The Influence of Serial Sections, Immunohistochemistry, and Extension of Pelvic Lymph Node Dissection on the Lymph Node Status in Clinically Localized Prostate Cancer

Klinikum Augsburg, Augsberg, Bavaria, Germany
European Urology (Impact Factor: 13.94). 03/2003; 43(2):132-6; discussion 137. DOI: 10.1016/S0302-2838(02)00450-5
Source: PubMed


Pelvic lymph node metastases indicate a poor prognosis for patients with clinically localized prostate cancer. The aim of the study was to investigate the value of extended histopathological techniques considering the extent of pelvic lymphadenectomy and preoperative risk factors.
Total of 194 patients with prostate cancer were examined. At first all patients had a sampling of the sentinel lymph nodes (SLN) followed in most cases by a modified or extended pelvic lymphadenectomy. Step sections, serial sections and immunohistochemistry (IHC, pancytokeratin antibody) were analyzed in all SLN and so-called non-SLN of the first 100 patients. Later serial sections and IHC of non-SLN were left out.
In 26.8% lymphatic metastases were found. The detection rate of lymph node-positive patients depend significantly on the chosen extension of pelvic lymphadenectomy. Limiting the histopathological investigation to the lymph node specimen of the obturator fossa only 44.2% of lymph node-positive cases would have been identified. An additional inclusion of all lymph nodes surrounding the external iliac vessels improves the sensitivity to 65.4% (46.7% and 73.3% for the first 100 patients). Compared to the extension of pelvic lymphadenectomy the diagnostic gain of serial section and IHC (13.8% versus 53.3%) was comparably low.
The extension of pelvic lymph node dissection is of outstanding value for the identification of node-positive patients. Limiting the number of lymph nodes to the ones with the highest probability of bearing lymphatic spread (SLN) makes the use of extensive histopathological techniques more feasible.

