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Guo T, Jang SS, Ogawa R, Davis M, Ashworth E, Barback CV, Hall DJ, Vera DR. Fluorescent Guided Sentinel Lymph Mapping of the Oral Cavity with Fluorescent-Labeled Tilmanocept. Laryngoscope 2024; 134:1299-1307. [PMID: 37668315 PMCID: PMC10912359 DOI: 10.1002/lary.31014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE With the shift toward utilization of sentinel lymph node biopsy (SLNB) in oral cavity cancer, improved techniques for intraoperative sentinel node identification are needed. This study investigates the feasibility of fluorescently labeled tilmanoscept in SLNB in an oral cancer rabbit model. METHODS An animal study was designed using 21 healthy male New Zealand rabbits. Gallium-68-labeled tilmanocept labeled with IRDye800CW was injected submucosally into the buccal mucosa (n = 6) or lateral tongue (n = 7) followed by PET imaging. One hour after injection, SLNB was performed using fluorescence imaging followed by a bilateral neck dissection and sampling of non-nodal surrounding tissue. All tissues were measured for radioactivity and fluorescence. In addition, eight rabbits were injected with delayed SLNB performed 48 h after injection. RESULTS Buccal injections all had ipsilateral SLN drainage and tongue injections exhibited 18.2% contralateral drainage. An average of 1.9 ± 1.0 SLN (range 1-5) were identified. In addition, an average of 16.9 ± 3.3 non-sentinel lymph nodes were removed per animal. SLNs had an average of 0.69 ± 0.60 percent-of-injected dose (%ID) compared with non-sentinel nodes with 0.012 ± 0.025 %ID and surrounding tissue with 0.0067 ± 0.015 %ID. There was 98.0% agreement between sentinel lymph nodes identified using fluorescence compared to radioactivity with Cohen's kappa coefficient of 0.879. In 48-h delayed SLNB, results were consistent with 97.8% agreement with radioactivity and Cohen's Kappa coefficient of 0.884. Fluorescence identified additional lymph nodes that were not identified by radioactivity, and with one false negative. CONCLUSION Fluorescent-labeled Tc-99 m-tilmanocept represents a highly accurate adjunct to enhance SLNB for oral cavity cancer. LEVEL OF EVIDENCE N/A Laryngoscope, 134:1299-1307, 2024.
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Affiliation(s)
- Theresa Guo
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, CA
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Sophie S. Jang
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, CA
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Ryotaro Ogawa
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
- Department of Radiology, University of California, San Diego, La Jolla, CA
| | - Morgan Davis
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, CA
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Edward Ashworth
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
- Department of Radiology, University of California, San Diego, La Jolla, CA
| | - Christopher V. Barback
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
- Department of Radiology, University of California, San Diego, La Jolla, CA
| | - David J. Hall
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
- Department of Radiology, University of California, San Diego, La Jolla, CA
| | - David R. Vera
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
- Department of Radiology, University of California, San Diego, La Jolla, CA
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Rovera G, de Koster EJ, Rufini V, Zollino M, Zagaria L, Giammarile F, Vidal-Sicart S, Valdés Olmos R, Collarino A. 99mTc-Tilmanocept performance for sentinel node mapping in breast cancer, melanoma, and head and neck cancer: a systematic review and meta-analysis from a European expert panel. Eur J Nucl Med Mol Imaging 2023; 50:3375-3389. [PMID: 37310426 DOI: 10.1007/s00259-023-06290-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
PURPOSE Although multiple radiopharmaceuticals are currently available for sentinel node (SN) biopsy, 99mTc-tilmanocept is of particular interest due to its low molecular weight and specific binding capability for the mannose receptors of lymphatic reticuloendothelial cells. In the current systematic review and meta-analysis, we aimed to provide an update from a European expert panel on the performance of 99mTc-tilmanocept for SN biopsy. METHODS A systematic literature search of the PubMed/Medline and Embase databases was performed to identify studies on the use of 99mTc-tilmanocept for SN identification in oncological patients. The articles' methodological quality was assessed before inclusion. The pooled estimates of the pre-/intraoperative detection rates (DR; proportion of patients with ≥ 1 SN identified) and/or pN + sensitivity (SN + /pN + patients ratio), with 95% confidence intervals (CIs), were calculated for breast cancer, melanoma, and head and neck cancer. RESULTS Twenty-four articles were included in the systematic review, and twenty-one provided data for the meta-analysis. According to data availability, the 99mTc-tilmanocept-estimated pooled preoperative and intraoperative DRs were 0.94 (95%CI, 0.88-1.01) and 0.99 (0.98-1.00) for breast cancer, 0.98 (0.96-0.99) and 1.00 (0.99-1.00) for melanoma, and 0.97 (0.93-1.02) and 0.99 (0.96-1.01) for head and neck carcinoma. Finally, the pooled sensitivity for nodal metastasis in melanoma was 0.97 (95% CI, 0.92-1.03). CONCLUSION 99mTc-tilmanocept is a promising radiotracer for SN mapping in patients with breast cancer, melanoma, or head and neck cancer. We strongly believe that multicenter trials are still needed to assess if 99mTc-tilmanocept is superior to other radiotracers used in clinical routine.
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Affiliation(s)
- Guido Rovera
- Nuclear Medicine, Department of Medical Sciences, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Elizabeth J de Koster
- Department of Medical Imaging, Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Vittoria Rufini
- Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Section of Nuclear Medicine, University Department of Radiological Sciences and Hematology, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Mariella Zollino
- Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Zagaria
- Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Giammarile
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Sergi Vidal-Sicart
- Nuclear Medicine Department, Hospital Clinic Barcelona, Universitat de Barcelona, Institut d'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Renato Valdés Olmos
- Interventional Molecular Imaging & Nuclear Medicine Section, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Angela Collarino
- Nuclear Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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He P, Tang H, Zheng Y, Xiong Y, Cheng H, Li J, Zhang Y, Liu G. Advances in nanomedicines for lymphatic imaging and therapy. J Nanobiotechnology 2023; 21:292. [PMID: 37620846 PMCID: PMC10463797 DOI: 10.1186/s12951-023-02022-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023] Open
Abstract
Lymph nodes play a pivotal role in tumor progression as key components of the lymphatic system. However, the unique physiological structure of lymph nodes has traditionally constrained the drug delivery efficiency. Excitingly, nanomedicines have shown tremendous advantages in lymph node-specific delivery, enabling distinct recognition and diagnosis of lymph nodes, and hence laying the foundation for efficient tumor therapies. In this review, we comprehensively discuss the key factors affecting the specific enrichment of nanomedicines in lymph nodes, and systematically summarize nanomedicines for precise lymph node drug delivery and therapeutic application, including the lymphatic diagnosis and treatment nanodrugs and lymph node specific imaging and identification system. Notably, we delve into the critical challenges and considerations currently facing lymphatic nanomedicines, and futher propose effective strategies to address these issues. This review encapsulates recent findings, clinical applications, and future prospects for designing effective nanocarriers for lymphatic system targeting, with potential implications for improving cancer treatment strategies.
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Affiliation(s)
- Pan He
- Department of Hepatobiliary Surgery, Academician (Expert) Workstation, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637600, China
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen, 361002, China
| | - Haitian Tang
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen, 361002, China
| | - Yating Zheng
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen, 361002, China
| | - Yongfu Xiong
- Department of Hepatobiliary Surgery, Academician (Expert) Workstation, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637600, China
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen, 361002, China
| | - Hongwei Cheng
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen, 361002, China
| | - Jingdong Li
- Department of Hepatobiliary Surgery, Academician (Expert) Workstation, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637600, China.
| | - Yang Zhang
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen, 361002, China.
| | - Gang Liu
- State Key Laboratory of Vaccines for Infectious Diseases, Center for Molecular Imaging and Translational Medicine, Xiang An Biomedicine Laboratory, National Innovation Platform for Industry-Education Integration in Vaccine Research, School of Public Health, Xiamen University, Xiamen, 361002, China.
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Coxon AT, Desai R, Patel PR, Vellimana AK, Willie JT, Dowling JL, Leuthardt EC, Kim AH, Johanns TM, Siegel BA, Dunn GP. A pilot study of lymphoscintigraphy with tracer injection into the human brain. J Cereb Blood Flow Metab 2023; 43:1382-1389. [PMID: 36994857 PMCID: PMC10369147 DOI: 10.1177/0271678x231160891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/08/2023] [Accepted: 01/14/2023] [Indexed: 03/31/2023]
Abstract
Many groups have reported lymphatic and glymphatic structures in animal and human brains, but tracer injection into the human brain to demonstrate real-time lymphatic drainage and mapping has not been described. We enrolled patients undergoing standard-of-care resection or stereotactic biopsy for suspected intracranial tumors. Patients received peritumoral injections of 99mTc-tilmanocept followed by planar or tomographic imaging. Fourteen patients with suspected brain tumors were enrolled. One was excluded from analysis because of tracer leakage during injection. There was no drainage of 99mTc-tilmanocept to regional lymph nodes in any of the patients. On average, after correcting for radioactive decay, 70.7% (95% CI: 59.9%, 81.6%) of the tracer in the injection site and 78.1% (95% CI: 71.1%, 85.1%) in the whole-head on the day of surgery remained the morning after, with variable radioactivity in the subarachnoid space. The retained fraction was much greater than expected based on the clearance rate from non-brain injection sites. In this pilot study, the lymphatic tracer 99mTc-tilmanocept was injected into the brain parenchyma, and there was no drainage outside the brain to the cervical lymph nodes. Our work demonstrates an inefficiency of drainage from peritumoral brain parenchyma and highlights a therapeutic opportunity to improve immunosurveillance of the brain.
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Affiliation(s)
- Andrew T Coxon
- Washington University School of Medicine, St. Louis, MO, USA
| | - Rupen Desai
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Pujan R Patel
- Washington University School of Medicine, St. Louis, MO, USA
| | - Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jon T Willie
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Joshua L Dowling
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric C Leuthardt
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Albert H Kim
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Tanner M Johanns
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Barry A Siegel
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
- Division of Nuclear Medicine, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gavin P Dunn
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
- Current address: Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
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Balkin DM, Tranah GJ, Wang F, O’Donoghue C, Morell EA, Porubsky C, Nosrati M, Vaquero EM, Kim H, Carr MJ, Montilla-Soler JL, Wu MC, Torre DM, Kashani-Sabet M, Zager JS, Leong SP. Lymphoscintigraphy Using Tilmanocept Detects Multiple Sentinel Lymph Nodes in Melanoma Patients. Cancer Control 2023; 30:10732748231153775. [PMID: 36705261 PMCID: PMC9893075 DOI: 10.1177/10732748231153775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Technetium-99m-labeled Tilmanocept, a multivalent mannose, is readily internalized by the CD206 surface receptor on macrophages and dendritic cells which are abundantly present in lymph nodes. We want to examine the drainage patterns of Technetium-99m-labeled Tilmanocept to sentinel lymph nodes (SLNs) in melanoma patients following the 10% rule. METHODS Multi-center retrospective review of patients with cutaneous melanoma undergoing SLN biopsy using Technetium-99m-labeled Tilmanocept between 2008 and 2014 was conducted. Statistical methods were used for data analyses. RESULTS Of the 564 patients (mean age of 60.3 and 62% male) with preoperative lymphoscintigraphy showing at least one SLN, several primary tumor sites were included: 27% head/neck, 33% trunk, 21% upper extremity and 19% lower extremity. For the head/neck primary site, 36.5% of patients had multiple draining basins; for the trunk site, 36.4% of patients; for the upper extremity site, 13% of patients; and for the lower extremity, 27.4% of patients. A median of 3 (range 1-18) SLNs were identified and resected. Overall, 78% of patients had >1 SLN identified by Technetium-99m-labeled Tilmanocept. In a multivariate model, patients with >1 SLN were significantly associated with age, Breslow depth, tumor location and higher AJCC tumor stage. A total of 17.7% of patients (100/564) had a positive SLN identified. A total of 145 positive SLNs were identified out of 1,812 SLNs with a positive SLN rate of 8%. Positive SLN status was significantly associated with younger age, greater Breslow depth, mitosis rate, higher AJCC tumor stage, presence of ulceration and angiolymphatic invasion. CONCLUSIONS Using the 10% rule, Technetium-99m-labeled Tilmanocept detects multiple SLNs in most melanoma patients.
