The use of iodine seed (I-125) as a marker for the localisation of lung nodules in minimal invasive pulmonary surgery

Radioguided surgery of mesenchymal tumors with 125I seeds

INTRODUCTION

Radioguided surgery uses radioactive substances to identify and remove hard-to-locate lesions. Mesenchymal tumors constitute a heterogeneous group of neoplasms derived from the mesoderm, including benign lesions and malignant sarcomas. The aim of this study was to evaluate the ability of 125I radioactive seeds to guide intraoperative localization of mesenchymal tumors, analyzing the complication rates and evaluating the margins of the surgical specimens retrieved.

METHODS

Retrospective observational study of all consecutive patients undergoing radioguided surgery of a mesenchymal tumor with a 125I radioactive seed from January 2012 to January 2020 at a tertiary referral center in Spain. The seed was inserted percutaneously guided by ultrasound or computed tomography in an outpatient setting.

RESULTS

Fifteen lesions were resected in 11 interventions in 11 patients, recovering all lesions marked (100%) with a 125I seed. The lesions included areas of benign fibrosis (26.7%), cellular angiofibroma (6.7%), desmoid tumor (20%), solitary fibrous tumor (13.3%), chondrosarcoma (6.7%), and pleomorphic sarcoma (26.7%), with a high rate of recurrent tumors (60%). There was only one complication (6.7%) due to the seed falling within the surgical bed. According to the UICC classification of residual tumors, 80% of the lesions resulted in an R0 resection, 6.7% were R1 resections, and 13.3% were R2 resections.

CONCLUSION

Radioguided surgery is an accurate technique for the resection of hard-to-locate mesenchymal tumors.

Radioactive seed localization of foreign body

Radioactive seed localization is a method widely used within breast cancer treatment. This case represents a 43-year-old male patient with a foreign body in his left axilla. We used radioactive seed localization for marking the foreign body, which made the subsequent surgery possible, quick, and minimal invasive.

Preoperative radio-guided localization of lung nodules with I-125 seeds: experience with 32 patients at a single institution

OBJECTIVES

Videothoracoscopic visualization and/or palpation of pulmonary nodules may be difficult due to their location, small size or limited solid component. The purpose of this study is to present our experience with computed tomography (CT)-guided preoperative localization of pulmonary nodules by percutaneous marking with radio-labelled iodine-125 seeds.

METHODS

A total of 34 pulmonary nodules were marked under CT with the placement of 33 radio-labelled iodine-125 seeds in 32 consecutive patients.

RESULTS

All patients underwent biportal video-assisted thoracic surgery (VATS) and in no case was conversion to thoracotomy necessary. A total of 88.2% of the lung nodules were successfully resected. In the remaining 11.8%, migration of the seed to the pleural cavity occurred, although these nodules were still resected during VATS. Of all the patients with pneumothorax after the marking procedure, only one required chest tube placement (3.1%). No major postoperative complications were observed.

CONCLUSIONS

Preoperative marking of pulmonary nodules with I-125 seeds under CT guidance is a feasible and safe technique that allows their intraoperative identification and resection.

Role of a portable gamma-camera with optical view for margins assessment of pulmonary nodules resected by radioguided surgery

PURPOSE

Radioguided occult lesion localization (ROLL) of pulmonary nodules is an alternative to hook-wire. Both required of a histological margin assessment. The activity emerging from the radiotracer allows to obtain an intraoperative scintigraphic image of the surgical specimen by a portable gamma-camera (PGC) fitted with an optical view, which provides information about the localization of the nodule in relation to the margins. The aim of this study was to evaluate the intraoperative use of a PGC for margin assessment of pulmonary nodules.

METHODS

ROLL technique was used in 38 nodules (36 pulmonary, 1 chest wall, and 1 pleural nodules). A PGC intraoperative image of the surgical specimen was obtained in 32. Scintigraphic results were compared to the histological assessment. Other factors, such as nodule size, distance from the pleural surface, or distance covered by the needle, were considered as possible factors for non-centered lesions.

RESULTS

PGC images showed that the lesion was in contact with the margins in 8/32 cases and centered in 24. In all cases in which the lesion was considered as centered by the PGC, the margins were free of involvement (NPV 100%), although the PPV is low.

