The rate of operative success achieved with radioguided occult lesion localization and intraoperative ultrasonography in patients with recurrent papillary thyroid cancer

Reliability of radioguided occult lesion localization in reoperation of loco-regional persistent/recurrent differentiated thyroid cancer: Retrospective cohort study

OBJECTIVES

We aimed to determine the radioguided occult lesion localization (ROLL) reliability in the reoperation of patients with differentiated thyroid cancer (DTC) and persistent or recurrent non-palpable loco-regional disease who underwent surgery at the Instituto Nacional de Cancerología between 2012 and 2021.

DESIGN

Observational retrospective cohort study.

PARTICIPANTS

We included data from patients with DTC that underwent resection with ROLL.

MAIN OUTCOME MEASURES

Reliability analysed as percentage of patients with complete resection of tumour lesion using ROLL, disease-free survival, second loco-regional relapse, adequate resectability and complications.

RESULTS

Two hundred and four cases were obtained. Pathological examination revealed papillary thyroid carcinoma in 202 patients, and follicular thyroid carcinoma in 2. Reliability was 96.57% in patients who underwent ROLL. When wide resection was performed-at surgeon's discretion-the reliability increased to 97.5%.

CONCLUSIONS

The high reliability obtained suggests that ROLL was effective to localize non-palpable relapsing lesions. To our knowledge, this is the largest sample size published on this topic to date.

Localización intraoperatoria de las recurrencias en cáncer de tiroides mediante la inyección de azul de metileno guiada por ecografía

Introducción. La cirugía para extirpación de metástasis en un cuello previamente intervenido afronta un reto para lograr una resección exitosa. El presente estudio pretende demostrar la utilidad de la técnica de inyección de azul de metileno, guiada por ecografía, para la localización intraoperatoria de lesiones recurrentes en cáncer de tiroides, para facilitar su resección. Métodos. Se realizó un estudio observacional, descriptivo y retrospectivo, en pacientes reintervenidos por recurrencia de carcinoma diferenciado de tiroides, durante un periodo de dos años y medio. Se utilizó la inyección intratumoral de azul de metileno guiada por ecografía para su identificación intraoperatoria de recurrencia. Se hizo análisis de variables demográficas y clínicas. Resultados. Este estudio incluyó 10 procedimientos en 9 pacientes, 77,8 % mujeres, con una media de edad de 54 años. Todos tenían un nivel de tiroglobulina detectable y elevado antes de la intervención; posteriormente, el 89 % presentó un descenso y el 33 % una adecuada respuesta bioquímica. La técnica agregó 10 minutos al tiempo quirúrgico. En el 100 % se identificaron de manera intraoperatoria los ganglios marcados; el promedio de ganglios resecados fue de 12, de los cuales, 6 fueron positivos, todos con carcinoma papilar de tiroides. Esta técnica se consideró de gran utilidad y de bajo costo en todos los casos. Discusión. Esta técnica se muestra como una estrategia efectiva para la identificación intraoperatoria de las recurrencias locorregionales en carcinoma de tiroides, permitiendo una disección ganglionar exitosa, disminuyendo complicaciones, tiempo quirúrgico y, especialmente, costos frente a otras intervenciones

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.

Radioguided occult lesion localization in patients with recurrent thyroid cancer

PURPOSE

Well planned re-surgery is critical for recurrent/persistent thyroid cancer (TC). We aimed to investigate the clinical outcome of radioguided-occult lesion localization (ROLL) guided surgery in patients with recurrent/persistent TC.

METHODS

This study includes 29 patients [F/M: 22/7, median age 43 ± 12 years (18-58)] with a diagnosis of TC (22 papillary, 2 follicular and 5 medullary). Before surgery, all patients underwent ultrasonography (USG) guided mapping and intra-lesional radioactivity injection. Surgery was performed based on the excision of radioactivity injected lesions by a gamma probe and non-injected tumor foci via USG-neck map. Researchers determined surgical success by post-operative tumor markers and neck-USG.

RESULTS

Among 29 patients, 60 metastatic lesions were identified by USG [median size 10 ± 6.3 mm (range 5-30)]. Neck-USG performed after surgery provided no evidence of disease (NED) in %97 (28/29) of TC patients. In the follow-up, stimulated thyroglobulin (Tg) levels were less than 1 ng/ml in 79%(19/24) of DTC patients and suppressed Tg < 0.2 ng/ml was noted in 92% (22/24).In patients with DTC with an incomplete structural response, we dramatically changed the American Thyroid Association (ATA) response category and achieved an excellent response in 92% (22/24) of patients. Among patients with MTC, 5/5 patients had normal USG and calcitonin levels were reduced by 60-80% in 4/5 and > 80% in1/5 patients.

CONCLUSIONS

In this study we have shown that, ROLL-guided surgery yielded NED rate of %97 (28/29) and increased excellent response rates according to ATA guidelines. Further studies with larger patient groups and longer follow-up should be performed to confirm the efficacy of this surgery.

Guided intraoperative scintigraphic tumor targeting of metastatic cervical lymph nodes in patients with differentiated thyroid cancer: a single-center report

OBJECTIVE

Our aim was to present our experiences related to performing neck surgery using the guided intraoperative scintigraphic tumor targeting (GOSTT) procedure for patients who had locally recurrent or persistent differentiated thyroid cancer (DTC) and who had undergone previous thyroid surgery.

