques in treatment of lower-limb lymphedema calls for better visualization of the lymphatic system, both preoperatively and intra-operatively. The aim of this prospective study was to investigate the feasibility of a novel combination of68Ga-NEB positron emission tomography (PET) with magnetic resonance lymphography (MRL) in evaluating lymphedema and guiding surgical intervention.
  
  
  METHODS
  A total of 11 patients (F 9, M 2, age range 29-69 y) with lower-limb lymphedema classified into stage I to III were recruited. PET acquisition was performed at 30, 60 and 90 min after subcutaneous injection of the albumin-binding radiotracer68Ga-NEB into the bilateral first web spaces of the feet. All the patients were also subjected to99mTc-sulfur colloid (SC) lymphoscintigraphy for comparison. Gd-DTPA-enhanced magnetic resonance imaging (MRI) was performed using sequences specialized for lymphatic vessel scans. All the patients underwent surgical interventions within a week. The surgical approach includes the use of a linear marker for edema localization and indocyanine green (ICG) lymphography with a near-infrared surgical navigation system intra-operatively.
  
  
  RESULTS
  Lymph transport in lymphatic channels was clearly observed by visualization of68Ga-NEB activity in the lymphatic vessels and within lymph nodes for all 11 patients as well as the visualization of the edema section plane with dermal backflow (DB), abnormally increased and disconnected uptake along the lymphatic channels. Preoperative68Ga-NEB PET combined with MRL provides advantageous three-dimensional images, higher temporal resolution, significantly shorter time lapse before image acquisition after tracer injection and more accurate pathological lymphatic vessel distribution than99mTc-SC lymphoscintigraphy combined with MRI.
  
  
  CONCLUSIONS
  This study documented an effective imaging pattern to combine68Ga-NEB PET and MRL in patients with lower-limb lymphedema. This strategy demonstrated significant advantage over99mTc-SC lymphoscintigraphy/MRL in the evaluation of lymphedema severity, staging and pathological location of lymph vessels to make an individualized treatment plan. Dual68Ga-NEB PET/MRL is thus recommended before the operation for staging and therapy planning.
authors.affiliation: Department of Plastic Surgery, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
authors.forename: Xiao
authors.initials: X
authors.lastname: Long
authors.affiliation: Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.|Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
authors.forename: Jingjing
authors.initials: J
authors.lastname: Zhang
authors.affiliation: Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
authors.forename: Daming
authors.initials: D
authors.lastname: Zhang
authors.affiliation: Department of Plastic Surgery, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
authors.forename: Chao
authors.initials: C
authors.lastname: Gao
authors.affiliation: Key Laboratory of Molecular Imaging of Chinese Academy of Sciences, Institute of Automation Chinese Academy of Sciences Beijing, Beijing, 100190, China.
authors.forename: Chongwei
authors.initials: C
authors.lastname: Chi
authors.affiliation: Department of Plastic Surgery, Peking Union Medical College Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
authors.forename: Elan
authors.initials: E
authors.lastname: Yang
authors.affiliation: Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
authors.forename: Huadan
authors.initials: H
authors.lastname: Xue
authors.affiliation: Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
authors.forename: Lixin
authors.initials: L
authors.lastname: Lang
authors.affiliation: Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH), Bethesda, MD, 20892, USA.
authors.forename: Gang
authors.initials: G
authors.lastname: Niu
authors.affiliation: Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China. zhuzhh@pumch.cn.
authors.forename: Zhaohui
authors.initials: Z
authors.lastname: Zhu
authors.affiliation: Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
authors.forename: Fang
authors.initials: F
authors.lastname: Li
authors.affiliation: Laboratory of Molecular Imaging and Nanomedicine (LOMIN), National Institute of Biomedical Imaging and Bioengineering (NIBIB), National Institutes of Health (NIH), Bethesda, MD, 20892, USA. shawn.chen@nih.gov.
authors.forename: Xiaoyuan
authors.identifier: http://orcid.org/0000-0002-9622-0870
authors.initials: X
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D056831:Coordination Complexes; D005260:Female; D006801:Humans; D035002:Lower Extremity / Q000000981:diagnostic imaging* / Q000601:surgery; D008209:Lymphedema / Q000000981:diagnostic imaging / Q000601:surgery*; D008220:Lymphography; D008279:Magnetic Resonance Imaging; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D064847:Multimodal Imaging; D049268:Positron-Emission Tomography; D057234:Preoperative Period; D025321:Surgery, Computer-Assisted
chemical_list: C000603981:68Ga-1,4,7-triazacyclononane-N,N',N''-triacetic acid; D056831:Coordination Complexes
keywords: 68Ga-NEB; Evans blue dye; ICG; Lymphangiography; Lymphedema; PET-MR