Laparoscopic Sentinel Lymph Node Dissection – A Novel Technique for the Staging of Prostate Cancer

doi:10.1016/j.eururo.2005.08.021

European Urology

Volume 49, Issue 2, February 2006, Pages 280-285

https://doi.org/10.1016/j.eururo.2005.08.021 Get rights and content

Abstract

Objectives

Pelvic lymph node metastases indicate a poor prognosis for prostate cancer patients. The aim of this study was to evaluate the suitability of laparoscopic radioisotope guided sentinel lymph node (SLN) dissection in staging of prostate carcinoma.

Methods

28 patients with prostate cancer and intermediate or high risk for lymph node metastases considered for external beam radiotherapy underwent laparoscopic pelvic lymphadenectomy at our institution. For visualization of individual SLN distribution, an image fusion system consisting of a gamma-camera with integrated X-ray tube was used. During laparoscopic lymphadenectomy, SLN were identified using a laparoscopic gamma probe.

Results

Preoperative imaging and laparoscopic gamma probe allowed an excellent delineation of SLN. 57% (preoperative imaging) as well as 48% (intraoperative measurements) of SLN were found outside the obturator fossa. All SLN were removed successfully without intra- or postoperative complications. Despite extended lymphadenectomy, no significant lymphocele appeared. 10 lymph node metastases were found in 7 out of the 31 patients (23%) with 3 of the 10 metastases lying outside the obturator fossa representing the standard lymphadenectomy area.

Conclusions

The present data demonstrate that laparoscopic SLN dissection is an excellent minimally invasive and technically feasible tool for staging of intermediate and high risk prostate cancer.

Introduction

Prevalence of lymph node metastasis in prostate cancer is associated with poor prognosis. Therefore, an exact staging diagnosis of lymph node status is essential before chosing the optimal therapy for the individual patient. Despite improvement in imaging techniques, pelvic lymph node dissection is still the most precise and reliable evaluation method for lymph node staging. The anatomical boundaries of pelvic lymph node dissection for the staging of prostate cancer are still controversially discussed. Although the obturator region is often considered the primary landing site for metastases, recent data demonstrate a more variable lymphatic drainage of the prostate. Therefore, some authors suggest a more extended dissection field to identify metastases that would be missed by a limited dissection [1], [2]. Recent data demonstrate incidences of 35% [3] and 19% [4] of metastases in areas outside the standard field, including the external iliac and obturator regions. However, an extended dissection has been shown to be associated with an increased risk of complications like lymphocele, deep venous thrombosis, ureteral injury or lower extremity edema [5]. Therefore, the sentinel lymph node (SLN) concept has been applied to lymph node staging in prostate cancer [6]. This concept implies that lymph node metastases are first identified in the SLN and that negative SLN exclude metastatic disease. The suitability of the SLN concept for prostate cancer staging has been shown by various authors [7], [8]. It was the aim of this study to evaluate whether SLN dissection can also be performed by means of the laparoscopic approach.

Section snippets

Patients and methods

A total of 28 patients with prostate cancer and intermediate or high risk for lymph node metastases considered for external beam radiotherapy underwent laparoscopic pelvic lymphadenectomy at our institution (Table 1). All patients were investigated with abdominal/pelvic CT and bone scans preoperatively. Mean PSA was 42 ± 28 ng/ml (10 to 289 ng/ml) with a mean Gleason Score of 6.3 ± 1.1 (3 to 9). Mean patient age was 65.6 ± 5.1 years There was no evidence of distant metastases as shown by bone scan and

Results

No allergic or septic complications occured after radioisotope injection. Transrectal ultrasound allowed an exact bilateral centrally placed intraprostatic injection of the tracer substance. By means of preoperative lymphoscintigraphy combined with a CT scan, a mean of 2.1 ± 1.1 lymph node stations per patient were identified as SLN. The image fusion system allowed an exact three-dimensional delineation of SLN. 43% of the lymph nodes were found in the obturator fossa, 12% in the presacral area,

