Dynamic Sentinel Node Biopsy Research Articles

PT380 - Modern imaging reduces false negative rate of Dynamic Sentinel Node Biopsy (DSNB) in penile cancer - a prospective study over a 8 year period in >100 patients

PT380 - Modern imaging reduces false negative rate of Dynamic Sentinel Node Biopsy (DSNB) in penile cancer - a prospective study over a 8 year period in >100 patients

Sentinel lymph node biopsy using indocyanine green in penile cancer.

Detection of positive nodes in men with moderate-risk to high-risk penile cancer and impalpable inguinal nodes is an important step in the therapeutic pathway. Detection using dynamic sentinel node biopsy with patent blue dye and radioisotope is associated with false negatives; indocyanine green might offer an alternative adjunct to improve detection rates.

MP11-06 PREDICTIVE FACTORS FOR LOCAL RECURRENCE (LR) AND CANCER-SPECIFIC SURVIVAL (CSS. AN EUROGEN RISK STRATIFICATION FOR GRADE 2 AND GRADE 3 TUMOURS

INTRODUCTION AND OBJECTIVE: The 8th edition of the unified TNM staging for penile SCC considers G2 disease as intermediate risk. The aim of this study was to analyse and compare predictors for LR and CSS between G2 and G3 tumours. METHODS: A retrospective analysis of 494 patients treated for penile SCC between 2008 and 2019 was performed. Univariate and multivariate Cox proportional hazards regression models were used to identify predictors for LR and CSS in grade 2 and grade 3 penile SCC. Kaplan-Meier analysis displayed CSS and recurrence free survival. RESULTS: 494 patients with penile SCC were identified from an institutional database. The median follow-up for LR and CSS was 58 months (IQR 25-93) and 35 months (IQR 25-93) respectively. At Cox regression univariate analysis, the only predictor for LR was lymphovascular invasion (LVI) (p=0.003). At univariate Cox regression analysis predictors for CSS included LVI, peri-neural invasion (PNI), inguinal lymph node disease, extracapsular spread (ECS), distant metastatic disease, pathological T-stage (all p<0.0001) and G2 vs. G3 (p=0.003). On multivariate analysis for CSS, only ECS, LVI, pathological T-stage and metastasis were found as independent predictors for CSS (all p<0.005). At multivariate analysis for CSS, G2 vs. G3 showed a p-value of 0.48 indicating that tumour grade does not contribute significantly compared to other independent predictors for CSS and LR. CONCLUSIONS: The EAU guidelines classify T1G2 tumours as intermediate risk when deciding options for inguinal lymph node management. Our findings suggest that the outcomes for G2 penile SCC are similar to G3 tumours and therefore dynamic sentinel lymph node biopsy should therefore be offered to patients presenting with grade 2 penile SCC with clinically impalpable inguinal nodes.Source of Funding: /

