Multimodal imaging and detection approach to 18F-FDG-directed surgery for patients with known or suspected malignancies: a comprehensive description of the specific methodology utilized in a single-institution cumulative retrospective experience

Abstract

Background: (18)F-FDG PET/CT is widely utilized in the management of cancer patients. The aim of this paper was to comprehensively describe the specific methodology utilized in our single-institution cumulative retrospective experience with a multimodal imaging and detection approach to (18)F-FDG-directed surgery for known/suspected malignancies.

Methods: From June 2005-June 2010, 145 patients were injected with (18)F-FDG in anticipation of surgical exploration, biopsy, and possible resection of known/suspected malignancy. Each patient underwent one or more of the following: (1) same-day preoperative patient diagnostic PET/CT imaging, (2) intraoperative gamma probe assessment, (3) clinical PET/CT specimen scanning of whole surgically resected specimens (WSRS), research designated tissues (RDT), and/or sectioned research designated tissues (SRDT), (4) micro PET/CT specimen scanning of WSRS, RDT, and/or SRDT, (5) total radioactivity counting of each SRDT piece by an automatic gamma well counter, and (6) same-day postoperative patient diagnostic PET/CT imaging.

Results: Same-day (18)F-FDG injection dose was 15.1 (± 3.5, 4.6-26.1) mCi. Fifty-five same-day preoperative patient diagnostic PET/CT scans were performed. One hundred forty-two patients were taken to surgery. Three of the same-day preoperative patient diagnostic PET/CT scans led to the cancellation of the anticipated surgical procedure. One hundred forty-one cases utilized intraoperative gamma probe assessment. Sixty-two same-day postoperative patient diagnostic PET/CT scans were performed. WSRS, RDT, and SRDT were scanned by clinical PET/CT imaging and micro PET/CT imaging in 109 and 32 cases, 33 and 22 cases, and 49 and 26 cases, respectively. Time from (18)F-FDG injection to same-day preoperative patient diagnostic PET/CT scan, intraoperative gamma probe assessment, and same-day postoperative patient diagnostic PET/CT scan were 73 (± 9, 53-114), 286 (± 93, 176-532), and 516 (± 134, 178-853) minutes, respectively. Time from (18)F-FDG injection to scanning of WSRS, RDT, and SRDT by clinical PET/CT imaging and micro PET/CT imaging were 389 (± 148, 86-741) and 458 (± 97, 272-656) minutes, 619 (± 119, 253-846) and 661 (± 117, 433-835) minutes, and 674 (± 186, 299-1068) and 752 (± 127, 499-976) minutes, respectively.

Conclusions: Our multimodal imaging and detection approach to (18)F-FDG-directed surgery for known/suspected malignancies is technically and logistically feasible and may allow for real-time intraoperative staging, surgical planning and execution, and determination of completeness of surgical resection.

Figure 1

Segment 7 hepatic metastasis from colorectal cancer: (a) Preoperative patient diagnostic PET/CT scan demonstrating an ¹⁸F-FDG-avid lesion in the liver (red circle). (b) Postoperative patient diagnostic PET/CT demonstrating complete removal of the ¹⁸F-FDG-avid lesion (red circle). (c) Digital photo of the WSRS (i.e., segment 7 liver resection specimen), visualizing the hepatic metastasis (red oval). (d) Clinical PET/CT specimen image and (e) micro PET/CT specimen image of the WSRS, demonstrating the ¹⁸F-FDG-avid lesion (red oval). (f) Digital photo depicting the first phase of the pathologic processing that produced the RDT, which consists of a single 0.5 cm slice through the hepatic metastasis. (g) Clinical PET/CT specimen image and (h) micro PET/CT specimen image of the RDT, demonstrating the ¹⁸F-FDG-avid lesion that corresponds to the hepatic metastasis. (i) Digital photo after sectioning of the RDT into five pieces of tissue, designated as SRDT, with two pieces containing visible tumor. (j) Clinical PET/CT specimen image and (k) micro PET/CT image of the SRDT, demonstrating ¹⁸F-FDG avidity in the two pieces that corresponds to the hepatic metastasis. (l) H&E stained, whole-mount slide (0.4× magnification) of the specific SRDT piece that is highlighted in the red rectangle in (i), (j), and (k), demonstrating histologic confirmation of a colorectal cancer hepatic metastasis and the corresponding location of tumor within this specific SRDT piece. Each division of the hatched line in (c), (f), and (i) represents 1 cm.

