Nodal Packets Research Articles

Incidence of sentinel lymph node metastases in apparent early-stage endometrial cancer: a multicenter observational study

ObjectiveUltrastaging is accurate in detecting nodal metastases, but increases costs and may not be necessary in certain low-risk subgroups. In this study we examined the risk of nodal involvement detected...

Prevalence of High-Risk Prostate Cancer Metastasis to Cloquet's Ilioinguinal Lymph Node.

Cloquet's node, located at the junction between the deep inguinal nodes and the external iliac chain, is easily accessible and commonly excised during pelvic lymph node dissection for prostate cancer. However, we hypothesize that Cloquet's node is not part of lymphatic metastatic spread of prostate cancer. Between September 2016 and June 2019, 105 consecutive patients with high-risk prostate cancer (cT3a or Grade Group 4/5, or prostate specific antigen >20 ng/ml) underwent a laparoscopic radical prostatectomy and pelvic lymph node dissection. First, Cloquet's node was identified, retrieved and submitted separately to pathology as right and left Cloquet's node. Next, a pelvic lymph node dissection was completed including the external iliac, obturator fossa and hypogastric nodal packets. Each lymph node was cut into 3 mm slices which were separately embedded in paraffin, stained with hematoxylin and eosin, and examined microscopically. The final analysis included 95 patients. In this high-risk population, the median number of nodes removed was 22 (IQR 18-29); 39/95 patients (41%) had lymph node metastasis. The median number of Cloquet's nodes removed was 2 (IQR 2-3). Cloquet's node was negative in all but 1 patient (1.1%), who had very high-risk features and high metastatic burden in the lymph nodes. In high-risk prostate cancer, metastasis to the ilioinguinal node of Cloquet is rare. Given this low prevalence, Cloquet's node can be safely excluded from the pelvic lymph node dissection template.

Management Trends and Outcomes of Patients Undergoing Radical Cystectomy for Urothelial Carcinoma of the Bladder: Evolution of the University of Southern California Experience over 3,347 Cases.

There are conflicting reports on outcome trends following radical cystectomy (RC) for bladder cancer. Evolution of modern bladder cancer management and its impact on outcomes was analyzed using a longitudinal cohort of 3,347 patients who underwent RC at an academic center between 1971 and 2018. Outcomes included recurrence-free survival (RFS) and overall survival (OS). Associations were assessed using univariable and multivariable models. In all, 70.9% of cases underwent open RC in the last decade, although trend for robot-assisted RC rose since 2009. While lymphadenectomy template remained consistent, nodal submission changed to anatomical packets in 2002 with increase in yield (p <0.001). Neoadjuvant chemotherapy (NAC) use increased with time with concomitant decrease in adjuvant chemotherapy; this was notable in the last decade (p <0.001) and coincided with improved pT0N0M0 rate (p=0.013). Median 5-year RFS and OS probabilities were 65% and 55%, respectively. Advanced stage, NAC, delay to RC, lymphovascular invasion and positive margins were associated with worse RFS (all, multivariable p <0.001). RFS remained stable over time (p=0.73) but OS improved (5-year probability, 1990-1999 51%, 2010-2018 62%; p=0.019). Among patients with extravesical and/or node-positive disease, those who received NAC had worse outcomes than those who directly underwent RC (p ≤0.001). Despite perioperative and surgical advances, and improved pT0N0M0 rates, there has been no overall change in RFS trend following RC, although OS rates have improved. While patients who are downstaged with NAC derive great benefit, our real-world experience highlights the importance of preemptively identifying NAC nonresponders who may have worse post-RC outcomes.