PD19-04 VALIDATION OF HYBRID ICG-99mTc-NANOCOLLOID FOR SENTINEL NODE BIOPSY IN A LARGE COHORT OF PENILE CANCER PATIENTS

INTRODUCTION AND OBJECTIVE: Dynamic sentinel node (SN) biopsy is an invasive lymph node (LN) staging method that is typically performed using 99mTc-nanocolloid combined with blue dye to detect micro-metastatic disease for ≥T1G2 penile cancer (PC) patients with no palpable inguinal LNs (cN0). Recent reports suggested that the hybrid tracer indocyanine green (ICG)-99mTc-nanocolloid may improve intraoperative optical SN identification relative to the blue dye. However, this evidence is supported by small sample size series. The aim of the current study was to confirm these findings relying on the largest single center cohort of PC patients who underwent SN biopsy using ICG-99mTc-nanocolloid and blue dye METHODS: 404 patients with ≥T1G2N0 penile squamous cell carcinoma were scheduled for SN biopsy and treatment of the primary tumour at a single European centre. Of those, 255 received SN biopsy using ICG-99mTc-nanocolloid and blue dye. After peritumoural injection of ICG-99mTc-nanocolloid, SNs were preoperatively identified based on lymphoscintigraphy and SPECT/CT. Shortly before surgery, blue dye was administered in all patients using the same injection sites as the hybrid tracer. Intraoperatively, SNs were pursued via gamma tracing, visual identification (blue dye) and near-infrared fluorescence imaging (ICG). Intraoperative SN identification rates of blue dye and ICG-99mTc-nanocolloid were compared using a two-sample t-test RESULTS: There were no tracer-related adverse events. Lymphoscintigraphy and SPECT/CT visualized at least one SN in all patients. All preoperatively defined SNs were intra-operatively identified using a combination of radio-, fluorescence- and blue dye guidance. A total of 841 SNs were excised (median 3 SNs per patient; range 1-9). Of these, 95% were visible with fluorescence imaging, while only 56% were stained by blue dye (p<0.001). Pathologic analyses of the 841 SNs removed, identified 58 positive nodes in 43 patients. Of those, 100% (n=58) and 69% (n=40) were fluorescent or stained blue, respectively. In 45 patients, blue dye did not identify any LN. Of these patients, 7% had positive nodes. Conversely, fluorescence imaging using the hybrid tracer enabled optical detection of at least one SN in all patients CONCLUSIONS: The use of fluorescence improved the optical detection rate of SNs of 39% relative to blue dye. Its use is safe and can replace blue dye for SN biopsy in patients with PC Source of Funding: None

Management of clinically node-negative groin in patients with penile cancer.

Malignant penile neoplasms are commonly squamous etiology, with the inguinal nodes being the first echelon of spread. The disease spreads to the pelvic lymph nodes only after metastases to the groin nodes, and this is the most important prognostic factor in penile carcinoma. While treatment of penile carcinoma with proven metastases to the inguinal lymph nodes mandates ilioinguinal lymph node dissection, the treatment of patients with impalpable nodes is more controversial. Overtreatment leads to excessive treatment-related morbidity in these patients, while a wait-and-see policy runs the risk of patients presenting with inguinal and distant metastases, which would have been curable at presentation. Unfortunately, no single imaging modality has been proved to be convincingly superior in the staging, and hence, management of the clinically negative groin has been subject to debate. While some high volume centers have promoted the use of dynamic sentinel lymph node biopsy, others advocate the use of the modified inguinal lymph node template to stage the groin adequately. Newer techniques such as video endoscopic inguinal lymph node dissection have been introduced as an alternative to the original radical inguinal lymphadenectomy to reduce morbidity.

Organ-sparing surgery of penile cancer: higher rate of local recurrence yet no impact on overall survival

PurposeTo report on the oncological outcome of organ-sparing surgery (OSS) compared to (total or partial) penectomy regarding recurrence patterns and survival in squamous cell carcinoma (SCC) of the penis.MethodsThis was a retrospective study of all patients with penile SCC and eligible follow-up data of at least 2 years at our institution. Patients with tumors staged ≥ pT1G2 underwent invasive lymph node (LN) staging by dynamic sentinel-node biopsy or modified inguinal lymphadenectomy. Radical inguinal lymphadenectomy was performed when LNs were palpable at diagnosis and in those with a positive LN status after invasive nodal staging. Follow-up visits were assessed, and local, regional and distant recurrences were defined and analyzed.Results55 patients were identified with a mean follow-up of 63.7 months. Surgical management was OSS in 26 patients (47.2%) and partial or total penectomy in 29 cases (52.8%). Histopathological staging was: pTis (12.7%), pTa (16.3%), pT1a (18.2%), pT1b (5.5%), pT2 (29.1%) and pT3 (18.2%), respectively. Patients in the penectomy group were significantly older (mean 68 vs. 62 years; p = 0.026) with a higher rate of advanced tumor stage (≥ pT2: 44.8% vs. 11.5%; p = 0.002). The local recurrence rate was 42.3% (n = 11) following OSS compared to 10.3% (n = 3) after penectomy (p = 0.007). Kaplan–Meier curves showed no significant differences between the two groups regarding metastasis-free and overall survival.ConclusionsOSS is associated with a higher local recurrence rate compared to penectomy, yet it has no negative impact on overall and metastasis-free survival.