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Affiliation(s)
- Daniel M. Balkin
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory J. Tranah
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Frederick Wang
- Kaiser Permanente Woodland Hills Medical Center, Woodland Hills, CA, USA
| | | | - Emily A. Morell
- Department of Pediatrics, Divisions of Pediatric Critical Care and Pediatric Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Caitlin Porubsky
- Philadelphia College of Osteopathic Medicine/North Fulton Hospital Medical Campus, Roswell, GA, USA
| | - Mehdi Nosrati
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Edith M. Vaquero
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - HanKyul Kim
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Michael J. Carr
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jaime L. Montilla-Soler
- Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Max C. Wu
- Department of Nuclear Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Donald M. Torre
- Department of Nuclear Medicine, California Pacific Medical Center, San Francisco, CA, USA
| | - Mohammed Kashani-Sabet
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - Jonathan S. Zager
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Stanley P. Leong
- Center for Melanoma Research and Treatment, California Pacific Medical Center Research Institute, San Francisco, CA, USA
- University of California School of Medicine San Francisco, San Francisco, CA, USA
- Stanley P. Leong, MD, MS, FACS, California Pacific Medical Center, Center for Melanoma Research and Treatment Chief of Cutaneous Oncology and Associate Director of the Melanoma Program 2340 Clay Street Floor 2, San Francisco, CA 94115, USA. ;
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Krishnan G, Cousins A, Pham N, Milanova V, Nelson M, Krishnan S, Shetty A, van den Berg N, Rosenthal E, Krishnan S, Wormald PJ, Foreman A, Thierry B. Preclinical evaluation of a mannose-labeled magnetic tracer for enhanced sentinel lymph node retention in the head and neck. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2022; 42:102546. [PMID: 35278683 DOI: 10.1016/j.nano.2022.102546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/25/2022] [Accepted: 03/01/2022] [Indexed: 05/26/2023]
Abstract
Sentinel lymph node biopsy in cancers of the head and neck offers demonstrated clinical and diagnostic value, but adoption is limited by concerns about the detrimental consequence to survival of false negative results in a highly curable setting. The aim of this study was to demonstrate potential to overcome this via application of a novel mannose-labeled magnetic iron oxide tracer. In a large animal model, preoperative imaging and intraoperative magnetometer detection were used to identify magnetic lymph nodes. Iron quantification mapped the distribution of tracer within lymphatic levels. Over a 4-week test period, uptake of magnetic tracer in lymph nodes increased in a linear-like fashion, with a substantial percentage of accumulated iron (83%) being retained in the sentinel node. This result indicates a high affinity of mannose-labeled particles to the sentinel node, while providing a means for the magnetometer probe to indicate node status based on intraoperative signal.
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Affiliation(s)
- Giri Krishnan
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Aidan Cousins
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, Australia.
| | - Nguyen Pham
- School of Chemistry, University of New South Wales, Sydney, NSW, Australia
| | - Valentina Milanova
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, Australia
| | | | - Shridhar Krishnan
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Anil Shetty
- Ferronova Pty Ltd., Mawson Lakes, SA, Australia
| | - Nynke van den Berg
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Eben Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Suren Krishnan
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Peter-John Wormald
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Andrew Foreman
- The Department of Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Benjamin Thierry
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, Australia.
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Recent Advances in the Development of Tetrazine Ligation Tools for Pretargeted Nuclear Imaging. Pharmaceuticals (Basel) 2022; 15:ph15060685. [PMID: 35745604 PMCID: PMC9227058 DOI: 10.3390/ph15060685] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 01/25/2023] Open
Abstract
Tetrazine ligation has gained interest as a bio-orthogonal chemistry tool within the last decade. In nuclear medicine, tetrazine ligation is currently being explored for pretargeted approaches, which have the potential to revolutionize state-of-the-art theranostic strategies. Pretargeting has been shown to increase target-to-background ratios for radiopharmaceuticals based on nanomedicines, especially within early timeframes. This allows the use of radionuclides with short half-lives which are more suited for clinical applications. Pretargeting bears the potential to increase the therapeutic dose delivered to the target as well as reduce the respective dose to healthy tissue. Combined with the possibility to be applied for diagnostic imaging, pretargeting could be optimal for theranostic approaches. In this review, we highlight efforts that have been made to radiolabel tetrazines with an emphasis on imaging.
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Eckhoff A, Farrow NE, Silvestri C, Stroobant E, Intenzo C, Leddy M, Tyler DS, Berger A, Beasley GM. How much time is enough? Sentinel lymph node mapping time depends on the radiotracer agent. J Surg Oncol 2022; 125:712-718. [PMID: 34786720 PMCID: PMC9906034 DOI: 10.1002/jso.26752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/20/2021] [Accepted: 11/08/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND In 2014, technetium-99m tilmanocept (TcTM) replaced technetium-99m sulfur colloid (TcSC) as the standard lymphoscintigraphy (LS) mapping agent in melanoma patients undergoing sentinel lymph node biopsy (SLNB). The aim of this study was to examine differences in mapping time, intra-operative identification of sentinel lymph node (SLN), and false negative rate (FNR) between patients who underwent SLNB with TcTM compared to TcSC. METHODS Patients who underwent SLNB between 2010 and 2018 were retrospectively identified. Patient demographic, tumor, and imaging data was stratified by receipt of TcSC (n = 258) or TcTM (n = 133). Student's t test and χ2 test were used to compare characteristics and outcomes. RESULTS Both cohorts were similar in demographic, primary tumor characteristics, and total number of SLN identified (TcTM 3.56 vs. TcSC 3.28, p = 0.244). TcTM was associated with significantly shorter LS mapping times (51.8 vs. 195.1 min, p < 0.01). There was no significant difference in the number of patients with positive SLN (TcTM 11.3 vs. TcSC 17.4%, p = 0.109) and the FNR was similar between both groups (TcTM 25% vs. TcSC 22%). CONCLUSION TcTM was associated with significantly shorter LS mapping time while identifying similar numbers of SLN. Our results support further study to ensure similar FNR and oncologic outcomes between agents.
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Affiliation(s)
- Austin Eckhoff
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Norma E. Farrow
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Caitlin Silvestri
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Emily Stroobant
- Department of Surgery, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Charles Intenzo
- Department of Nuclear Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Margaret Leddy
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Douglas S. Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Adam Berger
- Rutgers Cancer Institute, New Brunswick, New Jersey, USA
| | - Georgia M. Beasley
- Department of Surgery, Duke University, Durham, North Carolina, USA,Duke Cancer Institute, Duke University, Durham, North Carolina, USA
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New single photon radiopharmaceuticals for cancer imaging. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00211-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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10
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Mailey BA, Alrahawan G, Brown A, Yamamoto M, Hassanein AH. Sentinel Lymph Node Biopsy, Lymph Node Dissection, and Lymphedema Management Options in Melanoma. Clin Plast Surg 2021; 48:607-616. [PMID: 34503721 DOI: 10.1016/j.cps.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Melanoma tumor thickness and ulceration are the strongest predictors of nodal spread. The recommendations for sentinel lymph node biopsy (SLNB) have been updated in recent American Joint Committee on Cancer and National Comprehensive Cancer Network guidelines to include tumor thickness ≥0.8 mm or any ulcerated melanoma. Mitotic rate is no longer considered an indicator for determining T category. Improvements in disease-specific survival conferred from SLNB were demonstrated through level I data in the Multicenter Selective Lymphadenectomy Trial (MSLT) I. The role for completion lymph node dissection has evolved to less surgery in lieu of recent domestic (MSLT II) and international (Dermatologic Cooperative Oncology Group Selective Lymphadenectomy Trial [DeCOG-SLT]) level I data having similar melanoma-specific survival. Treatment options for the prevention of treatment of lymphedema have progressed to include immediate lymphatic reconstruction, lymphovenous anastomosis, and vascularized lymph node transfer.
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Affiliation(s)
- Brian A Mailey
- Brachial Plexus and Tetraplegia Clinic, Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 N. Rutledge Street, PO Box 19653, Springfield, IL 62794, USA.
| | - Ghaith Alrahawan
- University of Missouri Columbia, School of Medicine, 1 Hospital Dr, Columbia, MO 65212, USA
| | - Amanda Brown
- Southern Illinois University, School of Medicine, 747 N. Rutledge Street, PO Box 19653, Springfield, IL 62794, USA
| | - Maki Yamamoto
- Division of Surgical Oncology, Department of Surgery, University of California, Irvine, 333 City Blvd West, Suite 1600, Orange, CA 92868, USA
| | - Aladdin H Hassanein
- Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Dr, Suite 232, Indianapolis, IN 46202, USA
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11
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Papasavva A, Shegani A, Kiritsis C, Roupa I, Ischyropoulou M, Makrypidi K, Pilatis I, Loudos G, Pelecanou M, Papadopoulos M, Pirmettis I. Comparative Study of a Series of 99mTc(CO) 3 Mannosylated Dextran Derivatives for Sentinel Lymph Node Detection. Molecules 2021; 26:molecules26164797. [PMID: 34443384 PMCID: PMC8400719 DOI: 10.3390/molecules26164797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 12/04/2022] Open
Abstract
Sentinel lymph node detection (SLND) is rapidly entering common practice in the management of patients with tumors. The introduction of mannose molecules to 99mTc-labeled dextrans, so far, showed that the sentinel node could trap these agents due to their recognition by the mannose receptors of lymph node macrophages. The current study aimed to synthesize, characterize, and biologically evaluate a series of mannosylated dextran derivatives labeled with 99mTc for potential use in SLND. The compounds were designed to have a dextran with a molecular weight of 10–500 kDa as a backbone, S-derivatized cysteines, efficient SNO chelators, and mannose moieties for binding to mannose receptors. They were successfully synthesized, thoroughly characterized using NMR techniques, and labeled with the fac-[99mTc(CO)3]+ synthon. Labeling with high yields and radiochemical purities was achieved with all derivatives. In vivo biodistribution and imaging studies demonstrated high uptake in the first lymph node and low uptakes in the following node and confirmed the ability to visualize the SLN. Among the compounds studied, 99mTc-D75CM demonstrated the most attractive biological features, and in combination with the high radiochemical yield and stability of the compound, its further evaluation as a new radiopharmaceutical for sentinel lymph node detection was justified.
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Affiliation(s)
- Afroditi Papasavva
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
| | - Antonio Shegani
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
| | - Christos Kiritsis
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
| | - Ioanna Roupa
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
| | - Myrto Ischyropoulou
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
| | - Konstantina Makrypidi
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
| | - Irineos Pilatis
- BIOEMTECH Laboratories, Lefkippos Attica Technology Park—NCSR “Demokritos”, 15310 Athens, Greece; (I.P.); (G.L.)
| | - George Loudos
- BIOEMTECH Laboratories, Lefkippos Attica Technology Park—NCSR “Demokritos”, 15310 Athens, Greece; (I.P.); (G.L.)
| | - Maria Pelecanou
- Institute of Biosciences & Applications, NCSR “Demokritos”, 15310 Athens, Greece;
| | - Minas Papadopoulos
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
| | - Ioannis Pirmettis
- Institute of Nuclear and Radiological Sciences and Technology, Energy & Safety, NCSR “Demokritos”, 15310 Athens, Greece; (A.P.); (A.S.); (C.K.); (I.R.); (M.I.); (K.M.); (M.P.)
