Hybrid Surgical Guidance: Does Hardware Integration of γ- and Fluorescence Imaging Modalities Make Sense?

The clinically applied hybrid tracer indocyanine green-Tc-99m-nanocolloid enables combined radio-and fluorescence image guidance during sentinel node (SN) biopsy procedures. To provide optimal surgical guidance, this tracer requires the presence of both gamma- and fluorescence modalities in the operating room. We reasoned that the combination or integration of these modalities could further evolve the hybrid surgical guidance concept. To study this potential, we clinically applied 2 setups that included the combination of gamma-detection modalities and an open surgery fluorescence camera. Methods: To attach the fluorescence camera (VITOM) to either a gamma-ray detection probe (GP; VITOM-GP) or a portable gamma-camera (GC; Vitom GC), clip on brackets were designed and printed in 3-dimensional sterilizable RC31. Both combined modalities were evaluated in, respectively, 5 and 6 patients with penile cancer during an SN biopsy procedure using indocyanine green-Tc-99m-nanocolloid. Intraoperatively, radio and fluorescence-guided SN detection rates were scored at working distances of 0, 10, 20, and 30 cm for both combinations. Results: Using the VITOM-GP combination, we evaluated 9 SNs. gamma-tracing rates were shown to be 100%, 88.9%, 55.6%, and 55.6% at a respective working distance of 0, 10, 20, and 30 cm. Detection rates for the fluorescence imaging-based detection were found to be 100%, 77.8%, and 77.8%, at respective working distances of 10, 20, and 30 cm. When the VITOM-GC setup was used, all 10 intraoperatively evaluated SNs could be visualized with the -y-camera independent of the working distance. Fluorescence detection rates were 90%, 80%, and 80% at 10-, 20-, and 30 -cm working distances. The integrated detection modalities were shown to work synergistically; overall the, GC was most valuable for rough localization (10 to 30 -cm range) of the SNs, the GP for providing convenient realtime acoustic feedback, whereas fluorescence guidance allowed detailed real-time SN visualization. Conclusion: Our findings suggest that full integration of a fluorescence camera with gamma-detector (GP or GC) can be of value when a hybrid, radioactive and fluorescent tracer is used.