A. Okur, C. Bluemel, A. Ehlerding, K. Scheidhauer, A. Schnelzer Meme kanseri cerrahisinde freehandSPECT ile ilk tecrube: Aksiller sentinel lenf nodu biyopsisinde uc boyutlu navigasyon ve kalite guvencesi XI. Ulusal Meme Hastaliklari Kongresi, Antalya, Turkey, Oct. 5 - 9, 2011. (bib)
	AMAC: Meme kanserinde sentinel lenf nodu (SLN) biyopsisi standart ve gerekli bir yontemdir. Ancak, belli klinik senaryolarda, SLN’nin dogru saptanmasini engelleyen bazi sorunlardan bahsedilmektedir. Ayrica, dinamik bilgi veya ameliyat oncesi lenfosintigrafinin degeri gibi sentinel lenf nodunu tanimlayan kriterler sorgulanmaktadir. Bu sorunlarin bazilari, preoperatif goruntuleme bilgilerinin SLN biyopsisinin operatif prosedurune pratik bir sekilde aktarilamamasina dayanmaktadir. YONTEMLER: FreehandSPECT? (declipseSPECT, SurgicEye?, Almanya); gama prob (GP) ve kizilotesi optik izleme sistemini birlestirerek, prob aktivitesini ve pozisyonunu eszamanli isleyen bir uc boyutlu goruntuleme sistemidir. Bugune kadar hastanemizde, SLN biyopsisi uygulanan invaziv meme kanseri 34 hasta (37-84yas) SLN eksizyonundan once freehandSPECT ile taranmistir. FreehandSPECT? ile yapilan SLN lokalizasyonu GP ve mavi boya kullanilarak tespit edilenlerle karsilastirilmistir. Ayrica freehandSPECT, eksizyon sonrasi radyoaktivite kalmadigini dogrulamak icin kullanilmistir. Yeni tespit edilen bolgeler, GP ile teyit edildikten sonra ve ancak gerekliyse cerrah tarafindan rezeke edilmistir. Ameliyat oncesi yapilan duzlemsel sintigrafi referans olarak kullanilmistir. SONUCLAR: Preoperatif sintigrafide toplam 65 SLN saptanmistir. Pre-insizyon freehandSPECT taramasinda 33 hastada 62 SLN tespit edilmistir (95%). Ayrica freehandSPECT, 3 hastada sintigrafide gorulmeyen 3 SLN’yi goruntulemeyi basarmistir. GP ise 32 hastada toplam 48 SLN bulmustur (74%). 55 SLN rezeke edilmis ve ex-vivo radyoaktif oldugu dogrulanmistir. Post-eksizyon FreehandSPECT? taramasiyla yalniz GP ile fark edilmeyen 18 SLN (17 hasta, 50%) saptanmistir. Bunlarin 7 tanesinin (6 hasta, 18%) ex-vivo radyoaktif oldugu dogrulanmistir. 11 hastada ise ek SLN’lere dokunulmamistir. Cerrahi islem yaklasIk 5 dakika uzamistir. TARTISMA: FreehandSPECT? ile uc boyutlu intraoperatif goruntuleme, tek veya multipl SLN’nin tam ve kesin rezeksiyonunda rehber niteligi tasiyan hassas bir aractir. Sistem sayesinde SLN biyopsisinin basarisi dijital olarak belgelenebilir. FreehandSPECT?, sentinel lenf nodu kavrami ihtilaflarinda yeni bir alternatif olabilir. Uc boyutlu intraoperatif goruntuleme kullanilarak yapilan klinik arastirmalar, cerrahi rezeksiyon icin lenf nodullerinin secilmesiyle ilgili lenfatik aktivitenin rolu gibi pek cok tartisilan konuyu netlestirmek icin yardimci olabilir. Ayrica, preoperatif goruntulemeye ihtiyac duyulmamasi, minimal invazivite ve kalite guvencesi, standart prosedure gore avantajlar saglayabilir. ENGLISH VERSION GOALS: The sentinel lymph node (SLN) concept in breast cancer is an integral standard of care. However, several practical issues have been raised preventing proper identification of the sentinel node in certain clinical scenarios. Moreover, the criteria for definition of sentinel node have recently been questioned, including the value of dynamic information or the value of preoperative lymphoscintigraphy. The problems behind some of these questions rely on the impracticability to implement the preoperative imaging information into the operative procedure of sentinel lymph node biopsy (SLNB). METHODS: For the freehandSPECT (declipseSPECT, SurgicEye?, Germany) acquisition a gamma probe (GP) system and an infrared optical tracking system were combined in one system, which processes the readings of the probe and its position synchronously into a 3D image. To date, 34 patients with invasive breast cancer undergoing SLNB were recruited and scanned intraoperatively using freehandSPECT before excision of SLNs. The localization of SLNs with freehandSPECT was compared to the position of SLNs detected using gamma probe and blue dye. After excision, freehandSPECT was used to verify absence of radioactivity. Additionally detected hot spots were confirmed with GP and if clinically indicated resected by surgeon. Preoperative planar scintigraphy was used as a reference. RESULTS: Preoperatively, 65 SLNs were mapped with scintigraphy. In the pre-incision scan freehandSPECT managed to map 62 SLNs (95%) in 33 patients, as well as 3 further SLNs not seen in scintigraphy in 3 patients. GP mapped in total 48 SLNs (74%) in 32 patients. 55 SLNs were resected and confirmed to be radioactive ex-vivo. FreehandSPECT? detected 18 SLNs in 17 patients (50%) post-excision despite initial negative signal with GP. 7 additionally detected nodes were resected and confirmed to be radioactive ex vivo in 6 patients (18%). In 11 patients harvesting of the additional nodes was discarded as higher uptake SLNs had been removed already. The surgical procedure was extended by approx. 5 min. DISCUSSION: Intraoperative 3D imaging with freehandSPECT is a very sensitive tool to guide complete and precise resection of the sentinel node(s). The system can digitally document the success of the SLNB procedure. The freehandSPECT provides new options concerning the controversies in the sentinel lymph node concept. Controlled studies using 3D intraoperative imaging could help to clarify many of the discussed issues, including the role of lymphatic uptake on selecting the nodes for surgical resection. Also, the possibility to skip preoperative imaging, minimal invasivity and quality assurance bears additional advantages over the standard procedure.
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