Discussion

Despite negative CT scan, 25% of our patients presented with lymph node metastases. These findings confirm that modern imaging techniques have only limited sensitivity for lymph node involvement. Preliminary data indicate that innovative methods like ¹¹C-choline PET [9] or high-resolution magnetic resonance imaging with magnetic nanoparticles [10] might become sensitive tools for an accurate preoperative lymph node staging, however further clinical research is needed. With the introduction of

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Cited by (53)

Neoplasms of the Prostate
2020, Urologic Surgical Pathology
Prostatic intraepithelial neoplasia (PIN) refers to the preinvasive end of the continuum of cellular proliferations within the lining of prostatic ducts, ductules, and acini. High-grade PIN is the earliest identifiable stage in carcinogenesis, possessing most of the phenotypic, biochemical, and genetic changes of cancer without invasion into the fibromuscular stroma. The World Health Organization (WHO) contends that PIN is the only preinvasive lesion for prostate cancer. Other potential but unproven candidates for premalignancy in the prostate include atypical adenomatous hyperplasia, malignancy-associated changes arising in normal-appearing epithelium, and atrophy.
Sentinel Lymph Node Dissection to Select Clinically Node-negative Prostate Cancer Patients for Pelvic Radiation Therapy: Effect on Biochemical Recurrence and Systemic Progression
2017, International Journal of Radiation Oncology Biology Physics
To assess the efficacy of robotic-assisted laparoscopic sentinel lymph node (SLN) dissection (SLND) to select those patients with prostate cancer (PCa) who would benefit from additional pelvic external beam radiation therapy and long-term androgen deprivation therapy (ADT).
Radioisotope-guided SLND was performed in 224 clinically node-negative patients scheduled to undergo external beam radiation therapy. Patients with histologically positive SLNs (pN1) were also offered radiation therapy to the pelvic lymph nodes, combined with 3 years of ADT. Biochemical recurrence (BCR), overall survival, and metastasis-free (including pelvic and nonregional lymph nodes) survival (MFS) rates were retrospectively calculated. The Briganti and Kattan nomogram predictions were compared with the observed pN status and BCR.
The median prostate-specific antigen (PSA) value was 15.4 ng/mL (interquartile range [IQR] 8-29). A total number of 834 SLNs (median 3 per patient; IQR 2-5) were removed. Nodal metastases were diagnosed in 42% of the patients, with 150 SLNs affected (median 1; IQR 1-2). The 5-year BCR-free and MFS rates for pN0 patients were 67.9% and 87.8%, respectively. The corresponding values for pN1 patients were 43% and 66.6%. The PSA level and number of removed SLNs were independent predictors of BCR and MFS, and pN status was an additional independent predictor of BCR. The 5-year overall survival rate was 97.6% and correlated only with pN status. The predictive accuracy of the Briganti nomogram was 0.665. Patients in the higher quartiles of Kattan nomogram prediction of BCR had better than expected outcomes. The complication rate from SLND was 8.9%.
For radioisotope-guided SLND, the high staging accuracy is accompanied by low morbidity. The better than expected outcomes observed in the lower quartiles of BCR prediction suggest a role for SLN biopsy as a potential selection tool for the addition of pelvic radiation therapy and ADT intensification in pN1 patients.
Sentinel node approach in prostate cancer
2015, Revista Espanola de Medicina Nuclear e Imagen Molecular
Citation Excerpt :
To avoid the shine-through phenomenon, they used a gamma probe with the ability to detect gamma rays from 90 degrees laterally.10 Although a strict learning curve exists, laparoscopic extended pelvic lymphadenectomy for validation of the SLN concept is worth performing because this procedure yields an equivalent number of resected nodes with less morbidity.31 Preoperative anatomical information about the lymphatic drainage and the site of the SLNs remains essential during laparoscopy for both planning of operation and probe detection.
