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Sentinel nodes in complex areas: innovating radioguided surgery
Vermeeren, L.
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Citation for published version (APA):Vermeeren, L. (2011). Sentinel nodes in complex areas: innovating radioguided surgery.
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Download date: 29 Aug 2020
Chapter 3
SPECT/CT for preoperati ve senti nel node
localizati on
L. Vermeeren
I.M.C. van der Ploeg
R.A. Valdés Olmos
W. Meinhardt
W.M.C. Klop
B.B.R. Kroon
O.E. Nieweg
Journal of Surgical Oncology 2010;101:184-90
40 | Chapter 3
ABSTRACT
The value of SPECT/CT for detecti on and localizati on of senti nel nodes is reviewed. SPECT/
CT depicts extra senti nel nodes and identi fi es non-nodal tracer accumulati on. SPECT/CT is
indicated in pati ents with complex lymphati c drainage as oft en present in pati ents with head,
neck and scapular melanoma, breast cancer pati ents with extra-axillary senti nel nodes and
pati ents with tumours draining to pelvic nodes. SPECT/CT also clarifi es the drainage patt ern of
inconclusive conventi onal images (non-visualisati on or unclear locati on of the nodes).
SPECT/CT for preoperati ve senti nel node localizati on | 41
INTRODUCTION
Knowledge of the tumour status of the lymph nodes is relevant for staging and for prognosti c
and therapeuti c reasons. Senti nel node mapping is widely used in pati ents with breast cancer
or melanoma and its possible role in staging of other solid tumours is subject of ongoing
research.
Conventi onal (planar) lymphoscinti graphy is routi nely used to visualise the senti nel nodes
and their aff erent lymphati c vessels preoperati vely, and to determine their number and their
locati on. A new hybrid nuclear medicine and radiology technique has been developed for
these purposes.1,2 This multi modal approach combines single photon emission computed
tomography with CT (SPECT/CT). SPECT/CT is a more sensiti ve technique than conventi onal
lymphoscinti graphy because it corrects for ti ssue att enuati on and scatt er.3 The CT visualises
the anatomic surrounding of a senti nel node. SPECT/CT can be performed during or aft er
conventi onal lymphoscinti graphy and will take approximately twenty minutes. When a hybrid
system is used, the pati ent can usually stay in the same positi on on the bed of the gamma
camera. Additi onal injecti on of the radiopharmaceuti cal is not required and no contrast
medium is involved. A low dose CT is used limiti ng the radiati on exposure of the pati ent to
1.3-5 mGy.4
The purpose of this review is to report on the value of SPECT/CT for identi fi cati on and
localizati on of senti nel nodes in breast cancer, melanoma and in some specifi c other sites,
based on a literature review and on our own experience. The PubMed database was searched
for studies concerning SPECT/CT for lymphati c mapping. The following medical subject
headings (MeSH terms) were used to fi nd relevant arti cles: breast neoplasms, melanoma,
senti nel lymph node biopsy, and tomography, emission-computed, single-photon.
First, conventi onal senti nel node imaging and detecti on techniques are discussed and then the
value of adding SPECT/CT images is evaluated.
CONVENTIONAL IMAGING TECHNIQUES
Conventi onal lymphoscinti graphy is routi nely used for preoperati ve senti nel node detecti on.
In the late 1970’s, Robinson et al. demonstrated visualisati on of regional lymphati c drainage
with colloidal gold scanning in melanoma of the trunk.5 Conventi onal lymphoscinti graphy
aft er injecti on of a radiotracer has been widely applied since to visualise and localize senti nel
42 | Chapter 3
nodes preoperati vely, also in breast cancer.6 But sti ll no uniform guideline exists regarding this
imaging technique.
Various radiopharmaceuti cals are being used, most oft en techneti um-99m albumin
nanocolloid, techneti um-99m rhenium colloid or techneti um-99m sulfur colloid. Senti nel
node visualisati on depends on the transport of the radiopharmaceuti cal parti cles from the
injecti on site through lymphati c channels towards senti nel nodes.7 The radiolabeled parti cles
are then trapped within the node and absorbed by macrophages. The process of transport and
accumulati on can be infl uenced by several factors, such as parti cle size, parti cle concentrati on
and injected dose.8-10 Conti nuous transport of the radiopharmaceuti cal towards the senti nel
nodes enables visualisati on with a gamma camera and intra-operati ve detecti on with a gamma
ray detecti on probe for over 24 hours aft er injecti on.