MP67-13 COMPARISON OF MORBIDITY BETWEEN LIMITED AND EXTENDED PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: RESULTS FROM A LARGE, CLINICALLY-INTEGRATED, RANDOMIZED TRIAL

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy III (MP67)1 Apr 2020MP67-13 COMPARISON OF MORBIDITY BETWEEN LIMITED AND EXTENDED PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: RESULTS FROM A LARGE, CLINICALLY-INTEGRATED, RANDOMIZED TRIAL Karim Touijer, Daniel D. Sjoberg, Nicole Benfante, Claudia Mercader Barrull*, Natalia Picola Brau, Inés Rivero Belenchón, Vincent Laudone, Behfar Ehdaie, James A. Eastham, Peter T. Scardino, and Andrew Vickers Karim TouijerKarim Touijer More articles by this author , Daniel D. SjobergDaniel D. Sjoberg More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Claudia Mercader Barrull*Claudia Mercader Barrull* More articles by this author , Natalia Picola BrauNatalia Picola Brau More articles by this author , Inés Rivero BelenchónInés Rivero Belenchón More articles by this author , Vincent LaudoneVincent Laudone More articles by this author , Behfar EhdaieBehfar Ehdaie More articles by this author , James A. EasthamJames A. Eastham More articles by this author , Peter T. ScardinoPeter T. Scardino More articles by this author , and Andrew VickersAndrew Vickers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000947.013AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic lymph node dissection (PLND) in prostate cancer is controversial. Although it represents the most reliable procedure for lymph node staging, the extended PLND was reported to be associated with increased morbidity. METHODS: Between October 2011 and March 2017, men were consented to the trial and underwent radical prostatectomy at Memorial Sloan Kettering Cancer Center. The study design was a cluster randomization with crossover. Each surgeon was randomized to use a limited (external iliac nodal packet) vs. extended (external iliac, obturator fossa and hypogastric nodal packets) PLND template for a 3-month period. At the end of the 3-month period, surgeons were once again randomized. Morbidity data within 30 days of surgery was prospectively graded and collected in the clinical research database. RESULTS: A total of 1574 patients were randomized: 811 randomized to the extended and 763 to the limited template. Overall the rate of complication was 10.5% in the limited PLND group vs. 8.5% in the extended PLND group. There were no grade IV or V complications. Rates for grade II and III complications were similar (7.2% in limited vs. 6.3% in extended). CONCLUSIONS: In this large randomized trial the overall rate of grade II and III complications was low. There was no significant difference in complication rates between the limited and extended PLND. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1030-e1030 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Karim Touijer More articles by this author Daniel D. Sjoberg More articles by this author Nicole Benfante More articles by this author Claudia Mercader Barrull* More articles by this author Natalia Picola Brau More articles by this author Inés Rivero Belenchón More articles by this author Vincent Laudone More articles by this author Behfar Ehdaie More articles by this author James A. Eastham More articles by this author Peter T. Scardino More articles by this author Andrew Vickers More articles by this author Expand All Advertisement PDF downloadLoading ...

Intra-abdominal Lymph Nodes: A Privileged Donor Site for Vascularized Lymph Node Transfer.

Summary:A variety of donor options for vascularized lymph node transfer for the surgical treatment of lymphedema have been described. Intra-abdominal harvest sites including the gastroepiploic nodes within the omental flap and the mesenteric node flap are distinguished from their extra-abdominal counterparts by the absent risk of iatrogenic donor site lymphedema and discrete scar location, as well as the ability to harvest up to 3 vascularized nodal packets from 1 donor site. However, there are also potential morbidities including hernia and intra-abdominal visceral injuries. Patient selection and flap harvest techniques are reviewed.

Diagnostic and therapeutic value of pelvic lymph node dissection in the fossa of Marcille in patients with clinically localized high‐risk prostate cancer: Histopathological and molecular analyses