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    • "Therefore, this technique also enables the identification of potential tumour-bearing LNs outside the extended PLND (ePLND) template [2] [3] that would otherwise have been missed. When performing SN biopsy in combination with an ePLND, improved lymphatic staging can be achieved; pathologists can evaluate the SNs more extensively, decreasing the possibility of sampling errors, which can result in improved diagnostic accuracy [4] [5]. Since its introduction, the procedure has been subject to various refinements. "
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    ABSTRACT: Background The hybrid tracer was introduced to complement intraoperative radiotracing towards the sentinel nodes (SNs) with fluorescence guidance. Objective Improve in vivo fluorescence-based SN identification for prostate cancer by optimising hybrid tracer preparation, injection technique, and fluorescence imaging hardware. Design, setting, and participants Forty patients with a Briganti nomogram–based risk >10% of lymph node (LN) metastases were included. After intraprostatic tracer injection, SN mapping was performed (lymphoscintigraphy and single-photon emission computed tomography with computed tomography (SPECT-CT)). In groups 1 and 2, SNs were pursued intraoperatively using a laparoscopic gamma probe followed by fluorescence imaging (FI). In group 3, SNs were initially located via FI. Compared with group 1, in groups 2 and 3, a new tracer formulation was introduced that had a reduced total injected volume (2.0 ml vs 3.2 ml) but increased particle concentration. For groups 1 and 2, the Tricam SLII with D-Light C laparoscopic FI (LFI) system was used. In group 3, the LFI system was upgraded to an Image 1 HUB HD with D-Light P system. Intervention Hybrid tracer-based SN biopsy, extended pelvic lymph node dissection, and robot-assisted radical prostatectomy. Outcome measurements and statistical analysis Number and location of the preoperatively identified SNs, in vivo fluorescence-based SN identification rate, tumour status of SNs and LNs, postoperative complications, and biochemical recurrence (BCR). Results and limitations Mean fluorescence-based SN identification improved from 63.7% (group 1) to 85.2% and 93.5% for groups 2 and 3, respectively (p = 0.012). No differences in postoperative complications were found. BCR occurred in three pN0 patients. Conclusions Stepwise optimisation of the hybrid tracer formulation and the LFI system led to a significant improvement in fluorescence-assisted SN identification. Preoperative SPECT-CT remained essential for guiding intraoperative SN localisation. Patient summary Intraoperative fluorescence-based SN visualisation can be improved by enhancing the hybrid tracer formulation and laparoscopic fluorescence imaging system.
    European Urology 12/2014; 66(6). DOI:10.1016/j.eururo.2014.07.014 · 13.94 Impact Factor
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    • "Nonetheless, lymph node dissection (LND) is a reliable staging method for localized prostate and bladder cancer. Instead of being the sole method for staging, SLNB has been proposed by Wawroshek et al. [7] as an additional tool to decrease the morbidity of extended pelvic lymph node dissection (PLND). This procedure may improve staging and finding more micrometastases because of better pathological examination of the sentinel lymph nodes (SLNs), as well as standard examination of the other nodes. "
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    ABSTRACT: Introduction: Near infrared (NIR) technology has recently garnered much interest as a tool for intraoperative image-guided surgery in various surgical sub-disciplines. In urology, although nascent, NIR technology is also fostering much enthusiasm. This review discusses the two major fluorophores, indocyanine green (ICG) and methlyene blue (MB), with NIR guidance in experimental and clinical urology. The authors aim to illustrate and analyze the currently available initial studies to better understand the potential and practicability of NIR-guided imaging in the diagnosis and surgical outcome improvement. In the first part of the study we analyzed problems associated with sentinel lymph node biopsy, NIR-guided detection and imaging of tumors. Material and methods: PubMed and Medline databases were searched for ICG and MB use in urological settings, along with data published in abstracts of urological conferences. Results: Although NIR-guided ICG and MB are still in their initial phases, there have been significant developments in major domains of urology, including uro-oncological surgery: 1) sentinel lymph node biopsy, 2) detection and imaging of tumors. Conclusions: Much like in other fields of surgical medicine, the application of NIR technology in urology is at its early stages. Therefore, more studies are needed to assess the true potential and limitations of the technology. However, initial developments hint towards a pioneering tool that may influence various aspects of urology.
    06/2014; 67(2):142-8. DOI:10.5173/ceju.2014.02.art5
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    • "However, having the same template in different patients we have noticed its wide range (6–34). It was shown that quality of pathological assessment and the usage of immunohistochemical and other sophisticated techniques influence the number of LN found and assessed in the specimen [22]. We have also noticed that separate removal of specified pelvic LN packages is associated with a greater number of localized and assessed nodes in comparison to en-bloc removal of lymphatic tissue. "
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    ABSTRACT: Extended pelvic lymph node dissection (ePLND) is advised to complement radical prostatectomy (RP) in intermediate and high risk prostate cancer patients. To assess the risk of nodal involvement in patients subjected to laparoscopic radical prostatectomy and to characterize the group of patients with lymph node (LN) metastases. Data of patients subjected to laparoscopic radical prostatectomy with ePLND between February 2011 and June 2013 were analyzed. The LN that were removed included presacral nodes, common, external and internal iliac nodes and obturator ones. Mean number of removed LNs was 19. Metastases within LN were found in 13 (16.6%) patients. In comparison to those without LN involvement, patients who were found to have LN metastases had a greater number of positive biopsy cores (3.7 vs. 5.3, p < 0.01), maximum percentage of cancer in biopsy core (47.0 vs. 67.6, p < 0.01), greater biopsy and specimen Gleason scores (7.0 vs. 7.7 and 7.0 vs. 7.8) and more frequently advanced clinical and pathological stage. The most frequent landing sites of prostate cancer were obturator and presacral nodes (100% and 38%). Eleven patients (85%) among those with positive LN had locally advanced disease. The risk of LN metastases in intermediate and high risk prostate cancer patients is significant. Therefore, if radical prostatectomy is chosen, ePLND should be performed. The majority of patients with involvement of pelvic LN have locally advanced disease which would refer them to adjuvant radiation if managed without nodal dissection.
    Videosurgery and Other Miniinvasive Techniques / Wideochirurgia i Inne Techniki Malo Inwazyjne 03/2014; 9(1):64-70. DOI:10.5114/wiitm.2014.40986 · 1.09 Impact Factor
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