In pati ents with melanoma, several intradermal tracer deposits are placed around the
tumour or around the biopsy scar.11 In breast cancer pati ents, the tracer is oft en administered
in or around the tumour, guided by ultrasonography in case of a non-palpable lesion.12 Some
nuclear medicine physicians prefer injecti on superfi cial from the tumour or near the areola.13
Dynamic imaging immediately aft er the tracer administrati on demonstrates the lymph
vessel(s) and is performed when immediate lymphati c drainage can be expected, for instance
in pati ents with a tumour of the skin or mucosa. The visualisati on of lymphati c ducts enables
the disti ncti on between senti nel nodes and nodes downstream. Sequenti al stati c images can
visualise successive stages of drainage and can also help to disti nguish senti nel nodes from
second-ti er nodes.
The locati on of a senti nel node can be marked on the pati ent’s skin aft er the late images
by positi oning an external radioacti ve point source over the senti nel node during real ti me
imaging or with the aid of a gamma ray detecti on probe. Senti nel node biopsy based on
conventi onal images has been carried out in breast cancer pati ents with good detecti on rates
and rare false-negati ve results.14 In melanoma, identi fi cati on rate is close to 100% but the false
negati ve rate is typically between 10% and 20%.15
SPECT/CT IN PATIENTS WITH BREAST CANCER
A review of the literature on SPECT/CT for visualisati on and localizati on of senti nel nodes in
pati ents with breast cancer revealed ten studies.3,16-24 An overview of these studies is given
in table 1. The injected dose ranged from 37 148 MBq (1 4 mCi) and diff erent injecti on
techniques were used (intratumoural in three studies, peritumoural in three studies, combined
SPECT/CT for preoperati ve senti nel node localizati on | 43
peritumoural and intracutaneous in two studies, and periareolar in two studies). Additi onal
early sequenti al conventi onal images were made in six studies, three investi gators only
performed late stati c conventi onal images once and in one study no conventi onal images were
obtained. The ti ming of the SPECT/CT diff ered from thirty minutes aft er injecti on of the tracer
up to eighteen hours aft er injecti on.3,16-24 The visualisati on rates were bett er with SPECT/CT
(89 92%) than with conventi onal imaging (63%-88%) in all comparati ve studies.3,16-23
The fi rst large study on SPECT/CT in breast cancer reported improved preoperati ve
localizati on of hot nodes18. Subsequent studies confi rmed the value of SPECT/CT for this
purpose.3,16,17,20-23 SPECT/CT also detected hot nodes that are not seen on conventi onal
images. Non-nodal sites of tracer accumulati on, typically due to contaminati on, could be
identi fi ed as such, thereby avoiding surgical explorati on to pursue a non-existi ng senti nel
node.3,16-18,23 Senti nel nodes near the injecti on area are easily overlooked on conventi onal
images because some 98% of the radioacti vity does not travel and obscures the 0.16% of the
tracer that on average ends up in the senti nel node.25 SPECT/CT can discern such a node and also
depicts senti nel nodes in a substanti al number of pati ents in whom the conventi onal images
do not show enough uptake.21 Mapping of all direct tumour draining lymph nodes requires
knowledge of the number and locati on of these senti nel nodes, which will be provided by
SPECT/CT in additi on to planar images. Some authors have argued that excision of a maximum
of three senti nel nodes provides enough informati on for accurate staging.26-28 which would
make the detecti on more then three senti nel node less relevant. Gallowitsch et al. reported
that with the gamma probe even more senti nel nodes will be found then visualised on SPECT/
CT.19 However, these authors do not clearly state their defi niti on of a senti nel node. They may
have considered all radioacti ve nodes to be senti nel nodes without requiring direct drainage
from the primary tumour.19
SPECT/CT was also found to visualise lymphati c drainage in eight of fi ft een breast cancer
pati ents (53%) with non-visualisati on on conventi onal images, including three tumour-positi ve
senti nel nodes (fi gure 1). SPECT/CT may show the senti nel nodes in the axilla if conventi onal
images only show drainage to a node elsewhere.21
SPECT/CT appeared to be of parti cular value in obese pati ents. Conventi onal images failed
to visualise senti nel nodes in 28% of obese pati ents, while non-visualisati on was 13% with
SPECT/CT.3 The visualisati on rate using conventi onal images decreased with an increasing
body mass index, while the SPECT/CT results remained relati vely stable.
