Skip to main content

Advertisement

SpringerLink
Log in

Fusion of freehand SPECT and ultrasound: First experience in preoperative localization of sentinel lymph nodes

  • Original Article
  • Published:
European Journal of Nuclear Medicine and Molecular Imaging Aims and scope Submit manuscript

Abstract

Purpose

Radioguided sentinel lymph node biopsy (SLNB) is the standard of care in breast cancer and melanoma. Additional preoperative Single-photon emission computed tomography (SPECT/CT) for improved anatomical co-registration of the SLNs causes additional radiation exposure and is time-consuming and expensive. The aim of this prospective study was to evaluate a novel approach involving real-time fusion of freehand SPECT (fhSPECT) and ultrasound (US) for anatomical co-registration of SLNs.

Methods

From February 2015 to February 2016, 153 patients were included in this prospective study. All patients underwent lymphoscintigraphy according to practical guidelines and 151 (118 cases of breast cancer, 30 cutaneous malignancies, and three cases of vulvar cancer) of the 153 patients were additionally investigated with fhSPECT-US. FhSPECT connected to a hand-held gamma detector generates three-dimensional images of the radioactivity distribution in the scanned area. For co-registration and real-time fusion of fhSPECT and subsequently performed US, an infrared stereo tracking system was used.

Results

In all patients an SLN was found on lymphoscintigraphy, and the fhSPECT detected corresponding hotspots in all but one patient. In 72 % of patients and 73 % of lymph node basins, real-time anatomical co-registration with US was feasible. The rate of success in achieving good co-registration increased from 60 to 75 % after training by a radiologist specialized in breast imaging. A higher co-registration rate (78 %) was observed in patients with only one SLN than in those with two SLNs (68 %) or three or more SLNs (0 %).

Conclusions

Real-time fusion of fhSPECT and US for preoperative anatomical co-registration of SLNs is feasible. However, before this approach can completely replace preoperative lymphatic imaging, further technical developments are needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. NCCN. NCCN clinical practice guidelines in oncology (NCCN guidelines) breast cancer version 1.2016; 2016.

  2. NCCN. NCCN clinical practice guidelines in oncology (NCCN guideline) melanoma Version 2.2016; 2016.

  3. Bluemel C, Herrmann K, Giammarile F, Nieweg OE, Dubreuil J, Testori A, et al. EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma. Eur J Nucl Med Mol Imaging. 2015;42:1750–66.

    Article  PubMed  Google Scholar 

  4. Giammarile F, Alazraki N, Aarsvold JN, Audisio RA, Glass E, Grant SF, et al. The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer. Eur J Nucl Med Mol Imaging. 2013;40:1932–47.

    Article  CAS  PubMed  Google Scholar 

  5. Vermeeren L, van der Ploeg IM, Olmos RA, Meinhardt W, Klop WM, Kroon BB, et al. SPECT/CT for preoperative sentinel node localization. J Surg Oncol. 2010;101:184–90.

    PubMed  Google Scholar 

  6. Wagner T, Buscombe J, Gnanasegaran G, Navalkissoor S. SPECT/CT in sentinel node imaging. Nucl Med Commun. 2013;34:191–202.

    Article  CAS  PubMed  Google Scholar 

  7. Hutton BF. The origins of SPECT and SPECT/CT. Eur J Nucl Med Mol Imaging. 2014;41:S3–16.

    Article  PubMed  Google Scholar 

  8. Stoffels I, Boy C, Poppel T, Kuhn J, Klotgen K, Dissemond J, et al. Association between sentinel lymph node excision with or without preoperative SPECT/CT and metastatic node detection and disease-free survival in melanoma. JAMA. 2012;308:1007–14.

    Article  CAS  PubMed  Google Scholar 

  9. Jimenez-Heffernan A, Ellmann A, Sado H, Huic D, Bal C, Parameswaran R, et al. Results of a prospective multicenter international atomic energy agency sentinel node trial on the value of SPECT/CT over planar imaging in various malignancies. J Nucl Med. 2015;56:1338–44.