The optimal extent of lymph node dissection in radical prostatectomy has not been determined. Lymph nodes in the fossa of Marcille, which is an important pelvic lymphatic pathway and candidate for additional dissection, have not been evaluated at the molecular level. Here, we assessed by molecular analysis the presence of occult positive lymph nodes in the fossa of Marcille in patients with clinically localized high-risk prostate cancer. Fifty-two patients with clinically localized high-risk prostate cancer underwent pelvic lymph node dissection accompanied by robot-assisted radical prostatectomy. All nodal packets were dissected separately and grouped into right and left obturator, external and internal iliac regions (including common iliac region to ureter crossing), and fossa of Marcille. All lymph nodes were bisected and evaluated by histopathological or molecular analysis using a quantitative reverse transcription-polymerase chain reaction. The number of positive lymph nodes in the fossa of Marcille and the difference in detection rate were investigated using histopathological and molecular analyses. Perioperative complication rate and predictive factors for biochemical recurrence were evaluated. In the molecular analysis, there were seven positive lymph nodes in the fossa of Marcille in three patients, which were coexistent with positive nodes in other regions. The detection rate of positive lymph nodes was significantly higher using molecular than histopathological analysis (P < .01). Perioperative complication rate within 90 days after the operation was 25.0% and no Clavien-Dindo grade ≥3 complication was confirmed. Detection of metastasis by histopathological and molecular analysis was a significant factor related to biochemical recurrence in the Cox proportional hazards regression model. No case of positive lymph nodes in the fossa of Marcille that had skipped over other regions was confirmed. Additional lymph node dissection of fossa of Marcille did not lead to complete resection of molecularly positive lymph nodes.

A novel procedure of thoracoscopic 4L lymph node dissection: 4L posterior first technique

Background: Left lower paratracheal (4L) lymph node dissection for left lung cancer is difficult because of the anatomic configurations of the aortic arch, pulmonary artery, and left recurrent nerve. This study aimed to describe a novel procedure of thoracoscopic 4L lymph node dissection and determine its surgical outcomes. Methods: In this study, thoracoscopic lobectomy with lymphadenectomy was performed via four ports with confronting upside-down monitor setting. In our novel procedure, “4L posterior first technique,” we initially dissected the posterior side of 4L lymph nodes. The assistant surgeon retracted the lung with nodal packet, pulmonary artery, and vagus and left recurrent nerves; the retraction provided an excellent surgical view around the recurrent nerve. The bronchial arteries branching from the aorta were clipped and divided at the root. The dissection between the posterior side of nodal packet and the surrounding structures was completed before touching the hilar structures. The outcomes in the novel method group and the conventional method group were compared. Results: From 2016 to 2018, 40 and 38 patients underwent thoracoscopic 4L lymphadenectomy using the novel method and conventional method, respectively. The total operation time was 200±41 min, and the total blood loss was 27±28 mL. The postoperative hospital stay was for 6±3 days. None of the patients died, and none of them was converted to thoracotomy. The matched comparison revealed that the operation time was shorter (194±33 vs . 218±41 min, P=0.01), and the amount of bleeding was relatively smaller (22±21 vs . 33±21 mL, P=0.06) in the novel method group. Transient recurrent nerve paralysis was noted in one patient from the conventional method group (3.7%) and in no one from the novel group (0%). Conclusions: Our 4L posterior first technique is easier to perform and allows a more accurate dissection of thoracoscopic 4L lymph nodes.

Lymph Nodes Invasion of Marcille’s Fossa Associates with High Metastatic Load in Prostate Cancer Patients Undergoing Extended Pelvic Lymph Node Dissection: The Role of “Marcillectomy”

Introduction: To assess the incidence of malignancy involvement of lymph nodes (LNs) in Marcille’s fossa in patients undergoing robot assisted radical prostatectomy (RARP) and extended pelvic lymph nodes dissection (ePLND) for prostate cancer (PCa). Design, Setting, and Participants: Between January 2014 and December 2017, details of patients who underwent RARP and ePLND were prospectively analysed. All the nodal packets were dissected separately, grouped into left and right nodes and submitted in separate packages to dedicated pathologist. Results and Limitations: Two hundred and twenty-one patients underwent ePLND and RARP in the study period. In aggregate, Marcille’s LNs involvement was found in 5 (2.3%) of patients, 2 on the left side and 3 on the right side. Per cent of positive cores and Gleason at biopsy are clinical predictors of LNs invasion; moreover, in the surgical specimen, seminal vesicle invasion and high-grade cancer were factors related to loco-regional metastases. Conclusions: Marcille’s nodes involvement is associated to contemporarily multiple LN metastases in other template locations in high-risk PCa patients. The Marcille’s lymphadenectomy would be recommended when planning an ePLND in high-risk PCa.

