Laparoscopic sentinel lymph node biopsy for prostate cancer: the relevance of locations outside the extended dissection area.
ABSTRACT 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.
Article: Validation of sentinel lymph node dissection in prostate cancer: experience in more than 2,000 patients.[show abstract] [hide abstract]
ABSTRACT: Sentinel lymph node dissection (SLND) has replaced extended lymphadenectomy for nodal staging in several solid tumours. We present our results of SLND in prostate cancer in regard to detection and false-negative rate. In a 2-day protocol about 300 MBq (99m)Tc-nanocolloid are injected into the prostate. Two hours later static scans of the pelvis are performed to get information about the number and location of radioactive lymph nodes. During surgery the radioactive nodes are excised with the help of a gamma probe and sent separately to the pathologist. The histological procedure includes haematoxylin and eosin staining, serial sections and immunohistochemistry. Since 1999, a total of 2,020 men underwent SLND alone or in combination with either standard or extended lymphadenectomy after radical retropubic prostatectomy. Lymph nodes positive for metastases were found in 16.7% of patients. The scintigraphic detection rate was 97.6% and the intraoperative detection rate 98%. For 187 lymph node-positive men who had either standard or extended lymphadenectomy in addition to SLND the false-negative rate could be calculated, resulting in false-negative findings in 11 of 187 patients (6%). Our results demonstrate that SLND in prostate cancer is a reliable procedure for nodal staging.European Journal of Nuclear Medicine 06/2009; 36(9):1377-82. · 4.53 Impact Factor
Article: Laparoscopic sentinel node dissection for prostate carcinoma: technical and anatomical observations.[show abstract] [hide abstract]
ABSTRACT: To report experience with sentinel node (SN) lymphadenectomy which allows an assessment of the exact location of radioactive and of tumour-bearing lymph nodes, and evaluate differences in timing of the scintigraphy and surgery. The study included 35 patients who opted for external beam radiation therapy for prostate carcinoma of intermediate or poor prognosis. Agreement was reached between the participating urologists and the physicians of the nuclear medicine department on the definition of the relevant anatomical areas. The time between a transrectal intraprostatic injection with the radioactive nanocolloid and the laparoscopic SN procedure varied from 5 h to 26 h. Scintigrams were merged with the computed tomography scans until combined methods became available. A laparoscopic gamma-probe was used to identification the SNs, and an extensive laparoscopic node dissection undertaken in the same procedure. Lymph nodes were submitted to the pathologist in such a way that their exact location could be reconstructed. After surgery a graphic report was produced showing the exact location of the lymph nodes. Of the 35 patients 40% were node positive; a mean of 13.5 nodes were resected, and there were no false-negative results. The location of the vast majority of the tumour-positive SNs was around the bifurcation of the external and internal iliac artery, and so involved nodes from the internal iliac, external iliac, communis and obturator basins. Of the six SNs outside the extended node dissection area, two were positive but only one of them exclusively so (lateral to the external iliac artery). The scintigrams did not change after 4 h, and the operation should be done within 24 h to have sufficient radioactivity in the nodes to be detected by the probe. There were eight complications (23%) but only one could be attributed to the SN procedure; the others were thought to be related to the extended laparoscopic node dissection. The laparoscopic SN procedure is a reliable tool for diagnosing prostate cancer-bearing lymph nodes, but the extended laparoscopic node dissection has, in this series and others, too many complications for it to be attractive for diagnostic purposes. The SN procedure makes an extended node dissection unnecessary in most patients.BJU International 05/2008; 102(6):714-7. · 2.84 Impact Factor
Article: Technology insight: radioguided sentinel lymph node dissection in the staging of prostate cancer.[show abstract] [hide abstract]
ABSTRACT: Pelvic lymph node dissection is the only reliable method of staging for clinically localized prostate cancer. Despite the obvious prognostic advantages conferred by accurate staging, pelvic lymph node dissection is associated with significant morbidity and prolonged operative time. A substantial decrease in the sensitivity to lymph node metastasis occurs by simple reduction of the dissection area to the obturator fossa. Radioguided sentinel lymph node dissection provides accurate staging despite use of a minimal-area dissection template. Results from studies in prostate cancer indicate that this method has a high sensitivity for very early detection of lymphatic spread. A substantial number of the detected metastases are of a small size, solitary and widely distributed throughout the pelvic lymph nodes. These features make metastases undetectable by preoperative imaging modalities, and by the current, standard method of lymph node dissection limited to the obturator fossa.Nature Clinical Practice Urology 12/2006; 3(11):602-10. · 4.07 Impact Factor
