Clinical Cases

Primary Breast Tumor Surgery with ROLL/RSL Techniques

How can non palpable regions be safely localized and resected?

Besides the safe and robust detection and resection guidance for sentinel lymph nodes, declipse®SPECT was successfully applied in ROLL (Radio-guided occult lesion localization) and RSL (radio seed localization) [Lovrics2011]. In ROLL procedures, a Tc99m based radioisotope is injected in the primary tumor, and used for intraoperative guidance during resection. This technique replaces the standard wire guided localization approach and is more promising since dislocation of the wire cannot occur. It has been reported that the re-resection rate decreases significantly and the rate of clean resection margins increases [Ramesh2008]. RSL is similar but uses a solid radioactive seed (I-125) with a low radioactive dose instead of a fluid radiopharmaceutical [Riet2010]. While ROLL is more popular in Europe, RSL is more frequently used in North America with the same effect of reducing the recurrence of local tumor and increase of the safe tumor margins. declipse®SPECT was recently introduced to further facilitate the control of the tumor margins by guidance through a 3D image before the resection and a control 3D image in-vivo and ex-vivo [Brouwer2012a]. declipse®SPECT promises here a new standard for safe and minimally invasive treatment of primary breast lesions in lumpectomy.


  • Full 3-D image acquisition enables precise identification and localization
  • Direct correlation with anatomy provides orientation and localization
  • Overview of activity distribution ensures detection/identification of the labeled tumors, and in the case of combined surgery with SLNB the injection site and sentinel lymph nodes are clearly differentiated, even if they are in close vicinity to each other (declipse®SPECT eliminates shadowing effects)
Figure: The image shows a 3-D declipse®SPECT image of the radioactivity distribution in palpable primary tumor for sentinel lymph node marking and in a non palpable lesion for radio-guided occult lesion localization. The intraoperatively generated 3-D image data is overlaid using augmented reality visualization onto the operation situs for intuitive orientation.

Navigation to the non-palpable tumors during intervention:

  • Orientation, localization and identification in 3-D ensure safety during procedure
  • Depth measurement provides direct and minimally invasive access
Figure: Augmented reality image overlay for correlation of the 3-D image with the anatomy of the patient allows precise guidance for minimally invasive and complete resection of tumor tissue.

Control of clean border resection of all non-palpable tumors:

  • Ex-vivo 3-D scan provides confirmation of complete removal of radioactively marked tumors
  • Enables specimen examination after resection and radioactive boundary control through direct visual evaluation
  • Documentation enables transparent and reliable follow up treatments
Figure: After the removal of the primary tumor, both ex-vivo and in-vivo scans can be performed in order to confirm the radioactivity within the ex-vivo specimen or completely removed through the in-vivo scan. This allows direct estimation of radioactive tumor borders even before the pathology results are communicated to the operating room personal.

SurgicEye at EANM 2016 ⁄ Book published