Recent advances in nuclear and hybrid detection modalities for image-guided surgery

Development and evaluation of a prototype detector for an intraoperative laparoscopic coincidence imaging system with PET tracers

PURPOSE

Conventional positron emission tomography can be used only preoperatively to identify lymph node metastases, and hence, these growths are difficult to locate intraoperatively. Previously, an intraoperative laparoscopic coincidence imaging system, with an external fixed detector array and a detector probe that can be moved and inserted into the stomach, was proposed to identify lymph node metastases during stomach cancer surgery. This paper proposes a prototype detector for this system.

METHODS

GAGG:Ce (Gd₃Al₂Ga₃O₁₂:Ce) scintillator crystals, one to one coupled with silicon photomultipliers (SiPMs), were used to identify 511 keV photons. An optical tracking system followed the position and orientation of the movable detector. SiPM outputs were read out by time-over-threshold (TOT)-based application-specific integrated circuits, which converted the electrical charges into digital pulses. To identify the arrival time, channel number, and pulse width, which indicate the energy information of each TOT output, a data acquisition system was developed based on a field-programmable gate array.

RESULTS

The spatial resolution of the reconstructed images in lateral direction was better than 7 mm, but that of depth direction was limited, owing to inadequate projections. The prototype successfully reconstructed 44 kBq ¹⁸F-fluorodeoxyglucose sources during a 2-min scan.

CONCLUSION

We developed a prototype detector for an intraoperative laparoscopic coincidence imaging system. The prototype detector was evaluated successfully, and the produced images were similar to those obtained in the simulation results, thereby suggesting that this method offers a new possibility of imaging lymph node metastases intraoperatively.

A DROP-IN beta probe for robot-assisted 68Ga-PSMA radioguided surgery: first ex vivo technology evaluation using prostate cancer specimens

BACKGROUND

Recently, a flexible DROP-IN gamma-probe was introduced for robot-assisted radioguided surgery, using traditional low-energy SPECT-isotopes. In parallel, a novel approach to achieve sensitive radioguidance using beta-emitting PET isotopes has been proposed. Integration of these two concepts would allow to exploit the use of PET tracers during robot-assisted tumor-receptor-targeted. In this study, we have engineered and validated the performance of a novel DROP-IN beta particle (DROP-INβ) detector.

METHODS

Seven prostate cancer patients with PSMA-PET positive tumors received an additional intraoperative injection of ~ 70 MBq 68Ga-PSMA-11, followed by robot-assisted prostatectomy and extended pelvic lymph node dissection. The surgical specimens from these procedures were used to validate the performance of our DROP-INβ probe prototype, which merged a scintillating detector with a housing optimized for a 12-mm trocar and prograsp instruments.

RESULTS

After optimization of the detector and probe housing via Monte Carlo simulations, the resulting DROP-INβ probe prototype was tested in a robotic setting. In the ex vivo setting, the probe-positioned by the robot-was able to identify 68Ga-PSMA-11 containing hot-spots in the surgical specimens: signal-to-background (S/B) was > 5 when pathology confirmed that the tumor was located < 1 mm below the specimen surface. 68Ga-PSMA-11 containing (and PET positive) lymph nodes, as found in two patients, were also confirmed with the DROP-INβ probe (S/B > 3). The rotational freedom of the DROP-IN design and the ability to manipulate the probe with the prograsp tool allowed the surgeon to perform autonomous beta-tracing.

CONCLUSIONS

This study demonstrates the feasibility of beta-radioguided surgery in a robotic context by means of a DROP-INβ detector. When translated to an in vivo setting in the future, this technique could provide a valuable tool in detecting tumor remnants on the prostate surface and in confirmation of PSMA-PET positive lymph nodes.

Comparison of 3 γ-probes for simultaneous iodine-125-seed and technetium-99m breast cancer surgery: NEMA standard characterisation with extended processing

Purpose

Iodine-125 (¹²⁵I) seeds can be used as landmarks to locate non-palpable breast lesions instead of implanting metal wires. This relatively new technique requires a nuclear probe usually used for technetium-99m (^99mTc) sentinel node detection. This study aimed to compare the performances of different probes and valid the feasibility of this technique, especially in the case of simultaneous ¹²⁵I-seed and ^99mTc breast cancer surgery.

Methods

Three probes with different features (SOE-3211, SOE-3214 and GammaSUP-II) were characterised according to the NEMA NU3-2004 standards for a ^99mTc source and a ¹²⁵I-seed. Several tests such as sensitivity, linearity or spatial resolution allowed an objective comparison of their performances. NEMA testing was extended to work on signals discrimination in case of simultaneous detection of two different sources (innovative figure of merit “Shift Index”) and to assess the ^99mTc scatter fraction, a useful parameter for the improvement of the probes in terms of detector materials and electronic system.

