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R.J. Gray et al.
Fig. 8.8 Specimen radiograph with I-125 seed and
biopsy clip
remains within the breast (except minor Compton
scatter from Tc-99 as applicable) and to judge the
adequacy of the margins of excision based on the
Fig. 8.7 Intraoperative assessment of depth of I-125
seed/lesion with gamma probe
level of gamma activity at each. The excised tissue specimen is then submitted for specimen
radiography, providing additional confi rmation
that the targeted lesion and I-125 seed have been
made, the gamma probe is used to guide the surgeon to the lesion. The gamma counts and/or
audible feedback from the gamma probe allows a
judgment as to the distance from the I-125 seed
(and therefore the lesion) from any angle so that
planes of dissection can be developed and maintained at an appropriate distance from the lesion
excised and maintaining documentation of this
8.8 ). The seed-containing surgical speci-
(Fig.
men is transported for pathologic assessment
with radioactive material labeling to alert the
pathology providers that an I-125 seed is present
and needs to be recovered for appropriate decay
and disposal.
without excessive normal breast tissue. The surgeon is clearly aware when he or she is deep to
the seed and can safely come under the lesion
based on this feedback (Fig.
8.7 ). The dissection
through the breast tissue should be performed
preferably with a scalpel or electrocautery device,
rather than scissors. However, if scissors are
used, then care should be taken not to cut through
the titanium encasement of the I-125 seed. Since
the surgeon should be aware of the location of the
I-125 seed throughout the dissection with the use
of the probe, this is unlikely and has yet to be
reported.
The gamma probe is also used to confi rm that
the I-125 seed is contained within the resected
specimen and that no remaining I-125 activity
8.3.3 Pathologic Processing
The pathology staff retrieve the I-125 seed during
the gross examination, sectioning, and processing of the surgical specimen [ 29 ]. Because of the
low dose of radiation from the I-125 seed, there is
no need for radiation protective equipment, and it
is unnecessary for radiation badges to be worn by
the pathology staff [ 16 , 29 ]. After standard ink-
ing of margins, the specimen is serially sectioned
and the I-125 seed located. Identifi cation of the
I-125 seed can be aided with the use of a gamma
probe or other radiation detection device as
needed [ 29 ]. If properly positioned, the location
8 Radioguided Surgery for Non-palpable Breast Lesions: I-125 Radioactive Seed Localization
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131
of the I-125 seed within the specimen assists the
pathology personnel in identifying the breast
lesion. Once identifi ed, the I-125 seed is placed
into a lead container and returned to nuclear medicine for long-term decay. Some have employed
permanent containers within the pathology suite
for decay, but this is not common and the required
period of decay before disposal is approximately
2 years [ 16 , 29 ]. If pathologic review is per-
formed at a different institution than the institution that placed the I-125 seed, the I-125 seed can
be removed prior to transporting the specimen.
Otherwise, the pathology laboratory receiving
the I-125 seed and specimen must be authorized
to receive and handle radioactive materials
including disposal of the I-125 seeds. Written
protocols must be in place to ensure tracking of
I-125 seeds throughout the process.
8.4 Evidence and Outcomes
in Radioactive Seed
Localization
RSL has been consistently shown to be an effective alternative to WL that is preferred by physicians and patients. Many studies have demonstrated
other advantages, less consistently including lower
rates of inadequate margins of excision, smaller
specimen volumes and/or weights, shorter operative times, less pain for patients, and greater patient
convenience.
8.4.1 Early Studies in the United
States
The pilot study of RSL by Dauway et al. reported
in 1999 found that the operative time from incision to specimen removal was 4.60 ± 0.49 min
(range, 1–8 min) and specimen radiography and
pathologic examination confi rmed the retrieval of
the I-125 seeds and lesions in all cases [ 18 ]. The
fi rst randomized, prospective trial by Gray et al.
of 97 patients with non-palpable breast lesions
randomized to RSL or WL demonstrated that
RSL was associated with fewer patients requiring
margin re-excision (26 % vs. 57 %, p = 0.02) [ 19 ].
