No COVID-19 in Patients With Sudden Sensorineural Hearing Loss (SSNHL).

BACKGROUND: Various case reports have described sudden sensorineural hearing loss (SSNHL) in patients with the 2019 novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Our aim was to determine the incidence of COVID-19 in patients with SSNHL. METHODS: All consecutive patients with audiometric confirmed SSNHL between November 2020 and March 2021 in a Dutch large inner city teaching hospital were included. All patients were tested for COVID-19 by polymerase-chain-reaction (PCR) and awaited the results in quarantine. RESULTS: Out of 25 patients, zero (0%) tested positive for COVID-19. Two patients had previously tested positive for COVID-19: at three and eight months prior to the onset of hearing loss. CONCLUSIONS: This is the largest series to date investigating COVID-19 in SSNHL patients. In this series there is no apparent relationship between SSNHL and COVID-19.

Technologic (R)Evolution Leads to Detection of More Sentinel Nodes in Patients with Melanoma in the Head and Neck Region.

Sentinel lymph node (SN) biopsy (SNB) has proven to be a valuable tool for staging melanoma patients. Since its introduction in the early 1990s, this procedure has undergone several technologic refinements, including the introduction of SPECT/CT, as well as radioguidance and fluorescence guidance. The purpose of the current study was to evaluate the effect of this technologic evolution on SNB in the head and neck region. The primary endpoint was the false-negative (FN) rate. Secondary endpoints were number of harvested SNs, overall operation time, operation time per harvested SN, and postoperative complications. Methods: A retrospective database was queried for cutaneous head and neck melanoma patients who underwent SNB at The Netherlands Cancer Institute between 1993 and 2016. The implementation of new detection techniques was divided into 4 groups: 1993-2005, with preoperative lymphoscintigraphy and intraoperative use of both a γ-ray detection probe and patent blue (n = 30); 2006-2007, with addition of preoperative road maps based on SPECT/CT (n = 15); 2008-2009, with intraoperative use of a portable γ-camera (n = 40); and 2010-2016, with addition of near-infrared fluorescence guidance (n = 192). Results: In total, 277 patients were included. At least 1 SN was identified in all patients. A tumor-positive SN was found in 59 patients (21.3%): 10 in group 1 (33.3%), 3 in group 2 (20.0%), 6 in group 3 (15.0%), and 40 in group 4 (20.8%). Regional recurrences in patients with tumor-negative SNs resulted in an overall FN rate of 11.9% (group 1, 16.7%; group 2, 0%; group 3, 14.3%; group 4, 11.1%). The number of harvested nodes increased with advancing technologies (P = 0.003), whereas Breslow thickness and operation time per harvested SN decreased (P = 0.003 and P = 0.017, respectively). There was no significant difference in percentage of tumor-positive SNs, overall operation time, and complication rate between the different groups. Conclusion: The use of advanced detection technologies led to a higher number of identified SNs without an increase in overall operation time, possibly indicating an improved surgical efficiency. Operation time per harvested SN decreased; the average FN rate remained 11.9% and was unchanged over 23 y. There was no significant change in postoperative complication rate.

Dorsal Onlay with Diced Homologous Processed Rib Cartilage Grafts.

BACKGROUND: Diced cartilage wrapped in fascia or modeled with tissue sealant has successfully been used as dorsal onlay grafts in rhinoplasty. The use of autologous material introduces the risk of donor site morbidity, and sometimes availability is limited. METHODS: We present a series of nine cases that were performed using diced irradiated homologous rib cartilage as an onlay graft. RESULTS: Good functional and cosmetic outcomes were achieved in all nine patients, and no significant resorption was seen after a mean follow-up of 20 months. CONCLUSION: Homologous diced cartilage grafts are an attractive and well-tolerated alternative. The use of diced homologous material does not seem to lead to significant resorption. These results must be reproduced in larger series. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aggressive basal cell carcinoma of the head and neck: challenges in surgical management.