44 | Chapter 3Ta
ble
1 |
Stud
ies
repo
rti n
g on
the
valu
e of
SPE
CT/C
T fo
r ly
mph
ati c
map
ping
of b
reas
t can
cer.
NRe
mar
ksSN
vis
ualiz
ati o
nSP
ECT/
CTA
dditi
onal
SPE
CT/C
T re
sult
s
Plan
ar
imag
esSP
ECT/
CT
Extr
a SN
Ex
clus
ion
of a
SN
Hus
arik
et a
l. [1
6]
2007
41Cl
ose
to
inje
cti o
n si
te: i
n 14
%In
17%
Mor
e ac
cura
te in
form
ati o
n in
82%
. Im
prov
es
loca
lizati
on
and
incr
ease
s se
nsiti
vity
and
spe
cifi c
ity
of ly
mph
osci
nti g
raph
y.
Peck
ing
et a
l. [1
7]
2007
34Va
lue
of S
PECT
/CT
for
lym
phed
ema
asse
ssm
ent a
lso
anal
yzed
.
88%
(cle
ar:
62%
)91
%M
ore
prec
ise
loca
lizati
on.
Lerm
an e
t al.
[3]
2007
220
122
pati e
nts
with
BM
I >=2
5.
Som
e pa
ti ent
s al
so in
clud
ed in
a
prev
ious
stu
dy [1
1].
78%
91%
In 2
0 pa
ti ent
s
Pati e
nts
with
non
-vis
. on
plan
ar im
ages
had
a h
ighe
r m
ean
BMI.
SPEC
T/CT
has
enh
ance
d su
peri
ority
in
over
wei
ght p
ati e
nts.
Gal
lo-w
itsch
et
al.
[19]
200
851
SPEC
T: 5
1 SN
, CT:
65
SN, g
amm
a pr
obe:
68
SN.
SPEC
T/CT
pro
vide
s m
ore
accu
rate
loca
lizati
on
but
unde
resti
mat
es th
e nu
mbe
r of
SN
.
Muc
ient
es R
asill
a et
al.
[20]
200
825
Neo
-adj
uvan
t che
mot
hera
py
in 6
pati
ent
s. In
tra-
oper
ati v
e fi n
ding
s us
ed a
s go
ld s
tand
ard.
63%
90%
In 3
pa
ti ent
s
Prov
ides
val
uabl
e an
atom
ical
loca
lizati
on.
Iden
ti cal
fi n
ding
s fo
r pl
anar
imag
es a
nd S
PECT
/CT
in th
e ch
emot
hera
py g
roup
.
Van
der
Ploe
g et
al
. [21
] 200
928
*Su
bgro
up a
naly
ses:
15
non-
vis.
an
d 13
onl
y ex
tra-
axill
ary
SN
(con
venti
ona
l im
ages
).
0%
(non
-vis
.)53
%Pr
ovid
es e
xact
ana
tom
ical
loca
lizati
on
(esp
ecia
lly
usef
ul fo
r ex
tra-
axill
ary
SN).
Surg
ical
exp
lorati o
n is
use
ful t
o de
tect
SN
in c
ase
of
pers
iste
nt n
on-v
is.
0% (e
xtra
-ax
illar
y SN
on
ly)
Axi
llary
no
de: 1
5%
Van
der
Ploe
g et
al
. [22
] 200
913
4*So
me
pati e
nts
also
incl
uded
in
a pr
evio
us s
tudy
[16]
.84
%92
%19
SN
2 SN
Chan
ged
surg
ical
app
roac
h on
the
basi
s of
SPE
CT/
CT: 4
2%.
