Multimodal Imaging and Detection Strategy With 124 I-Labeled Chimeric\nMonoclonal Antibody cG250 for Accurate Localization and Confirmation of Extent of Disease\nDuring Laparoscopic and Open Surgical Resection of Clear Cell Renal Cell\nCarcinoma
A 60-year-old Caucasian male with a history of Ollier disease (a rare, nonhereditary,\nsporadic disorder characterized by multiple intraosseous benign cartilaginous tumors)\npresented with a right renal mass that was found at the time of a work-up for painless\nhematuria. CT scan of the abdomen showed a 10.3 cm × 7.6 cm × 6.7 cm mass in the superior\npole of the right kidney, with infiltration into the posterior hilum of the upper renal pole\n(). Retrograde cystoscopy\nwas completely negative.\n18F-FDG PET/CT imaging was performed during concomitant work-up of a suspicious\nleft femoral head/neck lesion related to the patient’s Ollier disease. 18F-FDG\nPET/CT imaging was performed 89 minutes following intravenous administration of 15.3 mCi of\n18F-FDG (). The\nattenuation correction non-contrast-enhanced CT portion of the 18F-FDG PET/CT\nimaging showed a large mass arising from the superior pole of the right kidney, with\n18F-FDG activity less than or equal to that of the normal 18F-FDG\naccumulation pattern within the remainder of either kidney. Mild, increased\n18F-FDG activity was seen in the left femoral head and neck region. No obvious\nsites of metastatic disease were originally identified in the initial interpretation of the\n18F-FDG PET/CT imaging.\n124I-cG250 PET/CT imaging was performed 4 days following intravenous\nadministration of 5.4 mCi of 124I-cG250 (). 124I-cG250 PET/CT imaging showed\nincreased 124I-cG250 activity within the renal mass in the superior pole of the\nright kidney, as well as increased 124I-cG250 activity within a retroperitoneal\nlymph node.\nThe patient was taken to the operating room and underwent a laparoscopic right radical\nnephrectomy with retroperitoneal lymph node dissection. Intraoperatively, a laparoscopic\ngamma detection probe (Neoprobe Model 2059, Neoprobe Corporation, Dublin, OH) was used to\nlocalize and identify all sites of 124I-cG250 uptake, to assist in the surgical\nresection, and for confirmation of complete removal of all sites of increased\n124I-cG250 activity. The laparoscopic gamma detection probe correctly identified\nincreased 124I-cG250 activity, both within the primary tumor of the right kidney\nand within the adjacent retroperitoneal lymph node tissues and provided confirmation of\nsuccessful laparoscopic surgical resection.\nThe intact right radical nephrectomy specimen and the intact retroperitoneal lymph node\ndissection specimen were imaged with 124I-cG250 PET/CT imaging and underwent\nsubsequent standard pathology processing and microscopic evaluation (). 124I-cG250 PET/CT imaging clearly\nidentified the sites of disease within the intact right radical nephrectomy specimen and the\nintact retroperitoneal lymph node dissection specimen. Histopathologic evaluation of the\nright nephrectomy specimen revealed an RCC (Fuhrman grade 3, 10.5 cm × 7.4 cm × 5.8 cm) of\nthe clear cell type with sarcomatoid features. It had surgical resection margins that were\nnegative, including Gerota’s fascia, the renal vessels, and the distal ureter. A total of 5\nregional lymph nodes were identified within the retroperitoneal lymph node dissection\nspecimen, with one lymph node metastasis identified and representing a lymph node nearly\ncompletely replaced by a tumor that was initially recognized on the preoperative\n124I-cG250 PET/CT imaging and resected with the assistance of the laparoscopic\ngamma detection probe.\nThe patient had a relatively uneventful postoperative course and was discharged to home on\npostoperative day 1. Two weeks later, the patient subsequently underwent an uneventful left\nproximal femur hemiarthroplasty, which showed a low-grade cartilaginous neoplasm, consistent\nwith his Ollier disease. The patient then went on to participate in the ASSURE (ECOG 2805)\nclinical trial, representing a randomized, double-blind, multi-institutional, phase III\nclinical trial comparing adjuvant sorafenib versus adjuvant sunitinib versus placebo in\npatients with resected RCC. At the time of this publication—30 months after the patient’s\nprevious laparoscopic right radical nephrectomy and retroperitoneal lymph node\ndissection—the patient is without evidence of disease.