Relationship Between Intraprostatic Tracer Deposits and Sentinel Lymph Node Mapping in Prostate Cancer Patients

Tessa Buckle; Oscar R. Brouwer; Renato A. Valdés Olmos; Henk G. van der Poel; Fijs W.B. van Leeuwen

doi:10.2967/jnumed.111.098517

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FIGURE 1.
Schematic representation of prostate. (A) Within prostate, discrimination can be made between peripheral and central zones because of differences in tissue morphology. Base of prostate is wider than apex and is next to bladder. (B) For quantification purposes, embedded sections of prostate samples were divided into 4 quadrants (Q1–Q4). Q1 and Q2 represent central zone, and Q3 and Q4 represent peripheral zone.
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FIGURE 2.
Variations in tracer distribution throughout prostate. (A) Patient for whom injected tracer was evenly distributed over left and right sides of peripheral zone (patient 8), and patient for whom tracer was mostly on right side of central zone with single deposit on left side of peripheral zone (patient 6). These images also illustrate variation in z-direction. (B) Overview of tracer deposits per prostate sample. Prostate is blue, and fluorescence deposits are green (light green for deposits with comparable or low intensity; dark green for deposits with high intensity).

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TABLE 1

Fluorescence Distribution Observed Ex Vivo

Patient no.	Q1	Q2	Q3	Q4	Injection site	Tracer distribution throughout prostate^*
1	12 ± 5	16 ± 5	34 ± 8	37 ± 15	L peripheral zone, R peripheral and central zone	No FL in mid gland; deposits near base and apex
2	19 ± 3	13 ± 1	40 ± 9	28 ± 7	Central in prostate, mostly peripheral zone	FL mostly in mid gland; hot spot L central zone
3	12 ± 4	17 ± 8	36 ± 6	37 ± 7	Central in prostate, peripheral zone	Evenly over all sections
4	11 ± 2	13 ± 3	35 ± 13	41 ± 11	Central in prostate, peripheral zone	FL mostly in central section
5	13 ± 3	26 ± 8	23 ± 6	36 ± 4	Central in prostate, peripheral zone	Evenly over all sections
6	15 ± 4	35 ± 18	23 ± 6	33 ± 12	Mostly central zone	Evenly over all sections
7	16 ± 8	12 ± 5	52 ± 16	20 ± 4	Mostly peripheral zone	FL in all sections; largest deposit near base
8	12 ± 2	12 ± 5	44 ± 9	32 ± 7	Peripheral zone	FL mostly in mid gland
9	12 ± 6	21 ± 13	43 ± 19	27 ± 14	L peripheral zone, R mostly central zone	FL in all sections; largest deposit near apex
10	13 ± 5	15 ± 5	31 ± 4	41 ± 7	Central in prostate, peripheral zone	Evenly over all sections
11	10 ± 3	9 ± 2	55 ± 5	26 ± 4	Peripheral zone	No FL in mid gland; deposits near base and apex
12	14 ± 4	25 ± 12	24 ± 4	37 ± 12	Peripheral zone and central zone	Evenly over all sections
13	12 ± 4	13 ± 3	44 ± 14	30 ± 12	Peripheral zone	No FL in mid gland; deposits near base (L) and apex (R)
14	23 ± 11	19 ± 9	34 ± 15	24 ± 10	Peripheral zone	FL in all sections; largest deposit near base
15	6 ± 1	24 ± 11	32 ± 12	37 ± 11	Peripheral zone and R central zone	Evenly over all sections
16	28 ± 13	16 ± 5	40 ± 13	16 ± 5	L central zone and peripheral zone	Evenly over all sections
17	43 ± 13	8 ± 3	41 ± 12	8 ± 2	L central zone	Evenly over all sections
18	18 ± 8	10 ± 5	52 ± 9	20 ± 7	L mostly central zone	Evenly over all sections
19	7 ± 3	40 ± 12	12 ± 5	48 ± 11	R mostly central zone	FL in all sections; largest deposit near base

↵* Figure 2 shows schematic overview of signal distribution throughout prostate per patient.
FL = fluorescence.
In Q1–Q4, mean percentage of fluorescence per quadrant is shown. Injection site was determined by evaluation of fluorescence signal in different zones of prostate (central, Q1 and Q2; peripheral, Q3 and Q4). Distribution throughout prostate was determined by evaluating fluorescence in each section of prostate.