There were no signifi cant differences between
RSL and WL in mean times for operative excision (5.4 vs. 6.1 min, respectively) or radiographical localization (13.9 vs. 13.2 min, respectively).
There were also no signifi cant differences in the
subjective ease of the procedures as rated by surgeons, radiologists, and patients [
In 2003, Cox and colleagues reported on 124
patients undergoing RSL breast procedures and
found that it would be feasible to eliminate specimen radiography in 79 % of the cases based on
intraoperative detection of gamma activity and
pathologic gross identifi cation of the targeted
lesion [ 20 ]. As would be expected, avoiding spec-
imen radiography reduced operative times. No
seed migration was documented, and the I-125
seeds were again retrieved in 100 % of cases [ 20 ].
In a 2004 prospective validation of RSL in which
100 patients were compared to the immediately
preceding cohort of 100 WL patients, Gray and
colleagues reported that RSL was associated with
lower rates of inadequate (<2 mm) margins of
excision (10 % vs. 24 %, respectively, p = 0.01)
and was rated as more convenient by patients if
the localization was at least 1 day prior to the
operation [ 21 ]. There were no differences in the
patients’ ratings of pain or the SLN identifi cation
rates which were 100 % in both groups [ 21 ]. In
an expanded series including all three Mayo
Clinic sites, RSL was again shown to be associated with better margin management with the
margins of the fi rst specimen being >2 mm in
73 % of RSL patients versus 54 % of WL patients
( p < 0.001) and a second operation for margins
being required in 8 % of RSL patients versus
25 % of WL patients ( p < 0.001). This series also
found improved patient ratings of convenience
with RSL but no difference in patient pain [
19 ].
22 ].
8.4.2 European Studies
of Radioactive Seed
Localization and Use
after Neoadjuvant Therapy
The fi rst European trial of RSL was reported
from Barcelona in 2009 and was a prospective
randomized study of RSL versus WL for 134
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R.J. Gray et al.
breast cancer patients undergoing breastconserving surgery and SLN biopsy [ 23 ]. All
lesions were successfully excised and the mean
time needed for radiologic localization was signifi cantly shorter for RSL ( p < 0.001). No statisti-
cal differences were found for the other
parameters studied including specimen volume,
rates of negative margins, and the rates of SLN
identifi cation [ 23 ]. This report was quickly fol-
lowed by a report from Catharina Hospital in the
Netherlands on 325 consecutive women undergoing RSL breast surgery for histologically proven
malignancy [ 30 ]. Complete tumor removal was
achieved in 95 % of these procedures. The same
group also reported that 47 consecutive patients
had successful RSL when undergoing I-125 seed
placement before starting neoadjuvant chemotherapy. The operations were performed after a
mean of 170 days (range, 70–220) from localization to surgery and the rate of positive margins
was 6 % [ 17 ].
The Netherlands Cancer Institute compared
the results of RSL after neoadjuvant chemotherapy ( n = 71) to radioguided occult lesion localiza-
tion (ROLL, n = 83) and found no differences in
the rates of reoperation for inadequate margins,
the median closest margin measurement, or the
weight of specimens. They concluded that RSL
simplifi ed scheduling and was preferred [ 27 ].
RSL has also been utilized at the Netherlands
Cancer Institute to localize lymph nodes with
known metastases prior to neoadjuvant chemotherapy which they dubbed the MARI (marking
the axilla with radioactive iodine seed) procedure. After neoadjuvant chemotherapy, the
marked lymph nodes were removed followed by
complete axillary lymph node dissection, and
among the 15 patients studied, the pathologic
response to chemotherapy in the RSL-marked
lymph node was indicative of the overall response
[
31 ]. In a separate report, this group assessed the
reliability of the positioning of I-125 seed radiologically and found that after a mean time in situ
of 59 days (range 3–136 days), the mean seed
migration was 0.9 mm. No differences in migration were found based on lesion type, days in
situ, type of surgery, or radiologic method used to
guide I-125 seed placement [ 32 ].
