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Beyond penile cancer, is there a role for sentinel node biopsy in urological malignancies?

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ABSTRACT

This review aims to discuss the current state-of-the-art of sentinel node (SN) mapping in urological malignancies. The principles and methodological aspects of lymphatic mapping and SN biopsy in urological malignancies are reviewed. Literature search was restricted to English language. The references of the retrieved articles were examined to identify additional articles. The review also includes meta-analyses published in the past 5 years. SN biopsy for penile cancer is recommended by the European Association of Urology as the preferred staging tool for clinically node-negative patients with at least T1G2 tumours (level of evidence 2a, Grade B). The feasibility of SN biopsy in prostate cancer has been repeatedly demonstrated and its potential value is increasingly being recognised. However, conclusive prospective clinical data as well as consensus on methodology and patient selection are still lacking. For bladder, renal and testicular cancer, only few studies have been published, and concerns around high false-negative rates remain. Throughout the years, the uro-oncological field has portrayed a pivotal role in the development of the SN concept. Recent advances such as hybrid tracers and novel intraoperative detection tools such as fluorescence and portable gamma imaging will hopefully encourage prospectively designed clinical trials which can further substantiate the potential of the SN approach in becoming an integral part of staging in urological malignancies beyond penile cancer.

No MeSH data available.


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Lymphatic mapping in penile cancer. Planar anterior image a showing drainage to two lymph nodes in the right groin and faint left inguinal uptake. By contrast, coronal (b) and transversal (c) fused SPECT/CT show clear uptake in the left groin corresponding to two lymph nodes (circle) along both sides of the femoral vessels as seen on CT (d). Note that intense uptake in the right groin corresponds with a cluster of four lymph nodes (circle)
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Fig2: Lymphatic mapping in penile cancer. Planar anterior image a showing drainage to two lymph nodes in the right groin and faint left inguinal uptake. By contrast, coronal (b) and transversal (c) fused SPECT/CT show clear uptake in the left groin corresponding to two lymph nodes (circle) along both sides of the femoral vessels as seen on CT (d). Note that intense uptake in the right groin corresponds with a cluster of four lymph nodes (circle)

Mentions: For penile cancer, there is a reasonable consensus regarding the preoperative lymphatic mapping procedure. The most widely applied radiocolloid (in Europe) is 99mTechnetium-nanocolloid which is generally injected intradermally within 1 cm radius proximally from the primary tumour or from the surgical scar in case of prior primary lesion excision. A total tracer dose of 50–90 MBq in 0.2–0.4 cc volume divided in three sites is injected [14, 15]. The technique is also feasible after removal of the primary penile tumour by, e.g., partial penectomy (in this case the tracer is injected at the base of the penis), allowing for rapid removal of the primary tumour where needed and subsequent SN dissection in a specialised centre in a separate session [16]. Recently, this approach has successfully been applied in a series of 92 patients [17]. The evolution of the SN procedure throughout the years has led to a SN identification rate of 97 % with an acceptable false-negative rate of 7 % [18]. Repeat SN biopsy after tumour recurrence is also a validated procedure [19]. Lymphoscintigraphy after radiocolloid injection is mostly performed at 10–20 min and 2 h postinjection [12, 15]. The most frequently visualised lymphatic drainage pattern is bilateral drainage to both groins (80 %) and this technique has a reproducibility rate of 100 % [20]. In case of non-visualisation or unilateral drainage, tracer re-injection can be performed [21]. Some centres add single-photon emission computed tomography-computed tomography (SPECT/CT) to the imaging protocol to provide additional anatomical information of the SNs. For instance, the modality can differentiate inguinal from iliac (most frequently second-echelon) lymph nodes and is also helpful to detect additional SNs (Fig. 2) [22]. Furthermore, SPECT/CT has been used to optimise the procedure and to analyse the lymphatic drainage of penile cancer by evaluating the possible implications for the extent of inguinal lymph node dissection. In 50 patients lymphatic drainage was visualised in 82 of 86 clinically node-negative groins (95 %) scheduled for the SN procedure. All SNs were located in the inguinal zones (medial superior 73 %, lateral superior 8.7 % and central 18.3 % on SPECT/CT (Fig. 1a). No lymphatic drainage to the inferior zones of the groin was seen which suggests the possibility to exclude these zones from a subsequent inguinal lymph node dissection in the case of a tumour-positive SN [23].Fig. 2