    Article  CAS  PubMed  Google Scholar 

  10. Law M, Ma WH, Leung R, Li S, Wong KK, Ho WY, et al. Evaluation of patient effective dose from sentinel lymph node lymphoscintigraphy in breast cancer: a phantom study with SPECT/CT and ICRP-103 recommendations. Eur J Radiol. 2012;81:e717–20.

    Article  PubMed  Google Scholar 

  11. Wendler T, Herrmann K, Schnelzer A, Lasser T, Traub J, Kutter O, et al. First demonstration of 3-D lymphatic mapping in breast cancer using freehand SPECT. Eur J Nucl Med Mol Imaging. 2010;37:1452–61.

    Article  PubMed  Google Scholar 

  12. Freesmeyer M, Winkens T, Opfermann T, Elsner P, Runnebaum I, Darr A. Real-time ultrasound and freehand-SPECT. Experiences with sentinel lymph node mapping. Nuklearmedizin. 2014;53:259–64.

    Article  CAS  PubMed  Google Scholar 

  13. Freesmeyer M, Opfermann T, Winkens T. Hybrid integration of real-time US and freehand SPECT: proof of concept in patients with thyroid diseases. Radiology. 2014;271:856–61.

    Article  PubMed  Google Scholar 

  14. Okur A, Hennersperger C, Runyan B, Gardiazaball J, Keicher M, Paepke S, et al. FhSPECT-US guided needle biopsy of sentinel lymph nodes in the axilla: is it feasible? Med Image Comput Comput Assist Interv. 2014;17:577–84.

    PubMed  Google Scholar 

  15. Bluemel C, Kirchner P, Kajdi GW, Werner RA, Herrmann K. Localization of parathyroid adenoma with real-time ultrasound: freehand SPECT fusion. Clin Nucl Med. 2016;41:e141–2.

    Article  PubMed  Google Scholar 

  16. Giammarile F, Bozkurt MF, Cibula D, Pahisa J, Oyen WJ, Paredes P, et al. The EANM clinical and technical guidelines for lymphoscintigraphy and sentinel node localization in gynaecological cancers. Eur J Nucl Med Mol Imaging. 2014;41:1463–77.

    Article  PubMed  Google Scholar 

  17. Bluemel C, Cramer A, Grossmann C, Kajdi GW, Malzahn U, Lamp N, et al. iROLL: does 3-D radioguided occult lesion localization improve surgical management in early-stage breast cancer? Eur J Nucl Med Mol Imaging. 2015;42:1692–9.

    Article  CAS  PubMed  Google Scholar 

  18. Bluemel C, Herrmann K, Kubler A, Buck AK, Geissinger E, Wild V, et al. Intraoperative 3-D imaging improves sentinel lymph node biopsy in oral cancer. Eur J Nucl Med Mol Imaging. 2014;41:2257–64.

    Article  CAS  PubMed  Google Scholar 

  19. Bluemel C, Schnelzer A, Okur A, Ehlerding A, Paepke S, Scheidhauer K, et al. Freehand SPECT for image-guided sentinel lymph node biopsy in breast cancer. Eur J Nucl Med Mol Imaging. 2013;40:1656–61.

    Article  PubMed  Google Scholar 

  20. Matthies P, Gardiazabal J, Okur A, Vogel J, Lasser T, Navab N. Mini gamma cameras for intra-operative nuclear tomographic reconstruction. Med Image Anal. 2014;18:1329–36.

    Article  PubMed  Google Scholar 

  21. Matthies P, Sharma K, Okur A, Gardiazabal J, Vogel J, Lasserl T, et al. First use of mini gamma cameras for intra-operative robotic SPECT reconstruction. Med Image Comput Comput Assist Interv. 2013;16:163–70.

    PubMed  Google Scholar 

  22. Heller S, Zanzonico P. Nuclear probes and intraoperative gamma cameras. Semin Nucl Med. 2011;41:166–81.

    Article  PubMed  Google Scholar 

  23. Tsuchimochi M, Hayama K. Intraoperative gamma cameras for radioguided surgery: technical characteristics, performance parameters, and clinical applications. Phys Med. 2013;29:126–38.