Extended Pelvic Lymph Node Dissection in Bladder Cancer.

Radical cystectomy and extended pelvic lymph node dissection (ePLND) are the gold standard treatment for muscle-invasive bladder cancer and BCG unresponsive nonmuscle-invasive bladder cancer. In this article, we review the rationale for ePLND in the treatment of bladder cancer and the evidence supporting the equipoise between robot-assisted (RA) and open ePLND. A step-by-step guide of robot-assisted ePLND (RA ePLND) is provided to illustrate the techniques currently employed at our institution. Medline and PubMed electronic databases were queried for English language articles on bladder cancer, ePLND, and RA ePLND. In addition, a step-by-step video of RA ePLND was assembled with narration and accompanying explanations of each step to illustrate our current techniques. Key images from the video were selected for illustration of the relevant anatomical landmarks. ePLND with a minimum nodal yield of 10 to 14 is tantamount in the treatment of bladder cancer. The number of lymph nodes resected influenced survival in both pathologically node positive and negative patients. In addition, RA ePLND was found to have equipoise as open ePLND by several groups. In our surgical atlas video, we illustrate key surgical steps, including port placement and exposure. Also, anatomic landmarks of dissection for the internal iliac, external iliac/obturator, and higher nodal packets are described in detail. We illustrate the techniques for a thorough RA ePLND, with the intention to help the robotic surgeon to meet the 10 to 14 nodal yield mandated by the Bladder Cancer Collaborative Group.

Fluorescence-Based Molecular Imaging of Porcine Urinary Bladder Sentinel Lymph Nodes.

The primary objective was to test the ability of a laparoscopic camera system to detect the fluorescent signal emanating from sentinel lymph nodes (SLNs) approximately 2 d after injection and imaging of a positron-emitting molecular imaging agent into the submucosa of the porcine urinary bladder. Methods: Three female pigs underwent a submucosal injection of the bladder with fluorescent-tagged tilmanocept, radiolabeled with both 68Ga and 99mTc. One hour after injection, a pelvic PET/CT scan was acquired for preoperative SLN mapping. Approximately 36 h later, robotic SLN mapping was performed using a fluorescence-capable camera system. After identification of the fluorescent lymph nodes, a pelvic lymph node dissection was completed with robotic assistance. All excised nodal packets (n = 36) were assayed for 99mTc activity, which established a lymph node as an SLN. 99mTc activity was also used to calculate the amount of dye within each lymph node. Results: All of the SLNs defined by the ex vivo γ-well assay of 99mTc activity were detected by fluorescence mode imaging. The time between injection and robotic SLN mapping ranged from 32 to 38 h. A total of 5 fluorescent lymph nodes were detected; 2 pigs had 2 fluorescent lymph nodes and 1 pig exhibited a single lymph node. Four of the 5 SLNs exhibited increased SUVs of 12.4-139.0 obtained from PET/CT. The dye content of the injection sites ranged from 371 to 1,441 pmol, which represented 16.5%-64.1% of the injected dose; the amount of dye within the SLNs ranged from 8.5 to 88 pmol, which was equivalent to 0.38%-3.91% of the administered dose. Conclusion: Fluorescent-labeled 68Ga-tilmanocept allows for PET imaging and real-time intraoperative detection of SLNs during robotic surgery.

Radical cystectomy with super-extended lymphadenectomy: impact of separate vs en bloc lymph node submission on analysis and outcomes.