8.4.3 Evidence from Implementation
Studies
Experiences with RSL program implementation
and complications over time have also been
reported [ 24 , 26 , 28 ]. In an initial experience
with RSL in a US public healthcare system, Rao
and colleagues reported no seed migration and
100 % success excising the targeted lesions
[ 24 ]. They found on a matched-pair analysis
that there was a 12 % lower rate of inadequate
margins of excision (42 % for RSL vs. 54 % for
WL), but this was not signifi cant ( p = 0.46), per-
haps due to small sample size. Importantly, this
group reported on the serious consequences of
misplacing an I-125 seed after it was removed
from a patient; this resulted in the regulatory
authorities temporarily suspending the RSL
program [ 24 ].
In a retrospective review of 1000 consecutive
RSL procedures performed at a single institution, 14 % of patients had more than one I-125
seed placed for a given procedure, 97 % of
patients achieved negative margins at the fi rst
operation, and SLN identifi cation was successful
in 99.8 % of cases [ 28 ]. Adverse events included
three I-125 seeds (0.3 %) not deployed correctly
on the fi rst attempt and 30 I-125 seed (2.6 %)
displaced from the breast specimen during excision of the targeted lesion. All I-125 seeds were
successfully retrieved, with no radiation safety
concerns. When outcomes were analyzed by surgeon experience, there was no evidence of a
learning curve [
In 2013 the group at Memorial Sloan
Kettering Cancer Center reported their initial
6-month experience with 432 RSL procedures
and compared the outcomes to the 256 WL procedures of the preceding 6-month period [ 26 ].
Positive margins were present in 7.7 % of RSL
versus 5.5 % of WL patients, and an additional
16.9 % of RSL versus 19.9 % of WL had margins <1 mm ( p = 0.38). The median operative
time was longer for lumpectomy and sentinel
lymph node biopsy in the RSL group (55 vs.
48 min, p < 0.0001). There was no signifi cant dif-
ference in the volume of tissue excised between
groups [ 26 ].
28 ].
8 Radioguided Surgery for Non-palpable Breast Lesions: I-125 Radioactive Seed Localization
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8.4.4 Canadian Randomized Trial
of Radioactive Seed
Localization
The largest prospective, randomized trial of RSL
versus WL was a multi-institutional trial in
Canada [ 25 ]. A total of 305 women with invasive
or in situ carcinoma underwent randomization
that was centralized, concealed, and stratifi ed by
surgeon. The procedures were performed at three
sites, by seven surgeons. Using intention-to-treat
analysis, there were no differences in positive
margins rates for RSL vs. WL (10.5 % and
11.8 %, respectively, p = 0.99) or for margins
<1 mm (RSL 19 % and WL 22 %; p = 0.61),
though there was a signifi cantly higher proportion of multifocal disease in the RSL group.
Mean operative time was signifi cantly shorter for
RSL and surgeons rated RSL as signifi cantly
easier. Specimen volume, weight, reoperation
rates, localization times, and radiologists’ ranking of ease were similar for the two groups [ 25 ].
8.4.5 Systematic Review and MetaAnalysis of Radioactive Seed
Localization
A systematic review [ 33 ] and a meta-analysis
[ 34 ] of RSL studies have been published. The
systematic review compared the outcomes of
RSL versus standard WL in the management of
non-palpable breast cancers. Eight studies were
considered clinically relevant to the study. The
analysis demonstrated an overall combined odds
ratio (OR) of 0.51 (95 % CI, 0.36–0.72; z = 3.88;
p = 0.0001) for involved surgical margin status,
an OR of 0.47 (95 % CI, 0.33–0.69; z = 3.96;
p < 0.0001) for reoperation rates, and mean dif-
ference (MD) of −1.32 (95 % CI, −2.32, −0.32;
z = 2.58; p = 0.01) for operative time favoring
RSL over WL. There was no signifi cant difference found for volume of tissue excised [
the meta–analysis, 4280 patients in 16 articles
were considered eligible for inclusion for examination of the rates of positive margins and reoperation. After contacting the authors and
exclusion of duplicate patient reports, 3168
33 ]. In
patients were analyzed. Margins of resection,
though reported differently by different institutions (0–2 mm from resection margin), were positive/inadequate in 10.3 % (range, 3–30 %) of the
patients having RSL resections. This resulted in a
fi nal re-excision rate of 14.2 % (range, 4–42 %).
