BACKGROUND: Given the constant increase in the healthcare demand for examinations related to radio-guided surgery (RGS), our hospital adopted new professional profiles in the RGS team, in order to partially reduce the time spent by nuclear medicine physicians on this task.
OBJECTIVE: To analyze the process of incorporating the profiles of Diagnostic Imaging Technician (DIT) and Sentinel Node Referent Nurse (SNRN), evaluating their deployment in the procedures linked to the technique.
METHODS: Analysis of RGS activity during the period 2018-2022, focusing on pre-surgical and surgical procedures related to breast cancer (BC) and malignant melanoma (MM), as they are those pathologies on which the transfer of care competencies was concentrated. Chronological evolution of the competencies assumed by the different profiles during their integration into the RGS team.
RESULTS: RGS\'s healthcare activity during the analyzed period experienced an increase of 109%. BC and MM were the pathologies that accounted for by far the greatest demand for care. The transfer of competencies in these two pathologies occurred in a progressive and staggered manner, with 74% (460/622) of the administration phase being carried out by the SNRN and 64% (333/519) of the surgeries by the DIT in 2022.
CONCLUSIONS: The creation of a multidisciplinary RGS team that includes different professional profiles (nuclear medicine physician [MN], ERGC and TSID) is an effective strategy to respond to the increase in the complexity and number of all procedures related to RGS.

BACKGROUND: Freehand SPECT can be a useful imaging technique for preoperative planning of sentinel lymph node biopsy (SLNB) as it allows localization of the sentinel node by 3D and real-time tomographic imaging and determines its depth after a few minutes of scanning. The aim of the study was to evaluate the correlation between the number of detected SNs between freehand SPECT images and lymphoscintigraphy (LS).
METHODS: 100 patients with a diagnosis of invasive breast cancer and no clinical evidence of lymph node involvement prospectively underwent SLNB. The preoperative study included freehand SPECT imaging at 15min after injection and LS imaging at 25 and 60-90min after injection (early and late). The observed agreement was analyzed and a concordance study was performed between the number of SNs detected with freehand SPECT and LS.
RESULTS: The observed agreement in the detection of SNs between freehand SPECT and early LS was 72%; between freehand SPECT and late LS was 85%; and between early and late LS was 87%. In the concordance study, there was moderate concordance between freehand SPECT and early LS (kappa coefficient: 0.42); moderate-high concordance between freehand SPECT and late LS (kappa coefficient: 0.60); and moderate-high concordance between early and late LS (kappa coefficient: 0.70), with no significant differences between them (p-value=0.16).
CONCLUSIONS: Freehand SPECT showed a moderate-high concordance with conventional imaging studies and could be a valid alternative for the presurgical study of SLNB in breast cancer.

OBJECTIVE: To evaluate by in- vivo lymphoscintigraphy and SPECT-CT imaging, the lymphatic drainage patterns of para-nasal sinus(PNS) tumors. To confirm or refute the belief of the retropharyngeal lymph node (RPLN) being the significant draining lymph node for such tumors.
METHODS: Prospective cohort study conducted on previously untreated PNS tumors with no clinico-radiological evidence of lymph node metastasis. Lymphoscintigraphy undertaken by nasal endoscopic assisted peritumoral injection of 99mTc Sulfur colloid. Injections were classified as anterior or posterior as per a vertical line along the maxillary sinus ostium.
RESULTS: 17 patients were included. Lymphoscintigraphy successfully identified 17 sentinel nodes in 15 patients and was unsuccessful (lymphoscintigraphy failure) in 2 patients. Predominant sites of sentinel lymphatic drainage were noted to be the RPLN (n = 8; 47%), and Level I (n = 7; 42%). Occasional drainage was identified at the peri-parotid node(n = 1) and at Level II (n = 1). Contralateral drainage was noted in 2 patients (level I-1 and RPLN-1). Anterior injections drained predominantly to Level I (6/8) and RPLN (2/8), while posterior injections drained predominantly to the RPLN ( 6/7). The relative risk of RPLN being identified as the sentinel node was significantly higher for posteriorly placed injections than for anteriorly placed injections (RR- 3.43; 95% CI-1.0-11.8, p = 0.05).
CONCLUSIONS: The RPLN is noted as a frequent draining node for sino-nasal tumours and merits routine attention in all sino-nasal tumors. The radio-colloid SPECT-CT technique described here offers an excellent in-vivo technique to further explore and validate the lymphatic drainage pathways of these tumours.