Hindawi Publishing Corporation
Volume 2012, Article ID 751753, 4 pages
LaparoscopicSentinelLymphNodeBiopsy forProstate Cancer:
W.Meinhardt,1H.G.vander Poel,1R.A.Vald´ es Olmos,1,2A. Bex,1
1Department of Urology, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121,
1066 CX Amsterdam, The Netherlands
2Department of Nuclear Medicine, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital,
Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
Correspondence should be addressed to W. Meinhardt, firstname.lastname@example.org
Received 10 May 2011; Revised 14 June 2011; Accepted 19 July 2011
Academic Editor: Ganesh S. Palapattu
Copyright © 2012 W. Meinhardt et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To assess the relevance of sentinel lymph nodes (SNs) outside the extended pelvic lymph node dissection area (e-
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
by resection or radiotherapy, these locations are relevant. When considering salvage treatment for prostate cancer, the method is
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
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
. Patients who opt for external beam radiation therapy
are candidates for a laparoscopic SN biopsy, when their
PSA is >10, Gleason >6 or Stage >T2b. Depending on the
nodal status, we adjust the radiation target volume and
the duration of the hormonal therapy. Other candidates
are patients who had local treatment failure and consider
Figure 1: Combined intraoperative surgical guidance using the
portable gamma camera and the laparoscopic gamma probe. On
the screen, the iodine seed on the tip of the probe is represented by
a circle, before (left) and after (right) excision of an SN.
salvage treatment of the prostate, since positive nodes make
us refrain from salvage prostate treatment.
2.2. Preoperative Imaging. Fifteen minutes after transrec-
tal injection of 99mTechnetium-nanocolloid (Amersham
Cygne, Eindhoven, The Netherlands) into both lobes of
the prostate, guided by ultrasound, the first static planar
lymphoscintigraphic image is acquired. This is repeated after
2 hours, and by comparing the 2 images, the distinction can
be made between SNs and second-echelon nodes. The first
lymph nodes in each station appearing on early planar imag-
ing were considered to be the SNs. Nodes appearing later in
were considered to be second-echelon nodes. In addition,
SPECT/CT (Symbia T, Siemens, Erlangen, Germany) was
performed at 2 hours after injection. After image fusion,
SNs were anatomically localized. If the SPECT/CT showed
more lymph nodes compared to the planar images, the same
2.3. Surgical Procedure. A laparoscopic gamma probe (Euro-
Probe, Euro medical Instruments, London, UK) was used to
acoustically localize radioactive nodes during the operation.
After the first 40 patients we refined the method by the
use of a portable gamma camera (Sentinella, Oncovision,
Valencia, Spain)  (Figure 1). The portable gamma camera
can visualize the radioactive hotspots on screen and can be
used to guide the gamma probe in the direction of the SN
by placing a radioactive iodine seed on the tip of the gamma
probe, which can be depicted separately on screen (Figure 1).
In addition, if the gamma camera showed residual focal
radioactivity after the removal of an SN at the same location,
it was considered as another possible SN and was also
removed.Exvivo, theremoved tissuewasalsoexamined with
the gamma probe to confirm the excised SN is radioactive
and to separate the radioactive SNs from adjacent tissue.
In case of unilateral nonvisualization of SNs at preopera-
tive imaging, a lymph-node dissection comprising the region
Table 1: Location and pathology results of SNs outside the
extended resection area. No = 37 patients (of the 121).
Was it the only positive
Behind the common
Lateral to the external
around the bifurcation of the common iliac artery, including
nodes of the common iliac, the internal iliac, the external
iliac, and the obturator regions was performed on that side.
The rationale for this is the possibility of nonvisualization in
case of major tumor involvement of a lymph node, leading
to rerouting of the 99mTechnetium-nanocolloid containing
In the first 35 patients, a confirmatory laparoscopic e-
PLND was performed in order to evaluate the reliability of
our SN method. The areas resected were around the external
iliac artery and vein, the common iliac up to the crossing of
the ureter, the internal iliac just passed the superior vesical
artery, and the obturator fossa. This series has been reported
before and showed no false-negative results .
After the first 35 patients, we abandoned the confirma-
tory e-PLND, since we considered our SN method to be
Between December 2005 and October 2010, 121 patients
were treated. Of these 121 patients, 49 (40%) were node
positive. In 37 patients (31%), SNs were identified and
excised outside the e-PLND template, at the following
locations: presacral, Cloquet’s node, inguinal, para-aortic,
abdominal wall, pararectal, behind the common iliac artery,
and lateral to the external iliac artery. In five patients, these
and 4% of all patients). However, in merely two cases,
this node was the only positive node retrieved from those
patients. SN results are listed in Table 1.