Ibus
uki e
t al.
[24]
20
0922
3N
o co
mpa
riso
n w
ith
conv
enti o
nal i
mag
es.
97%
Prov
ides
pre
oper
ati v
e lo
caliz
ati o
n of
SN
. Aty
pica
l di
stri
buti o
n of
SN
may
sug
gest
axi
llary
pos
iti vi
ty.
Onl
y th
e m
ost r
ecen
t stu
dy is
men
ti one
d in
cas
e of
pati
ent
coh
orts
that
hav
e pr
evio
usly
bee
n an
alyz
ed in
ano
ther
stu
dy; *
SPEC
T/CT
was
per
form
ed o
n in
dicati o
n on
ly: i
n ca
se o
f
an u
nusu
al d
rain
age
patt
ern,
diffi
cul
t to
inte
rpre
t dr
aina
ge o
n pl
anar
imag
es o
r no
n-vi
sual
izati
on;
N: n
umbe
r of
pati
ent
s, B
MI:
body
mas
s in
dex,
SN
: sen
ti nel
nod
e(s)
, non
-vis
.:
non-
visu
aliz
ati o
n.
SPECT/CT for preoperati ve senti nel node localizati on | 45
Figure 1 | A 67-year old pati ent with a non-
palpable breast tumour. The radiotracer was
injected in the tumour under ultrasonographic
guidance. Conventi onal images aft er fi ft een
minutes, two hours and four hours did not
show any lymphati c drainage. Additi onal
conventi onal images were performed aft er six
hours (A) but did not show a senti nel node.
Subsequent SPECT/CT visualised an axillary
senti nel node. Two dimensional fusion images
(B) localized the node at the lateral margin
of the pectoral muscles. Three-dimensional
reconstructi on (C) shows the node in relati on
to the injecti on area. During surgery, the
radioacti ve senti nel node was found and was
free of metastasis.
The value of SPECT/CT for the surgical approach was reported in a recent arti cle.22 In 15%
of all node positi ve pati ents, the involved senti nel nodes were depicted only on the SPECT/
CT images. The initi ally planned surgical incision, which was made to approach the senti nel
nodes, was changed on the basis of the anatomical informati on provided by SPECT/CT in 42%
of the pati ents. The locati on of the incision was more precise in 36%, an extra incision was
made in 4% and an incision was omitt ed in 1.5%.22 This study also showed the benefi t of
SPECT/CT images in pati ents with a senti nel node outside the axilla, for example in case of
46 | Chapter 3
parasternal senti nel nodes. The incision can be placed more precise in such pati ents, because
SPECT/CT shows the exact intercostal space that should be explored or a locati on underneath
a rib or behind the sternum.22
Senti nel node mapping for breast cancer has been performed safely without SPECT/CT
and the rate of axillary recurrence aft er a negati ve senti nel node biopsy has been very low.14
SPECT/CT should therefore be performed on specifi c indicati ons only. In this way, the majority
of pati ents who will not benefi t from this imaging technique are spared unnecessary cost and
inconvenience.
Based on the above-menti oned fi ndings, one can conclude that current indicati ons for
SPECT/CT appear to be non-visualisati on when conventi onal imaging is performed, obesity
and presence of extra-axillary senti nel nodes or otherwise unusual drainage (e.g. in case of
previous breast surgery). SPECT/CT might also be performed if the conventi onal images are
diffi cult to interpret (e.g. suspicion of contaminati on or a senti nel node near the injecti on
area).