To update our previous analysis of the clinical and pathological impact of the change in the submission of lymphadenectomy specimens from en bloc to 13 separate anatomically defined packets, which took place at the University of Southern California in May 2002, and to determine whether lymph node (LN) packeting resulted in any change in oncological outcomes. A total of 846 patients who underwent radical cystectomy (RC) with super-extended LN dissection for cTxN0M0 bladder cancer between January 1996 and December 2007 were identified. Specimens of 376 patients were sent en bloc (group 1), and specimens of 470 patients were sent in 13 separate anatomical packets (group 2). The pathological tumour stage distribution and the proportion of LN-positive patients (group 1: 82 patients [22%] versus group 2: 99 patients [21%]; P = 0.80) were similar between the two groups: the median [range] number of total LNs identified increased significantly (group 1: 32 [10-97] versus group 2: 65 [10-179]; P < 0.001). LN density decreased (group 1, 11% versus group 2, 4%; P = 0.005). The median [range] number of positive LNs removed was similar (group 1: 0 [0-30] versus group 2: 0 [0-97]; P = 0.87). No nodal stage shift was observed. The 5-year overall survival (group 1: 58% versus group 2: 59%; P = 0.65) and recurrence-free survival rates (group 1: 68% versus group 2: 70%; P = 0.57) were similar. The incidence of patients with positive LNs remained unchanged, regardless of how the LN specimen was submitted. Submitting 13 separate nodal packets significantly increased the total LN yield, but did not result in a significant increase in the number of positive LNs or a consecutive nodal stage shift and did not affect oncological outcomes. Based on these results LN density is not an accurate prognosticator.

FDG PET-CT for lymph node staging of bladder cancer: a prospective study of patients with extended pelvic lymphadenectomy.

The purpose of this study was to evaluate the diagnostic accuracy of [(18)F] fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) for lymph node (LN) staging of bladder cancer patients undergoing radical cystectomy (RC) with extended pelvic lymphadenectomy compared to conventional CT. A total of 61 patients underwent FDG PET-CT before RC and extended pelvic lymphadenectomy. A template for extended pelvic lymphadenectomy to the level of the inferior mesenteric artery was divided into 11 anatomic nodal packets. Definitive pathologic findings of resected LNs were correlated with the results of FDG PET-CT and CT alone in a patient- and nodal packet-based manner. Among the 61 patients, pathological staging confirmed LN metastasis in 17 patients (27.9 %). In total, 627 LN packets (2580 LNs) were resected and histologically evaluated. The mean number of LNs removed was 42 (median 40; range 22-118). Of the 627 LN packets removed, 27 packets (4.3 %) were positive for LN metastasis based on pathologic analysis. On a patient-based analysis, FDG PET-CT and conventional CT showed a sensitivity of 47.1 and 29.4 %, respectively, specificity of 93.2 and 97.7 %, respectively, positive predictive value (PPV) of 72.7 and 78.2 %, respectively, and negative predictive value (NPV) of 82.0 and 78.2 %, respectively. On a nodal packet-based analysis, sensitivity, specificity, PPV, and NPV were 14.8, 97.8, 23.5, and 96.2 %, respectively, for PET-CT and 11.1, 98.7, 27.3, and 96.1 %, respectively, for conventional CT. Combined FDG PET-CT did not improve the diagnostic accuracy of conventional CT for the detection of LN metastasis in bladder cancer patients scheduled for RC.

Robotic-assisted Fluorescence Sentinel Lymph Node Mapping Using Multimodal Image Guidance in an Animal Model

To investigate positron emission tomography/computed tomography (PET/CT) preoperative imaging and intraoperative detection of a fluorescent-labeled receptor-targeted radiopharmaceutical in a prostate cancer animal model. Three male beagle dogs underwent an intraprostatic injection of fluorescent-tagged tilmanocept, radiolabeled with both gallium Ga-68 and technetium Tc-99m. One hour after injection, a pelvic PET/CT scan was performed for preoperative sentinel lymph node (SLN) mapping. The definition of SLN was a standardized uptake value that exceeded 5% of the lymph node with the highest standardized uptake value. Thirty-six hours later, we performed robotic-assisted SLN dissection using a fluorescence-capable camera system. Fluorescent lymph nodes were clipped, the abdomen was opened, and the pelvic and retroperitoneal nodes were excised. All excised nodal packets were assayed by in vitro nuclear counting and reported as the percentage of injected dose. Preoperative PET/CT imaging identified a median of 3 SLNs per animal. All SLNs (100%) identified by the PET/CT were fluorescent during robotic-assisted lymph node dissection. Of all fluorescent nodes visualized by the camera system, 9 of 12 nodes (75%) satisfied the 5% rule defined by the PET/CT scan. The 2 lymph nodes that did not qualify accumulated <0.002% of the injected dose. Fluorescent-labeled tilmanocept has optimal logistic properties to obtain preoperative PET/CT and subsequent real-time intraoperative confirmation during robotic-assisted SLN dissection.