- Correspondence: ; Tel.: +30-210-650-3921
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12
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Mahieu R, de Maar JS, Nieuwenhuis ER, Deckers R, Moonen C, Alic L, ten Haken B, de Keizer B, de Bree R. New Developments in Imaging for Sentinel Lymph Node Biopsy in Early-Stage Oral Cavity Squamous Cell Carcinoma. Cancers (Basel) 2020; 12:cancers12103055. [PMID: 33092093 PMCID: PMC7589685 DOI: 10.3390/cancers12103055] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/03/2020] [Accepted: 10/15/2020] [Indexed: 12/18/2022] Open
Abstract
Sentinel lymph node biopsy (SLNB) is a diagnostic staging procedure that aims to identify the first draining lymph node(s) from the primary tumor, the sentinel lymph nodes (SLN), as their histopathological status reflects the histopathological status of the rest of the nodal basin. The routine SLNB procedure consists of peritumoral injections with a technetium-99m [99mTc]-labelled radiotracer followed by lymphoscintigraphy and SPECT-CT imaging. Based on these imaging results, the identified SLNs are marked for surgical extirpation and are subjected to histopathological assessment. The routine SLNB procedure has proven to reliably stage the clinically negative neck in early-stage oral squamous cell carcinoma (OSCC). However, an infamous limitation arises in situations where SLNs are located in close vicinity of the tracer injection site. In these cases, the hotspot of the injection site can hide adjacent SLNs and hamper the discrimination between tracer injection site and SLNs (shine-through phenomenon). Therefore, technical developments are needed to bring the diagnostic accuracy of SLNB for early-stage OSCC to a higher level. This review evaluates novel SLNB imaging techniques for early-stage OSCC: MR lymphography, CT lymphography, PET lymphoscintigraphy and contrast-enhanced lymphosonography. Furthermore, their reported diagnostic accuracy is described and their relative merits, disadvantages and potential applications are outlined.
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Affiliation(s)
- Rutger Mahieu
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, University of Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Josanne S. de Maar
- Division of Imaging and Oncology, University Medical Center Utrecht, University of Utrecht, 3584 CX Utrecht, The Netherlands; (J.S.d.M.); (R.D.); (C.M.)
| | - Eliane R. Nieuwenhuis
- Department of Magnetic Detection & Imaging, University of Twente, 7522 NB Enschede, The Netherlands; (E.R.N.); (L.A.); (B.t.H.)
| | - Roel Deckers
- Division of Imaging and Oncology, University Medical Center Utrecht, University of Utrecht, 3584 CX Utrecht, The Netherlands; (J.S.d.M.); (R.D.); (C.M.)
| | - Chrit Moonen
- Division of Imaging and Oncology, University Medical Center Utrecht, University of Utrecht, 3584 CX Utrecht, The Netherlands; (J.S.d.M.); (R.D.); (C.M.)
| | - Lejla Alic
- Department of Magnetic Detection & Imaging, University of Twente, 7522 NB Enschede, The Netherlands; (E.R.N.); (L.A.); (B.t.H.)
| | - Bennie ten Haken
- Department of Magnetic Detection & Imaging, University of Twente, 7522 NB Enschede, The Netherlands; (E.R.N.); (L.A.); (B.t.H.)
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, University Medical Center Utrecht, University of Utrecht, 3584 CX Utrecht, The Netherlands;
- Correspondence: ; Tel.: +31-88-7550819
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13
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Quartuccio N, Siracusa M, Pappalardo M, Arnone A, Arnone G. Sentinel Node Identification in Melanoma: Current Clinical Impact, New Emerging SPECT Radiotracers and Technological Advancements. An Update of the Last Decade. Curr Radiopharm 2020; 13:32-41. [PMID: 31749441 PMCID: PMC7509753 DOI: 10.2174/1874471012666191015100837] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/20/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Melanoma is the most lethal skin cancer with a mortality rate of 262 cases per 100.000 cases. The sentinel lymph node (SLN) is the first lymph node draining the tumor. SLN biopsy is a widely accepted procedure in the clinical setting since it provides important prognostic information, which helps patient management, and avoids the side effects of complete lymph node dissection. The rationale of identifying and removing the SLN relies on the low probability of subsequent metastatic nodes in case of a negative histological exam performed in the SLN. DISCUSSION Recently, new analytical approaches, based on the evaluation of scintigraphic images are also exploring the possibility to predict the metastatic involvement of the SLN. 99mTc-labeled colloids are still the most commonly used radiotracers but new promising radiotracers, such as 99mTc- Tilmanocept, are now on the market. In the last decades, single photon emission computed tomography- computerized tomography (SPECT/CT) has gained wider diffusion in clinical departments and there is large evidence about its superior diagnostic accuracy over planar lymphoscintigraphy (PL) in the detection of SLN in patients with melanoma. Scientists are also investigating new hybrid techniques combining functional and anatomical images for the depiction of SLN but further evidence about their value is needed. CONCLUSION This review examined the predictive and prognostic factors of lymphoscintigraphy for metastatic involvement of SLN, the currently available and emerging radiotracers and the evidence of the additional value of SPECT/CT over PL for the identification of SLN in patients with melanoma. Finally, the review discussed the most recent technical advances in the field.
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Affiliation(s)
- Natale Quartuccio
- Nuclear Medicine Unit, A.R.N.A.S. Ospedali Civico, Di Cristina e Benfratelli, Palermo, Italy
- Address correspondence to this author at the Nuclear Medicine Unit, A.R.N.A.S. Ospedali Civico, Di Cristina e Benfratelli, Palermo, Italy; Tel: +39091 666 2319; E-mail:
| | - Massimiliano Siracusa
- Nuclear Medicine Unit, A.R.N.A.S. Ospedali Civico, Di Cristina e Benfratelli, Palermo, Italy
| | - Marco Pappalardo
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Annachiara Arnone
- Nuclear Medicine Unit, A.R.N.A.S. Ospedali Civico, Di Cristina e Benfratelli, Palermo, Italy
| | - Gaspare Arnone
- Nuclear Medicine Unit, A.R.N.A.S. Ospedali Civico, Di Cristina e Benfratelli, Palermo, Italy
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14
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Eckelman WC, Kuwert T, Ciarmiello A, Riondato M, Mansi L. Changes over the years in radiopharmaceutical design. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2019; 66:261-271. [PMID: 31833739 DOI: 10.23736/s1824-4785.19.03216-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Of the many uses of radiopharmaceuticals, developing radiotracers that contribute significantly to diagnosis and therapy of patients has been a major focus. This requires a broad spectrum of expertise including that of the attending physician who lends insight to an unmet clinical need neither addressed by other imaging techniques nor by analysis of tissue, blood, and urine for diagnostics and addressed by pharmaceuticals for therapeutic applications. The design criteria have depended on radiochemistry, on matching the radiopharmaceutical with the imaging devices, and basing the design on current pharmaceuticals. The chelates of technetium-99m were based on radiochemistry rather than clinical need yet are still used today in >70% of the clinical studies. Targeted radiotracers in neurologic and psychiatric disorders, inflammation, cardiovascular disease, and oncology have all been studied with the goal of determining the change in the density of a target protein as a function of disease or treatment or, especially in oncology, detection of the total extent of disease. In latter approach PET in university settings leads the way; however, the use of SPECT/CT has increased the specificity of SPECT imaging to complement the cost- effective generator and instant kits already available. Remarkable advances has been achieved in radionuclide therapy using theragnostic agents, with the exclusive domain of oncology For this application the design of radionuclide therapy follows that used for diagnostics. The increased impact of the discipline depends on the opportunity to continue the search for the most appropriate radiopharmaceutical for each individual patient.
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Affiliation(s)
| | - Torsten Kuwert
- Clinic of Nuclear Medicine, University Hospital Erlangen, Erlangen, Germany
| | | | - Mattia Riondato
- Nuclear Medicine Unit, S. Andrea Hospital, La Spezia, Italy -
| | - Luigi Mansi
- Section Health and Development, Interuniversity Research Center for Sustainability (CIRPS), Napoli, Italy
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15
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Holliday RM, Jain MK, Accurso JM, Sharma A, Harrison SR, Aloszka DL, Bowman AW. Buffering the Suffering of Breast Lymphoscintigraphy. J Nucl Med Technol 2019; 48:51-53. [PMID: 31182657 DOI: 10.2967/jnmt.119.230011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/03/2019] [Indexed: 11/16/2022] Open
Abstract
Breast lymphoscintigraphy with 99mTc-sulfur colloid is frequently performed before breast-conserving surgery to delineate drainage to a sentinel node. Tracer injection for lymphoscintigraphy can be painful. Our aims were to determine whether administering a solution of buffered lidocaine immediately before lymphoscintigraphy injection could both reduce the patients' pain and increase nuclear medicine technologists' satisfaction with performing the procedure. Methods: A pain scale survey was obtained from patients undergoing breast lymphoscintigraphy with or without buffered lidocaine. Our nuclear medicine technologists were also surveyed for their satisfaction with the procedure, both with and without the addition of buffered lidocaine. Results: The patients' reported pain decreased by 86% with the addition of buffered lidocaine. Technologist satisfaction with performing the procedure increased by 36%. Conclusion: Lidocaine buffered with sodium bicarbonate injected before lymphoscintigraphy significantly reduces pain experienced by the patient and improves nuclear medicine technologist satisfaction in performing the procedure.
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Affiliation(s)
- Rex M Holliday
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Manoj K Jain
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Joseph M Accurso
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Akash Sharma
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Sara R Harrison
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Debora L Aloszka
- Division of Nuclear Medicine, Mayo Clinic, Jacksonville, Florida; and
| | - Andrew W Bowman
- Division of Hospital Radiology, Mayo Clinic, Jacksonville, Florida
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16
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Vahabzadeh-Hagh AM, Blackwell KE, Abemayor E, St John MA. Sentinel lymph node biopsy in cutaneous melanoma of the head and neck using the indocyanine green SPY Elite system. Am J Otolaryngol 2018; 39:485-488. [PMID: 29803536 DOI: 10.1016/j.amjoto.2018.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 05/17/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Lymph node status is the single most important prognostic factor for patients with early-stage cutaneous melanoma. Sentinel lymph node biopsy (SLNB) has become the standard of care for intermediate depth melanomas. Modern SLNB implementation includes technetium-99 lymphoscintigraphy combined with local administration of a vital blue dye. However, sentinel lymph nodes may fail to localize in some cases and false-negative rates range from 0 to 34%. Here we demonstrate the feasibility of a new sentinel lymph node biopsy technique using indocyanine green (ICG) and the SPY Elite near-infrared imaging system. MATERIALS AND METHODS Cases of primary cutaneous melanoma of the head and neck without locoregional metastasis, underwent SLNB at a single quaternary care institution between May 2016 and June 2017. Intraoperatively, 0.25 mL of ICG was injected intradermal in 4 quadrants around the primary lesion. 10-15 minute circulation time was permitted. SPY Elite identified the sentinel lymph node within the nodal basin marked by lymphoscintigraphy. Target first echelon lymph nodes were confirmed with a gamma probe and ICG fluorescence. RESULTS 14 patients were included with T1a to T4b cutaneous melanomas. Success rates for sentinel lymph node identification using lymphoscintigraphy and the SPY Elite system were both 86%. Zero false negatives occurred. Median length of follow-up was 323 days. CONCLUSIONS In this pilot study, Indocyanine green near-infrared fluorescence demonstrates a safe, and facile method of sentinel lymph node biopsy for cutaneous melanoma of the head and neck compared with lymphoscintigraphy and vital blue dyes.
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Affiliation(s)
- Andrew M Vahabzadeh-Hagh
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
| | - Keith E Blackwell
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
| | - Elliot Abemayor
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
| | - Maie A St John
- Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 62-132, Los Angeles, CA 90095, USA.