In general terms, one of the main objectives of sentinel lymph node (SLN) biopsy is to identify the 20-25% of patients with occult regional metastatic involvement. This technique reduces the associated morbidity from lymphadenectomy, as well as increasing the identification rate of occult lymphatic metastases by offering the pathologist those lymph nodes with the highest probability of containing metastatic cells. Pre-surgical lymphoscintigraphy is considered a “road map” to guide the surgeon towards the sentinel nodes and to ascertain unpredictable lymphatic drainages. In prostate cancer this aspect is essential due to the multidirectional character of the lymphatic drainage in the pelvis. In this context the inclusion of SPECT/CT should be mandatory in order to improve the SLN detection rate, to clarify the location when SLNs are difficult to interpret on planar images, to achieve a better definition of them in locations close to injection site, and to provide anatomical landmarks to be recognized during operation to locate SLNs.
Conventional and laparoscopic hand-held gamma probes allow the SLN technique to be applied in any kind of surgery. The introduction and combination of new tracers and devices refines this technique, and the use of intraoperative images. These aspects become of vital importance due to the recent incorporation of robot-assisted procedures for SLN biopsy. In spite of these advances various aspects of SLN biopsy in prostate cancer patients still need to be discussed, and therefore their clinical application is not widely used.
En términos generales uno de los principales objetivos de la biopsia del ganglio centinela (GC) es identificar el 20-25% de pacientes que presentan enfermedad ganglionar regional clínicamente oculta. Esta técnica minimiza la morbilidad asociada a la linfadenectomía y aumenta también la tasa de identificación de metástasis linfáticas ocultas al ofrecer al patólogo aquel o aquellos ganglios con mayor probabilidad de contener células tumorales. La linfogammagrafía prequirúrgica se considera como un “mapa de carreteras” para guiar al cirujano hacia los GC y para la localización de patrones de drenaje impredecibles. En cáncer de próstata este aspecto adquiere especial importancia debido a su drenaje multidireccional en la pelvis. En ese contexto la inclusión de SPECT/TC aparece como esencial para lograr un mejor índice global de detección del GC, clarificar la existencia y ubicación de ganglios centinelas difíciles de interpretar a las imágenes planares, conseguir una mejor definición de los mismos en localizaciones cercanas a la inyección y entregar puntos de referencia anatómica que puedan ser reconocidos durante la operación para localizar los GC.
La utilización de sondas detectoras de rayos gamma convencionales o laparoscópicas permiten la aplicación de la técnica en cualquier tipo de cirugía. La implementación y combinación de nuevos dispositivos y trazadores permite refinar la técnica, así como la utilización de imágenes intraoperatorias. Estos aspectos han ido adquiriendo especial importancia debido a la incorporación de la biopsia del GC en protocolos que emplean cirugía robótica. A pesar de ello, la aplicación clínica de la biopsia del GC en pacientes con cáncer de próstata todavía sigue incluyendo aspectos a discutir y por ello su aplicación clínica no se ha generalizado.
Functional imaging for prostate cancer: Therapeutic implications
2012, Seminars in Nuclear Medicine
Functional radionuclide imaging modalities, now commonly combined with anatomical imaging modalities computed tomography (CT) or magnetic resonance imaging (single photon emission computed tomography [SPECT]/CT, positron emission tomography [PET]/CT, and PET/magnetic resonance imaging), are promising tools for the management of prostate cancer, particularly for therapeutic implications. Sensitive detection capability of prostate cancer using these imaging modalities is one issue; however, the treatment of prostate cancer using the information that can be obtained from functional radionuclide imaging techniques is another challenging area. There are not many SPECT or PET radiotracers that can cover the full spectrum of the management of prostate cancer from initial detection to staging, prognosis predictor, and all the way to treatment response assessment. However, when used appropriately, the information from functional radionuclide imaging improves, and sometimes significantly changes, the whole course of the cancer management. The limitations of using SPECT and PET radiotracers with regard to therapeutic implications are not so much different from their limitations solely for the task of detecting prostate cancer; however, the specific imaging target and how this target is reliably imaged by SPECT and PET can potentially make significant impact in the treatment of prostate cancer. Finally, although the localized prostate cancer is considered manageable, there is still significant need for improvement in noninvasive imaging of metastatic prostate cancer, in treatment guidance, and in response assessment from functional imaging, including radionuclide-based techniques. In this review article, we present the rationale of using functional radionuclide imaging and the therapeutic implications for each of radionuclide imaging agent that have been studied in human subjects.