With exponentially increasing numbers of basal cell carcinoma (BCC) of the head and neck region, also the locally advanced BCCs are increasing in number. These tumours are associated with aggressive biological behaviour with invasion of soft tissues, organs or bone and present with wide variation in management strategies. The objectives of the study was to describe the biological behaviour of aggressive BCCs and their clinical presentation in the head and neck region with a series of cases treated in our tertiary hospital, discuss management plans of such complex cases in terms of surgical planning and reconstruction. A series of five cases of aggressive BCC in the head and neck region with involvement of organs such as nose, orbit, temporal bone, facial nerve, paranasal sinuses and mandible was studied. Locally advanced, aggressive BCC should be evaluated and treated as head and neck tumours. Multidisciplinary team (MDT) discussion is advisable wherein the strategies on surgical excision, reconstruction options, facial nerve rehabilitation, indications for prosthesis and further adjuvant treatment such as radiotherapy and chemotherapy are carefully planned.

Complications of balloon packing in epistaxis.

Although balloon packing appears to be efficient to control epistaxis, severe local complications can occur. We describe four patients with local lesions after balloon packing. Prolonged balloon packing can cause damage to nasal mucosa, septum and alar skin (nasal mucosa, the cartilaginous skeleton and the overlying soft-tissue envelope) and should, therefore, be avoided. We suggest early nasendoscopy in general anesthesia to identify and treat the bleeding focus, if bleeding cannot be controlled with regular packing.

Development of the reflux finding score for infants and its observer agreement.

OBJECTIVE: It is hypothesized that laryngeal edema is caused by laryngopharyngeal reflux (LPR) (ie, gastroesophageal reflux extending into the larynx and pharynx). The validated reflux finding score (RFS) assesses LPR disease in adults. We, therefore, aimed to develop an adapted RFS for infants (RFS-I) and assess its observer agreement. STUDY DESIGN: Visibility of laryngeal anatomic landmarks was assessed by determining observer agreement. The RFS-I was developed based on the RFS, the found observer agreement, and expert opinion. An educational tutorial was developed which was presented to 3 pediatric otorhinolaryngologists, 2 otorhinolaryngologists, and 2 gastroenterology fellows. They then scored videos of flexible laryngoscopy procedures of infants who were either diagnosed with or specifically without laryngeal edema. RESULTS: In total, 52 infants were included with a median age of 19.5 (0-70) weeks, with 12 and 40 infants, respectively, for the assessment of the laryngeal anatomic landmarks and the assessment of the RFS-I. Overall interobserver agreement of the RFS-I was moderate (intraclass correlation coefficient = 0.45). Intraobserver agreement ranged from moderate to excellent agreement (intraclass correlation coefficient = 0.50-0.87). CONCLUSION: A standardized scoring instrument was developed for the diagnosis of LPR disease using flexible laryngoscopy. Using this tool, only moderate interobserver agreement was reached with a highly variable intraobserver agreement. Because a valid scoring system for flexible laryngoscopy is lacking up until now, the RFS-I and flexible laryngoscopy should not be used solely to clinically assess LPR related findings of the larynx, nor to guide treatment.

Comparing the hybrid fluorescent-radioactive tracer indocyanine green-99mTc-nanocolloid with 99mTc-nanocolloid for sentinel node identification: a validation study using lymphoscintigraphy and SPECT/CT.