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17
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Unkart JT, Wallace AM. Use of 99mTc-Tilmanocept as a Single Agent for Sentinel Lymph Node Identification in Breast Cancer: A Retrospective Pilot Study. J Nucl Med Technol 2017; 45:181-184. [PMID: 28705929 DOI: 10.2967/jnmt.117.194415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023] Open
Abstract
99mTc-tilmanocept received recent Food and Drug Administration approval for lymphatic mapping in 2013. However, to our knowledge, no prior studies have evaluated the use of 99mTc-tilmanocept as a single agent in sentinel lymph node (SLN) biopsy in breast cancer. Methods: We executed this retrospective pilot study to assess the ability of 99mTc-tilmanocept to identify sentinel nodes as a single agent in clinically node-negative breast cancer patients. Patients received a single intradermal injection overlying the tumor of either 18.5 MBq (0.5 mCi) of 99mTc-tilmanocept on the day of surgery or 74.0 MBq (2.0 mCi) on the day before surgery by a radiologist. Immediate 3-view lymphoscintigraphy was performed. Intraoperatively, SLNs were identified with a portable γ-probe. A node was classified as hot if the count (per second) of the node was more than 3 times the background count. Descriptive statistics are reported. Results: Nineteen patients underwent SLN biopsy with single-agent 99mTc-tilmanocept. Immediate lymphoscintigraphy identified at least 1 sentinel node in 13 of 17 patients (76.5%). Intraoperatively, at least 1 (mean, 1.7 ± 0.8; range, 1-3) hot node was identified in all patients. Three patients (15.8%) had 1 disease-positive SLN. Conclusion: In this small, retrospective pilot study, 99mTc-tilmanocept performed well as a single agent for intraoperative sentinel node identification in breast cancer. A larger, randomized clinical trial is warranted to compare 99mTc-tilmanocept as a single agent with other radiopharmaceuticals for sentinel node identification in breast cancer.
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Affiliation(s)
- Jonathan T Unkart
- Department of Surgery, Moores Cancer Center, University of California-San Diego, La Jolla, California
| | - Anne M Wallace
- Department of Surgery, Moores Cancer Center, University of California-San Diego, La Jolla, California
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18
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Pant K, Sedláček O, Nadar RA, Hrubý M, Stephan H. Radiolabelled Polymeric Materials for Imaging and Treatment of Cancer: Quo Vadis? Adv Healthc Mater 2017; 6. [PMID: 28218487 DOI: 10.1002/adhm.201601115] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/24/2016] [Indexed: 12/15/2022]
Abstract
Owing to their tunable blood circulation time and suitable plasma stability, polymer-based nanomaterials hold a great potential for designing and utilising multifunctional nanocarriers for efficient imaging and effective treatment of cancer. When tagged with appropriate radionuclides, they may allow for specific detection (diagnosis) as well as the destruction of tumours (therapy) or even customization of materials, aiming to both diagnosis and therapy (theranostic approach). This review provides an overview of recent developments of radiolabelled polymeric nanomaterials (natural and synthetic polymers) for molecular imaging of cancer, specifically, applying nuclear techniques such as positron emission tomography (PET) and single-photon emission computed tomography (SPECT). Different approaches to radiolabel polymers are evaluated from the methodical radiochemical point of view. This includes new bifunctional chelating agents (BFCAs) for radiometals as well as novel labelling methods. Special emphasis is given to eligible strategies employed to evade the mononuclear phagocytic system (MPS) in view of efficient targeting. The discussion encompasses promising strategies currently employed as well as emerging possibilities in radionuclide-based cancer therapy. Key issues involved in the clinical translation of radiolabelled polymers and future scopes of this intriguing research field are also discussed.
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Affiliation(s)
- Kritee Pant
- Helmholtz-Zentrum Dresden-Rossendorf; Institute of Radiopharmaceutical Cancer Research; Bautzner Landstraße 400 01328 Dresden Germany
| | - Ondřej Sedláček
- Institute of Macromolecular Chemistry; The Academy of Sciences of the Czech Republic; Heyrovského námeˇstí 2 16206 Prague 6 Czech Republic
| | - Robin A. Nadar
- Helmholtz-Zentrum Dresden-Rossendorf; Institute of Radiopharmaceutical Cancer Research; Bautzner Landstraße 400 01328 Dresden Germany
| | - Martin Hrubý
- Institute of Macromolecular Chemistry; The Academy of Sciences of the Czech Republic; Heyrovského námeˇstí 2 16206 Prague 6 Czech Republic
| | - Holger Stephan
- Helmholtz-Zentrum Dresden-Rossendorf; Institute of Radiopharmaceutical Cancer Research; Bautzner Landstraße 400 01328 Dresden Germany
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19
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Lee HJ, Barback CV, Hoh CK, Qin Z, Kader K, Hall DJ, Vera DR, Kane CJ. Fluorescence-Based Molecular Imaging of Porcine Urinary Bladder Sentinel Lymph Nodes. J Nucl Med 2017; 58:547-553. [PMID: 28153955 DOI: 10.2967/jnumed.116.178582] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/31/2016] [Indexed: 11/16/2022] Open
Abstract
The primary objective was to test the ability of a laparoscopic camera system to detect the fluorescent signal emanating from sentinel lymph nodes (SLNs) approximately 2 d after injection and imaging of a positron-emitting molecular imaging agent into the submucosa of the porcine urinary bladder. Methods: Three female pigs underwent a submucosal injection of the bladder with fluorescent-tagged tilmanocept, radiolabeled with both 68Ga and 99mTc. One hour after injection, a pelvic PET/CT scan was acquired for preoperative SLN mapping. Approximately 36 h later, robotic SLN mapping was performed using a fluorescence-capable camera system. After identification of the fluorescent lymph nodes, a pelvic lymph node dissection was completed with robotic assistance. All excised nodal packets (n = 36) were assayed for 99mTc activity, which established a lymph node as an SLN. 99mTc activity was also used to calculate the amount of dye within each lymph node. Results: All of the SLNs defined by the ex vivo γ-well assay of 99mTc activity were detected by fluorescence mode imaging. The time between injection and robotic SLN mapping ranged from 32 to 38 h. A total of 5 fluorescent lymph nodes were detected; 2 pigs had 2 fluorescent lymph nodes and 1 pig exhibited a single lymph node. Four of the 5 SLNs exhibited increased SUVs of 12.4-139.0 obtained from PET/CT. The dye content of the injection sites ranged from 371 to 1,441 pmol, which represented 16.5%-64.1% of the injected dose; the amount of dye within the SLNs ranged from 8.5 to 88 pmol, which was equivalent to 0.38%-3.91% of the administered dose. Conclusion: Fluorescent-labeled 68Ga-tilmanocept allows for PET imaging and real-time intraoperative detection of SLNs during robotic surgery.
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Affiliation(s)
- Hak J Lee
- Department of Urology, University of California, San Diego, La Jolla, California
| | - Christopher V Barback
- Department of Radiology, University of California, San Diego, La Jolla, California; and.,UCSD Molecular Imaging Program, University of California, San Diego, La Jolla, California
| | - Carl K Hoh
- Department of Radiology, University of California, San Diego, La Jolla, California; and.,UCSD Molecular Imaging Program, University of California, San Diego, La Jolla, California
| | - Zhengtao Qin
- Department of Radiology, University of California, San Diego, La Jolla, California; and.,UCSD Molecular Imaging Program, University of California, San Diego, La Jolla, California
| | - Kareem Kader
- Department of Urology, University of California, San Diego, La Jolla, California
| | - David J Hall
- Department of Radiology, University of California, San Diego, La Jolla, California; and.,UCSD Molecular Imaging Program, University of California, San Diego, La Jolla, California
| | - David R Vera
- Department of Radiology, University of California, San Diego, La Jolla, California; and .,UCSD Molecular Imaging Program, University of California, San Diego, La Jolla, California
| | - Christopher J Kane
- Department of Urology, University of California, San Diego, La Jolla, California
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20
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Seim NB, Wright CL, Agrawal A. Contemporary use of sentinel lymph node biopsy in the head and neck. World J Otorhinolaryngol Head Neck Surg 2016; 2:117-125. [PMID: 29204556 PMCID: PMC5698522 DOI: 10.1016/j.wjorl.2016.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 05/11/2016] [Indexed: 02/04/2023] Open
Abstract
Sentinel lymph node biopsy has become a well-established and commonplace practice in many oncologic disease sites as a means to stage the regional lymphatics, avoid unnecessary surgery and decrease patient morbidity. In the head and neck, its role is well established for cutaneous melanoma with proven fidelity and survival benefit. Its role in use for other sites such as oral cavity carcinoma continues to develop with promising results from several recent trials. Although not widely adopted, the potential benefits of sentinel lymph node biopsy in the management of oral cavity carcinoma are apparent. Refinements in technology and protocols including development of novel radiopharmaceutical tracers, routine incorporation of detailed anatomic imaging, increasing surgeon experience and development of new intraoperative identification aids will likely lead to improvements in the use and accuracy of this technique.
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Affiliation(s)
- Nolan B Seim
- Department of Otolaryngology-Head and Neck Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, 4000 Eye and Ear Institute, 915 Olentangy River Road, Columbus, OH, 43210, USA
| | - Chadwick L Wright
- Wright Center of Innovation in Biomedical Imaging, Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, The Ohio State University Wexner Medical Center, 395 W, 12th Avenue, Rm. 430, Columbus, OH, 43210, USA
| | - Amit Agrawal
- Department of Otolaryngology-Head and Neck Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Wexner Medical Center, 4000 Eye and Ear Institute, 915 Olentangy River Road, Columbus, OH, 43210, USA
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21
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Cope FO, Abbruzzese B, Sanders J, Metz W, Sturms K, Ralph D, Blue M, Zhang J, Bracci P, Bshara W, Behr S, Maurer T, Williams K, Walker J, Beverly A, Blay B, Damughatla A, Larsen M, Mountain C, Neylon E, Parcel K, Raghuraman K, Ricks K, Rose L, Sivakumar A, Streck N, Wang B, Wasco C, Schlesinger LS, Azad A, Rajaram MVS, Jarjour W, Young N, Rosol T, Williams A, McGrath M. The inextricable axis of targeted diagnostic imaging and therapy: An immunological natural history approach. Nucl Med Biol 2016; 43:215-25. [PMID: 26924502 PMCID: PMC4794336 DOI: 10.1016/j.nucmedbio.2015.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/13/2015] [Accepted: 11/16/2015] [Indexed: 12/30/2022]
Abstract
In considering the challenges of approaches to clinical imaging, we are faced with choices that sometimes are impacted by rather dogmatic notions about what is a better or worse technology to achieve the most useful diagnostic image for the patient. For example, is PET or SPECT most useful in imaging any particular disease dissemination? The dictatorial approach would be to choose PET, all other matters being equal. But is such a totalitarian attitude toward imaging selection still valid? In the face of new receptor targeted SPECT agents one must consider the remarkable specificity and sensitivity of these agents. (99m)Tc-Tilmanocept is one of the newest of these agents, now approved for guiding sentinel node biopsy (SLNB) in several solid tumors. Tilmanocept has a Kd of 3×10(-11)M, and it specificity for the CD206 receptor is unlike any other agent to date. This coupled with a number of facts, that specific disease-associated macrophages express this receptor (100 to 150 thousand receptors), that the receptor has multiple binding sites for tilmanocept (>2 sites per receptor) and that these receptors are recycled every 15 min to bind more tilmanocept (acting as intracellular "drug compilers" of tilmanocept into non-degraded vesicles), gives serious pause as to how we select our approaches to diagnostic imaging. Clinically, the size of SLNs varies greatly, some, anatomically, below the machine resolution of SPECT. Yet, with tilmanocept targeting, the SLNs are highly visible with macrophages stably accruing adequate (99m)Tc-tilmanocept counting statistics, as high target-to-background ratios can compensate for spatial resolution blurring. Importantly, it may be targeted imaging agents per se, again such as tilmanocept, which may significantly shrink any perceived chasm between the imaging technologies and anchor the diagnostic considerations in the targeting and specificity of the agent rather than any lingering dogma about the hardware as the basis for imaging approaches. Beyond the elements of imaging applications of these agents is their evolution to therapeutic agents as well, and even in the neo-logical realm of theranostics. Characteristics of agents such as tilmanocept that exploit the natural history of diseases with remarkably high specificity are the expectations for the future of patient- and disease-centered diagnosis and therapy.