Feasibility study of sentinel lymph node of prostate cancer by laparoscopy: First results
2011, Medecine Nucleaire
Le curage standard est actuellement remis en question dans la prise en charge du cancer de la prostate. Le but de cette étude prospective est d’évaluer les performances de la technique du ganglion sentinelle (GS) par cœlioscopie chez des patients porteurs d’un cancer localisé de prostate candidats à un traitement local.
Les patients étaient injectés par voie transrectale échoguidée avec 0,3 mL/100MBq de 99^mTc-sulfure de rhénium colloïdal dans chaque lobe prostatique la veille de l’intervention. Une lymphoscintigraphie était réalisée deux heures après. La radiodétection peropératoire était réalisée avec une sonde cœlioscopique (Clerad^® Gamma Sup) suivie d’un curage extensif. Les comptages des GS étaient réalisés in vivo et confirmés ex vivo. L’analyse anatomopathologique était réalisée par HPS, suivie d’un immunomarquage si GS indemnes.
Soixante-dix patients, porteurs d’un cancer de la prostate à risque intermédiaire ou élevé de métastases ganglionnaires (D’Amico), PSA médian 9,5 ng/mL [6–130] ont été inclus dans l’étude. Le taux de détection lymphoscintigraphique a été de 94,2 % (66/70) et peropératoire de 97,0 % (68/70). Quatorze patients présentaient des métastases ganglionnaires, six uniquement dans les GS. Le taux de faux négatifs était de 2/14 (14,0 %). La région iliaque interne est le premier site métastatique (40,9 %). Un curage limité ou standard aurait ignoré respectivement 72,7 % et 59,0 % des métastases ganglionnaires.
La voie cœlioscopique est adaptée à un large repérage des GS et un curage ciblé de ces ganglions limiterait significativement le risque chirurgical du curage étendu tout en maintenant la précision de l’information.
The standard lymphadenectomy is currently a challenge in the management of prostate cancer. The aim of this prospective study was to evaluate the performance of the sentinel lymph node (SLN) by laparoscopy in patients with localized prostate cancer, candidates for local treatment.
Patients were injected transrectal ultrasound-guided with 0.3 mL/100MBq 99^mTc-Sulfur rhenium colloid in each prostatic lobe, the day before surgery. Lymphoscintigraphy was performed after 2 hours. The detection was realized intraoperatively with a laparoscopic probe (Gamma Sup Clerad^®) followed by extensive dissection. Counts of SLN were performed in vivo and confirmed ex vivo. The histological analysis was performed by HPS staining and followed by immunochemistry if SLN was free.
Seventy patients with carcinoma of the prostate at intermediate or high risk of lymph node metastases (D’Amico), PSA median 9.5 ng/mL [6–130], were included in the study. The lymphoscintigraphic detection rate was 94.2% (66/70) and intraoperative of 97.0% (68/70). Fourteen patients had lymph node metastases, six only in SLN. The false negative rate was 2/14 (14.0%). The internal iliac region is the first metastatic site (40.9%). Limited or standard lymph node dissection would have ignored respectively 72.7% and 59.0% of lymph node metastases.
The laparoscopy is adapted to a broad identification of SLN and targeted dissection of these lymph nodes significantly limits the risk of surgical extended dissection while maintaining the accuracy of the information.
Sentinel lymph node procedure in prostate cancer
2011, Medecine Nucleaire
L’intérêt urologique de la technique du ganglion sentinelle dans le cancer de la prostate ainsi que la méthodologie sont présentés dans cet article, conforme à la présentation faite à l’action concertée en medecine nucléaire (Acomen).
Urological interest of sentinel lymph node procedure in prostate cancer, and methods, both are presented in conformity with the presentation of action concertée en medecine nucléaire (ACOMEN).

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Prostate CancerLaparoscopic Sentinel Lymph Node Dissection – A Novel Technique for the Staging of Prostate Cancer

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

J Urol

J Urol

J Urol

J Urol

J Urol

J Urol

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Prostate Cancer
Laparoscopic Sentinel Lymph Node Dissection – A Novel Technique for the Staging of Prostate Cancer