UNLABELLED: The purpose of this study was to compare the lymphoscintigraphic drainage patterns of a hybrid sentinel node tracer consisting of the fluorescent dye indocyanine green (ICG) and (99m)Tc-nanocolloid with the drainage pattern of (99m)Tc-nanocolloid alone, the current standard tracer in many European countries. METHODS: Twenty-five patients with a melanoma in the head and neck region (n = 10), a melanoma on the trunk (n = 6), or penile carcinoma (n = 9) who were scheduled for sentinel node biopsy were prospectively included. First, the standard (99m)Tc-nanocolloid procedure was performed. After injection at the lesion site, lymphoscintigraphy was performed with a 10-min dynamic study and static planar images at 10 min and 2 h after injection, followed by SPECT/CT. The same scintigraphic procedure was repeated after injection of hybrid ICG-(99m)Tc-nanocolloid the same afternoon in 10 patients or the next morning in 15 patients. The paired images of both injections were evaluated, and count rates in the sentinel nodes were calculated and compared. Sentinel nodes were surgically localized using blue dye, a γ-ray detection probe, a portable γ-camera, and a fluorescence camera. RESULTS: Lymphatic drainage was visualized in all 25 patients using (99m)Tc-nanocolloid, leading to the identification of 66 sentinel nodes in total. These same sentinel nodes were also identified during the second scintigraphic procedure with ICG-(99m)Tc-nanocolloid. Moreover, a high correlation between the radioactive counting rates in the sentinel nodes of both scintigraphic studies was observed (mean R(2) = 0.83). Intraoperatively (4-23 h after the second injection), all preoperatively identified sentinel nodes could be localized using radio- and fluorescence guidance combined. In total, 95% of the sentinel nodes could be intraoperatively visualized by means of fluorescence imaging, whereas merely 54% stained blue. Ex vivo, all radioactive sentinel nodes were fluorescent and vice versa. No adverse reactions were observed. CONCLUSION: The lymphatic drainage pattern of ICG-(99m)Tc-nanocolloid is identical to that of (99m)Tc-nanocolloid. This observation, together with the added value of intraoperative fluorescence guidance, warrants wider evaluation of hybrid ICG-(99m)Tc-nanocolloid as a tracer for sentinel node procedures.

The additional value of lymphatic mapping with routine SPECT/CT in unselected patients with clinically localized melanoma.

PURPOSE: To investigate whether single photon emission computed tomography camera with integrated radiographic computed tomography (SPECT/CT) is of additional value compared to conventional lymphoscintigraphy in routine lymphatic mapping in patients with melanoma. METHODS: Thirty-five unselected patients with a primary melanoma who were scheduled for wide local excision and sentinel node biopsy underwent conventional lymphoscintigraphy and subsequently SPECT/CT. We determined whether SPECT/CT showed additional sentinel nodes, whether it provided better information on the location of the sentinel nodes, and whether this additional anatomic information led to a change in the planned surgical approach. RESULTS: SPECT/CT depicted the same 69 sentinel nodes as conventional lymphoscintigraphy in all 35 patients plus found eight additional sentinel nodes in seven patients (20%). In two of these patients (5.7%), an additional nodal basin had to be explored to find the extra sentinel nodes. SPECT/CT provided additional anatomic information that was helpful to the surgeon in 11 patients (31%) and led to an adjustment of the surgical approach in 10 patients (29%). CONCLUSIONS: SPECT/CT provided relevant additional information in 16 (46%) of the 35 patients. Routine use of SPECT/CT in addition to conventional lymphoscintigraphy is recommended in melanoma patients undergoing lymphatic mapping.

Feasibility of sentinel node biopsy in head and neck melanoma using a hybrid radioactive and fluorescent tracer.

PURPOSE: This study was designed to examine the feasibility of combining lymphoscintigraphy and intraoperative sentinel node identification in patients with head and neck melanoma by using a hybrid protein colloid that is both radioactive and fluorescent. METHODS: Eleven patients scheduled for sentinel node biopsy in the head and neck region were studied. Approximately 5 h before surgery, the hybrid nanocolloid labeled with indocyanine green (ICG) and technetium-99m ((99m)Tc) was injected intradermally in four deposits around the scar of the primary melanoma excision. Subsequent lymphoscintigraphy and single photon emission computed tomography with computed tomography (SPECT/CT) were performed to identify the sentinel nodes preoperatively. In the operating room, patent blue dye was injected in 7 of the 11 patients. Intraoperatively, sentinel nodes were acoustically localized with a gamma ray detection probe and visualized by using patent blue dye and/or fluorescence-based tracing with a dedicated near-infrared light camera. A portable gamma camera was used before and after sentinel node excision to confirm excision of all sentinel nodes. RESULTS: A total of 27 sentinel nodes were preoperatively identified on the lymphoscintigraphy and SPECT/CT images. All sentinel nodes could be localized intraoperatively. In the seven patients in whom blue dye was used, 43% of the sentinel nodes stained blue, whereas all were fluorescent. The portable gamma camera identified additional sentinel nodes in two patients. Ex vivo, all radioactive lymph nodes were fluorescent and vice versa, indicating the stability of the hybrid tracer. CONCLUSIONS: ICG-(99m)Tc-nanocolloid allows for preoperative sentinel node visualization and concomitant intraoperative radio- and fluorescence guidance to the same sentinel nodes in head and neck melanoma patients.