Figure 2

Right lower lobe lung cancer: (a) Preoperative patient diagnostic PET/CT scan demonstrating an ¹⁸F-FDG-avid lesion in the right lower lobe (red circle). (b) Postoperative patient diagnostic PET/CT demonstrating complete removal of the ¹⁸F-FDG-avid lesion (red circle). (c) Digital photo of the WSRS (i.e. right lower lobectomy specimen), visualizing the lung cancer (red circle). (d) Clinical PET/CT specimen image of the WSRS, demonstrating the ¹⁸F-FDG-avid lesion (red circle). (e) Digital photo depicting the first phase of the pathologic processing that produced the RDT, which consists of a single 0.5 cm slice through the lung cancer. (f) Clinical PET/CT specimen image and (g) micro PET/CT specimen image of the RDT, demonstrating the ¹⁸F-FDG-avid lesion that corresponds to the lung cancer. (h) Digital photo after sectioning of the RDT into six pieces of tissue, designated as SRDT, with four pieces containing visible tumor. (i) Clinical PET/CT specimen image and (j) micro PET/CT image of the SRDT, demonstrating ¹⁸F-FDG avidity in the four pieces that corresponds to the lung cancer. (k) H&E stained, whole-mount slide (0.4× magnification) of the specific SRDT piece that is highlighted in the red rectangle in (h), (i), and (j), demonstrating histologic confirmation of the lung cancer and the corresponding location of tumor within this specific SRDT piece. Each division of the hatched line in (c), (e), and (h) represents 1 cm.

Figure 3

Left axillary recurrence from breast cancer: (a) Preoperative patient diagnostic PET/CT scan demonstrating an ¹⁸F-FDG-avid lesion in the left axilla (red circle). (b) Postoperative patient diagnostic PET/CT demonstrating complete removal of the ¹⁸F-FDG-avid lesion (red circle). (c) Digital photo of the WSRS (i.e., left axillary lymph node dissection specimen), with the white circle corresponding to a suspicious palpable lymph node that is to be further processed. (d) Clinical PET/CT specimen image and (e) micro PET/CT specimen image of the WSRS, with the red circle demonstrating the ¹⁸F-FDG-avid lesion that is to be further processed. (f) Digital photo depicting the first phase of the pathologic processing that produced the RDT, which consists of a single 0.5 cm slice through a piece of tissue containing the suspicious palpable lymph node. (g) Clinical PET/CT specimen image and (h) micro PET/CT specimen image of the RDT, demonstrating the ¹⁸F-FDG-avid lesion that corresponds to the piece of tissue containing the suspicious palpable lymph node. (i) Digital photo after sectioning of the RDT into four pieces of tissue, designated as SRDT, with visible tumor seen within the piece of tissue shown in the red square. (j) Clinical PET/CT specimen image and (k) micro PET/CT image of the SRDT, demonstrating ¹⁸F-FDG avidity within the piece of tissue shown in the red square that corresponds to the visible tumor within the previously processed portion of the suspicious palpable lymph node. (l) H&E stained, whole-mount slide (0.4× magnification) of the specific SRDT piece that is highlighted in the red square in (i), (j), and (k), demonstrating histologic confirmation breast cancer within the corresponding previously processed portion of the suspicious palpable lymph node. Each division of the hatched line in (c), (f), and (i) represents 1 cm.

Figure 4

Rectosigmoid colon recurrence from cervical cancer: (a) Preoperative patient diagnostic PET/CT scan demonstrating an ¹⁸F-FDG-avid lesion in the rectosigmoid colon (red circle). (b) Postoperative patient diagnostic PET/CT demonstrating complete removal of the ¹⁸F-FDG-avid lesion (red circle). (c) Digital photo of the WSRS (i.e., segmental rectosigmoid colon resection specimen), demonstrating the area of the rectosigmoid colon recurrence (white oval). (d) Clinical PET/CT specimen image and (e) micro PET/CT specimen image of the WSRS, demonstrating the ¹⁸F-FDG-avid lesion (red oval). (f) Digital photo depicting the first phase of the pathologic processing that produced the RDT, which consists of a single 0.5 cm slice through the rectosigmoid colon recurrence. (g) Clinical PET/CT specimen image and (h) micro PET/CT specimen image of the RDT, demonstrating the ¹⁸F-FDG-avid lesion that corresponds to the rectosigmoid colon recurrence. (i) Digital photo after sectioning of the RDT into four pieces of tissue, designated as SRDT, with two pieces containing visible tumor. (j) Clinical PET/CT specimen image and (k) micro PET/CT image of the SRDT, demonstrating ¹⁸F-FDG avidity in the two pieces that corresponds to the rectosigmoid colon recurrence. (l) H&E stained, whole-mount slide (0.4× magnification) of the specific SRDT piece that is highlighted in the red square in (i), (j), and (k), demonstrating histologic confirmation of the rectosigmoid colon recurrence of cervical cancer and the corresponding location of tumor within this specific SRDT piece. Each division of the hatched line in (c), (f), and (i) represents 1 cm.