PD56-10 SUPERFICIAL INGUINAL LYMPH NODE DISSECTION IS AN EFFECTIVE STAGING TOOL FOR CLINICALLY NODE-NEGATIVE HIGH RISK PENILE CANCER: RESULTS FROM A MULTI-INSTITUTIONAL REVIEW WITH LONG-TERM FOLLOW-UP

INTRODUCTION AND OBJECTIVES:Penile Cancer guideline-based care for patients with invasive high risk primary tumors recommends the use of dynamic sentinel lymph node biopsy (DSNB) or superficial ing...

MP49-17 INTERNATIONAL MULTI-CENTER ANALYSIS OF FACTORS PREDICTING THE PRESENCE OF NON-SENTINEL NODE INGUINAL METASTASES IN PENILE CANCER PATIENTS UNDERGOING COMPLETION INGUINAL LYMPH NODE DISSECTION FOLLOWING POSITIVE SENTINEL NODE BIOPSY

INTRODUCTION AND OBJECTIVES:Currently, penile cancer patients with impalpable inguinal lymph nodes routinely undergo dynamic sentinel node biopsy (DSNB) to diagnose metastatic spread to the inguina...

The use of dynamic sentinel node biopsy in case of penile cancer. A case report

The use of dynamic sentinel node biopsy in case of penile cancer. A case report

488 - Outcomes of penile cancer patients with micro-metastases in dynamic sentinel lymph node biopsy specimens: An eUROGEN collaboration

INTRODUCTION AND OBJECTIVES:Prognosis of penile squamous cell carcinoma is determined by TNM staging. Inguinal nodal involvement can be associated with poor survival; therefore investigation of bot...

493 - International multi-center analysis of factors predicting the presence of non-sentinel node inguinal metastases in penile cancer patients undergoing completion inguinal lymph node dissection following positive sentinel node biopsy

INTRODUCTION AND OBJECTIVES:Currently, penile cancer patients with impalpable inguinal lymph nodes routinely undergo dynamic sentinel node biopsy (DSNB) to diagnose metastatic spread to the inguina...

The use of dynamic sentinel node biopsy in case of penile cancer. A case report

The use of dynamic sentinel node biopsy in case of penile cancer. A case report

MP37-11 CAN SQUAMOUS CELL CARCINOMA OF THE ANTERIOR MALE URETHRA BE MANAGED BY FOLLOWING A PENILE CANCER BEST PRACTICE PATHWAY?