BACKGROUND: In 2019 the opportunity to add a nurse within the radioguided surgery (RGS) team was generated. The referent nurse model was adapted to, the sentinel node (SN) preoperative approaches.
OBJECTIVE: To describe the process performed to define the sentinel node referent nurse (SNRN) profile, to validate its practical application and to establish its clinical implementation.
METHODS: Methodology of analysis and continuous improvement in the management of processes (cycle PDCA): definition and planning of the SNRN functions in the breast cancer protocol, performance of a pilot test with 20 patients and analysis of the data in order to validate the circuit and establish its final clinical implementation.
RESULTS: New procedure flows-charts were elaborated, adding the figure of the SNRN, its function and nursing interventions during the process. In the pilot test a 58.3% reduction in subjective anxiety, a 75% decrease of the overall anxiety level, a 100% knowledge of the test and an acceptable patient perception of pain\'s level during the radiotracer administration were obtained. Regarding technical quality, 8/10 items assessed reached the level previously established by the RGS team.
CONCLUSIONS: The increasing complexity of the SN biopsy technique has created the opportunity to implement nursing care in the presurgical SN localization process. The profile of the SNRN is ideal for carrying it out and has led to improvements in the nursing diagnoses and assessed items.

Lymphoscintigraphy represents the \"gold standard\" for diagnosis of lymphedema, but an important limitation is the lack of procedural standardization. The aim of this Italian expert panel was to provide a procedural standard for lymphoscintigraphy in the evaluation of lymphatic system disorders. Topic anaesthetic gels containing lidocaine should be avoided. Patients should remove compressive dressings. Total recommended activity for 99mTc-nanocolloid administration in adults is 74MBq, or 37MBq per limb and per investigated compartment, in single or multiple aliquots. 2-3 subcutaneous injections should be performed (II-III±I interdigital space of each hand/foot), avoiding intravascular injection. Deep lymphatic system of lower limbs should be evaluated in presence of dermal back-flow or lymphatic stasis (1-2 subfascial administrations in retro-malleolar or plantar region). Planar images should be acquired from injection site to liver with whole-body or serial static acquisitions 20\' and 90\' after subcutaneous administration. Additional information on lymphatic pathways is obtained after a quick and/or prolonged exercise protocol. SPECT/CT is recommended to study the thoracic, abdominal and pelvic territories. When required, deep lymphatic system of lower limbs should be evaluated with static acquisition 90\' after subfascial administration. The report should describe administration and imaging procedure, exercise protocol, qualitative and semi-quantitative analysis (wash-out rate, transport index), potential sources of error. Due to the essential role fulfilled by lymphoscintigraphy in clinical management of primary and secondary lymphedema, an effort for the standardization of this technique should be made to provide the clinicians with a homogeneous and reliable technical methodology.

Lymphoscintigraphy in breast cancer usually shows lymphatic drainage to the ipsilateral axilla. Drainage to extraaxillary or contralateral axillary regions is rare and there is still controversy about its management. Due to the significant clinical impact of an accurate staging, a literature research is made based on a case of a patient with recurrence of left breast cancer with contralateral axillary sentinel lymph node detection, without evidence of lymphatic drainage to other locations.

BACKGROUND: Lipedema is a syndrome that is characterised by edema, an accumulation of fat, pain and haematomas in the lower limbs that principally affects women. Diagnosis is currently based on clinical criteria, since there is no accurate diagnostic imaging for the condition. The aim of our study was to describe the lymphoscintigraphic findings in patients with lipedema.
METHODS: A prospective cohort study of women with clinical criteria of lipedema who underwent lymphoscintigraphy. Two independent nuclear physicians described and classified the lymphoscintigraphy findings in different grades of severity, according to the migration and distribution of the radiopharmaceutical. Eighty three patients were included with a median age of 49.7years (range: 18-80) and a mean body mass index (BMI) of 29.9kg/m2 (95%CI: 28.4-31.3) RESULTS: Lymphoscintigraphy showed alterations in 47% of the patients, most were low (35.9%) or low-moderate grade (48.7%). None of the patients were severely affected (no migration of the radiopharmaceutical). The degree of lymphoscintigraphic involvement bore no relation to age (P=.674), Stemmer\'s sign (P=.506), or BMI (P=.832). We found lymphoscintigraphy findings in all the clinical stages of lipedema, with no significant differences between the grade of lymphoscintigraphic involvement and the clinical stage of lipedema (P=.142).
CONCLUSIONS: Although lymphoscintigraphy has been used to differentiate lipedema from lymphedema, we found frequent alterations in the patients with lipedema, therefore the presence of findings dues not discount a diagnosis of lip1aedema.

