T. Wendler, K. Herrmann, A. Schnelzer, T. Lasser, J. Traub, O. Kutter, A. Ehlerding, K. Scheidhauer, T. Schuster, M. Kiechle, M. Schwaiger, N. Navab, S. I. Ziegler, A. K. Buck First demonstration of 3-D lymphatic mapping in breast cancer using freehand SPECT European Journal of Nuclear Medicine and Molecular Imaging, Springer Berlin/Heidelberg, 2010 Aug;37(8):1452-61. Epub 2010 Mar 31. (bib)
	Aims Freehand SPECT is a 3D tomographic imaging modality based on data acquisition with a hand-held detector that is moved freely, in contrast to conventional, fixed gamma camera systems. In this pilot study, the feasibility of freehand SPECT for 3D lymphatic mapping in breast cancer was evaluated. Methods: A total of 85 patients (pts) (age, 29–88 years) with an initial diagnosis of invasive breast cancer and no clinical evidence of nodal involvement prospectively underwent sentinel lymph node (SLN) biopsy. Preoperative lymphatic mapping (35–87 MBq 99mTc-Nanocoll) included tomographic imaging with a SPECT/CT device (Siemens Symbia T6) serving as reference. Initially, the freehand SPECT approach was assessed in a pilot study consisting of 50 pts. The quality of each freehand SPECT acquisition was assessed and ranked as good, intermediate, or poor. In another series comprising a further 35 pts (validation study), a guidance system for the acquisition was implemented based on the results of the pilot study, ensuring acquisitions with good quality. For 3D tomographic image reconstruction, ad hoc models and iterative reconstruction algorithms were used in all 85 pts. To allow for adequate comparison, SPECT/CT data and freehand SPECT data were registered within the same coordinate system. Results: In the pilot study, freehand SPECT enabled mapping of 24/83 SLNs in 20/44 pts (3 drop-outs, 3 pts without SLN neither in SPECT/CT nor in freehand SPECT). Using SPECT/CT as reference, the accuracy of freehand SPECT was 77.8% (7/9 nodes) in scans with good quality, while for intermediate and poor quality scans, the accuracy was reduced to 34.3% and 12.8%, respectively. In the validation study, quality feedback improved the results significantly and freehand SPECT enabled the mapping of at least one SLN in 87.5% of the pts (28/32 – 3 drop-outs). Compared to the reference method, freehand SPECT showed a sensitivity of 83.3% (35/42 nodes). False negative findings were related to insufficient scanning time, insufficient coverage of the axillary region, close proximity of the SLN to the injection site, and low tracer uptake in the SLNs. Conclusions: In this preliminary study, we could demonstrate that 3D localization of SLNs is feasible using freehand SPECT technology. Prerequisites for acquisition of a good scan quality, most likely allowing precise SLN mapping, have been defined. This approach has high potential to allow image-guided biopsy and further standardization of SLN dissection, thus bringing 3D nuclear imaging into the operating room.
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