Intraoperative imaging for sentinel node identification in prostate carcinoma: its use in combination with other techniques.

UNLABELLED: We evaluated a portable γ-camera for sentinel node identification during laparoscopic sentinel lymphadenectomy for prostate cancer. METHODS: We analyzed the portable γ-camera for intraoperative sentinel node visualization in 55 patients after (99m)Tc injection, preoperative planar lymphoscintigraphy, and SPECT/CT. RESULTS: Sixteen percent of 178 nodes seen on SPECT/CT could not be detected with the portable γ-camera. A seed pointer was useful for localizing sentinel nodes intraoperatively in 27% of patients. Seventeen additional sentinel nodes (2 tumor-positive nodes) were removed by monitoring after excision. The location of each sentinel node was significantly associated with the ability to detect it intraoperatively. CONCLUSION: Intraoperative imaging leads to excision of more radioactive nodes and can determine the residual radioactivity after excision. The use of a radioactive source as a pointer enables efficient identification of nodes in difficult locations (paraaortic nodes) and in patients with a high body mass index.

SPECT/CT and a portable gamma-camera for image-guided laparoscopic sentinel node biopsy in testicular cancer.

UNLABELLED: The purpose of this study was to evaluate the utility of SPECT/CT and real-time intraoperative imaging with a portable γ-camera for laparoscopic sentinel node (SN) localization in stage I testicular cancer. METHODS: Ten patients with clinical stage I testicular cancer were studied between November 2006 and November 2010. Their mean age was 37 y (range, 25-50 y). The primary tumors were situated on the right side in 5 patients and on the left side in 5. After a funicular block with 2% lidocaine, an average dose of 80 MBq (range, 59-98 MBq) of (99m)Tc-nanocolloid in a volume of 0.2 mL was injected into the testicular parenchyma. Shortly after injection, a 10-min dynamic study was performed, followed by the acquisition of static planar images at 15 min and 2 h. SPECT/CT was performed at 2 h. After image fusion, SNs were visualized, and their exact anatomic location was determined. The SPECT/CT images were displayed in the operation room to guide SN detection using a laparoscopic γ-ray probe and a portable γ-camera. RESULTS: Lymphatic drainage to the retroperitoneum was seen in all patients. SPECT/CT identified interaortocaval or paracaval SNs in the 5 patients with right-sided tumors, one of whom had an additional SN adjacent to the testicular vessels. In all 5 patients with left-sided tumors, paraaortic SNs were visualized; a node along the testicular vessels was visualized in 2 of these 5. Twenty-six SNs were laparoscopically removed (range, 1-4 per patient). An SN contained metastases in 1 case. No recurrences developed in the 9 patients with a tumor-free SN during a median follow-up of 21 mo (range, 2-50 mo). CONCLUSION: SPECT/CT enables accurate anatomic localization of retroperitoneal SNs in patients with testicular cancer, facilitating their laparoscopic retrieval. Real-time image guidance by a portable γ-camera improves intraoperative SN detection and appears to identify (20%) additional SNs.

Assessment of lymphatic drainage patterns and implications for the extent of neck dissection in head and neck melanoma patients.

BACKGROUND AND OBJECTIVES: The aim of this study is to evaluate lymphatic drainage with sentinel node location data in patients with head and neck cutaneous melanoma, and to determine the implications for the extent of therapeutic neck dissections. METHODS: Sixty-five patients with head and neck cutaneous melanoma without evidence of regional metastases at ultrasound guided fine needle aspiration cytology examination were included. Lymphatic drainage patterns were investigated using planar and dynamic lymphoscintigraphy, and SPECT/CT. Biopsy of sentinel nodes was guided by images and gamma probe. The incidence of discordant sentinel nodes was determined by comparing actual drainage patterns to "O'Briens map" and to the treatment guidelines of The Netherlands Cancer Institute. RESULTS: Sentinel node identification was successful in 98% of the patients. Fifteen patients (23%) were diagnosed with a tumor-positive sentinel node. Two sentinel node-negative patients (3%) developed a regional lymph node metastasis (false-negative ratio: 12%). Twenty-three percent of the harvested sentinel nodes were discordant according to "O'Brien's map," while 14% were discordant according to the treatment guidelines of The Netherlands Cancer Institute (P < 0.001). CONCLUSIONS: Almost a quarter of head and neck melanomas metastasize outside clinically predicted neck levels. Neck surgery guidelines of The Netherlands Cancer Institute provide for a smaller number of discordant sentinel nodes.