You have accessJournal of UrologySexual Function/Dysfunction: Penis/Testis/Urethra: Benign Disease & Malignant Disease I1 Apr 2018MP37-11 CAN SQUAMOUS CELL CARCINOMA OF THE ANTERIOR MALE URETHRA BE MANAGED BY FOLLOWING A PENILE CANCER BEST PRACTICE PATHWAY? Aditya Manjunath, Hussain AlNajjar, Catherine Corbishley, Benjamin Ayres, and Nick Watkin Aditya ManjunathAditya Manjunath More articles by this author , Hussain AlNajjarHussain AlNajjar More articles by this author , Catherine CorbishleyCatherine Corbishley More articles by this author , Benjamin AyresBenjamin Ayres More articles by this author , and Nick WatkinNick Watkin More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1217AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Primary squamous cell carcinoma of the anterior male urethra (SCCmu) is rare and the largest published series to date is only 18 patients. In our experience, we believe that SCCmu behaves in a similar way to primary squamous cell carcinoma of the penis (SCCp). In our tertiary referral centre we have managed patients with SCCmu based on our penile cancer pathway in a multi-disciplinary setting in the absence of alternative clinical evidence. We report a comparative study to test the hypothesis that it is oncologically acceptable to manage SCCmu according to the more established SCCp pathway. METHODS Data was collected prospectively on all patients with SCCmu and SCCp from 2001 to 2016. Cases of urothelial tumour, melanoma of urethral origin and metastases to the penis from other sites were excluded. All patients were discussed at our supra-regional MDT and managed according to network guidelines. Management included penile and urethral preserving surgery where possible and inguinal dynamic sentinel node biopsy for cN0 patients (from 2003). Pathology was reported and reviewed by specialist genito-urethral pathologists according to national guidelines. Comparative outcome measures included T stage, grade, histological sub-type and incidence of node positivity in cN0 and cN+ at presentation. 3 year cancer specific survival was calculated with Kaplan-Meier analysis for the 2 groups. RESULTS 77 SCCmu patients and 882 SCCp were compared. T stage (>pT1) 48% SCCmu vs 35% SCCp. High grade disease 78% SCCmu vs 48% SCCp. Basaloid subtypes SCCmu 58% vs 18.3% SCCp. Node negative (pN0) 49% SCCmu vs 60% SCCp. Extra capsular spread (ECS) 26% SCCmu vs 13.3% SCCp. Sentinel node biopsy positivity rate in cN0 28.8% SCCmu vs 22.3% SCCp. 3 year disease specific survival (DSS) 80.5% SCCmu vs 83.6% SCCp. 3 year DSS in the ECS group 55.9% (95% confidence interval 65.8 - 89.3) SCCmu vs 33.7% (95% confidence interval 9.9 - 57.5) SCCp. CONCLUSIONS SCCmu presents with more advanced disease and worse biological characteristics. Nodal drainage is primarily to inguinal nodes. Although 3 year DSS is similar, in the highest risk nodal group 3 year DSS is better in SCCmu with the same treatment algorithm. Our data supports continuing to manage SCCmu patients with our established SCCp pathway. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e495-e496 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Aditya Manjunath More articles by this author Hussain AlNajjar More articles by this author Catherine Corbishley More articles by this author Benjamin Ayres More articles by this author Nick Watkin More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

919 - Pre- and intraoperative radiation exposure of medical staff during dynamic sentinel node biopsy in penile cancer patients

919 - Pre- and intraoperative radiation exposure of medical staff during dynamic sentinel node biopsy in penile cancer patients

Role of perioperative dynamic sentinel node biopsy for cN0 penile cancer management: experience from an Italian tertiary referral center.

Inguinal lymphadenectomy (iLAD) reduces mortality in patients with cN0 penile cancer but yields high complication rates. Thus, its prophylactic role has been questioned and dynamic sentinel node biopsy (DSNB) was introduced to select men who should undergo the procedure. Our aim was to investigate the accuracy of a contemporary DSNB cohort. We performed a retrospective analysis of ≥T1 or ≥G2 cN0 penile cancer undergoing perioperative DSNB from June 2009 to June 2015 at a tertiary referral center. We excluded men with <18 months follow-up or with local recurrence after primary curative treatment. Complications were graded according to the Clavien-Dindo classification. Thirty-five men underwent DSNB; 85.71% had ≤T2 penile cancer with ≤G2a histology. Per groin detection rate was 80% (scintigraphy being positive bilaterally in 60% and unilaterally in 20.0%). In no cases did DSNB prolong the postoperative course compared to primary surgery. Nine men (n = 15/109 nodes removed) had positive results, 8 of whom underwent iLAD. Among negative DSNB patients, 2 developed nodal penile cancer recurrence; none of them had node biopsy due to inconclusive scintigraphy. At a median follow-up of 42 months (interquartile range 30-78 months), if considering only men with scintigraphy detected inguinal nodes, per-patient sensitivity and specificity were 50% and 80% whereas positive predictive value and negative predictive value were 25% and 92.3%, respectively. Perioperative DSNB is a safe procedure, yielding promising results when performed at a tertiary referral center. Future prospective large studies are needed to investigate how to optimize detection rate and reduce false-negative rates.