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Affiliation(s)
- Frederick O Cope
- Navidea Biopharmaceuticals, Drug Development, 5600 Blazer Parkway, Dublin, OH 43017.
| | - Bonnie Abbruzzese
- Navidea Biopharmaceuticals, Drug Development, 5600 Blazer Parkway, Dublin, OH 43017
| | - James Sanders
- Navidea Biopharmaceuticals, Drug Development, 5600 Blazer Parkway, Dublin, OH 43017
| | - Wendy Metz
- Navidea Biopharmaceuticals, Drug Development, 5600 Blazer Parkway, Dublin, OH 43017
| | - Kristyn Sturms
- Navidea Biopharmaceuticals, Drug Development, 5600 Blazer Parkway, Dublin, OH 43017
| | - David Ralph
- Navidea Biopharmaceuticals, Drug Development, 5600 Blazer Parkway, Dublin, OH 43017
| | - Michael Blue
- Navidea Biopharmaceuticals, Drug Development, 5600 Blazer Parkway, Dublin, OH 43017
| | - Jane Zhang
- The University of California San Francisco and the San Francisco General Hospital, AIDS and Cancer Specimen Resource Center, The Department of Pathology, 1001 Potrero Ave, Bldg. 3, Rm 207 San Francisco, CA 94110
| | - Paige Bracci
- The University of California San Francisco and the San Francisco General Hospital, AIDS and Cancer Specimen Resource Center, The Department of Pathology, 1001 Potrero Ave, Bldg. 3, Rm 207 San Francisco, CA 94110
| | - Wiam Bshara
- Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263
| | - Spencer Behr
- Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263
| | - Toby Maurer
- Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263
| | - Kenneth Williams
- Boston College, Department of Biology, 14 Commonwealth Ave, Chestnut Hill, Massachusetts 02467
| | - Joshua Walker
- Boston College, Department of Biology, 14 Commonwealth Ave, Chestnut Hill, Massachusetts 02467
| | - Allison Beverly
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Brooke Blay
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Anirudh Damughatla
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Mark Larsen
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Courtney Mountain
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Erin Neylon
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Kaeli Parcel
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Kapil Raghuraman
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Kevin Ricks
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Lucas Rose
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Akhilesh Sivakumar
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Nicholas Streck
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Bryan Wang
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Christopher Wasco
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | | | | | | | | | | | | | - Amifred Williams
- Navidea Biopharmaceuticals Drug Development Internship Program, 5600 Blazer Parkway, Dublin, OH 43017
| | - Michael McGrath
- The University of California San Francisco and the San Francisco General Hospital, AIDS and Cancer Specimen Resource Center, The Department of Pathology, 1001 Potrero Ave, Bldg. 3, Rm 207 San Francisco, CA 94110
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22
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Bradbury MS, Pauliah M, Zanzonico P, Wiesner U, Patel S. Intraoperative mapping of sentinel lymph node metastases using a clinically translated ultrasmall silica nanoparticle. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2015; 8:535-53. [PMID: 26663853 DOI: 10.1002/wnan.1380] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 09/29/2015] [Accepted: 10/12/2015] [Indexed: 12/22/2022]
Abstract
The management of regional lymph nodes in patients with melanoma has undergone a significant paradigm shift over the past several decades, transitioning from the use of more aggressive surgical approaches, such as lymph node basin dissection, to the application of minimally invasive sentinel lymph node (SLN) biopsy methods to detect the presence of nodal micrometastases. SLN biopsy has enabled reliable, highly accurate, and low-morbidity staging of regional lymph nodes in early stage melanoma as a means of guiding treatment decisions and improving patient outcomes. The accurate identification and staging of lymph nodes is an important prognostic factor, identifying those patients for whom the expected benefits of nodal resection outweigh attendant surgical risks. However, currently used standard-of-care technologies for SLN detection are associated with significant limitations. This has fueled the development of clinically promising platforms that can serve as intraoperative visualization tools to aid accurate and specific determination of tumor-bearing lymph nodes, map cancer-promoting biological properties at the cellular/molecular levels, and delineate nodes from adjacent critical structures. Among a number of promising cancer-imaging probes that might facilitate achievement of these ends is a first-in-kind ultrasmall tumor-targeting inorganic (silica) nanoparticle, designed to overcome translational challenges. The rationale driving these considerations and the application of this platform as an intraoperative treatment tool for guiding resection of cancerous lymph nodes is discussed and presented within the context of alternative imaging technologies. WIREs Nanomed Nanobiotechnol 2016, 8:535-553. doi: 10.1002/wnan.1380 For further resources related to this article, please visit the WIREs website.
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Affiliation(s)
- Michelle S Bradbury
- Department of Radiology, Sloan Kettering Institute for Cancer Research, New York, NY, USA.,Department of Molecular Pharmacology and Chemistry Program, Sloan Kettering Institute for Cancer Research, New York, NY, USA
| | - Mohan Pauliah
- Department of Radiology, Sloan Kettering Institute for Cancer Research, New York, NY, USA
| | - Pat Zanzonico
- Department of Medical Physics, Sloan Kettering Institute for Cancer Research, New York, NY, USA
| | - Ulrich Wiesner
- Department of Material Science & Engineering, Cornell University, Ithaca, NY, USA
| | - Snehal Patel
- Department of Surgery, Sloan Kettering Institute for Cancer Research, New York, NY, USA
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23
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A tri-modal molecular imaging agent for sentinel lymph node mapping. Nucl Med Biol 2015; 42:917-22. [DOI: 10.1016/j.nucmedbio.2015.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/12/2015] [Accepted: 07/29/2015] [Indexed: 11/17/2022]
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Azad AK, Rajaram MVS, Metz WL, Cope FO, Blue MS, Vera DR, Schlesinger LS. γ-Tilmanocept, a New Radiopharmaceutical Tracer for Cancer Sentinel Lymph Nodes, Binds to the Mannose Receptor (CD206). JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2015; 195:2019-29. [PMID: 26202986 PMCID: PMC4543904 DOI: 10.4049/jimmunol.1402005] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 06/23/2015] [Indexed: 02/06/2023]
Abstract
γ-Tilmanocept ((99m)Tc-labeled-tilmanocept or [(99m)Tc]-tilmanocept) is the first mannose-containing, receptor-directed, radiolabeled tracer for the highly sensitive imaging of sentinel lymph nodes in solid tumor staging. To elucidate the mannose-binding receptor that retains tilmanocept in this microenvironment, human macrophages were used that have high expression of the C-type lectin mannose receptor (MR; CD206). Cy3-labeled tilmanocept exhibited high specificity binding to macrophages that was nearly abolished in competitive inhibition experiments. Furthermore, Cy3-tilmanocept binding was markedly reduced on macrophages deficient in the MR by small interfering RNA treatment and was increased on MR-transfected HEK 293 cells. Finally, confocal microscopy revealed colocalization of Cy3-tilmanocept with the macrophage membrane MR and binding of labeled tilmanocept to MR(+) cells (macrophages and/or dendritic cells) in human sentinel lymph node tissues. Together these data provide strong evidence that CD206 is a major binding receptor for γ-tilmanocept. Identification of CD206 as the γ-tilmanocept-binding receptor enables opportunities for designing receptor-targeted advanced imaging agents and therapeutics for cancer and other diseases.
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Affiliation(s)
- Abul K Azad
- Center for Microbial Interface Biology, The Ohio State University, Columbus, OH 43210; Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210
| | - Murugesan V S Rajaram
- Center for Microbial Interface Biology, The Ohio State University, Columbus, OH 43210; Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210
| | - Wendy L Metz
- Clinical and Medical Groups, Navidea Biopharmaceuticals, Inc., Dublin, OH 43017; and
| | - Frederick O Cope
- Clinical and Medical Groups, Navidea Biopharmaceuticals, Inc., Dublin, OH 43017; and
| | - Michael S Blue
- Clinical and Medical Groups, Navidea Biopharmaceuticals, Inc., Dublin, OH 43017; and
| | - David R Vera
- Department of Radiology, UC San Diego Moores Cancer Center, University of California, San Diego, La Jolla, CA 92093
| | - Larry S Schlesinger
- Center for Microbial Interface Biology, The Ohio State University, Columbus, OH 43210; Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210;
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25
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Cousins A, Balalis GL, Thompson SK, Forero Morales D, Mohtar A, Wedding AB, Thierry B. Novel handheld magnetometer probe based on magnetic tunnelling junction sensors for intraoperative sentinel lymph node identification. Sci Rep 2015; 5:10842. [PMID: 26038833 PMCID: PMC4454146 DOI: 10.1038/srep10842] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/26/2015] [Indexed: 11/17/2022] Open
Abstract
Using magnetic tunnelling junction sensors, a novel magnetometer probe for the identification of the sentinel lymph node using magnetic tracers was developed. Probe performance was characterised in vitro and validated in a preclinical swine model. Compared to conventional gamma probes, the magnetometer probe showed excellent spatial resolution of 4.0 mm, and the potential to detect as few as 5 μg of magnetic tracer. Due to the high sensitivity of the magnetometer, all first-tier nodes were identified in the preclinical experiments, and there were no instances of false positive or false negative detection. Furthermore, these preliminary data encourage the application of the magnetometer probe for use in more complex lymphatic environments, such as in gastrointestinal cancers, where the sentinel node is often in close proximity to other non-sentinel nodes, and high spatial resolution detection is required.
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Affiliation(s)
- A Cousins
- Ian Wark Research Institute, University of South Australia, Mawson Lakes, SA 5095, Australia
| | - G L Balalis
- Discipline of Surgery, University of Adelaide, Adelaide, SA 5000, Australia
| | - S K Thompson
- School of Engineering, University of South Australia, Mawson Lakes, SA 5095, Australia
| | - D Forero Morales
- School of Engineering, University of South Australia, Mawson Lakes, SA 5095, Australia
| | - A Mohtar
- Medical Device Research Institute, School of Computer Science, Engineering and Mathematics, Flinders University, Bedford Park, SA 5042, Australia
| | - A B Wedding
- School of Engineering, University of South Australia, Mawson Lakes, SA 5095, Australia
| | - B Thierry
- Ian Wark Research Institute, University of South Australia, Mawson Lakes, SA 5095, Australia
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Bozzetto J, Dubreuil J, Rubello D, Giammarile F. Sentinel lymph node in melanoma: present aspects and future trends. Clin Transl Imaging 2015. [DOI: 10.1007/s40336-015-0122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Doepker MP, Zager JS. Sentinel Lymph Node Mapping in Melanoma in the Twenty-first Century. Surg Oncol Clin N Am 2015; 24:249-60. [DOI: 10.1016/j.soc.2014.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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28
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Azad AK, Schlesinger LS. Mannose receptor (CD206)-mediated imaging in sentinel lymph node localization. Clin Transl Imaging 2015. [DOI: 10.1007/s40336-015-0117-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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29
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Tausch C, Baege A, Rageth C. Mapping lymph nodes in cancer management - role of (99m)Tc-tilmanocept injection. Onco Targets Ther 2014; 7:1151-8. [PMID: 25028560 PMCID: PMC4077853 DOI: 10.2147/ott.s50394] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Two decades ago, lymphatic mapping of sentinel lymph nodes (SLN) was introduced into surgical cancer management and was termed sentinel node navigated surgery. Although this technique is now routinely performed in the management of breast cancer and malignant melanoma, it is still under investigation for use in other cancers. The radioisotope technetium (99mTc) and vital blue dyes are among the most widely used enhancers for SLN mapping, although near-infrared fluorescence imaging of indocyanine green is also becoming more commonly used. 99mTc-tilmanocept is a new synthetic radioisotope with a relatively small molecular size that was specifically developed for lymphatic mapping. Because of its small size, 99mTc-tilmanocept quickly migrates from its site of injection and rapidly accumulates in the SLN. The mannose moieties of 99mTc-tilmanosept facilitate its binding to mannose receptors (CD206) expressed in reticuloendothelial cells of the SLN. This binding prevents transit to second-echelon lymph nodes. In Phase III trials of breast cancer and malignant melanoma, and Phase II trials of other malignancies, 99mTc-tilmanocept had superior identification rates and sensitivity compared with blue dye. Trials comparing 99mTc-tilmanocept with other 99mTc-based agents are required before it can be routinely used in clinical settings.