CONCLUSIONS

The use of a PGC for margin assessment after pulmonary nodule resection is feasible and provides a high NPV in our series. In addition, the short intraoperative time required for its use makes the PGC a useful tool for providing supplementary information to histopathologic results. Further studies from different surgical teams are required for an external validation.

Real-Time Fluorescence Image-Guided Oncolytic Virotherapy for Precise Cancer Treatment

Oncolytic virotherapy is one of the most promising, emerging cancer therapeutics. We generated three types of telomerase-specific replication-competent oncolytic adenovirus: OBP-301; a green fluorescent protein (GFP)-expressing adenovirus, OBP-401; and Killer-Red-armed OBP-301. These oncolytic adenoviruses are driven by the human telomerase reverse transcriptase (hTERT) promoter; therefore, they conditionally replicate preferentially in cancer cells. Fluorescence imaging enables visualization of invasion and metastasis in vivo at the subcellular level; including molecular dynamics of cancer cells, resulting in greater precision therapy. In the present review, we focused on fluorescence imaging applications to develop precision targeting for oncolytic virotherapy. Cell-cycle imaging with the fluorescence ubiquitination cell cycle indicator (FUCCI) demonstrated that combination therapy of an oncolytic adenovirus and a cytotoxic agent could precisely target quiescent, chemoresistant cancer stem cells (CSCs) based on decoying the cancer cells to cycle to S-phase by viral treatment, thereby rendering them chemosensitive. Non-invasive fluorescence imaging demonstrated that complete tumor resection with a precise margin, preservation of function, and prevention of distant metastasis, was achieved with fluorescence-guided surgery (FGS) with a GFP-reporter adenovirus. A combination of fluorescence imaging and laser ablation using a KillerRed-protein reporter adenovirus resulted in effective photodynamic cancer therapy (PDT). Thus, imaging technology and the designer oncolytic adenoviruses may have clinical potential for precise cancer targeting by indicating the optimal time for administering therapeutic agents; accurate surgical guidance for complete resection of tumors; and precise targeted cancer-specific photosensitization.

Diagnosis and radio-guided surgery of lung nodules

The detection of pulmonary nodules has increased in recent decades due to the introduction of lung cancer screening programs and the massively use of routine chest computed tomography in patients with malignant neoplasms. Percutaneous biopsy of these nodules does not always characterize them, so sometimes a surgical biopsy is necessary, which often requires a presurgical localization. The radioguided occult lesion localization (ROLL) described for breast lesions was first applied in the resection of pulmonary nodules in 2000, becoming an alternative to other presurgical localization techniques such as hook-wire. The technique provides high detection rate with minimal morbidity, enhancing multidisciplinary work with specialists in Radiology and Chest Surgery. The present paper describes the different pre-surgical localization techniques currently available, the methodological procedure of the ROLL technique and the collected results in 20 years of experience.

125I radioactive seed localization (RSL) in surgery of cervical metastasis of thyroid cancer

INTRODUCTION

The aim of this work is the evaluation of usefulness of radioactive seed localization (RSL) for the detection of cervical recurrence of thyroid cancer in order to improve the surgical outcome.

MATERIAL AND METHOD

Ten patients with thyroid cancer and lymph node involvement (4 naive and 6 with cervical recurrence) evidenced by ultrasound, cytology/Tg-FNAB (reoperated group) were selected for this procedure. A ¹²⁵I seed was placed in the metastatic lesion using a needle guided by ultrasound. During surgery, a handheld gamma probe/portable gammacamera were used for lesion localization and excision. After removing the target tissue, it was verified that the seed was included in the excised tissue. Surgical intervention duration, lesion location, seed activity, thyroglobulin level, effective radiation dose, complications and the degree of surgical resection were analyzed.

RESULTS

All the marked nodes were positive in histology. The mean duration of the ultrasound procedure was 11.4±3.4minutes. Seed was kept inside the patient, in average, during 4days (1-7) and the average surgical time was 44.7±29.1minutes. We found 21 metastatic specimens with an average diameter 13.9±6.3mm. The mean activity of the implanted seed was 71.27±21.6MBq (42.8-105) In the reoperated group, thyroglobulin level was 2.08±1.56ng/dl and decreased after surgery to 0.13±0.12ng/dl, P<.01. Only one case of transient hypoparathyroidism was found in the total group.