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 Dec 2017Editorial Comment Gregory B. Auffenberg Gregory B. AuffenbergGregory B. Auffenberg More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.06.108AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 198(6), p. 1351 References 1 : Contemporary management of regional nodes in penile cancer—improvement of survival?. J Urol2014; 191: 68. Link, Google Scholar 2 : Penile carcinoma: lessons learned from vulvar carcinoma. J Urol2013; 189: 17. Link, Google Scholar 3 : Dynamic sentinel lymph node biopsy in patients with invasive squamous cell carcinoma of the penis: a prospective study of the long-term outcome of 500 inguinal basins assessed at a single institution. Eur Urol2013; 63: 657. Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 198Issue 6December 2017Page: 1351 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gregory B. Auffenberg More articles by this author Expand All Advertisement PDF downloadLoading ...

Contemporary management of patients with penile cancer and lymph node metastasis.

Penile cancer is a rare disease that causes considerable physical and psychological patient morbidity, especially at advanced stages. Patients with low-stage nodal metastasis can achieve durable survival with surgery alone, but those with extensive locoregional metastasis have overall low survival. Contemporary management strategies for lymph node involvement in penile cancer aim to minimize the morbidity associated with traditional radical inguinal lymphadenectomy through appropriate risk stratification while optimizing oncological outcomes. Modified (or superficial) inguinal lymph node dissection and dynamic sentinel lymph node biopsy are diagnostic modalities that have been recommended in patients with high-risk primary penile tumours and nonpalpable inguinal lymph nodes. In addition, advances in minimally invasive and robot-assisted lymphadenectomy techniques are being investigated in patients with penile cancer and might further decrease lymphadenectomy-related adverse effects. The management of patients with advanced disease has evolved to include multimodal treatment with systemic chemotherapy before surgical intervention and can include adjuvant chemotherapy after pelvic lymphadenectomy. The role of radiotherapy in the neoadjuvant or adjuvant setting remains largely unclear, owing to a lack of high-level evidence of possible benefits. New targeted therapies have shown efficacy in squamous cell carcinomas of other sites and might also prove effective in patients with penile cancer.

Investigating the role of SPECT/CT in dynamic sentinel lymph node biopsy for penile cancers

PurposeCurrently, most centres use 2-D planar lymphoscintigraphy when performing dynamic sentinel lymph node biopsy in penile cancer patients with clinically impalpable inguinal nodes. This study aimed to investigate the role of SPECT/CT following 2-D planar lymphoscintigraphy (dynamic and static) in the detection and localization of sentinel lymph nodes in the groin.MethodsA qualitative (visual) review was performed on planar followed by SPECT/CT lymphoscintigraphy in 115 consecutive patients (age 28–86 years) who underwent injection of 99mTc-nanocolloid followed by immediate acquisition of dynamic (20 min) and early static scans (5 min) initially and further delayed static (5 min) images at 120 min followed by SPECT/CT imaging. The lymph nodes detected in each groin on planar lymphoscintigraphy and SPECT/CT were compared.ResultsA total of 440 and 467 nodes were identified on planar scintigraphy and SPECT/CT, respectively. Overall, SPECT/CT confirmed the findings of planar imaging in 28/115 cases (24%). In the remaining 87 cases (76%), gross discrepancies were observed between planar and SPECT/CT images. SPECT/CT identified 17 instances of skin contamination (16 patients, 13%) and 36 instances of in-transit lymphatic tract activity (24 patients, 20%) that had been interpreted as tracer-avid lymph nodes on planar imaging. In addition, SPECT/CT identified 53 tracer-avid nodes in 48 patients (42%) that were not visualized on planar imaging and led to reclassification of the drainage basins (pelvic/inguinal) of 27 tracer-avid nodes.ConclusionsThe addition of SPECT/CT improved the rate of detection of true tracer-avid lymph nodes and delineated their precise (3-D) anatomic localization in drainage basins.