Results

Although the GammaSUP-II probe saturated at a lower activity (1.6 MBq at 10 mm depth), it allowed better sensitivity and spatial resolution at the different NEMA tests performed with the ^99mTc source (7865 cps/MBq and 15 mm FWHM at 10 mm depth). With the ¹²⁵I-seed, the GammaSUP-II was the most sensitive probe (3106 cps/MBq at 10 mm depth) and the SOE-3211 probe had the best spatial resolution (FWHM 20 mm at 10 mm depth). The SOE-3214 probe was more efficient on discriminating ¹²⁵I from ^99mTc in case of simultaneous detection. The SOE probes were more efficient concerning ^99mTc scatter fraction assessments. The SOE-3211 probe, with overall polyvalent performances, seemed to be an interesting trade-off for detection of both ¹²⁵I and ^99mTc.

Conclusion

The three probes showed heterogeneous performances but were all suitable for simultaneous ^99mTc sentinel node and ¹²⁵I-seed detection. This study provides an objective and innovative methodology to compare probes performances and then choose the best trade-off regarding their expected use.

Nuclear medicine and molecular imaging advances in the 21st century

Currently, Nuclear Medicine has a clearly defined role in clinical practice due to its usefulness in many medical disciplines. It provides relevant diagnostic and therapeutic options leading to patients' healthcare and quality of life improvement. During the first two decades of the 21stt century, the number of Nuclear Medicine procedures increased considerably.Clinical and research advances in Nuclear Medicine and Molecular Imaging have been based on developments in radiopharmaceuticals and equipment, namely, the introduction of multimodality imaging. In addition, new therapeutic applications of radiopharmaceuticals, mainly in oncology, are underway.This review will focus on radiopharmaceuticals for positron emission tomography (PET), in particular, those labeled with Fluorine-18 and Gallium-68. Multimodality as a key player in clinical practice led to the development of new detector technology and combined efforts to improve resolution. The concept of dual probe (a single molecule labeled with a radionuclide for single photon emission computed tomography)/positron emission tomography and a light emitter for optical imaging) is gaining increasing acceptance, especially in minimally invasive radioguided surgery. The expansion of theranostics, using the same molecule for diagnosis (γ or positron emitter) and therapy (β minus or α emitter) is reshaping personalized medicine.Upcoming research and development efforts will lead to an even wider array of indications for Nuclear Medicine both in diagnosis and treatment.

Image-Guided Surgery: Are We Getting the Most Out of Small-Molecule Prostate-Specific-Membrane-Antigen-Targeted Tracers?

Expressed on virtually all prostate cancers and their metastases, the transmembrane protein prostate-specific membrane antigen (PSMA) provides a valuable target for the imaging of prostate cancer. Not only does PSMA provide a target for noninvasive diagnostic imaging, e.g., PSMA-positron emission tomography (PSMA-PET), it can also be used to guide surgical resections of PSMA-positive lesions. The latter characteristic has led to the development of a plethora of PSMA-targeted tracers, i.e., radiolabeled, fluorescent, or hybrid. With image-guided surgery applications in mind, this review discusses these compounds based on clinical need. Here, the focus is on the chemical aspects (e.g., imaging label, spacer moiety, and targeting vector) and their impact on in vitro and in vivo tracer characteristics (e.g., affinity, tumor uptake, and clearance pattern).

Trending: Radioactive and Fluorescent Bimodal/Hybrid Tracers as Multiplexing Solutions for Surgical Guidance

By contributing to noninvasive molecular imaging and radioguided surgery, nuclear medicine has been instrumental in the realization of precision medicine. During the last decade, it has also become apparent that nuclear medicine (e.g., in the form of bimodal/hybrid tracers) can help to empower fluorescence-guided surgery. More specifically, when using hybrid tracers, lesions can be noninvasively identified and localized with a high sensitivity and precision (guided by the radioisotope) and ultimately resected under real-time optical guidance (fluorescent dye). This topical review discusses early clinical successes, preclinical directions, and key aspects that could have an impact on the future of this field.

Characterisation of a β detector on positron emitters for medical applications

PURPOSE

Radio Guided Surgery (RGS) is a technique that helps the surgeon to achieve an as complete as possible tumor resection, thanks to the intraoperative detection of particles emitted by a radio tracer that bounds to tumoral cells. In the last years, a novel approach to this technique has been proposed that, exploiting β^- emitting radio tracers, overtakes some limitations of established γ-RGS. In this context, a first prototype of an intraoperative β particle detector, based on a high light yield and low density organic scintillator, has been developed and characterised on pure β^- emitters, like ⁹⁰Y. The demonstrated very high efficiency to β^- particles, together with the remarkable transparency to photons, suggested the possibility to use this detector also with β⁺ emitting sources, that have plenty of applications in nuclear medicine. In this paper, we present upgrades and optimisations performed to the detector to reveal such particles.

METHODS

Laboratory measurement have been performed on liquid Ga68 source, and were used to validate and tune a Monte Carlo simulation.

RESULTS

The upgraded detector has an ~80% efficiency to electrons above ~110keV, reaching a plateau value of ~95%. At the same time, the probe is substantially transparent to photons below ~200keV, reaching a plateau value of ~3%.

CONCLUSIONS

The new prototype seems to have promising characteristics to perform RGS also with β⁺ emitting isotopes.