CONCLUSIONS

The introduction of RSL in our unit has shown benefits for the patient and medical team, being a safe and effective procedure that also improves surgical programming.

Radioactive seed localization of renal cell carcinoma in a patient with Von Hippel-Lindau disease

This report describes the case of a patient, who had successful radioactive seed localization (RSL) performed to improve the identification and excision of a renal cell carcinoma. RSL is a new method of preoperative localization, which can ease the surgical procedure, minimize tissue trauma, and ultimately benefit the patient.

CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is standard of care for small lung resections at many centres. Computed tomography (CT)-guided insertion of microcoils can aid surgeons in performing VATS resections for non-palpable lung nodules deep to the lung surface.

METHODS

Retrospective analysis of CT-guided microcoil insertions prior to VATS lung resection at a single institution from October 2008 to January 2014.

RESULTS

A total of 63 patients were included (37% male, mean age 61.6±11.4 years). Forty-two patients (67%) had a history of smoking, with 10 current smokers. Sixty one (97%) patients underwent wedge resection and 3 (5%) patients had segmentectomy. Three (5%) patients required intra-operative staple line re-resection for positive or close margins. Eleven (17%) patients had a completion lobectomy, 5 of which were during the same anaesthetic. The average time between the CT-guided insertion and start of operation was 136.6±89.0 min, and average operative time was 84.0±53.3 min. The intra-operative complication rate was 5% (n=3), including 1 episode of hemoptysis, and 2 conversions to thoracotomy. The post-operative complication rate was 8% (5 patients), and included 2 air leaks, 1 hemothorax (drop in hemoglobin), 1 post chest tube removal pneumothorax, and one venous infarction of the lingula after lingula-sparing lobectomy requiring completion lobectomy. . Average post-operative length of stay was 2.2 days. A diagnosis was made for all patients.

CONCLUSIONS

CT-guided microcoil insertion followed by VATS lobectomy is safe, with short operative times, short length of stay and 100% diagnosis of small pulmonary nodules. This technique will become more important in the future with increasing numbers of small nodules detected on CT as part of lung cancer screening programs.

Iodine 125 Seed for Localization in Primary Hyperparathyroidism

Background. Preoperative localization of the parathyroid gland prior to a minimally invasive parathyroidectomy (MIP) is important because of varying locations of the parathyroid gland. Several methods have been described to localize the affected gland. One novel technique is the use of an iodine 125 (I-125) seed as a marker. The aim of this study is to evaluate the feasibility of using an I-125 seed in localizing the diseased parathyroid gland prior to MIP. Materials and methods. This is a pilot study of 10 patients performed in the Amphia Hospital, the Netherlands. Patients in whom primary hyperparathyroidism (PHPT) was diagnosed in combination with 1 enlarged parathyroid gland on ultrasound (US) and scintigraphy and who were eligible for MIP were included in this study. These patients underwent a preoperative US-guided I-125 seed placement in the affected parathyroid gland. The main study parameters were the feasibility of the placement, intraoperative localization of the diseased gland and complications. Results. A total of 10 patients were included. The US-guided I-125 placement in the affected parathyroid gland was technically feasible in the majority of cases. Because of the anatomical location of the gland, the placement was difficult in 2 patients, resulting in suboptimal position and possible misplacement of the marker. MIP was uncomplicated in most cases. Complications during surgery were mainly intraoperative bleeding. Conclusions. The use of an I-125 seed for preoperative localization in PHPT is a relatively safe technique in parathyroid surgery. More research is needed to compare this technique with other preoperative localization techniques.

Preoperative planning of thoracic surgery with use of three-dimensional reconstruction, rapid prototyping, simulation and virtual navigation

For the past decades, surgeries have become more complex, due to the increasing age of the patient population referred for thoracic surgery, more complex pathology and the emergence of minimally invasive thoracic surgery. Together with the early detection of thoracic disease as a result of innovations in diagnostic possibilities and the paradigm shift to personalized medicine, preoperative planning is becoming an indispensable and crucial aspect of surgery. Several new techniques facilitating this paradigm shift have emerged. Pre-operative marking and staining of lesions are already a widely accepted method of preoperative planning in thoracic surgery. However, three-dimensional (3D) image reconstructions, virtual simulation and rapid prototyping (RP) are still in development phase. These new techniques are expected to become an important part of the standard work-up of patients undergoing thoracic surgery in the future. This review aims at graphically presenting and summarizing these new diagnostic and therapeutic tools.