Dynamic sentinel node biopsy for penile cancer: an initial experience in an Irish Hospital.

The presence of nodal metastases is the single most important prognostic factor in penile cancer. However, reliable assessment of nodal status in clinically node-negative (cN0) patients poses a challenge. Approximately 20% of these patients harbour occult nodal metastases. Currently available non-invasive radiological investigations are unreliable in excluding micrometastatic disease. Dynamic sentinel node biopsy (DSNB) is a minimally invasive procedure for assessing lymph node involvement. We report our initial experience with DSNB in assessing the status of regional lymph nodes in cN0 penile cancer patients. DSNB was performed in penile cancer patients with at least one cN0 groin. All patients undergoing DSNB at our institution were included. Lymphoscintigraphic images were obtained from all patients, after intradermal, peritumoral injection of a Technetium-99m nanocolloid. The sentinel nodes were defined as the nodes identified on lymphoscintigraphy, which were also radioactive intraoperatively using a gamma probe. In total, 18 groins from 11 patients underwent DSNB. Of these, 11 patients underwent bilateral DSNB and 4 had unilateral DSNB. The mean (range) age of patients at the time of presentation of their primary tumour was 63 (39-78) years. A mean of 1.2 nodes per groin was retrieved. One lymph node was positive in one patient, who subsequently underwent a bilateral inguinal lymph node dissection. Overall, the median (range) follow-up was 12.8 (2.7-31.3) months with no local or regional recurrences. Further cases and longer follow-up will define the accuracy of this technique in the Irish population.

Management of non-visualization following dynamic sentinel lymph node biopsy for squamous cell carcinoma of the penis.

To review the management and clinical outcomes of uni- or bilateral non-visualization of inguinal lymph nodes during dynamic sentinel lymph node biopsy (DSNB) in patients diagnosed with penile cancer and clinically impalpable inguinal lymph nodes (cN0), and to develop an algorithm for the management of patients in which non-visualization occurs. This is a retrospective observational study over a period of 4 years, comprising 166 patients with penile squamous cell carcinoma undergoing DSNB and followed up for a minimum of 6 months. All cases diagnosed with uni- or bilateral non-visualization of sentinel nodes in this cohort were identified from a penile cancer database. The management of the inguinal lymph nodes after non-visualization and the oncological outcomes including local and regional recurrence rates were documented. Out of 166 consecutive patients undergoing DSNB, 20 patients (12%) had unilateral non-visualization after injection of intradermal 99m Tc. Of these 20 patients, seven underwent repeat DSNB at a later date, with six having successful visualization. One patient had persistent non-visualization and proceeded to a superficial modified inguinal lymphadenectomy (SML). None of these patients experienced recurrence at follow-up. A further seven patients underwent modified SML with on-table frozen-section analysis of the lymph node packet; none of these patients were found to have micrometastatic disease in the inguinal lymph nodes, although one patient developed metastatic inguinal node disease at a later date. Six patients elected to undergo clinical surveillance and have remained disease-free. Patients with impalpable inguinal lymph nodes undergoing DSNB with ≥G2 T1 disease should ideally have bilateral visualization of the sentinel lymph nodes, reflecting the drainage pattern from the primary tumour. In the present series, 12% of patients were found to have unilateral non-visualization after DSNB. Among patients offered a repeat DSNB at a later date, localizing the sentinel node was successful in 86% of cases. Patients with favourable histological characteristics can be placed on clinical surveillance. Those with high-risk disease can be offered a repeat DSNB procedure on the proviso that SML may be carried out if there is repeated non-visualization. Larger cohorts are required to validate this proposed algorithm.