SPECT/CT IN PATIENTS WITH MELANOMA
There are just a few case reports and cohort studies on SPECT/CT for lymphati c mapping in
pati ents with melanoma and these are listed in table 2.29-35 The investi gators of the cohort
studies administered four intracutaneous deposits with a total dose of 74-185 MBq (2 5 mCi)
of the radiopharmaceuti cal. Most investi gators performed dynamic conventi onal imaging
followed by sequenti al stati c imaging and subsequent SPECT/CT.31-33,35 Covarelli et al. only
investi gated pati ents with a head and neck melanoma and administered 10 MBq (0.3 mCi)
when pati ents where operated on the same day and 50 MBq (1.4 mCi) if pati ents were operated
the next day. They performed conventi onal imaging in half of the pati ents and SPECT/CT in the
other half of the pati ents.34
Several authors underlined the important additi onal anatomic informati on SPECT/CT can
provide.31,33,35 Even-Sapir et al. found that a substanti al number of additi onal senti nel nodes
were depicted with SPECT/CT in pati ents with a melanoma on the head, in the neck or on the
trunk, while in other areas of the body no additi onal value of SPECT/CT was established. In two
out of the 15 pati ents with a head and neck tumour, a senti nel node only visualised with SPECT/
CT was tumour-bearing.31 Ishihara et al. concluded that SPECT/CT is useful for exact localizati on
of senti nel nodes in melanoma pati ents, regardless of their positi on, while Kretschmer et al.
specifi cally menti oned its relevance for the identi fi cati on of pelvic senti nel nodes in pati ents
SPECT/CT for preoperati ve senti nel node localizati on | 47Ta
ble
2 |
Stud
ies
repo
rti n
g on
the
valu
e of
SPE
CT/C
T fo
r ly
mph
ati c
map
ping
in p
ati e
nts
with
mel
anom
a.
NRe
mar
ksSN
vis
ualiz
ati o
nSP
ECT/
CTA
dditi
onal
SPE
CT/C
T re
sult
s
Extr
a SN
SN e
xclu
sion
Even
-Sap
ir e
t al
. [31
] 200
328
6
pati e
nts
with
squ
amou
s ce
ll ca
rcin
oma
also
incl
uded
.N
ot m
enti o
ned
In 4
3% o
f pati
ent
s w
ith m
elan
oma
of
trun
k &
H&
N.
1 SN
Prov
ides
add
iti on
al d
ata
of c
linic
al
rele
vanc
e in
mel
anom
a of
the
trun
k or
H
&N
regi
on.
Kret
schm
er
et a
l. [3
2]
2003
31
Mel
anom
a of
low
er e
xtre
mity
and
lo
wer
trun
k on
ly. 3
1 ou
t of 5
1 ha
d SP
ECT/
CT.
Plan
ar im
ages
nec
essa
ry
to d
isti n
guis
h SN
from
se
cond
-ti e
r no
de.
Succ
essf
ul fu
sion
in 2
9 pa
ti ent
s. P
reci
se
locati o
n of
SN
and
iden
ti fi c
ati o
n of
true
pe
lvic
SN
.
Ishi
hara
et a
l. [3
3] 2
006
26
9 pa
ti ent
s w
ith tu
mou
rs o
ther
th
an m
elan
oma
also
incl
uded
.Bl
ue d
ye: 8
5%SP
ECT/
CT: 1
00%
Use
ful f
or a
nato
mic
loca
lizati
on
of S
N.
Cova
relli
et a
l. [3
4] 2
007
23M
elan
oma
of H
&N
onl
y.11
pati
ent
s on
ly p
lana
r im
agin
g,
12 p
ati e
nts
only
SPE
CT/C
T.
Plan
ar im
ages
:82
%SP
ECT/
CT: 1
00%
Ope
rati o
n ti m
e w
as s
ignifi c
antly
sho
rter
in
the
SPEC
T/CT
gro
up.
Van
der
Ploe
g et
al.
[35]
20
09
85*
Som
e pa
ti ent
s al
so in
clud
ed in
a
prev
ious
stu
dy [1
6].
Plan
ar im
ages
: 99%
*SP
ECT/
CT: 1
00%
12 S
N
in 7
pati
ent
sFa
cilit
ates
sur
gica
l exp
lorati o
n in
diffi
cul
t ca
ses
(cha
nge
of s
urgi
cal a
ppro
ach
in
35%
) and
may
impr
ove
stag
ing.