SUBJECTS AND METHODS

We retrospectively evaluated 11 patients who had locally recurrent or persistent DTC, who had undergone previous surgery, and for whom reoperation was planned for metastatic cervical lymph nodes (LNs). We performed the neck surgery using the GOSTT procedure on all patients and at a single academic institution.

RESULTS

The 11 patients had a total of 26 LNs, as marked with a radiotracer, and those LNs' mean size was 14.7 ± 8.2 mm (range: 5-34 mm). Histopathological examinations revealed DTC metastasis in all 26 of the preoperatively marked LNs. Of the 11 patients, only one needed a reoperation in the neck; she had another successful surgery (also using the GOSTT procedure). In the evaluation of the patients' final status, all were disease-free in their necks. There also were no GOSTT-associated postoperative complications.

CONCLUSION

The GOSTT procedure is a useful, successful, inexpensive, and comfortable procedure for marking and mapping metastatic LNs, especially in DTC patients who have undergone previous surgery.

Impact of Radioguided Occult Lesion Localization (ROLL) in the management of cervical recurrences from differentiated thyroid cancer

BACKGROUND

Surgery is the elective treatment for cervical relapse from differentiated thyroid cancer (DTC) but it is technically challenging, with risk of failure and morbidity. We explored the feasibility and the efficacy of Radioguided Occult Lesion Localization (ROLL) with intratumoral 99mTc radiolabeled human albumin macroaggregates ([99mTc]MAA) injection in this setting.

METHODS

Fifteen patients who underwent ROLL by ultrasonography (US)-guided intratumoral injection of [99mTc]MAA between December 2013 and October 2016 for DTC recurrence were considered for this study. An hand-held gamma-probe was employed for intrasurgical lesion detection. Mini-invasive ROLL-guided excision for soft tissue recurrence and ROLL-assisted modified radical neck dissection for lymph-node metastases were performed respectively.

RESULTS

DTC recurrence was located in loco-regional lymph-nodes (n=8 patients) and in thyroid bed (n=7 patients). A total of 27 lesions was identified and injected before surgery. On a total of 124 lesions resected, histology showed 38 DTC metastases. In particular, 26 out of 27 lesions injected with [99mTc]MAA were correctly detected intra-operatively and resected without surgical complications. Ten patients received subsequent radioactive iodine (RAI) treatment to verify the complete recurrence resection. At a median follow-up of 16 months patients were classified in complete response (n=4), biochemical incomplete response (n=3), indeterminate response (n=1) with no evidence of structural disease. The remaining 7 patients were classified as structural incomplete response for cervical persistent disease (n=2), for cervical recurrence (n=2) and for both cervical and lung metastases progression (n=3).

CONCLUSIONS

ROLL is a simple and safe procedure in the surgical management of DTC loco-regional relapse.

Extraction of a Foreign Body from the Breast Using Radio-guided Occult Lesion Localization (ROLL): Metallic Foreign Body in the Breast

The most common clinical causes of metallic foreign body in the breast are surgical clips, pieces of guide-wire and gunshot wounds. Metallic foreign bodies can lead to local breast pain, abscesses, pneumothorax after granulomas or migration, and cardiac tamponade. Mammotome biopsy, fluoroscopy, guide-wire biopsy and radio-guided occult lesion localization (ROLL) are the standard techniques applied for surgical excision of non-palpable breast lesions. This article presents the second case in the literature undergoing the ROLL technique for the removal of a metallic foreign body from the breast.

Hybrid radioguided occult lesion localization (hybrid ROLL) of (18)F-FDG-avid lesions using the hybrid tracer indocyanine green-(99m)Tc-nanocolloid

PURPOSE

To assess if combined fluorescence- and radio-guided occult lesion localization (hybrid ROLL) is feasible in patients scheduled for surgical resection of non-palpable (18)F-FDG-avid lesions on PET/CT.

METHODS

Four patients with (18)F-FDG-avid lesions on follow-up PET/CT that were not palpable during physical examination but were suspected to harbor metastasis were enrolled. Guided by ultrasound, the hybrid tracer indocyanine green (ICG)-(99m)Tc-nanocolloid was injected centrally in the target lesion. SPECT/CT imaging was used to confirm tracer deposition. Intraoperatively, lesions were localized using a hand-held gamma ray detection probe, a portable gamma camera, and a fluorescence camera. After excision, the gamma camera was used to check the wound bed for residual activity.

RESULTS

A total of six (18)F-FDG-avid lymph nodes were identified and scheduled for hybrid ROLL. Comparison of the PET/CT images with the acquired SPECT/CT after hybrid tracer injection confirmed accurate tracer deposition. No side effects were observed. Combined radio- and fluorescence-guidance enabled localization and excision of the target lesion in all patients. Five of the six excised lesions proved tumor-positive at histopathology.

CONCLUSION

The hybrid ROLL approach appears to be feasible and can facilitate the intraoperative localization and excision of non-palpable lesions suspected to harbor tumor metastases. In addition to the initial radioguided detection, the fluorescence component of the hybrid tracer enables high-resolution intraoperative visualization of the target lesion. The procedure needs further evaluation in a larger cohort and wider range of malignancies to substantiate these preliminary findings.