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30
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Nichols B, Qin Z, Yang J, Vera DR, Devaraj NK. 68Ga chelating bioorthogonal tetrazine polymers for the multistep labeling of cancer biomarkers. Chem Commun (Camb) 2014; 50:5215-5217. [PMID: 24589653 PMCID: PMC4119763 DOI: 10.1039/c3cc49530b] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We have developed a (68)Ga metal chelating bioorthogonal tetrazine dextran probe that is highly reactive with trans-cyclooctene modified monoclonal antibodies for multistep imaging applications. Confocal microscopy and positron emission tomography (PET) were used to characterize the dextran probe in vitro and in vivo.
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Affiliation(s)
- Brandon Nichols
- Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Zhengtao Qin
- Department of Radiology, UCSD in vivo Cancer and Molecular Imaging Center, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Jun Yang
- Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA, 92093, USA
| | - David R. Vera
- Department of Radiology, UCSD in vivo Cancer and Molecular Imaging Center, University of California, San Diego, La Jolla, CA, 92093, USA
| | - Neal K. Devaraj
- Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA, 92093, USA
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31
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Fluorescent-tilmanocept for tumor margin analysis in the mouse model. J Surg Res 2014; 190:528-34. [PMID: 24923630 DOI: 10.1016/j.jss.2014.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/22/2014] [Accepted: 05/02/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Dendritic cells (DC) are localized in close proximity to cancer cells in many well-known tumors, and thus maybe a useful target for tumor margin assessment. MATERIALS AND METHODS [(99m)Tc]- cyanine 7 (Cy7)-tilmanocept was synthesized and in vitro binding assays to bone marrow-derived DC were performed. Fifteen mice, implanted with either 4T1 mouse mammary or K1735 mouse melanoma tumors, were administered 1.0 nmol of [(99m)Tc]-Cy7-tilmanocept via tail vein injection. After fluorescence imaging 1 or 2 h after injection, the tumor, muscle, and blood were assayed for radioactivity to calculate percent-injected dose. Digital images of the tumors after immunohistochemical staining for DC were analyzed to determine DC density. RESULTS In vitro binding demonstrated subnanomolar affinity of [(99m)Tc]-Cy7-tilmanocept to DC (KA = 0.31 ± 0.11 nM). After administration of [(99m)Tc]-Cy7-tilmanocept, fluorescence imaging showed a 5.5-fold increase in tumor signal as compared with preinjection images and a 3.3-fold difference in fluorescence activity when comparing the tumor with the surgical bed after tumor excision. Immunohistochemical staining analysis demonstrated that DC density positively correlated with tumor percent of injected dose per gram (r = 0.672, P = 0.03), and higher DC density was observed at the periphery versus center of the tumor (186 ± 54 K versus 64 ± 16 K arbitrary units, P = 0.001). CONCLUSIONS [(99m)Tc]-Cy7-tilmanocept exhibits in vitro and in vivo tumor-specific binding to DC and maybe useful as a tumor margin targeting agent.
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Marcinow AM, Hall N, Byrum E, Teknos TN, Old MO, Agrawal A. Use of a novel receptor-targeted (CD206) radiotracer, 99mTc-tilmanocept, and SPECT/CT for sentinel lymph node detection in oral cavity squamous cell carcinoma: initial institutional report in an ongoing phase 3 study. JAMA Otolaryngol Head Neck Surg 2013; 139:895-902. [PMID: 24051744 DOI: 10.1001/jamaoto.2013.4239] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Sentinel lymph node biopsy has been proposed as an alternative to up-front elective neck dissection (END) for determination of pathologic nodal status in patients undergoing surgical treatment for oral cavity squamous cell carcinoma (OSCC) with clinically negative neck (cN0). Sentinel lymph node biopsy using current standard tracer agents and imaging adjuncts such as radiolabeled sulfur-colloid and planar lymphoscintigraphy (LS), however, is associated with several drawbacks. OBJECTIVE To assess the preliminary utility of technetium Tc 99m (99mTc)-tilmanocept, a novel molecular imaging agent for sentinel lymph node (SLN) mapping, in OSCC. DESIGN, SETTING, AND PARTICIPANTS Prospective, nonrandomized, single-arm, part of an ongoing phase 3 clinical trial. Patients had previously untreated, clinically and radiographically node-negative OSCC (T1-4aN0M0) at an academic tertiary referral center. INTERVENTIONS Patients received a single dose of 50 µg 99mTc-tilmanocept injected peritumorally followed by dynamic planar LS and fused single-photon emission computed tomography/computed tomography (SPECT/CT) prior to surgery. Surgical intervention consisted of excision of the primary tumor and radioguided SLN dissection followed by planned END. The excised lymph nodes (SLNs and non-SLNs) underwent histopathologic evaluation for presence of metastatic disease. MAIN OUTCOMES AND MEASURES False-negative rate and negative predictive value of SLNB using 99mTc-tilmanocept and comparison of planar LS with SPECT/CT in SLN localization. RESULTS Twelve of 20 patients (60%) had metastatic neck disease on pathologic examination. All 12 had at least 1 SLN positive for metastases. No patients had a positive END node who did not have at least 1 positive SLN. These data yield a false-negative rate of 0% and negative predictive value of 100% using 99mTc-tilmanocept in this setting. Dynamic planar LS and SPECT/CT revealed a mean (range) number of hot spots per patient of 2.9 (1-7) and 3.7 (1-12), respectively. Compared with planar LS, SPECT/CT identified additional putative SLNs in 11 of 20 cases (55%). CONCLUSIONS AND RELEVANCE The high negative predictive value and low false-negative rate in identification of occult metastases shows 99mTc-tilmanocept to be a promising agent in SLN identification in patients with OSCC. Use of SPECT/CT improves preoperative SLN localization including delineation of SLN locations near the primary tumor when compared with planar LS imaging. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00911326.
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Affiliation(s)
- Anna M Marcinow
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University College of Medicine, Columbus
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33
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Cousins A, Thompson SK, Wedding AB, Thierry B. Clinical relevance of novel imaging technologies for sentinel lymph node identification and staging. Biotechnol Adv 2013; 32:269-79. [PMID: 24189095 DOI: 10.1016/j.biotechadv.2013.10.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 10/12/2013] [Accepted: 10/27/2013] [Indexed: 01/07/2023]
Abstract
The sentinel lymph node (SLN) concept has become a standard of care for patients with breast cancer and melanoma, yet its clinical application to other cancer types has been somewhat limited. This is mainly due to the reduced accuracy of conventional SLN mapping techniques (using blue dye and/or radiocolloids as lymphatic tracers) in cancer types where lymphatic drainage is more complex, and SLNs are within close proximity to other nodes or the tumour site. In recent years, many novel techniques for SLN mapping have been developed including fluorescence, x-ray, and magnetic resonant detection. Whilst each technique has its own advantages/disadvantages, the role of targeted contrast agents (for enhanced retention in the SLN, or for immunostaging) is increasing, and may represent the new standard for mapping the SLN in many solid organ tumours. This review article discusses current limitations of conventional techniques, limiting factors of nanoparticulate based contrast agents, and efforts to circumvent these limitations with modern tracer architecture.
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Affiliation(s)
- Aidan Cousins
- Ian Wark Research Institute, University of South Australia, Mawson Lakes Campus, Mawson Lakes, SA 5095, Australia
| | - Sarah K Thompson
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - A Bruce Wedding
- School of Engineering, University of South Australia, Mawson Lakes Campus, Mawson Lakes, SA 5095, Australia
| | - Benjamin Thierry
- Ian Wark Research Institute, University of South Australia, Mawson Lakes Campus, Mawson Lakes, SA 5095, Australia.
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34
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Qin Z, Hall DJ, Liss MA, Hoh CK, Kane CJ, Wallace AM, Vera DR. Optimization via specific fluorescence brightness of a receptor-targeted probe for optical imaging and positron emission tomography of sentinel lymph nodes. JOURNAL OF BIOMEDICAL OPTICS 2013; 18:101315. [PMID: 23958947 PMCID: PMC3745642 DOI: 10.1117/1.jbo.18.10.101315] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 06/05/2013] [Accepted: 06/27/2013] [Indexed: 05/20/2023]
Abstract
The optical properties of a receptor-targeted probe designed for dual-modality mapping of the sentinel lymph node (SLN) was optimized. Specific fluorescence brightness was used as the design criterion, which was defined as the fluorescence brightness per mole of the contrast agent. Adjusting the molar ratio of the coupling reactants, IRDye 800CW-NHS-ester and tilmanocept, enabled us to control the number of fluorescent molecules attached to each tilmanocept, which was quantified by H1 nuclear magnetic resonance spectroscopy. Quantum yields and molar absorptivities were measured for unconjugated IRDye 800CW and IRDye 800CW-tilmanocept (800CW-tilmanocept) preparations at 0.7, 1.5, 2.3, 2.9, and 3.8 dyes per tilmanocept. Specific fluorescence brightness was calculated by multiplication of the quantum yield by the molar absorptivity and the number of dyes per tilmanocept. It predicted that the preparation with 2.3 dyes per tilmanocept would exhibit the brightest signal, which was confirmed by fluorescence intensity measurements using three optical imaging systems. When radiolabeled with Ga68 and injected into the footpads of mice, the probe identified SLNs by both fluorescence and positron emission tomography (PET) while maintaining high percent extraction by the SLN. These studies demonstrated the feasibility of 800CW-tilmanocept for multimodal SLN mapping via fluorescence and PET-computed tomography imaging.
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Affiliation(s)
- Zhengtao Qin
- University of California, San Diego, Department of Chemistry, La Jolla, California 92093
- University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
- University of California, San Diego, Department of Radiology, La Jolla, California 92093
- University of California, San Diego, In Vivo Cancer and Molecular Imaging Center, La Jolla, California 92093
| | - David J. Hall
- University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
- University of California, San Diego, Department of Radiology, La Jolla, California 92093
- University of California, San Diego, In Vivo Cancer and Molecular Imaging Center, La Jolla, California 92093
| | - Michael A. Liss
- University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
- University of California, San Diego, Department of Surgery, La Jolla, California 92093
| | - Carl K. Hoh
- University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
- University of California, San Diego, Department of Radiology, La Jolla, California 92093
- University of California, San Diego, In Vivo Cancer and Molecular Imaging Center, La Jolla, California 92093
| | - Christopher J. Kane
- University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
- University of California, San Diego, Department of Surgery, La Jolla, California 92093
| | - Anne M. Wallace
- University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
- University of California, San Diego, Department of Surgery, La Jolla, California 92093
| | - David R. Vera
- University of California, San Diego, Moores Cancer Center, La Jolla, California 92093
- University of California, San Diego, Department of Radiology, La Jolla, California 92093
- University of California, San Diego, In Vivo Cancer and Molecular Imaging Center, La Jolla, California 92093
- University of California, San Diego, Department of Surgery, La Jolla, California 92093
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Eckelman WC, Jones AG, Duatti A, Reba RC. Progress using Tc-99m radiopharmaceuticals for measuring high capacity sites and low density sites. Drug Discov Today 2013; 18:984-91. [DOI: 10.1016/j.drudis.2013.06.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/14/2013] [Accepted: 06/17/2013] [Indexed: 01/11/2023]
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Wallace AM, Han LK, Povoski SP, Deck K, Schneebaum S, Hall NC, Hoh CK, Limmer KK, Krontiras H, Frazier TG, Cox C, Avisar E, Faries M, King DW, Christman L, Vera DR. Comparative evaluation of [(99m)tc]tilmanocept for sentinel lymph node mapping in breast cancer patients: results of two phase 3 trials. Ann Surg Oncol 2013; 20:2590-9. [PMID: 23504141 PMCID: PMC3705144 DOI: 10.1245/s10434-013-2887-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sentinel lymph node (SLN) surgery is used worldwide for staging breast cancer patients and helps limit axillary lymph node dissection. [(99m)Tc]Tilmanocept is a novel receptor-targeted radiopharmaceutical evaluated in 2 open-label, nonrandomized, within-patient, phase 3 trials designed to assess the lymphatic mapping performance. METHODS A total of 13 centers contributed 148 patients with breast cancer. Each patient received [(99m)Tc]tilmanocept and vital blue dye (VBD). Lymph nodes identified intraoperatively as radioactive and/or blue stained were excised and histologically examined. The primary endpoint, concordance (lower boundary set point at 90 %), was the proportion of nodes detected by VBD and [(99m)Tc]tilmanocept. RESULTS A total of 13 centers contributed 148 patients who were injected with both agents. Intraoperatively, 207 of 209 nodes detected by VBD were also detected by [(99m)Tc]tilmanocept for a concordance rate of 99.04 % (p < 0.0001). [(99m)Tc]tilmanocept detected a total of 320 nodes, of which 207 (64.7 %) were detected by VBD. [(99m)Tc]Tilmanocept detected at least 1 SLN in more patients (146) than did VBD (131, p < 0.0001). In 129 of 131 patients with ≥1 blue node, all blue nodes were radioactive. Of 33 pathology-positive nodes (18.2 % patient pathology rate), [(99m)Tc]tilmanocept detected 31 of 33, whereas VBD detected only 25 of 33 (p = 0.0312). No pathology-positive SLNs were detected exclusively by VBD. No serious adverse events were attributed to [(99m)Tc]tilmanocept. CONCLUSION [(99m)Tc]Tilmanocept demonstrated success in detecting a SLN while meeting the primary endpoint. Interestingly, [(99m)Tc]tilmanocept was additionally noted to identify more SLNs in more patients. This localization represented a higher number of metastatic breast cancer lymph nodes than that of VBD.