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TABLE 2

Radioactivity-Based Distribution in Preoperatively Defined SN

		Left			Right
Patient no.	SNs on lymphoscintigraphy	Number of LNs	SN1 (counts)	Total (counts)	Number of LNs	SN1 (counts)	Total (counts)
1	L: 2 (ext., int.,)	4^*	1,971	3,943	1	1,573	1,573
	R: 1 (ext.)		^†	^‡
2	L: 2 (int., presacral)	4^*	1,808	4,714	1	1,705	1,705
	R: 1 (ext.)		^†	^‡
3	L: 3 (obt.)	2^*	1,973	2,928	1	799	799
	R: 1 (obt.)		^†	^‡
4	L: 3 (obt.)	3^*	553	1,435	1	1,051	1,051
	R: 1 (obt.)			^‡		^†
5	L: 1–2 (obt.)	1	796	796	1	1,367	1,367
	R: 1 (comm. bif.)					^†	^‡
6	L: —	—	—	—	—	—	—
	R: —
7	L: 1 (ext.)	1	2,292	2,292	1	1,505	1,505
	R: 1 (comm.)		^†	^‡
8	L: 2 (obt., aorta bifurcation)	3	4,087	10,008	2	2,998	4,022
	R: 1(obt.)		^†	^‡
9	L: 1 (obt.)	5	2,396	6,507	5	1,772	5,622
	R: 2 (obt., paracaval)		^†	^‡
10	L: 2 (ext., int.,)	4^*	3,050	5,053	2	1,576	2,084
	R: 2 (ext., int.,)		^†	^‡
11	L: 1 (obt.)	2^*	639	1,134	1	1,784	1,784
	R: 1 (ext.)					^†	^‡
12	L: 2 (ext., int.,)	4^*	3,233	7,787	2	1,188	3,128
	R: 1 (ext.)		^†	^‡
13	L: 1 (obt.)	1	585	585	2*	982	1,324
	R: 1 (obt.)					^†	^‡
14	L: 2 (obt., comm.)	3^*	1,851	3,967	1	—	632
	R: —		^†	^‡
15	L: —	—	—	371	—	—^§	404
	R: 1 (obt.)					^†	^‡
16	L: 2 (obt., int., ext.)	2	4,005	5,775	2	877	1,745
	R: 1 (obt.)		^†	^‡
17	L: 2 (int., comm.)	2^*	1,305	2,131	—	—	772
	R: —		^†	^‡
18	L: 1 (obt.)	2^*	691	1,120	1	454	454
	R: 1 (obt.)		^†	^‡
19	L: —	—	—	760	2^*	1,227	2,093
	R: 1 (ext.)					^†	^‡

↵* Highest number of visualized LNs (L or R).
↵† Highest amount of counts in SN1 (L or R).
‡ Highest activity (total; L or R).
§ SN visualized only on SPECT/CT.
ext. = external iliac; int. = internal iliac; obt. = obturator; comm. bif. = common iliac bifurcation; comm. = common iliac.

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TABLE 3

Relationship Between Location of Fluorescent Tracer Deposits and Lymphatic Drainage

	FL (%)		Total RA (%)			RA in SN1 (%)
Patient no.	Left	Right	Left	Right	Correlation between FL and total RA	Left	Right	Correlation between FL and RA in SN1
1	47 ± 11	53 ± 11	71	29	No (inverted)	55	45	Yes (larger variance in FL)
2	59 ± 6	41 ± 6	73	27	Yes (larger difference in RA)	52	48	Yes
3	49 ± 7	54 ± 4	79	21	No (inverted)	71	29	No (inverted)
4	46 ± 13	54 ± 13	58	42	Yes (larger difference in FL)	35	65	Yes (larger difference in RA)
5	39 ± 7	61 ± 7	37	63	Yes	37	63	Yes
6	38 ± 6	69 ± 9	—	—	(No drainage)	—	—	(No drainage)
7	68 ± 8	32 ± 8	37	63	No (inverted)	60	40	Yes
8	56 ± 9	44 ± 9	71	29	Yes (larger difference in RA)	58	42	Yes
9	55 ± 21	48 ± 24	54	46	Yes	58	42	Yes
10	45 ± 4	55 ± 4	71	29	No	66	34
11	65 ± 4	35 ± 4	39	61	No (inverted)	26	74	No (inverted)
12	38 ± 0	66 ± 0	71	29	No (inverted)	73	27	No (inverted)
13	57 ± 13	43 ± 13	31	69	No (inverted and larger difference in RA)	37	63	No
14	57 ± 18	43 ± 18	86	14	No (no difference in FL, clear difference in RA)	100	—	Yes
15	38 ± 12	61 ± 12	48	52	Yes	—	—	Yes^*
16	68 ± 4	32 ± 4	77	23	Yes	82	18	Yes (larger difference in RA)
17	84 ± 3	16 ± 3	73	27	Yes	100	—	Yes
18	70 ± 11	30 ± 11	71	29	Yes	60	40	Yes
19	20 ± 5	87 ± 16	27	73	Yes	—	100	Yes

↵* SN visualized with SPECT/CT instead of lymphoscintigraphy.
RA = radioactivity.
In each patient, fluorescence within different sections of prostate was determined and mean percentage of fluorescence (%FL) was calculated on both sides of body (L/R). To evaluate relationship between presence of fluorescence and radioactivity, percentages on L and R were compared. When highest percentage of FL and RA was measured on one side of body (L or R), this was noted as positive correlation.