Tracer-cocktail injections for combined pre- and intraoperative multimodal imaging of lymph nodes in a spontaneous mouse prostate tumor model.

To improve surgical guidance toward prostate draining lymph nodes, we investigate the potential of intraoperative fluorescence imaging and combined pre- and intraoperative multimodality imaging approaches. Transgenic adenocarcinoma mouse prostate mice with spontaneous prostate tumors are injected intratumorally with: 1. a cocktail of patent blue (Pb) and indocyanine green (ICG); 2. a cocktail of albumin radiocolloids (99mTc-NanoColl), Pb, and ICG; or 3. a cocktail of radiolabeled albumin (99mTc-Vasculosis), Pb, and ICG. The distribution of these imaging agents over the lymph nodes (LNs) are studied at different time points after injection. We find that at 60-min postinjection, ICG significantly improves the detection of the LNs compared to Pb, 53 versus 7%, respectively. Moreover, a cocktail of ICG and 99mTc-NanoColl improves the fluorescent detection rate to 86%, equalling that of the clinically applied 99mTc-NanoColl. A similar overlap is observed in our initial clinical pilot data. Fluorescent detection of the LNs using a ICG with 99mTc-Vasculosis gives similar results as "free" ICG (58%; 60 min). A 99mTc-NanoColl, Pb, and cocktail ICG enriches the standard 99mTc-NanoColl approach by adding optical detection of the sentinel lymph nodes. Furthermore, this approach improves fluorescent-based guidance and enables both accurate surgical planning and intraoperative detection, based on a single injection.

SPECT/CT for sentinel lymph node mapping in head and neck melanoma.

BACKGROUND: The additional value of single photon emission computed tomography with CT (SPECT/CT) for detection and localization of sentinel nodes in patients with a melanoma of the head and neck was determined. METHODS: Thirty-eight patients received conventional lymphoscintigraphy followed by hybrid SPECT/CT. The number of sentinel nodes visualized and anatomic information provided were analyzed. Changes in surgical approach due to additional information from the SPECT/CT were evaluated in 20 patients. RESULTS: SPECT/CT visualized a mean of 2.6 sentinel nodes per patient (range, 1-6). SPECT/CT depicted an additional sentinel node in 16% of the patients and clearly showed the anatomic location of the hot nodes in all patients. The surgical approach was adjusted on the basis of SPECT/CT images in 11 patients (55%). CONCLUSION: SPECT/CT visualizes more sentinel nodes than conventional images and shows their anatomic location. SPECT/CT is recommended in patients with a melanoma in the head or neck.

Is there an indication for routine chest X-ray in initial staging of melanoma?

BACKGROUND: Our aim was to evaluate therapeutic consequences of preoperative staging with Chest X-ray (CXR) in patients with a primary melanoma planned for sentinel node biopsy (SNB). METHODS: From a prospective database, 248 medical records of patients treated for primary melanoma were extracted. CXRs were made prior to SNB, and examined by radiologists. Results were classified as follows: no metastasis, inconclusive, or suspect for metastasis. Furthermore, changes in planned treatment were recorded. RESULTS: CXR was performed in 227 (92%) cases. In 95% of these patients, the CXR showed no metastasis. In 5%, the CXR was inconclusive; all of these CXR results appeared to be false-positive after complementary radiodiagnostic imaging and/or follow-up. All patients received a SNB. CONCLUSION: Preoperative CXR did not identify pulmonary metastasis and did not change planned treatment strategies. We suggest that CXR has no added value in the routine workup of patients with a primary melanoma.