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Affiliation(s)
- Anne M Wallace
- Divisions of Surgical Oncology and Plastic Surgery, UCSD Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA.
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Immunospecific targeting of CD45 expressing lymphoid cells: towards improved detection agents of the sentinel lymph node. Cancer Lett 2012; 328:271-7. [PMID: 23043762 DOI: 10.1016/j.canlet.2012.09.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 09/27/2012] [Accepted: 09/27/2012] [Indexed: 12/21/2022]
Abstract
This study was designed to demonstrate the potential of small nanoparticulate lymphotropic contrast agents designed to bind with high affinity to lymphoid cells overexpressing the CD45 antigen. To this end, small gold nanoparticles used as model were conjugated to anti-CD45 antibodies and injected in mice in the dorsal toe of the fore/hind paw. Chemical analysis demonstrated rapid uptake and transport of the nanoparticles in the lymphatic as well as significant retention of the nanoparticles with high binding affinity to lymphoid cells in the popliteal and axillary lymph nodes in comparison to non-targeted nanoparticles.
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Sondak VK, King DW, Zager JS, Schneebaum S, Kim J, Leong SPL, Faries MB, Averbook BJ, Martinez SR, Puleo CA, Messina JL, Christman L, Wallace AM. Combined analysis of phase III trials evaluating [⁹⁹mTc]tilmanocept and vital blue dye for identification of sentinel lymph nodes in clinically node-negative cutaneous melanoma. Ann Surg Oncol 2012; 20:680-8. [PMID: 23054107 PMCID: PMC3560941 DOI: 10.1245/s10434-012-2612-z] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Indexed: 12/11/2022]
Abstract
Background [99mTc]Tilmanocept is a CD206 receptor-targeted radiopharmaceutical designed for sentinel lymph node (SLN) identification. Two nearly identical nonrandomized phase III trials compared [99mTc]tilmanocept to vital blue dye. Methods Patients received [99mTc]tilmanocept and blue dye. SLNs identified intraoperatively as radioactive and/or blue were excised and histologically examined. The primary end point, concordance, was the proportion of blue nodes detected by [99mTc]tilmanocept; 90 % concordance was the prespecified minimum concordance level. Reverse concordance, the proportion of radioactive nodes detected by blue dye, was also calculated. The prospective statistical plan combined the data from both trials. Results Fifteen centers contributed 154 melanoma patients who were injected with both agents and were intraoperatively evaluated. Intraoperatively, 232 of 235 blue nodes were detected by [99mTc]tilmanocept, for 98.7 % concordance (p < 0.001). [99mTc]Tilmanocept detected 364 nodes, for 63.7 % reverse concordance (232 of 364 nodes). [99mTc]Tilmanocept detected at least one node in more patients (n = 150) than blue dye (n = 138, p = 0.002). In 135 of 138 patients with at least one blue node, all blue nodes were radioactive. Melanoma was identified in the SLNs of 22.1 % of patients; all 45 melanoma-positive SLNs were detected by [99mTc]tilmanocept, whereas blue dye detected only 36 (80 %) of 45 (p = 0.004). No positive SLNs were detected exclusively by blue dye. Four of 34 node-positive patients were identified only by [99mTc]tilmanocept, so 4 (2.6 %) of 154 patients were correctly staged only by [99mTc]tilmanocept. No serious adverse events were attributed to [99mTc]tilmanocept. Conclusions [99mTc]Tilmanocept met the prespecified concordance primary end point, identifying 98.7 % of blue nodes. It identified more SLNs in more patients, and identified more melanoma-containing nodes than blue dye.
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Emerson DK, Limmer KK, Hall DJ, Han SH, Eckelman WC, Kane CJ, Wallace AM, Vera DR. A receptor-targeted fluorescent radiopharmaceutical for multireporter sentinel lymph node imaging. Radiology 2012; 265:186-93. [PMID: 22753678 DOI: 10.1148/radiol.12120638] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To determine the imaging and receptor-binding properties of a multireporter probe designed for sentinel lymph node (SLN) mapping via nuclear and fluorescence detection. MATERIALS AND METHODS The animal experiments were approved by the institutional animal care and use committee. A multireporter probe was synthesized by covalently attaching cyanine 7 (Cy7), a near-infrared cyanine dye, to tilmanocept, a radiopharmaceutical that binds to a receptor specific to recticuloendothelial cells. In vitro binding assays of technetium 99m (99mTc)-labeled Cy7 tilmanocept were conducted at 4°C by using receptor-bearing macrophages. Optical SLN imaging after foot pad administration was performed by using two molar doses of Cy7 tilmanocept. Six mice were injected with 0.11 nmol of 99mTc-labeled Cy7 tilmanocept (low-dose group); an additional six mice were injected with 31 nmol of 99mTc-labeled Cy7 tilmanocept (high-dose group) to saturate the receptor sites within the SLN. After 2.5 hours of imaging, the mice were euthanized, and the sentinel and distal lymph nodes were excised and assayed for radioactivity for calculation of SLN percentage of injected dose and extraction. Four mice were used as controls for autofluorescence. Standard optical imaging software was used to plot integrated fluorescence intensity against time for calculation of the SLN uptake rate constant and scaled peak intensity. Significance was calculated by using the Student t test. RESULTS In vitro binding assays showed subnanomolar affinity (mean dissociation constant, 0.25 nmol/L±0.10 [standard deviation]). Fluorescence imaging showed a detection sensitivity of 1.6×10(3) counts·sec(-1)·μW(-1) per picomole of Cy7. All four imaging metrics (percentage of injected dose, SLN extraction, SLN uptake rate constant, and expected peak fluorescence intensity) exhibited higher values (P=.005 to P=.042) in the low-dose group than in the high-dose group; this finding was consistent with receptor-mediated image formation. CONCLUSION The multireporter probe 99mTc-labeled Cy7 tilmanocept exhibits in vitro and in vivo receptor-binding properties for successful receptor-targeted SLN mapping with nuclear and optical imaging.
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Affiliation(s)
- Derek K Emerson
- Moores UCSD Cancer Center, Department of Radiology, Department of Surgery, and UCSD In Vivo Cancer and Molecular Imaging Center, University of California, San Diego, 3855 Health Sciences Dr, La Jolla, CA 92093
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Preoperative sentinel lymph node mapping of the prostate using PET/CT fusion imaging and Ga-68-labeled tilmanocept in an animal model. Clin Exp Metastasis 2012; 29:673-80. [PMID: 22714690 DOI: 10.1007/s10585-012-9498-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 05/28/2012] [Indexed: 10/28/2022]
Abstract
Sentinel lymph node (SLN) identification with preoperative image guidance may improve pathological staging of prostate cancer by identifying nodes outside the standard template of dissection. Four anesthetized male dogs received an intra-prostatic injection of Ga-68-labeled tilmanocept. Every 20 min the pelvic lymph nodes were imaged using PET/CT fusion imaging. At 90 min post-injection a prostatectomy and extended lymphadenectomy were completed; ex vivo radioactivity was recorded for each node using a handheld gamma detector, and confirmed by calculation of percent-of-injected dose (%ID) via assay of Ga-68 radioactivity. SLNs were defined as containing >10 % of the maximum %ID. Preoperative PET/CT fusion imaging identified a mean of 4.25 lymph nodes per animal (range 3-7); the mean number of SLN per animal was 4.00 (range 2-6).Of the excised SLNs, 29 % were located in the standard external iliac and obturator distribution. The SLN %ID ranged from 0.07 to 2.40 % (mean 0.744 % ± 0.641 %); SLN ex vivo count rate ranged from 88 to 2,175 cpm (mean 896 ± 715 cpm); and the SLN standardize uptake values (SUVs) ranged from 13 to 237 (mean 79 ± 67).There was a high concordance of PET-CT imaging to SLN activity, with sensitivity of 93 %. In this feasibility study, pelvic SLNs attained SUVs within 60 min. PET/CT effectively identified SLNs with good anatomic specificity, and radioactivity by hand-held detection and scintillation counts demonstrated high concordance with preoperative imaging. Gallium-68-labaled tilmanocept was highly specific for sentinel nodes. Image-guided tumor resection and lymphadenectomy may become a promising future application in urologic oncology and warrants further investigation.
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Sondak VK, Han D, Deneve J, Kudchadkar R. Current and planned multicenter trials for patients with primary or metastatic melanoma. J Surg Oncol 2011; 104:430-7. [PMID: 21858839 DOI: 10.1002/jso.21867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Multicenter clinical trials have established new standards of care in the surgical and medical management of malignant melanoma. They have led to the testing of new therapies and improved outcomes for patients with loco-regional and distant disease. Many pressing questions remain, however, and additional multicenter trials are currently underway to address them. The purpose of this review is to summarize relevant ongoing and planned multicenter trials that have and continue to define current melanoma management.
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Affiliation(s)
- Vernon K Sondak
- The Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA.
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Leong SPL, Kim J, Ross M, Faries M, Scoggins CR, Metz WLR, Cope FO, Orahood RC. A phase 2 study of (99m)Tc-tilmanocept in the detection of sentinel lymph nodes in melanoma and breast cancer. Ann Surg Oncol 2011; 18:961-9. [PMID: 21331809 DOI: 10.1245/s10434-010-1524-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND Several (99m)Tc-labeled agents that are not approved by the U.S. Food and Drug Administration are used for lymphatic mapping. A new low-molecular-weight mannose receptor-based, reticuloendothelial cell-directed, (99m)Tc-labeled lymphatic imaging agent, (99m)Tc-tilmanocept, was used for lymphatic mapping of sentinel lymph nodes (SLNs) from patients with primary breast cancer or melanoma malignancies. This novel molecular species provides the basis for potentially enhanced SLN mapping reliability. METHODS In a prospectively planned, open-label phase 2 clinical study, (99m)Tc-tilmanocept was injected into breast cancer and cutaneous melanoma patients before intraoperative lymphatic mapping. Injection technique, preoperative lymphoscintigraphy (LS), and intraoperative lymphatic mapping with a handheld gamma detection probe were performed by investigators per standard practice. RESULTS Seventy-eight patients underwent (99m)Tc-tilmanocept injection and were evaluated (47 melanoma, 31 breast cancer). For those whom LS was performed (55 patients, 70.5%), a (99m)Tc-tilmanocept hot spot was identified in 94.5% of LS patients before surgery. Intraoperatively, (99m)Tc-tilmanocept identified at least one regional SLN in 75 (96.2%) of 78 patients: 46 (97.9%) of 47 in melanoma and 29 (93.5%) of 31 in breast cancer cases. Tissue specificity of (99m)Tc-tilmanocept for lymph nodes was 100%, displaying 95.1% mapping sensitivity by localizing in 173 of 182 nodes removed during surgery. The overall proportion of (99m)Tc-tilmanocept-identified nodes that contained metastatic disease was 13.7%. Five procedure-related serious adverse events occurred, none related to (99m)Tc-tilmanocept. CONCLUSIONS Our results demonstrate the safety and efficacy of (99m)Tc-tilmanocept for use in intraoperative lymphatic mapping. The high intraoperative localization and lymph node specificity of (99m)Tc-tilmanocept and the identification of metastatic disease within the nodes suggest SLNs are effectively identified by this novel mannose receptor-targeted molecule.