8.4.6 Summary of Evidence
The available individual studies, meta-analysis
[ 34 ], and review articles [ 33 , 35 – 37 ] demonstrate
that RSL is clearly safe, feasible, and effective for
the localization and surgical excision of
non- palpable breast lesions. It is at least as effective as WL (and ROLL) in achieving negative
margins of excision for malignant lesions without
compromising localization times, operative times,
specimen volumes, or the patient experience. In
many of the studies, these factors were better for
RSL and in no study was WL superior to RSL in
any of these measures except operative time in
one study of early experience. On the basis of this
evidence, RSL should be considered at least the
equal of what is widely considered the “gold standard” for the localization of breast lesions while at
a minimum providing more fl exible scheduling
procedures for patients and providers.
8.5 Issues in Establishing
a Radioactive Seed
Localization Program
While having a RSL program has many advantages, starting a program involves signifi cant
effort in achieving multidisciplinary coordination
and regulatory compliance. The most signifi cant
obstacles have been reported to be administrative
barriers, billing and coding, not having a multidisciplinary team that is supportive of RSL, and
radiation safety/regulatory issues.
8.5.1 Administrative Barriers
The identifi cation and coordination of a multidisciplinary team to plan a RSL program, gain
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regulatory approval, and produce institutional
changes in procedural fl ow and billing require
considerable effort. Physicians interested in RSL
have been able to drive such change but not without institutional support. Thus it is important for
a breast care team to assure institutional administrative support early in RSL program planning to
assure success. The ability to achieve improved
scheduling fl exibility and higher patient satisfaction [ 21 , 22 , 36 ] is important to institutional
administrators and helps achieve buy-in for these
efforts. RSL program institution often requires
many months of planning which is best sustained
through administrative support to the physician
leaders of these programs.
In many practices, the place where radiologic
localization occurs is different from where the
operative excision occurs which may also be different from where the pathologic processing
occurs. In such circumstances, the administrative
leadership for each site must be willing to coordinate their efforts in achieving regulatory approval
when operating under separate licenses. Some
programs have required creative protocols to
avoid licensure confl icts such as the surgeon inking and serially sectioning the specimen in order
to retrieve the radioactive seed before submitting
the specimen to another site for pathologic assessment. Such protocols, however, can only be
achieved if the administrative and regulatory
issues are identifi ed appropriately, usually through
strong administrator-physician partnership.
8.5.2 Billing and Coding
Billing and coding for RSL has become simplifi ed in recent years. In the United States, the
Current Procedural Terminology (CPT) codes
used for the RSL radiological localization procedure and surgical excision procedure are now the
same as those used for WL procedures. It is
important, however, to consult with one’s billing
and coding personnel to assure the appropriate
transition to such billing to avoid miscoding or
the use of miscellaneous codes that may reimburse at lower rates. RSL programs appear to be
cost-effective [ 38 ].
8.5.3 Multidisciplinary Support
RSL programs are often desired by surgeons, but
the procedure requires willing partners in breast
imaging, nuclear medicine, pathology, and radiation safety. Failures in attempts to establish RSL
programs are often precipitated by a lack of coordinated effort from each of these disciplines.
Successful efforts generally involve planning
meetings of individuals from each of these
disciplines with an agreement that all judge the
effort in establishing a RSL program to be worthwhile. Each participant must be invested since
each plays a crucial role in assuring nuclear regulatory approval, realistic and safe protocols, and
the needed communication lines required if
unexpected events or problems arise. Even after
the RSL program begins, follow-up assessments
can assure that all procedures are working properly and any safety or “near-miss” events are
addressed among all the disciplines to avoid risks
of nuclear regulatory noncompliance [ 24 ].