OBJECTIVE: The aim of this study was to review the feasibility of selective sentinel lymph node biopsy in patients with previous surgery for breast cancer, as well as to examine the factors that may interfere with sentinel node detection.
METHODS: A retrospective review was performed on 91 patients with breast cancer and previous breast surgery, and who underwent sentinel lymph node biopsy. Patients were divided into two groups according to their previous treatment: aesthetic breast surgery in 30 patients (group I) and breast-conserving surgery in 61 (group II). Lymphoscintigraphy was performed after an intra-tumour injection in 21 cases and a peri-areolar injection in 70 cases. An analysis was made of lymphatic drainage patterns and overall sentinel node detection according to clinical, pathological and surgical variables.
RESULTS: The overall detection of the sentinel lymph node in the lymphoscintigraphy was 92.3%, with 7.7% of extra-axillary drainages. The identification rate was similar after aesthetic breast surgery (93.3%) and breast-conserving surgery (91.8%). Sentinel lymph nodes were found in the contralateral axilla in two patients (2.2%), and they were included in the histopathology study. The non-identification rate in the lymphoscintigraphy was 7.7%. There was a significantly higher non-detection rate in the highest histological grade tumours (28.6% grade III, 4.5% grade I and 3.6% grade II).
CONCLUSIONS: Sentinel lymph node biopsy in patients with previous breast surgery is feasible and deserves further studies to assess the influence of different aspects in sentinel node detection in this clinical scenario. A high histological grade was significantly associated with a lower detection.

Radio-guided surgery has been developed for application in those disease scheduled for surgical management, particularly in areas of complex anatomy. This is based on the use of pre-operative scintigraphic planar, tomographic and fused SPECT/CT images, and the possibility of 3D reconstruction for the subsequent intraoperative locating of active lesions using handheld devices (detection probes, gamma cameras, etc.). New tracers and technologies have also been incorporated into these surgical procedures. The combination of visual and acoustic signals during the intraoperative procedure has become possible with new portable imaging modalities. In daily practice, the images offered by these techniques and devices combine perioperative nuclear medicine imaging with the superior resolution of additional optical guidance in the operating room. In many ways they provide real-time images, allowing accurate guidance during surgery, a reduction in the time required for tissue location and an anatomical environment for surgical recognition. All these approaches have been included in the concept known as (radio) Guided intraOperative Scintigraphic Tumour Targeting (GOSTT). This article offers a general view of different nuclear medicine and allied technologies used for several GOSTT procedures, and illustrates the crossing of technological frontiers in radio-guided surgery.

BACKGROUND: The local recurrence of pancreatic cancer is around 30% when complete resection can be achieved. Extended lymphatic resections may improve survival, but increases severe morbidity. As accurate patient selection should be mandatory, a new method is presented for pancreatic sentinel lymph node (SLN) detection with lymphoscintigraphy and gamma probe.
METHODS: Seven patients with cT2N0M0 pancreatic head cancer were enrolled between 2009 and 2012 in this prospective study. One day prior to surgery, preoperative lymphoscintigraphy with echoendoscopic intratumoural administration of Tc(99m)-labelled nanocolloid was performed, with planar and SPECT-CT images obtained 2h later. Gamma probe detection of SLN was also carried out during surgery.
RESULTS: Radiotracer administration was feasible in all patients. Scintigraphy images showed inter-aortocaval lymph nodes in 2 patients, hepatoduodenal ligament lymph nodes in 1, intravascular injection in 3, intestinal transit in 5, and main pancreatic duct visualisation in 1. Surgical resection could only be achieved in 4 patients owing to locally advanced disease. Intraoperative SLN detection was accomplished in 2 patients, both with negative results. Only in one patient could SLN be confirmed as truly negative by final histopathological analysis.
CONCLUSIONS: This new method of pancreatic SLN detection is technically feasible, but challenging. Our preliminary results with 7 patients are not sufficient for clinical validation.