Level IIB lymph node metastasis in laryngeal and hypopharyngeal squamous cell carcinoma: Single‐institution case series and review of the literature

To determine the incidence of level IIB lymph node metastasis in patients with laryngeal or hypopharyngeal squamous cell carcinoma and to evaluate the need for elective and therapeutic neck dissection of level IIB. Retrospective cohort study and review of the literature. Patients with laryngeal or hypopharyngeal squamous cell carcinoma (N = 65) were primarily treated with surgery at Mayo Clinic (Rochester, Minnesota) from 2004 through 2010. Neck dissection specimens were analyzed by a pathologist, and metastases to level IIB were reported. In addition, 18 previously published studies, totaling 1,114 neck dissections, were reviewed. Level IIB lymph node metastases were present in 4% and 17% of elective and therapeutic neck dissections, respectively. Ipsilateral IIB metastasis was more common than contralateral IIB metastasis in elective and therapeutic neck dissection specimens. Level IIB lymph node metastasis was not significantly associated with level IIA nodal metastasis, level III nodal metastasis, clinical primary tumor stage, clinical nodal stage, or pathologic confirmation of extracapsular spread in either laryngeal or hypopharyngeal squamous cell carcinoma. The rate of occult IIB metastasis in laryngeal and hypopharyngeal squamous cell carcinoma is exceedingly low. In a clinically node-negative case, the ipsilateral and contralateral level IIB nodal packet should not be dissected. For clinically node-positive cases, ipsilateral level IIB dissection should be performed; contralateral IIB dissection should be performed only when indicated.

1880 ACCURACY OF FDG PET-CT COMPARED WITH CONVENTIONAL CT FOR THE LYMPH NODE STAGING IN MUSCLE INVASIVE BLADDER CANCER: PROSPECTIVE STUDY OF 58 PATIENTS WITH EXTENDED LYMPHADENECTOMY

