Multimodal imaging and detection approach to F-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

Background: 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 F-FDG-directed surgery for known/suspected malignancies. Methods: From June 2005-June 2010, 145 patients were injected with 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 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 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 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, 272656) minutes, 619 (± 119, 253-846) and 661 (± 117, 433-835) minutes, and 674 (± 186, 299-1068) and 752 (± 127, 499-976) minutes, respectively. * Correspondence: [email protected] Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University Medical Center, Columbus, Ohio, 43210, USA Full list of author information is available at the end of the article Povoski et al. World Journal of Surgical Oncology 2011, 9:152 http://www.wjso.com/content/9/1/152 WORLD JOURNAL OF SURGICAL ONCOLOGY © 2011 Povoski et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conclusions: Our multimodal imaging and detection approach to 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. Background F-fluorodeoxyglucose (F-FDG) positron emission tomography/computed tomography (PET/CT) is widely used in the clinical management of cancer patients and has become the cornerstone of diagnostic imaging, staging, follow-up surveillance, and monitoring of ongoing therapy for a wide variety of malignancies [1-7]. In this regard, there has been increased interest and growth in clinical research directed towards the use of F-FDG for the intraoperative detection of known and occult malignant disease during cancer surgery [8-48]. The application of F-FDG for intraoperative detection during cancer surgery was first described in 1999 for colorectal cancer [8]. Since that time, a significant portion of this ongoing work related to the use of F-FDG for intraoperative detection during cancer surgery has been conducted at The Ohio State University and has been directed toward multiple solid malignancies [8-10,22-24,28-33,36,37,40]. Collectively, such efforts have been directed toward colorectal cancer, melanoma, lymphoma, breast cancer, gynecologic malignancies, head and neck malignancies, and lung cancer [8-48]. The motivation behind using F-FDG for intraoperative detection during cancer surgery has been multifactorial, including exploring its applicability for real-time intraoperative staging, surgical planning and execution, and determination of completeness of surgical resection for F-FDG-avid lesions. In 2007, we first reported upon our ongoing efforts to formulate a truly multimodal imaging and detection approach to F-FDG-directed surgery [23,32,36,40]. In the general schema for this multimodal approach, patients undergoing same-day intravenous administration of F-FDG were subjected to one or more of a variety of F-FDG-related diagnostic procedures, including (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) (Table 1), (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. Herein, we have comprehensively described the specific methodology utilized in our single-institution cumulative retrospective experience with a multimodal imaging and detection approach to F-FDG-directed surgery for patients with known or suspected malignancies, in order to assess its technical and logistic feasibility for realtime intraoperative staging, surgical planning and execution, and determination of completeness of surgical resection for F-FDG-avid lesions detected in patients who are deemed as appropriate surgical candidates.