Objective. To assess the relevance of sentinel lymph nodes (SNs) outside the extended pelvic lymph node dissection area (e-PLND). Patients and Methods. Evaluation of our laparoscopic SN procedures for prostate cancer patients of intermediate prognosis. Retrospective data collection on the exact location of the excised SNs and the pathology results were analyzed. Results and Limitations. Of the 121 patients, 49 had positive lymph nodes. 37 patients (31%) had SNs outside the e-PLND template. Five of these nodes were tumor bearing but only twice exclusively so. Of the 14 patients considered for salvage treatment, 6 were node positive. 7 of these 14 patients (50%) had SNs outside the extended dissection area, yet none of these nodes were tumor positive. Limitations are those of a retrospective study. Conclusions. Laparoscopic SN biopsy may show SNs outside the e-PLND template in 31% of the patients. However, nodes that are exclusively positive in one of these areas are rare. For the dichotomy positive or negative nodes, the locations outside the e-PLND area are not often relevant. Nevertheless, when all positive nodes are to be treated by resection or radiotherapy, these locations are relevant. When considering salvage treatment for prostate cancer, the method is feasible. 1. Introduction Sentinel node (SN) biopsy for prostate cancer has been validated in open surgery, combined with a prostatectomy, as well as in laparoscopic surgery [1–3]. The SN concept is based on the concept of sequential metastatic spread, starting with 1 or more nodes on a direct drainage pathway from the primary tumor site. A negative tumor status of the SN is equivalent to the absence of lymphatic involvement. The SN method does not pretend to identify all tumor-bearing nodes. Distinguishing the SN from second echelon nodes on only one preoperative image can be difficult in the pelvic region, since lymphatic channels are seldom visualized. An alternative way to make the distinction between the SN and second echelon nodes is by acquiring several sequential images and use the order of appearance as a criterion. Compared to an extended pelvic lymph node dissection (e-PLND), SN biopsy has the advantage that it enables identification of SNs outside the e-PLND area [3, 4]. In the present study, our experience with this aspect is presented. 2. Patients and Methods 2.1. Patients According to the EAU guidelines, we perform a laparoscopic SN procedure only in prostate cancer patients for whom the results will influence treatment decisions [5]. Patients who opt for external beam radiation
References
[1]
G. Holl, R. Dorn, H. Wengenmair, D. Weckermann, and J. Sciuk, “Validation of sentinel lymph node dissection in prostate cancer: experience in more than 2,000 patients,” European Journal of Nuclear Medicine and Molecular Imaging, vol. 36, no. 9, pp. 1377–1382, 2009.
[2]
W. Meinhardt, R. A. Valdés Olmos, H. G. van der Poel, A. Bex, and S. Horenblas, “Laparoscopic sentinel node dissection for prostate carcinoma: technical and anatomical observations,” British Journal of Urology International, vol. 102, no. 6, pp. 714–717, 2008.
[3]
A. Beri and G. Janetschek, “Technology insight: radioguided sentinel lymph node dissection in the staging of prostate cancer,” Nature Clinical Practice Urology, vol. 3, no. 11, pp. 602–610, 2006.
[4]
A. Briganti, F. K. H. Chun, A. Salonia et al., “Complications and other surgical outcomes associated with extended pelvic Lymphadenectomy in men with localized prostate cancer,” European Urology, vol. 50, no. 5, pp. 1006–1013, 2006.
[5]
“EUA guidelines on prostate cancer, N stage,” 2010, http://www.uroweb.org/gls/pdf/Prostate%20Cancer%202010%20June%2017th.pdf.
[6]
L. Vermeeren, R. A. Valdés Olmos, W. Meinhardt et al., “Intraoperative radioguidance with a portable gamma camera: a novel technique for laparoscopic sentinel node localisation in urological malignancies,” European Journal of Nuclear Medicine and Molecular Imaging, vol. 36, no. 7, pp. 1029–1036, 2009.
[7]
F. Wawroschek, H. Vogt, H. Wengenmair et al., “Prostate lymphoscintigraphy and radio-guided surgery for sentinel lymph node identification in prostate cancer: technique and results of the first 350 cases,” Urologia Internationalis, vol. 70, no. 4, pp. 303–310, 2003.
[8]
U. Ganswindt, D. Schilling, A. -C. Müller, R. Bares, P. Bartenstein, and C. Belka, “Distribution of prostate sentinel nodes: a SPECT-derived anatomic atlas,” International Journal of Radiation Oncology Biology Physics, vol. 79, no. 5, pp. 1364–1372, 2011.
[9]
D. L. Morton, D. R. Wen, J. H. Wong et al., “Technical details of intraoperative lymphatic mapping for early stage melanoma,” Archives of Surgery, vol. 127, no. 4, pp. 392–399, 1992.
[10]
S. Horenblas, L. Jansen, W. Meinhardt, C. A. Hoefnagel, D. De Jong, and O. E. Nieweg, “Detection of occult metastasis in squamous cell carcinoma of the penis using a dynamic sentinel node procedure,” Journal of Urology, vol. 163, no. 1, pp. 100–104, 2000.
[11]
B. Roth, M. P. Wissmeyer, P. Zehnder et al., “A new multimodality technique accurately maps the primary lymphatic landing sites of the bladder,” European Urology, vol. 57, no. 2, pp. 205–211, 2010.
[12]
J. A.P. Leijte, I. M.C. Van Derploeg, R. A. Valdés Olmos, O. E. Meweg, and S. Horenblas, “Visualization of tumor blockage and rerouting of lymphatic drainage in penile cancer patients by use of SPECT/CT,” Journal of Nuclear Medicine, vol. 50, no. 3, pp. 364–367, 2009.
[13]
E. Huang, B. S. Teh, D. R. Mody, L. S. Carpenter, and E. B. Butler, “Prostate adenocarcinoma presenting with inguinal lymphadenopathy,” Urology, vol. 61, no. 2, pp. 463–464, 2003.
[14]
A. S. N. Jackson, S. A. Sohaib, J. N. Staffurth et al., “Distribution of lymph nodes in men with prostatic adenocarcinoma and lymphadenopathy at presentation: a retrospective radiological review and implications for prostate and pelvis radiotherapy,” Clinical Oncology, vol. 18, no. 2, pp. 109–116, 2006.
[15]
M. Golimbu, P. Morales, S. Al-Askari, and J. Brown, “Extended pelvic lymphadenectomy for prostatic cancer,” Journal of Urology, vol. 121, no. 5, pp. 617–620, 1979.
[16]
A. H？cker, S. Jeschke, K. Leeb et al., “Detection of pelvic lymph node metastases in patients with clinically localized prostate cancer: comparison of [18F]fluorocholine positron emission tomography-computerized tomography and laparoscopic radioisotope guided sentinel lymph node dissection,” Journal of Urology, vol. 176, no. 5, pp. 2014–2019, 2006.
