Preoperative Localization and Robotic ROLL-Guided Biopsy of Internal Mamary Lymph Node

The authors present the case of a 65-year-old man with a previous medical history of tuberculosis 35 years ago, a nephrectomy due to papillary cell renal carcinoma in March 2019, and COPD. During the follow-up, two nodules, measuring 11 and 12 mm on the RUL, were observed on a computed tomography (CT) scan in June 2019. The positron emission tomography (PET) scan on July 2019 showed two hypermetabolic nodules on RUL (SUV max 5), one nodule on LUL (SUV max 2.5), and some hypermetabolic lymph nodes in the left internal mammary artery (SUV max 4.4). The PET scan in September showed a decrease in the size of the lung nodules but an increase in the hypermetabolism of the lymph nodes on the left internal mammary artery (SUV max 5). The case was presented at the tumor board, and the decision was to biopsy the lymph nodes in the left mammary to rule out the existence of metastatic disease.

On the same day of the procedure, the patient underwent a CT scan to localize and inject 0.4 mCi of MAA-99mTc (0,2 mL) and 0.2 ml of air. The correct location of the radiotracer was confirmed by SPECT. The patient was transferred to the OR for a robotic-assisted biopsy of the internal mammary artery lymph nodes. The patient was placed on the left edge of the table, with a sheet-roll under his left side. The patient’s left arm was positioned below the level of the table, with the shoulder extended, to allow better port placement. The camera port (8 mm) was placed in the fifth intercostal space at the anterior axillary line, the right-hand port (8 mm) was approximately 10 cm away from the camera port along the anterior axillary line toward the axilla and posterior to the pectoralis muscle. A finder needle can be used to determine the correct position of this port as it should aim toward the innominate vein. Last, the left-hand port (8 mm) was placed medially, approximately 10 cm away from the camera port, in the sixth or seventh intercostal space, at the midclavicular line. An assistant port (Airseal 12 mm) was placed between the camera and the left-hand port, just above the insertion of the diaphragm. The chest was insufflated with carbon dioxide at a flow of 6 to 8 mL/min at a set pressure of 8-12 mm Hg. The radioprobe was inserted through the assistant port, and the area with increased activity was localized. The area was dissected, and we found two lymph nodes that were resected completely. Then the radioprobe was inserted again to confirm that the area of major activity had been resected and also that the specimen on the backtable had the major activity.

The immediate postoperative chest X-ray showed an expanded lung. The pleural drainage tube was removed 24 hours after surgery, and the patient was discharged on the third postoperative day. The pathological report showed a lymphoid follicular hyperplasia. Radioguided Occult Lesion Localization (ROLL) is a useful and simple technique to achieve a complete excision of lesions difficult to find.