8.5.4 Radiation Safety and Nuclear
Regulatory Compliance
For the clinicians involved, part of the beauty of
transitioning to a RSL program is that no new
skills or capital equipment are required. The team
must, however, be trained in safe handling of the
I-125 seeds and in procedures for identifi cation
of I-125 seeds to assure safe return. The surgeon
involved may need certifi cation from the radiation safety offi cer or committee on the safe handling of radioactive material. He or she also plays
an important role in developing a fail-safe plan
for identifying and recovering each I-125 seed.
Nuclear medicine physicians and radiation
safety offi cers are valuable partners in developing a RSL program because of their knowledge
of nuclear regulatory compliance and the facilities and protocols available for receipt, storage,
and decay of radioactive materials. Similarly, a
process for tracking the I-125 seeds must be
established including receipt by the institution,
distribution for the localization procedure,
retrieval from the pathology department, and
8 Radioguided Surgery for Non-palpable Breast Lesions: I-125 Radioactive Seed Localization
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135
return to nuclear medicine for decay or return to
the vendor. In the United States, the use of I-125
seeds for breast lesion localization is performed
under the direction of the diagnostic authorized
users of radioactive material.
Post-localization mammogram and specimen
radiographs are strongly advised for all RSL
cases to document I-125 seed placement in the
patient and I-125 seed removal from the patient,
respectively. That the source is no longer in the
patient can also be documented by identifi cation
of the I-125 seed by the pathologist based on
institutional practice [ 20 ]. One must document a
proper nuclear survey if these requirements are
not met. These records must be available for
review to meet nuclear safety regulations.
Radiation safety requirements vary by country
and state. It is therefore essential that your radiation safety offi cer investigate the necessary steps
within your country and state to gain this
approval. RSL has been endorsed by the US
Nuclear Regulatory Commission which has provided guidance at its website. In Europe, there
are generally nuclear regulations for each country in addition to those of the European Union
which must be met.
The institutional protocol should include steps
to ensure safety and that no I-125 seed will be misplaced or lost. In general, it is required (and is wise
regardless of regulatory requirement) to mark the
specimen with a radioactive material label to
assure every handler is aware of the presence of a
radioactive device within the specimen. The low
dose of the I-125 seed means there is no need for
providers or patients to undergo any special monitoring or labeling [
16 ]. The radiation exposure to
the residual breast tissue from the I-125 seed after
a typical dose, exposure time, and lumpectomy
volume is similar to the peak skin dose from a
standard two-view mammogram [ 16 ].
8.5.5 Lost I-125 Seed Protocol
Developing a fail-safe I-125 seed identifi cation
procedure in case of a lost I-125 seed is essential. If the plane of surgical dissection passes
through the plane of the I-125 seed or a hematoma
containing the I-125 seed, it can become free in
the surgical fi eld and then lost into suction
devices, sponges, or elsewhere [ 24 , 28 ]. The sur-
geon must use the gamma probe intraoperatively
to assure the I-125 seed is within the excised
specimen before passing the specimen off the
fi eld and must also assure no remaining I-125
activity is within the breast (other than minor
background gamma activity detected from the
Compton scatter of the Tc-99 used for the SLN
injection). If the I-125 seed is not identifi ed
within the specimen, the gamma probe should be
used to scan the lumpectomy cavity for the displaced I-125 seed. If not identifi ed, the gamma
probe should be used to scan the suction device,
suction tubing, suction canister, surgical sponges,
surgical drapes, and even the operating room
fl oor to identify the I-125 seed. If the I-125 seed
remains lost, a radiation safety team should survey the operating room and any other necessary
location to fi nd the missing I-125 seed. No personnel, specimens, or other items should leave
the operating room until this has been accomplished. Failing to properly identify all I-125
seeds can threaten one’s nuclear regulatory
license [ 24 ] and result in a threat to not only
maintaining a RSL program but an institutional
radioactive license.
