The GOSTT concept and hybrid mixed/virtual/augmented reality environment radioguided surgery

The popularity gained by the sentinel lymph node (SLN) procedure in the last two decades did increase the interest of the surgical disciplines for other applications of radioguided surgery. An example is the gamma-probe guided localization of occult or difficult to locate neoplastic lesions. Such guidance can be achieved by intralesional delivery (ultrasound, stereotaxis or CT) of a radiolabelled agent that remains accumulated at the site of the injection. Another possibility rested on the use of systemic administration of a tumour-seeking radiopharmaceutical with favourable tumour accumulation and retention. On the other hand, new intraoperative imaging devices for radioguided surgery in complex anatomical areas became available. All this a few years ago led to the delineation of the concept Guided intraOperative Scintigraphic Tumour Targeting (GOSTT) to include the whole spectrum of basic and advanced nuclear medicine procedures required for providing a roadmap that would optimise surgery. The introduction of allied signatures using, e.g. hybrid tracers for simultaneous detection of the radioactive and fluorescent signals did amply the GOSTT concept. It was now possible to combine perioperative nuclear medicine imaging with the superior resolution of additional optical guidance in the operating room. This hybrid approach is currently in progress and probably will become an important model to follow in the coming years. A cornerstone in the GOSTT concept is constituted by diagnostic imaging technologies like SPECT/CT. SPECT/CT was introduced halfway the past decade and was immediately incorporated into the SLN procedure. Important reasons attributing to the success of SPECT/CT were its combination with lymphoscintigraphy, and the ability to display SLNs in an anatomical environment. This latter aspect has significantly been improved in the new generation of SPECT/CT cameras and provides the base for the novel mixed reality protocols of image-guided surgery. In these protocols the generated virtual SPECT/CT elements are visually superimposed in the body of the patient in the operating room to directly facilitate, by means of visualization on screen or using head-mounted devices, the localization of radioactive and/or fluorescent targets by minimal invasive approaches in areas of complex anatomy. All these technological advances will play an increasing role in the future extension and the clinical impact of the GOSTT concept.