Beyond penile cancer, is there a role for sentinel node biopsy in urological malignancies?
Lymphatic mapping in penile cancer. Planar anterior image a showing drainage to two lymph nodes in the right groin and faint left inguinal uptake. By contrast, coronal (b) and transversal (c) fused SPECT/CT show clear uptake in the left groin corresponding to two lymph nodes (circle) along both sides of the femoral vessels as seen on CT (d). Note that intense uptake in the right groin corresponds with a cluster of four lymph nodes (circle)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5037151&req=5

Fig2: Lymphatic mapping in penile cancer. Planar anterior image a showing drainage to two lymph nodes in the right groin and faint left inguinal uptake. By contrast, coronal (b) and transversal (c) fused SPECT/CT show clear uptake in the left groin corresponding to two lymph nodes (circle) along both sides of the femoral vessels as seen on CT (d). Note that intense uptake in the right groin corresponds with a cluster of four lymph nodes (circle)
Mentions: For penile cancer, there is a reasonable consensus regarding the preoperative lymphatic mapping procedure. The most widely applied radiocolloid (in Europe) is 99mTechnetium-nanocolloid which is generally injected intradermally within 1 cm radius proximally from the primary tumour or from the surgical scar in case of prior primary lesion excision. A total tracer dose of 50–90 MBq in 0.2–0.4 cc volume divided in three sites is injected [14, 15]. The technique is also feasible after removal of the primary penile tumour by, e.g., partial penectomy (in this case the tracer is injected at the base of the penis), allowing for rapid removal of the primary tumour where needed and subsequent SN dissection in a specialised centre in a separate session [16]. Recently, this approach has successfully been applied in a series of 92 patients [17]. The evolution of the SN procedure throughout the years has led to a SN identification rate of 97 % with an acceptable false-negative rate of 7 % [18]. Repeat SN biopsy after tumour recurrence is also a validated procedure [19]. Lymphoscintigraphy after radiocolloid injection is mostly performed at 10–20 min and 2 h postinjection [12, 15]. The most frequently visualised lymphatic drainage pattern is bilateral drainage to both groins (80 %) and this technique has a reproducibility rate of 100 % [20]. In case of non-visualisation or unilateral drainage, tracer re-injection can be performed [21]. Some centres add single-photon emission computed tomography-computed tomography (SPECT/CT) to the imaging protocol to provide additional anatomical information of the SNs. For instance, the modality can differentiate inguinal from iliac (most frequently second-echelon) lymph nodes and is also helpful to detect additional SNs (Fig. 2) [22]. Furthermore, SPECT/CT has been used to optimise the procedure and to analyse the lymphatic drainage of penile cancer by evaluating the possible implications for the extent of inguinal lymph node dissection. In 50 patients lymphatic drainage was visualised in 82 of 86 clinically node-negative groins (95 %) scheduled for the SN procedure. All SNs were located in the inguinal zones (medial superior 73 %, lateral superior 8.7 % and central 18.3 % on SPECT/CT (Fig. 1a). No lymphatic drainage to the inferior zones of the groin was seen which suggests the possibility to exclude these zones from a subsequent inguinal lymph node dissection in the case of a tumour-positive SN [23].Fig. 2

View Article: PubMed Central - PubMed

ABSTRACT

This review aims to discuss the current state-of-the-art of sentinel node (SN) mapping in urological malignancies. The principles and methodological aspects of lymphatic mapping and SN biopsy in urological malignancies are reviewed. Literature search was restricted to English language. The references of the retrieved articles were examined to identify additional articles. The review also includes meta-analyses published in the past 5 years. SN biopsy for penile cancer is recommended by the European Association of Urology as the preferred staging tool for clinically node-negative patients with at least T1G2 tumours (level of evidence 2a, Grade B). The feasibility of SN biopsy in prostate cancer has been repeatedly demonstrated and its potential value is increasingly being recognised. However, conclusive prospective clinical data as well as consensus on methodology and patient selection are still lacking. For bladder, renal and testicular cancer, only few studies have been published, and concerns around high false-negative rates remain. Throughout the years, the uro-oncological field has portrayed a pivotal role in the development of the SN concept. Recent advances such as hybrid tracers and novel intraoperative detection tools such as fluorescence and portable gamma imaging will hopefully encourage prospectively designed clinical trials which can further substantiate the potential of the SN approach in becoming an integral part of staging in urological malignancies beyond penile cancer.

No MeSH data available.


Related in: MedlinePlus