Clinical articles
Multimodal image registration for localization of sentinel nodes in head and neck squamous cell carcinoma

https://doi.org/10.1016/j.joms.2004.02.017Get rights and content

Purpose

The aim of this clinical study was to propose a new method of preoperative 3-dimensional localization of the neck sentinel node in clinically and radiographically N0 squamous cell carcinoma of the oral cavity.

Patients and methods

This prospective study was carried out between August 2002 and August 2003. Ten patients with staged oral squamous cell cancer underwent this method of preoperative localization of the sentinel lymph node. At the present time, lymphoscintigraphy is recognized as the investigation of choice for the preoperative detection of sentinel nodes. Although we found it to be highly sensitive (100% in our study), it does not allow precise localization of the sentinel node in the anatomic context of the neck. To overcome this drawback, we used multimodal image registration applied to the cervical region in association with the imaging modalities of scintigraphy (single-photon emission computed tomography [SPECT] and gamma transmission) and computed tomography (CT). SPECT and gamma transmission (barium-133 sources) were carried out with a triple-head Philips-Marconi camera (Philips Medical System, Cleveland, OH), and CT was carried out with a General Electric console (GE Medical Systems, Milwaukee, WI). Gamma transmission was used to place the SPECT images in a reference cervical anatomic context (CT images). Registration involved the use of a manual method based on definition of homologous volume structures.

Results

Preoperative image registration effectively localized the cervical sentinel node in 9 of the 10 patients, enabling a guided surgical approach in 90% of cases. The sentinel node was localized and resected using a hand-held gamma probe.

Conclusions

This original study adapts a new tool (multimodal image registration) to obtain precise preoperative localization of the cervical sentinel node in N0 oral squamous cell carcinoma. We confirmed the feasibility of this method in this indication. Although this method is a novel one, we believe that it will become extremely useful once a consensus has been reached on exclusive excision of the cervical sentinel node in oral cancers, as is the case for melanoma or breast cancer.

Section snippets

Patients

All patients were treated in the Department of Maxillofacial and Plastic Surgery, Purpan University Hospital, Toulouse, France, between August 2002 and August 2003. The clinical series included 10 patients with N0 oral cancer (8 men and 2 women; age range, 42 to 67 years; mean age, 55.5 ± 7.8 years). Clinical examination and systematic preoperative CT scan did not detect any suspicious cervical lymph nodes. Five patients (50%) had a unilateral tumor (gingivae, oral tongue, lateral floor of the

Planar lymphoscintigraphy

In our study, the sensitivity of PLS was 100%; that is, the camera preoperatively detected at least 1 SN in all our patients. In all cases of midline tumors, PLS revealed at least 1 right and 1 left cervical SN.

Image registration

Although the sensitivity of PLS is 100%, multimodal image registration localized the SN in only 9 of 10 cases. This shows the limits of image registration, but it also shows the value of intraoperative use of the hand-held gamma probe, which enabled us to identify and resect the SN

Discussion

Of the various radiotracers that are available for lymphoscintigraphy, only 99mTc-sulfur colloid (99mTc-SC) Nanocis (CIS Bio International) and 99mTc-albumin colloid (99mTc-CA) (Nanocoll; GE Healthcare, London, United Kingdom) are obtainable in Europe and have been approved for medical use. Nanocis and Nanocoll represent the properties of the ideal radiotracer, 19, 20, 21 with rapid, predictable flow and durable uptake in the SN.

In our study, the sensitivity of PLS was 100%; that is, in all

References (39)

  • J.C. Alex et al.

    The gamma-probe-guided resection of radiolabeled primary lymph nodes

    Surg Oncol Clin North Am

    (1996)
  • M.L. Kessler et al.

    Integration of multimodality imaging data for radiotherapy treatment planning

    Int J Radiat Oncol Biol Phys

    (1991)
  • J.A. Woolgar

    Detailed topography of cervical lymph-node metastases from squamous cell carcinoma

    Int J Oral Maxillofac Surg

    (1997)
  • R.M. Cabanas

    An approach for the treatment of penile carcinoma

    Cancer

    (1977)
  • D.L. Morton et al.

    Technical details of intraoperative lymphatic mapping for early stage melanoma

    Arch Surg

    (1992)
  • J.L. Messina et al.

    Pathologic examination of the sentinel lymph node in malignant melanoma

    Am J Surg Pathol

    (1999)
  • E.R. Fisher et al.

    Detection and significance of occult axillary node metastases in patients with invasive breast cancer

    Cancer

    (1978)
  • A.E. Giuliano et al.

    Lymphatic mapping and sentinel lymphadenectomy for breast cancer

    Ann Surg

    (1994)
  • S.J. Stoeckli et al.

    Histopathological features of occult metastasis detected by sentinel lymph node biopsy in oral and oropharyngeal squamous cell carcinoma

    Laryngoscope

    (2002)
  • J.A. Werner et al.

    Number and location of radiolabeled, intraoperatively identified sentinel nodes in 48 head and neck cancer patients with clinically staged N0 and N1 neck

    Eur Arch Otorhinolaryngol

    (2002)
  • A.J. Wilhelm et al.

    Radiopharmaceuticals in sentinel lymph-node detection—an overview

    Eur J Nucl Med

    (1999)
  • J. Maublant et al.

    The detection of sentinel lymph node in nuclear medicine

    Bull Cancer

    (2002)
  • G. Tartaglione et al.

    Lymphatic mapping and sentinel node identification in squamous cell carcinoma and melanoma of the head and neck

    Tumori

    (2002)
  • A.R. Freire et al.

    Computed tomography and lymphoscintigraphy to identify lymph node metastases and lymphatic drainage pathways in oral and oropharyngeal squamous cell carcinomas

    Eur Arch Otorhinolaryngol

    (2003)
  • I. Kazem et al.

    Clinical evaluation of lymph node scanning utilizing colloidal gold-198

    Radiology

    (1968)
  • Union Internationale Contre le CancerConsensus/Consultation Session on Oral Cancer

    (1999)
  • M.W. van den Brekel et al.

    The incidence of micrometastases in neck dissection specimens obtained from elective neck dissections

    Laryngoscope

    (1996)
  • P. Ambrosch et al.

    Micrometastases in carcinoma of the upper aerodigestive tractDetection, risk of metastasizing, and prognostic value of depth of invasion

    Head Neck

    (1995)
  • J.A. Brennan et al.

    Molecular assessment of histopathological staging in squamous-cell carcinoma of the head and neck

    N Engl J Med

    (1995)
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