Nuclear medicine in the operating room: present and future

The current role of nuclear medicine in the operating room is closely related to the enhancement of the sentinel node (SN) procedure developed more than 3 decades ago. At that moment, the so-called triple approach (lymphoscintigraphy, gamma probe detection, and blue dye) was established as the standard of care for SN biopsy in melanoma and breast cancer. It also marked a first international multidisciplinary learning effort based on skill transfer and outcome evaluation, laying the fundaments to delineate the emerging field of interventional nuclear medicine (iNM) thanks to a similar multimodality approach and multidisciplinary practice. Currently, imaging modalities like SPECT/CT and PET/CT allow to preoperatively generate precision roadmaps for navigation in the operating room. The combination of modern technologies has facilitated iNM incorporation for surgery in more complex anatomical areas. The SN procedure has been expanded to different gynecological and urological malignancies as well as head and neck and gastrointestinal cancers. Besides iNM for open surgery, it is also possible to guide robot-assisted laparoscopic procedures for both SN biopsy and resection of oligometastases. The increasing development of hybrid tracers for combined radioguidance and fluorescence will reinforce the role of iNM in the future. The aim of this review is to comprehensively evaluate the contribution of nuclear medicine concerning current clinical applications and technological advances in the field of radioguided surgery.