Conclusions
RSL for non-palpable breast lesions is effective, safe, and provides important fl exibility in
scheduling that improves the patient experience and institutional effi ciency. It is at least
as effective as WL in achieving negative margins of excision for malignant lesions without
compromising localization times, operative
times, specimen volumes, or the patient
experience.
RSL does, however, require coordinated
efforts from a multidisciplinary team to implement. The actual technical procedures are
easy to learn and familiar to breast imagers
and surgeons. Breast surgeons’ familiarity
with radioguided surgery makes the procedure
intuitive and welcomed. RSL is a most attractive alternative to WL for non-palpable breast
lesions.
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Radioguided Surgery
https://t.me/med1917
of Non- palpable Breast
Lesions: Radio Occult Lesion
Localization (ROLL)
Bas Pouw , Marie-Jeanne T. F. D. Vrancken Peeters ,
and Renato A. Valdés Olmos
9
Contents
9.1 Background and Clinical Application 140
9.1.1 General Background 140
9.1.2 Tracer Administration 140
9.1.3 Combining ROLL with SLNB 141
9.1.4 Imaging 143
9.1.5 Surgical Localization 143
9.1.6 Histopathology 143
9.2 Overall Results of ROLL 145
9.3 Results Compared to Other
Techniques 145
9.3.1 ROLL-WGL 145
9.3.2 ROLL-Ultrasound 145
9.3.3 ROLL (Tc-99m)-RSL
(I-125-Seed) 145
9.4 Discussion 146
Conclusive 146
References 146
B. Pouw , MSc (*)
Departement of nuclear medicine , The Netherlands
Cancer Institute , Amsterdam , The Netherlands
b.pouw@nki.nl
e-mail:
M.-J. T. F. D. Vrancken Peeters , MD, PhD
Departement of surgical oncology , The Netherlands
Cancer Institute , Amsterdam , The Netherlands
R. A. Valdés Olmos , MD, PhD
Departement of nuclear medicine , The Netherlands
Cancer Institute , Amsterdam , The Netherlands
Leiden University Medical Centre ,
Leiden , The Netherlands
© Springer International Publishing Switzerland 2016
K. Herrmann et al. (eds.), Radioguided Surgery: Current Applications and Innovative
Directions in Clinical Practice, DOI 10.1007/978-3-319-26051-8_9
Abstract
The incidence of non-palpable breast cancer is
rising since national screening programs were
introduced. More than 25 % of the radiological
suspicious breast lesions are considered clinically occult or non-palpable. Surgical removal
of non-palpable breast tumors requires a specifi c approach. The main challenge of resecting
non-palpable lesions is to ensure clear margins
while minimizing the resection of healthy tissue
and cosmetic damage. Radioguided occult
lesion localization (ROLL) using a radioactive
tracer (e.g., technetium 99m; half-life of approximately 6 hours) was developed in 1996 and is
nowadays used in several institutes as a reliable
alternative for wire-guided localization. The
commonly used radiotracer is technetium 99m
(Tc 99m) macroaggregate albumin (MAA) with
a particle size of 10–150 μm, which can be
detected by the surgeon using a gamma probe.
The tracer is administered by an intratumoral
injection, and accordingly, this site is surgically
excised at the operating room while using a
gamma probe. At the moment more than 29
peer-reviewed articles have emerged about
ROLL. The general consensus is that ROLL,
using Tc 99m, is preferable over wire-guided
localization with the main advantages: the
patient comfort, positive margins, and localization time. Furthermore, the procedure can be
combined with a sentinel lymph node biopsy.
139
140
https://t.me/med1917
B. Pouw et al.
9.1 Background and Clinical
Application
9.1.1 General Background
The incidence of non-palpable breast cancer is rising since national screening programs were introduced. Breast cancer screening has changed the
type and stage of detected breast cancer lesions.
