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Ken Herrmann · Omgo E. Nieweg
Stephen P. Povoski Editors
Radioguided
Surgery
Current Applications
and Innovative Directions
in Clinical Practice
123

Radioguided Surgery


Ken Herrmann • Omgo E. Nieweg
Stephen P. Povoski
Editors
Radioguided Surgery
Current Applications and Innovative
Directions in Clinical Practice

Editors
https://t.me/med1917
Ken Herrmann
Department of Nuclear Medicine
Universitätsklinikum Würzburg
Würzburg
Germany
Omgo E. Nieweg
Melanoma Institute Australia and
The University of Sydney
Sydney
New South Wales
Australia
Stephen P. Povoski
Division of Surgical Oncology
Department of Surgery
The Ohio State University
Comprehensive Cancer Center –
Arthur G. James Cancer Hospital and
Richard J. Solove Research Institute
Columbus , OH
USA
ISBN 978-3-319-26049-5 ISBN 978-3-319-26051-8 (eBook)
DOI 10.1007/978-3-319-26051-8
Library of Congress Control Number: 2016933448
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specifi c statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, express or implied, with respect to the material
contained herein or for any errors or omissions that may have been made.
Printed on acid-free paper
Springer International Publishing AG Switzerland is part of Springer Science+Business Media
www.springer.com)
(

https://t.me/med1917
We would like to dedicate this book to our families and loved
ones, not only for their understanding and sacrifi ce during the
writing of this book but also for their endearing and endless
support throughout our entire medical careers.
Ken Herrmann
Omgo E. Nieweg
Stephen P. Povoski

https://t.me/med1917

F o r e w o r d
https://t.me/med1917
My own journey into radioguided surgery began in the late 1970s. Two principles were the basis for further developing this technology. First, surgery
should be based upon more science and less emotion. Second, it is not what
is removed at the time of cancer surgery that is important, but it is what is left
behind (residual cancer) that is most impactful. Based upon these two principles, I have spent the past 40 years attempting to improve surgical outcomes. Therefore, it is most apropos that Chapter 1 of this book succinctly
professes “radioguided surgery provides the surgeon with critical and realtime information regarding the exact location of disease and the overall extent
of disease burden, as well as allowing the surgeon to minimize the degree of
surgical invasiveness associated with many commonplace diagnostic and
therapeutic surgical procedures, while still maintaining maximum treatmentdirected benefi ts to the patient.”
Radioguided surgery requires a signifi cant amount of technology for its
implementation. Surgeons and nuclear medicine physicians should have
knowledge and expertise relevant to this technology that extends beyond
standard training. Likewise, nuclear medicine technologists, operating room
personnel, and pathologists should be very familiar with this technology.
Therefore, appropriate resources are needed that adequately describe all
aspects of radioguided surgery. This book fully addresses all of the basic
principles of radioguided surgery and provides a comprehensive overview of
the technical details of various radioguided surgical procedures for a variety
of malignancies. As a resource, this book is invaluable.
This book includes 29 chapters written and edited by well-known experts
in the fi eld of radioguided surgery. Chapter
for understanding the basic principles of radiodetection. The terminology and
explanations target a wide array of audiences. The contents of this chapter
should prove intelligible and understandable.
Complete resection of all tumor-containing tissues is critical for the best
survival potential for cancer patients. During radioguided surgery, radiodetection with handheld gamma detection probes can provide the surgeon with
real-time information regarding the location of the target lesions and helps
confi rm accurate lesion resection. With limitations to handheld gamma detection probes, intraoperative gamma cameras have been designed to further
facilitate radioguided surgery. These gamma camera imaging systems must
meet several requirements to be employed in the operating room: (1) a portable and mobile design, (2) no delay between image acquisition and display,
2 provides essential knowledge
vii

viii
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and (3) the possibility for continuous monitoring, spatial orientation on
screen, real-time quantifi cation, and display of radioactive count data. Such
systems should also have an adequate spatial resolution, sensitivity, and fi eld
of view. Chapter 3 provides an in-depth description of this technology.
The proper use and handling of radioactive substances for radioguided
surgery requires adherence to strict principles of radiation safety in order to
limit the risk to patients and staff, including those in the nuclear medicine
department, the operating room, and the pathology department. The knowledge of proper disposal of radioactive waste is of utmost importance. Chapter
6 stresses the importance of all these principles.
The histologic status of the axillary lymph nodes remains one of the most
important prognostic indicators in breast cancer and impacts recommendations for adjuvant therapies. Axillary lymph node dissection, once considered
the standard of care for diagnostic axillary staging in all breast cancer patients,
has been largely replaced by sentinel lymph node biopsy in patients with a
clinically negative axilla and in a select group of patients with node-positive
breast cancer. This has reduced the extensive morbidity of full axillary lymph
node dissection. Chapter
7 reviews the lymphatic drainage patterns of the
breast, the technical aspects of sentinel lymph node biopsy (with particular
attention to the radioguided surgical aspects), and the clinical implications of
the fi ndings. The development of radioguided sentinel lymph node biopsy is
truly one of the greatest success stories in contemporary surgical oncology.
The role of surgery in the treatment of cancer has not changed appreciably
over the past 100 years. With cancer being the second leading cause of death,
it is clear that there is a need for a more scientifi c approach to the removal of
cancer. Updated technology in the operating room is needed to enhance the
surgeon’s ability to identify the extent of disease and perform a more complete resection of the cancer. Staging and grading of malignant disease plays
a signifi cant role in determining prognosis. Chapter 24 nicely describes the
history of radioimmunoguided surgery and its invaluable role in improving
the ability to accurately stage tumors. Hopefully, as we continue to learn how
to better integrate this technology into future radioguided surgical approaches,
it will become a more recognizable method for improving our ability to forecast prognosis.
As discussed in this book, fully integrated whole body preoperative
nuclear medicine imaging and intraoperative radioguided detection of a
radiotracer (using a single injection dose) is the most effective way to perform radioguided surgery. This allows the nuclear medicine physician and
surgeon to jointly generate a virtual navigation roadmap regarding the location of the expected and unexpected lesions, including locations of distant
metastatic disease. The navigation concept can provide the operating specialist with information regarding the location and margins of target lesions during surgery and as such can help improve the accuracy of the surgical
procedure. This enhanced radioguided surgery technology has the potential
to signifi cantly impact upon the success of cancer operations and improve
long-term survival for our patients.
Foreword

Foreword
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ix
It is very evident that radioguided surgery has a long history dating back
to the late 1940s, with signifi cant groundbreaking contributions from many
individuals. Therefore, the collective expectations of this book are to show
exactly how the wide variety of current applications and future innovative
directions of radioguided surgery can impact all disciplines within the clinical practice of surgery. Clearly, the co-editors of this book, Prof. Ken
Herrmann, Prof. Omgo E. Nieweg, and Dr. Stephen P. Povoski, have fully
met these expectations. As radioguided surgery moves forward through the
twenty-fi rst century, we envision further growth of its current technological
platforms along with the development of other innovative methods.
Edward W. Martin Jr.
Division of Surgical Oncology, Department of Surgery
Arthur G. James Cancer Hospital and Richard J. Solove Research
Institute and Comprehensive Cancer Center
The Ohio State University
Columbus, USA
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