The use of a portable gamma camera for preoperative lymphatic mapping: a comparison with a conventional gamma camera.

PURPOSE: Planar lymphoscintigraphy is routinely used for preoperative sentinel node visualization, but large gamma cameras are not always available. We evaluated the reproducibility of lymphatic mapping with a smaller and portable gamma camera. METHODS: In two centres, 52 patients with breast cancer received preoperative lymphoscintigraphy with a conventional gamma camera with a field of view of 40 × 40 cm. Static anterior and lateral images were performed at 15 min, 2 h and 4 h after injection of the radiotracer ((99m)Tc-nanocolloid). At 2 h after injection, anterior and oblique images were also performed with a portable gamma camera (Sentinella, Oncovision) positioned to obtain a field of view of 20 × 20 cm. Visualization of lymphatic drainage on conventional images and images with the portable device were compared for number of nodes depicted, their intensity and localization of sentinel nodes. RESULTS: The images performed with the conventional gamma camera depicted sentinel nodes in 94%, while the portable gamma camera showed drainage in 73%. There was however no significant difference in visualization between the two devices when a lead shield was used to mask the injection area in 43 patients (95 vs 88%, p = 0.25). Second-echelon nodes were visualized in 62% of the patients with the conventional gamma camera and in 29% of the cases with the portable gamma camera. CONCLUSION: Preoperative imaging with a portable gamma camera fitted with a pinhole collimator to obtain a field of view of 20 × 20 cm is able to depict sentinel nodes in 88% of the cases, if a lead shield is used to mask the injection site. This device may be useful in centres without the possibility to perform a preoperative image.

Lymphatic drainage from the treated versus untreated prostate: feasibility of sentinel node biopsy in recurrent cancer.

PURPOSE: The goal of this study was to establish the feasibility of sentinel node biopsy in patients with recurrent prostate cancer after initial local treatment and to compare lymphatic drainage patterns of the treated versus untreated prostate. METHODS: In ten patients with a proven local recurrence after initial local treatment (four external beam radiation, four brachytherapy and two high-intensity focused ultrasound), the radiotracer ((99m)Tc-nanocolloid, GE Healthcare) was injected into the prostate. Planar images after 15 min and 2 h were followed by SPECT/CT (Symbia T, Siemens) to visualize lymphatic drainage. Laparoscopic sentinel lymphadenectomy was assisted by a gamma probe (Europrobe, EuroMedical Instruments) and a portable gamma camera (Sentinella, S102, Oncovision). Sentinel node identification and lymphatic drainage patterns were compared to a consecutive series of 70 untreated prostate carcinoma patients from our institute. RESULTS: Lymphatic drainage was visualized in all treated patients, with a median of 3.5 sentinel nodes per patient. Most sentinel nodes were localized in the pelvic area, although the percentage of patients with a sentinel node outside the pelvic para-iliac region (para-aortic, presacral, inguinal or near the ventral abdominal wall) was high compared to the untreated patients (80 versus 34%, p = 0.01). In patients with recurrent prostate cancer, 95% of the sentinel nodes could be harvested and half of the patients had at least one positive sentinel node on pathological examination. CONCLUSION: Lymphatic mapping of the treated prostate appears feasible, although sentinel nodes are more frequently found in an aberrant location. Larger trials are needed to assess the sensitivity and therapeutic value of lymphatic mapping in recurrent prostate cancer.

A portable gamma-camera for intraoperative detection of sentinel nodes in the head and neck region.

UNLABELLED: We introduced and evaluated a portable gamma-camera for intraoperative visualization of sentinel nodes in the head and neck region. METHODS: Planar lymphoscintigraphy and SPECT/CT were performed after peritumoral injection of (99m)Tc-nanocolloid in 25 patients (head and neck melanoma or oral cavity carcinoma). Sentinel nodes were localized intraoperatively with a portable gamma-camera and a hand-held gamma-probe. The portable gamma-camera was used to determine the distribution of remaining radioactivity after excision of the sentinel nodes. RESULTS: The portable gamma-camera visualized all 70 preoperatively identified sentinel nodes. Sentinel nodes at difficult sites could be localized more efficiently, and in 6 patients, 9 additional nodes (1 tumor-positive) were identified with the portable gamma-camera after excision. CONCLUSION: Intraoperative identification of sentinel nodes in the head and neck region with a portable gamma-camera is feasible and might lead to detection of more sentinel nodes.