More than 25 % of the radiological suspicious
breast lesions are considered clinically occult or
non-palpable [ 1 ]. This includes small invasive
lesions, ductal carcinoma in situ (DCIS), or
smaller clusters of microcalcifi cations. The surgical removal of non-palpable breast tumors requires
a specifi c approach. The main challenge of resecting non-palpable lesions is to ensure clear margins
while minimizing the resection of healthy tissue
and cosmetic damage [ 2 ]. For this purpose, mostly
three different techniques are used for intraoperative tumor localization: wire-, ultrasound (US)-,
and radioguided localization (i.e., guided by a
radioactive tracer or radioactive marker). At present, wire-guided localization (WGL) is still the
most commonly used technique for non-palpable
breast cancer (75 %) [ 1 , 3 ]. Nonetheless, wire
placement is a cumbersome technique for both the
surgeon and the patient. The limitations of WGL
include (1) technical complications such as wire
dislodging [ 4 , 5 ], migration [ 6 , 7 ], kinking or frac-
ture; (2) logistic challenges as the wire is to be
placed a maximum of one day in advance of surgery; (3) higher patient discomfort as opposed to
alternative techniques [
outcome [ 10 , 11 ]. Dislodging and poor localiza-
tion are causes for relatively high irradicality rates
for WGL ranging from 10 to 50 % [ 1 , 5 , 12 – 17 ].
Radioguided occult lesion localization (ROLL)
using a radioactive tracer (e.g., technetium 99m)
was developed in 1996 and is nowadays used in
several institutes as a reliable alternative for WGL
[ 1 , 16 , 18 – 22 ]. A relatively newer and still less fre-
quently used localization technique is the ROLL
technique using a radioactive marker (e.g., iodine
125
125 (
I) marker), named radioactive seed localization (RSL) [ 23 , 24 ]. One study describes the
use of ROLL as an addition to WGL [ 25 ]. In this
setting, the tumor localization was guided by the
8 , 9 ]; and (4) poor cosmetic
Tc 99m and the wire was used to guide intratumoral blue dye injection. Afterward the results of
the WGL + ROLL were compared with WGL only.
9.1.2 Tracer Administration
The principle of the ROLL technique using a
radioactive tracer consists of an image-guided
intratumoral injection of this radioactive tracer.
The most frequently used techniques to visualize
the tumor are ultrasound and/or stereotaxis. The
radiotracer that is commonly used is technetium
99m (Tc 99m) macroaggregate albumin (MAA)
with a particle size of 10–150 μm, which is
retained within the tumor without any signifi cant
migration to lymph nodes and can be detected by
the surgeon using a gamma probe. The dosage of
radiolabeled MAA varies from 1 MBq to
123 MBq in literature [ 26 – 28 ].
Both the ultrasound-guided and the stereotacticguided administration routes enable real-time
feedback about the needle tip position and the
tumor location. By real-time validation of this
location, a secure intratumoral injection is facilitated (Fig. 9.1 ). The injected suspension consists
of 0.5 μg MAA radiolabeled with Tc 99m in a volume of 0.2 ml. When the lesion can be accurately
visualized with both stereotaxis and ultrasound,
the preferred injection method is the ultrasoundguided technique because of better needle tracking
[ 29 ]. For both stereotaxis and ultrasound, a spinal
needle (22 gauge) is recommended in order to
facilitate the connection of the syringe with the
radioactive tracer. Usually the radiologist introduces the needle into the tumor under continuous
monitoring by ultrasound. Subsequently, the
nuclear physician connects the syringe containing
the radiotracer to the needle. A 1 ml tuberculin
syringe with Luer-Lok connection is strongly recommended in order to prevent leakage of the tracer
during injection. A 0.1 ml air bubble, positioned
behind the radioactivity volume, in the syringe
may help to fl ush the tracer rest from the needle.
Figure
Pitfalls during the tracer administration are spill on
the skin (contamination), missed localization, and
spillage to the liver by puncturing a blood vessel.
9.2 illustrates stepwise the procedure.
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