    Article  PubMed  Google Scholar 

  24. Engelen T, Winkel BM, Rietbergen DD, KleinJan GH, Vidal-Sicart S, Olmos RA, et al. The next evolution in radioguided surgery: breast cancer related sentinel node localization using a freehandSPECT-mobile gamma camera combination. Am J Nucl Med Mol Imaging. 2015;5:233–45.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Hellingman D, de Wit-van der Veen LJ, Klop WM, Olmos RA. Detecting near-the-injection-site sentinel nodes in head and neck melanomas with a high-resolution portable gamma camera. Clin Nucl Med. 2015;40:e11–6.

    Article  PubMed  Google Scholar 

  26. van den Berg NS, Brouwer OR, Schaafsma BE, Matheron HM, Klop WM, Balm AJ, et al. 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. Radiology. 2015;275:521–9.

    Article  PubMed  Google Scholar 

  27. Ewertsen C. Image fusion between ultrasonography and CT, MRI or PET/CT for image guidance and intervention - a theoretical and clinical study. Dan Med Bull. 2010;57:B4172.

    PubMed  Google Scholar 

  28. de Bree R, Pouw B, Heuveling DA, Castelijns JA. Fusion of freehand SPECT and ultrasound to perform ultrasound-guided fine-needle aspiration cytology of sentinel nodes in head and neck cancer. Am J Neuroradiol. 2015;36:2153–8.

    Article  PubMed  Google Scholar 

  29. Paepke S, Horn M, Wendler T. Minimally invasive, image-guided core needle biopsy of sentinel lymph nodes as nonsurgical method to detect lymph node metastases. In: Herrmann K, Nieweg OE, Povoski SP, editors. Radioguided surgery - current applications and innovative directions in clinical practice. Springer; 2016. p. 491–4.

  30. Paepke S, Pfob C, Ohlinger R, Gruber I, Thill M, Blohmer J, et al. Abstract P3-01-16: can sentinel node staging be performed using a minimally invasive needle-biopsy? Results of German multicentric pilot study. Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8–12; San Antonio, TX Philadelphia (PA): AACR; Cancer Res 2016;76:Abstract nr P3-01-16; 2016. p. P3-01-16.

  31. Voit C, Van Akkooi AC, Schafer-Hesterberg G, Schoengen A, Kowalczyk K, Roewert JC, et al. Ultrasound morphology criteria predict metastatic disease of the sentinel nodes in patients with melanoma. J Clin Oncol. 2010;28:847–52.

    Article  PubMed  Google Scholar 

  32. Deurloo EE, Tanis PJ, Gilhuijs KG, Muller SH, Kroger R, Peterse JL, et al. Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer. Eur J Cancer. 2003;39:1068–73.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Nuclear Medicine, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany

    Christina Bluemel, Gonca Safak, Jan-Stefan Schmid, Franz Kaiser, Andreas K. Buck & Ken Herrmann

  2. Department of Obstetrics and Gynecology, Missionsärztliches Klinikum Würzburg, Würzburg, Germany

    Andreas Cramer

  3. Department of Obstetrics and Gynecology, University Hospital of Würzburg, Würzburg, Germany

    Achim Wöckel

  4. Department of Dermatology, Venerology and Allergology, University Hospital of Würzburg, Würzburg, Germany

    Anja Gesierich

  5. Institute of Pathology, University of Würzburg, Würzburg, Germany

    Elena Hartmann

  6. Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Ken Herrmann

Authors
  1. Christina Bluemel
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gonca Safak
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andreas Cramer
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Achim Wöckel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Anja Gesierich
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Elena Hartmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jan-Stefan Schmid
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Franz Kaiser
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Andreas K. Buck
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ken Herrmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christina Bluemel.

Ethics declarations

Disclosure of potential conflicts of interest

Ken Herrmann and Andreas K. Buck are co-founders of SurgicEye GmbH (Munich, Germany), the company that owns and manufactures the fhSPECT system discussed in this manuscript (declipse®SPECT; SurgicEye, Munich, Germany). All other authors have nothing to disclose.

Research involving human participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the local ethics committee (213/14).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bluemel, C., Safak, G., Cramer, A. et al. Fusion of freehand SPECT and ultrasound: First experience in preoperative localization of sentinel lymph nodes. Eur J Nucl Med Mol Imaging 43, 2304–2312 (2016). https://doi.org/10.1007/s00259-016-3443-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00259-016-3443-0

Keywords

Search

Navigation