In case of unilateral nonvisualization of SNs, a dissection
on that side revealed positive lymph nodes in 4 of 12 cases.
Characteristics of patients considered for salvage treat-
ment in case of a prostate cancer recurrence are shown in
Table 2. 6 of the 14 patients were node positive. In 7 of these
14 patients, we retrieved nodes outside the extended dissec-
tion area; however, none of these nodes were tumor positive.
So, although in salvage candidates the occurrence of SNs
outside the extended template is higher (50% versus 28%),
harvesting these nodes did not result in change of treatment.
Table 2: Characteristics of 14 patients with a recurrence in the prostate and the outcome of the SN procedure. None of the nodes outside
the extended dissection area was tumor positive.
Previous treatment and
External beam, 9y
Brachy therapy, 8y
External beam, 5y
External beam, 8y
Brachy therapy, 6y
PSA at time of
+: tumor bearing nodes
Location outside of
extended dissection area
Abdominal wall, near
Inguinal node (negative)
Abd. Wall, next to
65yBrachy therapy, 7y117
Brachy therapy, 2y
External beam, 3y
External beam, 5y
External beam, 3y
63y HIFU, 1y5.46
External beam, 6y
Brachy therapy, 5y
By comparing the early and late static planar images,
we make the distinction between SNs and second-echelon
nodes. If this distinction is not made, we agree with
Weckermann that it is better to avoid the term SN biopsy but
use “radio guided surgery” instead . The SN technique is
designed to individualize the diagnostics and the therapeutic
decisions. Pooling these data to draw conclusions on what an
extended dissection area might be, or which area should be
radiated, results in unpractical large areas .
The original application of the SN concept in melanoma
and penile cancer often shows 1 or 2 lymphatic vessels
leading to SNs [9, 10]. In the pelvic region, this is seldomly
the case. Results of a recent study in bladder carcinoma
illustrate this. Only the healthy side of the bladder was
injected with tracer and crossing to the contralateral side
was often found even to contralateral tumor bearing nodes
. In the pelvis, it is more appropriate to consider the
lymphatics as a reticulum with only a few valves.
Blockage of the lymph flow by tumor in the node may
lead to nonvisualization and rerouting and even retrograde
lymph flow of the 99mTechnetium-nanocolloid containing
lymphatic flow. This concept has been visualized with
SPECT/CT . In our patients, it is illustrated by the fact
that in the case of nonvisualization on one particular side,
positive nodes on that side were found in a third of those
The appearance of radioactive nodes in the abdominal
wall near the umbilical ligament, of pararectal nodes, of
direct drainage to Cloquet’s nodes and even to inguinal
nodes may be explained by the above-named mechanisms.
Tumor-positive nodes of prostate cancer in the inguinal
region have been reported before by others. This may also
be explained by leakage of the tracer during the injection,
transrectally near the linea dentata. However, inguinal nodes
have been reported without any transrectal injections [13,
14]. This leakage may also explain the drainage to pararectal
nodes, which is often reported but hazardous to dissect
Radioactive lymphnodes are regularly identified outside
the extended resection area more cranially and around the
lymph flow, and often these nodes might well be second-
echelon nodes. In older studies, the presacral area is already
included in the regular drainage regions of the prostate .
However, laparoscopic excision of these nodes may also be
Salvage treatment of the prostate may result in serious
complications. Identifying even micrometastases is impor-
tant, since the balance between the potential benefits and
risks for this type of treatment is different. We only consider
salvage prostate treatment when the prostate is the only
tumor-bearing site. As lymph node micrometastases cannot
be accurately visualized using current imaging modalities,
removal of lymph nodes for microscopic investigation is still
indicated . The usual parameters to stratify patients in
prostate, as illustrated by our high percentage of positive
nodes in this group.
In prostate carcinoma, the laparoscopic SN technique identi-
fied positive lymph nodes outside the e-PLND area in 31%
of the cases. They were the only site of tumor bearing
nodes in 4% of the patients with positive nodes. For diag-
nostic purposes only, this vmakes these locations less
relevant. However, for dissection or radiation of lymph
nodes with curative intent, these locations are relevant, since
they contained tumor in 10% of node positive patients.
When considering salvage treatment for prostate cancer, the
method is feasible, and in almost half of these patients, the
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