* SP
ECT/
CT w
as p
erfo
rmed
on
indi
cati o
n on
ly: i
n ca
se o
f an
unus
ual d
rain
age
patt
ern,
diffi
cul
t to
inte
rpre
t dra
inag
e or
non
-vis
ualiz
ati o
n on
pla
nar i
mag
es; N
: num
ber o
f pati
ent
s,
SN: s
enti n
el n
ode,
H&
N: h
ead
and
neck
.
48 | Chapter 3
with a melanoma on the lower extremity.32,33 In our insti tuti on, SPECT/CT is performed
only for certain indicati ons. SPECT/CT was found to lead to a change in surgical approach
in 35% of the pati ents with an unusual drainage patt ern on the conventi onal images, with
conventi onal images that were diffi cult to interpret or with conventi onal images without
senti nel node visualisati on.35 On the basis of the SPECT/CT, a diff erent incision was made
in 20% of the pati ents, an incision at another site was made in 9% and 6% of the pati ents
received an extra incision. Additi onal value of SPECT/CT was present in all pati ents with
a melanoma of the head and neck, in 71% of the pati ents with a melanoma of the trunk
(mainly tumours near the midline with drainage to multi ple nodal basins) and in 27% of the
pati ents with a melanoma on the leg. Furthermore, three nodes (in two pati ents) that were
only depicted on SPECT/CT appeared to contain metastasis.35 Figure 2 shows an example of
a pati ent with complex drainage on the conventi onal images in whom SPECT/CT identi fi ed an
additi onal subcutaneous senti nel node underneath the injecti on area. The value of SPECT/
CT for lymphati c mapping of melanoma of the head and neck is underlined by Covarelli et al,
who demonstrated that senti nel node biopsy based on SPECT/CT images took signifi cantly
less ti me than senti nel node biopsy based on conventi onal images.34 The authors argue that
more precise preoperati ve localizati on of a senti nel node and knowledge of the relati onship
with anatomical structures facilitated surgical excision.34 They also menti on that SPECT/CT can
detect senti nel nodes in spite of scatt ered radiati on of the injecti on site. This benefi t is also
present in lymphati c mapping of oral cavity carcinoma.36,37
In pati ents with melanoma, SPECT/CT appears to be indicated in case of complex
conventi onal images as is oft en the case in melanomas in the head and neck or in the scapular
region. In these pati ents, SPECT/CT can detect additi onal senti nel nodes and the surgical
approach can be planned based on the localizati on informati on SPECT/CT provides. In the
future, the exact localizati on of second-ti er nodes may have implicati ons for the extent of a
completi on node dissecti on in case of a positi ve senti nel node and a SPECT/CT can then be
useful in the identi fi cati on of such nodes.38
SPECT/CT IN PATIENTS WITH OTHER MALIGNANCIES
Various authors describe that SPECT/CT provides useful informati on as to the exact locati on
of senti nel nodes in head and neck malignancies,31,34,36,37,39-41 as is exemplifi ed in fi gure 3.
SPECT/CT has been reported to visualise additi onal senti nel nodes in this anatomically complex
area.31,36,39,41-43 Senti nel nodes located in the vicinity of the injecti on site are easily missed
SPECT/CT for preoperati ve senti nel node localizati on | 49
on the conventi onal images and can oft en be discerned using SPECT/CT.36,37 Non-nodal tracer
accumulati on is oft en thought to represent a senti nel node on conventi onal images but its true
nature, mostly contaminati on, can be identi fi ed with SPECT/CT.31,42,43
Figure 2 | A pati ent who had undergone excision of a melanoma of the left abdominal wall. The
radiopharmaceuti cal was injected intracutaneously around the scar. Conventi onal images aft er fi ft een
minutes (A: anterior, B: left lateral, C: right lateral) show complex drainage, with visualisati on of
several lymphati c channels and at least one senti nel node in each axilla. Late conventi onal images
(D: anterior view) sti ll show radioacti vity in the lymphati c channels and also uptake in several nodes.
