Stephanie Pitre

The Usefulness of a Preoperative Compact Imager, a Hand-Held γ-Camera for Breast Cancer Sentinel Node Biopsy: Final Results of a Prospective Double-Blind, Clinical Study

The aim of this study was to compare the effectiveness of a hand-held preoperative compact imager (POCI) camera with conventional lymphoscintigraphy using a γ-camera for sentinel lymph node (SLN) detection in breast cancer. Methods: The main objective was to demonstrate the noninferiority of the POCI relative to conventional lymphoscintigraphy and to compare the number of SLNs detected by the 2 imaging devices. Our study, a clinical prospective, double-blind, noninferiority study, planned to include 200 patients with early breast cancer and started in January 2006. A standard SLN protocol (4 periareolar injections of 37 MBq of 99mTc-nanocolloids, 2 h before lymphoscintigraphy) was performed preoperatively using a conventional γ-camera and then the POCI camera. Scans were obtained by 2 different nuclear medicine physicians unaware of each others results. The day after, in the operating room, the surgeon, after receiving the previous results, used the counting probe for surgical SLN biopsy. The number and localization of axillary SLNs obtained by lymphoscintigraphy and the POCI and the duration of the whole procedure were determined. Results: Among the 162 patients included, 138 were evaluable. The POCI detected more SLNs than did lymphoscintigraphy in 50 patients (36%), the same number of in 54 patients (39%), and fewer SLNs in 34 patients (25%), representing 84 (61%) discordant pairs. The noninferiority of preoperative compact imaging of axillary SLNs numbers was found to be statistically significant (95% confidence interval, 30%–52%, P = 0.025) using the McNemar test. The duration of acquisition was shorter using the POCI (<10 min in 84% [n = 117] of patients; mean, 7.5 ± 3.3 min) than lymphoscintigraphy (13% [n = 18] of patients; mean, 15.7 ± 3.4 min), with P < 0.001 using the McNemar test for paired proportions. Conclusion: Preoperative compact imaging using a hand-held camera was able to predict the number and localization of breast cancer SLNs and was not inferior to conventional lymphoscintigraphy in this study. Further studies will determine whether preoperative compact imaging could replace lymphoscintigraphy, especially in surgical centers without an on-site nuclear medicine department.

An Intraoperative Beta Probe Dedicated to Glioma Surgery: Design and Feasibility Study

Surgery is considered as the primary therapeutic procedure for gliomas and several recent clinical studies have shown that total tumor resection is directly associated with longer survival when compared to subtotal resection. In order to refine the resection in the boundaries of gliomas, we are developing an intraoperative probe specifically dedicated to the localization of residual tumor labeled with positron emitters. The probe is designed to be compact and electrically safe in order to be directly coupled to the excision tool leading to simultaneous detection and removal of tumor tissues. It is built with clear and plastic scintillating fibers held in a closed packed annular arrangement ensheathing the excision tool. The annihilation gamma ray background is eliminated by a real-time subtraction method. Validation of the technical choice and optimization of the probe geometry were performed by preliminary measurements and Monte Carlo simulations based on the MCNP-4C code and an anthropomorphic brain phantom. The theoretical probe sensitivity was found to be 82 cps/muCi/ml with a gamma ray rejection efficiency of 99.6%. The expected minimum radiotracer detectable concentration for tumors labeled with 18 F-FET was 0.10 muCi/ml. When compared to the 0.29 muCi/ml average concentration in the bulk of the tumor, this result demonstrate the potential ability of the probe to define more accurately the extent of brain tumor resection

Physical Performance of an Intraoperative Beta Probe Dedicated to Glioma Radioguided Surgery

The precise delineation and excision of brain tumor extent allows to improve survival outcome and quality of life of surgically treated patients. In order to refine the resection of gliomas, we are developing a novel intraoperative probe specifically dedicated to the localization of residual tumor after the bulk has been excised. The probe, built around clear and plastic scintillating fibers, was designed to detect positrons emitted from radiolabeled brain tissue in order to discriminate more specifically neoplastic from normal tissues. The probe was also built to be directly coupled to the excision tool leading to simultaneous detection and removal of tumor. We report here performances of the first radio-isotopic configuration of the intraoperative probe which consists of a detection head composed of eight detection elements held around the excision tool in a closed packed annular arrangement. This head is coupled to an optic fiber bundle that exports the scintillating light to a multi-channel photomultiplier tube. The gamma ray background generated by the annihilation of beta+ in tissues is eliminated by a real-time subtraction method. The detector exhibits a beta sensitivity of 139 cps/kBq and a gamma ray rejection efficiency of 99.5%. The ability of the probe to detect residual lesions was evaluated with a realistic brain phantom representing the surgical cavity and the boundaries of the tumor. We showed that lesions as small as 5 mm in diameter can be detected for tumor to normal tissue uptake ratios of fluorinated tracers greater than 3.5. This ratio is achieved with radiopharmaceuticals like 18F-FET or 18F-choline. These promising results suggest that the features of our system are compatible with in situ localization of residual radiolabeled tumors.