Optimizing the colloid particle concentration for improved preoperative and intraoperative image-guided detection of sentinel nodes in prostate cancer.

PURPOSE: Lymphatic mapping for prostate cancer can be used to determine therapeutic strategies. Sentinel node visualization requires sufficient nodal tracer uptake. We evaluated the effect of an increase in particle concentration on preoperative and intraoperative sentinel node depiction. METHODS: Enrolled in the study were 50 consecutive patients with prostate cancer. The first 25 patients (group A) received nanocolloid with standard labelling (0.4 ml (99m)Tc per 0.1 mg nanocolloid). The last 25 patients (group B) received nanocolloid with a reduced labelling dilution volume (0.4 ml (99m)Tc per 0.2 mg nanocolloid). The aimed injected volume and dosage were the same for both groups (225 MBq in 0.4 ml). Intratumoral tracer injection was followed by planar lymphoscintigraphy (15 min and 2 h), SPECT/CT and laparoscopic sentinel lymphadenectomy. Lymph node visualization was evaluated using a four-point scoring system (0 nonvisualization to 3 intense visualization) and count quantification on the 2-h anterior lymphoscintigram. In addition to the gamma ray detection probe, a portable gamma camera was used for intraoperative sentinel node visualization. RESULTS: Preoperative visualization in group A was 88% (mean 2.0 sentinel nodes per patient) versus 100% in group B (mean 2.6 sentinel nodes per patient). Visualization scores (p=0.008), total counts (p=0.001) and maximum counts per pixel (p=0.034) in the sentinel nodes were significantly better in group B. This also led to more efficient intraoperative detection of the sentinel nodes with the portable gamma camera (84% in group A versus 100% in group B). CONCLUSION: Enhancement of the particle concentration may lead to significant improvement in sentinel node visualization and intraoperative localization in patients with prostate cancer. Further research regarding optimization of radiotracer labelling by changing the particle concentration is warranted.

Paraaortic sentinel lymph nodes: toward optimal detection and intraoperative localization using SPECT/CT and intraoperative real-time imaging.

UNLABELLED: Paraaortic sentinel node biopsy may be a challenging procedure because the sentinel nodes are located retroperitoneally in close proximity to vital structures. The purpose of this study was to describe and evaluate the value of preoperative SPECT/CT for lymphatic mapping, and a portable gamma-camera for intraoperative radioguidance, in patients with paraaortic sentinel nodes. METHODS: We evaluated our practice in 18 patients, who were treated at The Netherlands Cancer Institute with sentinel lymphadenectomy for different urologic malignancies and showed paraaortic drainage on preoperative images. After intratumoral injection of (99m)Tc-nanocolloid, the patients underwent sequential planar lymphoscintigraphy, hybrid SPECT/CT, and sentinel lymphadenectomy. Intraoperative node detection and localization were guided by a laparoscopic gamma-probe and a portable gamma-camera. This gamma-camera was set to display both the (99m)Tc signal and the (125)I-seed signal. This (125)I seed was placed on top of the gamma-probe, functioning as a pointer on screen, thus enabling real-time sentinel node localization with the gamma-camera. RESULTS: In 16 patients with midabdominal drainage on planar images and in 2 patients with nonvisualization on planar images, SPECT/CT showed clear localization of paraaortic sentinel nodes in relation to the abdominal vessels. Five patients underwent open surgery, and 13 patients underwent laparoscopy. The paraaortic sentinel nodes were successfully localized and removed in 15 patients with the help of the portable gamma-camera and gamma-probe and in 3 patients with the gamma-probe only. In 1 patient, the paraaortic sentinel node showed a metastasis. CONCLUSION: If retroperitoneal drainage is expected, SPECT/CT provides good detection and clear localization of sentinel nodes in relation to anatomic structures. Detection and removal of paraaortic sentinel nodes by means of a laparoscopic gamma-probe and real-time imaging with a portable gamma-camera is a successful method with high intraoperative detection rates.