Iodine seed- versus wire-guided localization in breast-conserving surgery for non-palpable ductal carcinoma in situ

Background

Breast-conserving surgery for isolated non-palpable ductal carcinoma in situ (DCIS) is associated with high rates of incomplete surgical resection in comparison with unifocal invasive breast cancer. Therefore, accurate preoperative localization of the lesion is very important to facilitate adequate resection. Wire-guided localization (WGL) remains the standard for localization of DCIS. Recently, iodine-125 seed-guided localization (I-125 GL) was introduced as an alternative localization technique. The aim of this study was to compare the efficacy of these localization techniques in the resection of DCIS by breast-conserving surgery.

Methods

Between March 2006 and June 2013, 169 patients with non-palpable DCIS were treated with breast-conserving surgery. Only patients with pure DCIS on both preoperative core biopsy and definitive pathology were included.

Results

WGL was performed in 78 patients and I-125 GL in 91 patients. The groups did not differ with respect to age, size of DCIS or type of imaging used. Patients in the I-125 GL group had a significantly lower risk of extensively involved resection margins than those in the WGL group (4 versus 13 per cent respectively; P = 0·048).

Conclusion

In patients treated with breast-conserving surgery for non-palpable DCIS, localization with iodine-125 seeds is superior to the WGL technique in reducing the risk of extensively involved resection margins.

Radio-guided occult lesion localisation using iodine 125 Seeds "ROLLIS" to guide surgical removal of an impalpable posterior chest wall melanoma metastasis

Cancer screening and surveillance programmes and the use of sophisticated imaging tools such as positron emission tomography-computed tomography (PET-CT) have increased the detection of impalpable lesions requiring imaging guidance for excision. A new technique involves intra-lesional insertion of a low-activity iodine-125 (¹²⁵I) seed and detection of the radioactive signal in theatre using a hand-held gamma probe to guide surgery. Whilst several studies describe using this method to guide the removal of impalpable breast lesions, only a handful of publications report its use to guide excision of lesions outside the breast. We describe a case in which radio-guided occult lesion localisation using an iodine 125 seed was used to guide excision of an impalpable posterior chest wall metastasis detected on PET-CT.

Precise navigation surgery of tumours in the lung in mouse models enabled by in situ fluorescence labelling with a killer-reporter adenovirus

Background

Current methods of image-guided surgery of tumours of the lung mostly rely on CT. A sensitive procedure of selective tumour fluorescence labelling would allow simple and high-resolution visualisation of the tumour for precise surgical navigation.

Methods

Human lung cancer cell lines H460 and A549 were genetically transformed to express red fluorescent protein (RFP). Tumours were grown subcutaneously for each cell line and harvested and minced for surgical orthotopic implantation on the left lung of nude mice. Tumour growth was measured by fluorescence imaging. After the tumours reached 5 mm in diameter, they were injected under fluorescence guidance with the telomerase-dependent green fluorescent protein (GFP)-containing adenovirus, OBP-401. Viral labelling of the lung tumours with GFP precisely colocalised with tumour RFP expression. Three days after administration of OBP-401, fluorescence-guided surgery (FGS) was performed.

Results

FGS of tumours in the lung was enabled by labelling with a telomerase-dependent adenovirus containing the GFP gene. Tumours in the lung were selectively and brightly labelled. FGS enabled complete lung tumour resection with no residual fluorescent tumour.

Conclusions

FGS of tumours in the lung is feasible and more effective than bright-light surgery.

Characteristics and management strategies for the incidental pulmonary nodule

SUMMARY: 

Pulmonary nodules are frequent, unanticipated findings on imaging studies obtained for other purposes across all areas of medical practice. As nodule detection raises concern for malignancy, evaluation and follow-up of an incidental nodule is imperative. Clinicians are charged with counseling patients and directing further evaluation amid uncertainty and anxiety. The goals of follow-up and management are to identify malignant lesions at an early stage, while avoiding unnecessary procedures and potential harm to patients with benign nodules. In this review, we aim to outline the clinical and radiographic characteristics that can aid in likelihood stratification, to identify gaps in our current knowledge, and to present a logical approach to nodule management, based on the available evidence.