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Affiliation(s)
- Stanley P L Leong
- California Pacific Medical Center and Sutter Pacific Medical Foundation and Research Institute, University of California, San Francisco, CA, USA.
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Choi JY, Jeong JM, Yoo BC, Kim K, Kim Y, Yang BY, Lee YS, Lee DS, Chung JK, Lee MC. Development of 68Ga-labeled mannosylated human serum albumin (MSA) as a lymph node imaging agent for positron emission tomography. Nucl Med Biol 2010; 38:371-9. [PMID: 21492786 DOI: 10.1016/j.nucmedbio.2010.09.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 09/25/2010] [Accepted: 09/29/2010] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Although many sentinel lymph node (SLN) imaging agents labeled with (99m)Tc have been developed, no positron-emitting agent has been specifically designed for SLN imaging. Furthermore, the development of the beta probe and the requirement for better image resolution have increased the need for a positron-emitting SLN imaging agent. Here, we describe the development of a novel positron-emitting SLN imaging agent labeled with (68)Ga. METHODS A mannosylated human serum albumin (MSA) was synthesized by conjugating α-d-mannopyranosylphenyl isothiocyanate to human serum albumin in sodium carbonate buffer (pH 9.5), and then 2-(p-isothiocyanatobenzyl)-1,4,7-triazacyclononane-1,4,7-triacetic acid was conjugated to synthesize NOTA-MSA. Numbers of mannose and NOTA units conjugated in NOTA-MSA were determined by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. NOTA-MSA was labeled with (68)Ga at room temperature. The stability of (68)Ga-NOTA-MSA was checked in labeling medium at room temperature and in human serum at 37°C. Biodistribution in normal ICR mice was investigated after tail vein injection, and micro-positron emission tomography (PET) images were obtained after injecting (68)Ga-NOTA-MSA into a tail vein or a footpad. RESULTS The numbers of conjugated α-d-mannopyranosylphenyl isothiocyanate and 2-(p-isothiocyanatobenzyl)-1,4,7-triazacyclononane-1,4,7-triacetic acid units in NOTA-MSA were 10.6 and 6.6, respectively. The labeling efficiency of (68)Ga-NOTA-MSA was greater than 99% at room temperature, and its stability was greater than 99% at 4 h. Biodistribution and micro-PET studies of (68)Ga-NOTA-MSA showed high liver and spleen uptakes after intravenous injection. (68)Ga-NOTA-MSA injected into a footpad rapidly migrated to the lymph node. CONCLUSIONS (68)Ga-NOTA-MSA was successfully developed as a novel SLN imaging agent for PET. NOTA-MSA is easily labeled at high efficiency, and subcutaneously administered (68)Ga-NOTA-MSA was found to migrate rapidly to the lymph node.
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Affiliation(s)
- Jae Yeon Choi
- Department of Nuclear Medicine, Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, South Korea
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Baldwin BT, Cherpelis BS, Sondak V, Fenske NA. Sentinel lymph node biopsy in melanoma: Facts and controversies. Clin Dermatol 2010; 28:319-23. [PMID: 20541686 DOI: 10.1016/j.clindermatol.2009.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Three decades after its introduction in the 1990s, the sentinel lymph node biopsy for patients with localized cutaneous melanoma is still the subject of great debate in dermatology. Many questions remain unanswered, and studies currently in progress may or may not bring us any closer to determining the truth about sentinel lymph node biopsy and melanoma. We discuss the effect of sentinel lymph node biopsy on overall survival, the clinical and therapeutic implications of sentinel lymph node biopsy, and the melanoma patients who might be candidates for sentinel lymph node biopsy.
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Affiliation(s)
- Brooke T Baldwin
- Department of Dermatology and Cutaneous Surgery, University of South Florida, College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
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Oral cavity squamous cell carcinoma and the clinically n0 neck: the past, present, and future of sentinel lymph node biopsy. Curr Oncol Rep 2010; 12:129-35. [PMID: 20425598 DOI: 10.1007/s11912-010-0090-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Oral cavity squamous cell carcinoma (OCSCC) has a yearly incidence of 274,000 patients. Twenty percent to 30% of patients will harbor occult regional metastases, an important feature that correlates with worse outcomes. Supraomohyoid neck dissection (SND) is the gold standard treatment, but because of recent successes of sentinel lymph node (SLN) biopsy in the management of breast cancer and melanoma, many have begun evaluating its use in head and neck mucosal cancers. SLN biopsy offers patients decreased morbidity compared with SND, and has shown reproducibly low false-negative rates, high-negative predictive values, and high sensitivities. Limitations with floor-of-mouth primaries and delayed secondary SNDs have been described, but a new agent designed to address these shortcomings, Lymphoseek (Neoprobe Corp.; Dublin, OH), is currently under investigation. This article reviews the current literature on SLN biopsy and introduces a phase 3 study evaluating the efficacy of Lymphoseek in SLN biopsy of OCSCCs.
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Bagaria SP, Faries MB, Morton DL. Sentinel node biopsy in melanoma: technical considerations of the procedure as performed at the John Wayne Cancer Institute. J Surg Oncol 2010; 101:669-76. [PMID: 20512942 DOI: 10.1002/jso.21581] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Since its first description in 1990, sentinel node (SN) biopsy has become the standard for accurate staging of a melanoma-draining regional lymphatic basin. This minimally invasive, multidisciplinary technique can detect occult metastases by selective sampling and focused pathologic analysis of the first nodes on the afferent lymphatic pathway from a primary cutaneous melanoma. An understanding of preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and the definition of SN are critical for surgical expertise with SN biopsy.
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Affiliation(s)
- Sanjay P Bagaria
- John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California 90404, USA
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Wallace AM, Hoh CK, Limmer KK, Darrah DD, Schulteis G, Vera DR. Sentinel lymph node accumulation of Lymphoseek and Tc-99m-sulfur colloid using a "2-day" protocol. Nucl Med Biol 2009; 36:687-92. [PMID: 19647175 DOI: 10.1016/j.nucmedbio.2009.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 03/16/2009] [Accepted: 04/10/2009] [Indexed: 11/24/2022]
Abstract
Lymphoseek is a receptor-binding radiopharmaceutical specifically designed for sentinel lymph node (SLN) mapping. We conducted a clinical trial which measured the injection site clearance and sentinel lymph node accumulation after a single intradermal injection of Lymphoseek or unfiltered [(99m)Tc]sulfur colloid (TcSC) using a "2-day" protocol for SLN mapping of breast cancer. Eleven patients with breast cancer participated in this study. Five patients received an intradermal administration of 1.0 nmol of (99m)Tc-labeled Lymphoseek; SLN mapping was performed on four subjects within 19 to 27 h. Six subjects received an intradermal administration of TcSC; SLN mapping was performed on five subjects within 18 to 26 h. Lymphoseek exhibited a significantly (P<.001) faster injection site clearance than TcSC. The mean Lymphoseek clearance half-time was 2.18+/-1.09 h compared to 57.4+/-92.8 h for TcSC. The mean sentinel lymph node uptake of Lymphoseek (1.5+/-1.7%) and TcSC (3.5+/-3.1%) was statistically equivalent (P=.213). When an intradermal injection is employed, Lymphoseek demonstrated faster injection site clearance than unfiltered [(99m)Tc]sulfur colloid and persistent SLN accumulation for at least 24 h.
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Affiliation(s)
- Anne M Wallace
- Department of Surgery, University of California, San Diego, CA 92103, USA; Moores UCSD Cancer Center, University of California, La Jolla, CA 92093, USA
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Phan GQ, Messina JL, Sondak VK, Zager JS. Sentinel lymph node biopsy for melanoma: indications and rationale. Cancer Control 2009; 16:234-9. [PMID: 19556963 DOI: 10.1177/107327480901600305] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The disease status of regional lymph nodes is the most important prognostic indicator for patients with melanoma. Sentinel lymph node biopsy (SLNB) was developed as a technique to surgically assess the regional lymph nodes and spare node-negative patients unnecessary and potentially morbid complete lymphadenectomies. METHODS We reviewed the literature on SLNB for cutaneous melanoma to provide insight into the rationale for the current widespread use of SLNB. RESULTS Multiple studies show that the status of the SLN is an important prognostic indicator. Those with positive SLNs have significantly decreased disease-free and melanoma-specific survival compared with those who have negative SLNs. In the Multicenter Selective Lymphadenectomy Trial I (MSLT-I), in which patients with intermediate-thickness melanoma were randomized to SLNB (and immediate completion lymphadenectomy if the SLN was positive) vs observation (and a lymphadenectomy only after presenting with clinically evident recurrence), the 5-year survival rate was 72.3% for patients with positive sentinel nodes and 90.2% for those with negative sentinel nodes (P < .001). Although overall survival was not increased in patients who underwent SLNB compared with those who were randomized to observation, patients who underwent SLNB had a significantly increased 5-year disease-free survival rate compared with those who underwent observation alone (78.3% in the biopsy group and 73.1% in the observation group; P = .009). For those with nodal metastases, patients who underwent SLNB and immediate lymphadenectomy had an increased overall 5-year survival rate compared with those who had lymphadenectomy only after presenting with clinically evident disease (72.3% vs 52.4%; P = .004). Moreover, other studies show that for patients with thin melanomas <or= 1.0 mm, the overall survival rate is significantly worse for those with positive SLNs compared to those with negative SLNs. For thin melanomas, Breslow depth >or= 0.76 mm and increased mitotic rate have been shown to be associated with an increased incidence of SLN metastases. CONCLUSIONS SLNB provides important prognostic and staging data with minimal morbidity and can be used to identify regional node-negative patients who would not benefit from a complete nodal dissection. In our opinion, SLNB should be performed on most patients (with acceptable surgical and anesthesia risk) who have melanomas with a Breslow depth >or= 0.76 mm.
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Affiliation(s)
- Giao Q Phan
- Department of Cutaneous Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida 33612, USA
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Roses RE, Kumar R, Alavi A, Czerniecki BJ. The Role of Lymphatic Mapping and Sentinel Lymph Node Biopsy in the Staging of Breast Cancer. PET Clin 2009; 4:265-76. [PMID: 27157099 DOI: 10.1016/j.cpet.2009.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The widespread application of sentinel lymph node biopsy in the evaluation of patients with breast cancer has allowed for the more limited, selective treatment of regional lymph nodes and decreased the number of complete regional dissections performed in patients without nodal metastases. Surgical excision and pathologic evaluation of nodes for metastases allow for reliable staging and prediction of additional lymph node metastases. Sentinel lymph node biopsy also enables a meticulous histologic evaluation of multiple sections augmented by immunohistochemical staining. The current role of sentinel lymph node biopsy in the staging of breast cancer and ongoing controversies relating to the procedure are discussed.
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Affiliation(s)
- Robert E Roses
- Department of Surgery, University of Pennsylvania School of Medicine, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abass Alavi
- Department Section, Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Brian J Czerniecki
- Department of Surgery, University of Pennsylvania School of Medicine, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA; Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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Lee JH, Rosen EL, Mankoff DA. The Role of Radiotracer Imaging in the Diagnosis and Management of Patients with Breast Cancer: Part 1—Overview, Detection, and Staging. J Nucl Med 2009; 50:569-81. [DOI: 10.2967/jnumed.108.053512] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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