Two-dimensional fused SPECT/CT (E) shows a subcutaneous senti nel node underneath the injecti on
site that is not visible on the conventi onal images. The three-dimensional reconstructi on (F) shows an
overview of all hot spots. The hot spots with arrows were regarded as senti nel nodes, because they
appeared to be on a direct drainage pathway: underneath the primary tumour site, in the left internal
mammary chain and in each axilla. The node in the internal mammary chain could also be a second-
echelon node from the subcutaneous senti nel node, but was considered as possible senti nel node
because the presence of a separate lymphati c channel leading to this node could not be ruled out. One
of the senti nel nodes (right axilla) contained metastasis.
The value of SPECT/CT for senti nel lymph node mapping in malignancies with pelvic or
retroperitoneal drainage has been less extensively studied. Small studies have been performed
50 | Chapter 3
in pati ents with urological and gynaecological tumours and the investi gators conclude that the
new technique increases the yield of senti nel nodes.44-46 We examined the use of additi onal
SPECT/CT in 46 senti nel node procedures for prostate cancer.47 SPECT/CT not only provided
useful anatomical informati on about the locati on of the senti nel nodes but also revealed
senti nel nodes that had not been depicted on the conventi onal images. This was especially
relevant for senti nel nodes outside the pelvic area and nodes in close proximity to the prostate,
where a substanti al number of senti nel nodes would have been missed without SPECT/CT.47
Figure 4 shows an example of a presacral senti nel node that is only visualised on SPECT/CT
images. Preoperati ve imaging of lymph drainage with SPECT/CT can also alter the targeted
radiotherapy fi eld and opti mize pelvic irradiati on.48
Figure 3 | A pati ent with an oral cavity
carcinoma (localized medially in the fl oor
of the mouth) with drainage to both
sides of the neck on the conventi onal
images (A: anterior, B: left oblique, C:
right oblique), two hours aft er injecti on
of the radiopharmaceuti cal. Three-
dimensional SPECT/CT reconstructi on
(D) is comparable to the conventi onal
images and can be rotated along its axis
in order to see the locati on of all nodes
visualised on the oblique conventi onal
image (C). Scrolling down the two-
dimensional SPECT/CT fusion images,
the exact anatomic locati on of the
caudally situated second-ti er node (E)
is shown as well as the more cranially
depicted senti nel nodes (F). None of the
senti nel nodes was tumour bearing.
SPECT/CT for preoperati ve senti nel node localizati on | 51
Figure 4 | A pati ent with prostate cancer. The radiotracer
was injected at the tumour site under guidance of
transrectal ultrasonography. Conventi onal images (A)
show vague drainage to senti nel nodes on both sides
in the pelvic area. Two-dimensional reconstructi on
(B) shows the exact locati on of two senti nel nodes in
the right obturator fossa and one in the left obturator
fossa. Two-dimensional reconstructi on (C) also shows
a presacral node dorsally from the prostate that is
obscured by the radioacti vity at the injecti on area on
the conventi onal image. All senti nel nodes were found
to be free of metastasis.
CONCLUSIONBased on a review of the literature and on our own experience, we conclude that the use
of SPECT/CT in additi on to conventi onal lymphoscinti graphy leads to improved preoperati ve
visualisati on and localizati on of senti nel nodes, especially if performed for specifi c indicati ons.
Sequenti al conventi onal images remain useful to disti nguish senti nel nodes from secondary
nodes.
52 | Chapter 3
In breast cancer, SPECT/CT can depict senti nel nodes that are not visible on conventi onal
images. Depicti on of the exact locati on of extra-axillary nodes with SPECT/CT facilitates the
planning and executi on of the operati on. In pati ents with melanoma, SPECT/CT adds relevant
informati on in areas with a complex anatomy like head and neck and the scapular region,
or when an unexpected drainage patt ern is observed. SPECT/CT may be performed in every
pati ent with lymphati c drainage to senti nel nodes in the pelvic and retroperitoneal regions, for
instance in prostate cancer, to ensure complete and accurate staging.
SPECT/CT is indicated in all pati ents with conventi onal images that are diffi cult to interpret,
because it facilitates accurate localizati on of senti nel nodes and diff erenti ates these from non-
nodal tracer accumulati on sites.
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