You have accessJournal of UrologyBladder Cancer: Metastatic Disease + Staging1 Apr 20131880 ACCURACY OF FDG PET-CT COMPARED WITH CONVENTIONAL CT FOR THE LYMPH NODE STAGING IN MUSCLE INVASIVE BLADDER CANCER: PROSPECTIVE STUDY OF 58 PATIENTS WITH EXTENDED LYMPHADENECTOMY Taekmin Kwon, In Gab Jeong, Ju Hyun Lim, Sung Woo Hong, Dalsan You, Bumsik Hong, Jun Hyuk Hong, Hanjong Ahn, and Choung-Soo Kim Taekmin KwonTaekmin Kwon Seoul, Korea, Republic of More articles by this author , In Gab JeongIn Gab Jeong Seoul, Korea, Republic of More articles by this author , Ju Hyun LimJu Hyun Lim Seoul, Korea, Republic of More articles by this author , Sung Woo HongSung Woo Hong Seoul, Korea, Republic of More articles by this author , Dalsan YouDalsan You Seoul, Korea, Republic of More articles by this author , Bumsik HongBumsik Hong Seoul, Korea, Republic of More articles by this author , Jun Hyuk HongJun Hyuk Hong Seoul, Korea, Republic of More articles by this author , Hanjong AhnHanjong Ahn Seoul, Korea, Republic of More articles by this author , and Choung-Soo KimChoung-Soo Kim Seoul, Korea, Republic of More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2299AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Current imaging modalities for the lymph node staging in muscle invasive bladder cancer scheduled for radical cystectomy have limited accuracy. The aim of this prospective study is to evaluate the diagnostic accuracy of FDG PET-CT for the lymph node staging of patients undergoing radical cystectomy with extended pelvic lymphadenectomy and compare that with the diagnostic accuracy of conventional CT. METHODS From June 2009 to April 2012, 58 patients underwent FDG PET-CT before radical cystectomy and extended pelvic lymphadenectomy. Extended pelvic lymphadenectomy template to the level of the inferior mesenteric artery was divided into 11 anatomic nodal packets. Definitive pathologic findings of resected lymph node were correlated with the results of FDG PET-CT and CT alone in a patient- and nodal packet- based manner. RESULTS Among the 58 patients, pathological staging confirmed 15 patients (25.9%) had lymph node metastasis. In total, 587 lymph node packets (2,443 lymph nodes) were resected and histologically evaluated. The mean number of lymph node removed was 42 with median of 39 (22-118). Of the 587 lymph nodes packets removed, 25 (4.3%) packets had lymph node metastasis pathologically. On a patient-based analysis, FDG PET-CT and conventional CT showed a sensitivity of 40% and 26.7%, specificity of 93% 97.7%, positive predictive value (PPV) of 66.7% and 80%, negative predictive value (NPV) of 81.6% and 79.3%, respectively. On a nodal packet-based analysis, sensitivity, specificity, PPV, and NPV for PET/CT were 21.4%, 98.3%, 23.1%, and 98.1%, respectively, and for conventional CT alone as 8.0%, 98.8%, 22.2%, and 96%, respectively. CONCLUSIONS Combined FDG PET-CT could not improve the diagnostic accuracy of conventional CT alone for the detection of lymph node metastasis in muscle-invasive bladder cancer scheduled for radical cystectomy. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e771 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Taekmin Kwon Seoul, Korea, Republic of More articles by this author In Gab Jeong Seoul, Korea, Republic of More articles by this author Ju Hyun Lim Seoul, Korea, Republic of More articles by this author Sung Woo Hong Seoul, Korea, Republic of More articles by this author Dalsan You Seoul, Korea, Republic of More articles by this author Bumsik Hong Seoul, Korea, Republic of More articles by this author Jun Hyuk Hong Seoul, Korea, Republic of More articles by this author Hanjong Ahn Seoul, Korea, Republic of More articles by this author Choung-Soo Kim Seoul, Korea, Republic of More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Indications for and anatomical extent of pelvic lymph node dissection for prostate cancer: Practice patterns of uro-oncologists in North America

PurposeTo investigate the prevailing practice of uro-oncologists regarding the indications for and extent of pelvic lymph node dissection (PLND) for prostate cancer. Materials and methodsA 9-question survey was sent as a hyperlink by electronic mail to all members of the Society of Urologic Oncology. Participants were asked about their surgical volume, indications for PLND, which nodal packets are dissected as delineated on anatomical schema, and type of surgical approach. ResultsOf 340 members, 183 urologists (58%) completed the survey. Of these, 43% were ≥10 years out of fellowship and 62% performed >50 radical prostatectomies per year. Of the surveyed surgeons, 45% performed PLND on all patients undergoing radical prostatectomy. The remainder used various risk-stratification schemas. A total of 32 different indications for PLND were reported, the most common being “intermediate risk” according to the American Urological Association's risk classification. As to extent of PLND, 15% perform a PLND limited to the external iliac, while 30% include the external iliac, obturator fossa, and hypogastric lymph nodes. Among surgeons using both open and robotic approaches, 19% reported that the indication for and extent of lymphadenectomy performed differ based on the surgical approach used. ConclusionsThe results of this survey provide insight into the practice patterns of uro-oncologists regarding PLND and highlight the lack of uniformity in determining when and how a PLND should be performed. Collaborative efforts are needed to develop guidelines on this issue and are a necessary step toward standardization of reporting the outcomes of surgical clinical trials.

Pelvic Lymph Node Dissection for Patients with Elevated Risk of Lymph Node Invasion During Radical Prostatectomy: Comparison of Open, Laparoscopic and Robot-Assisted Procedures

Published outcomes of pelvic lymph node dissection (PLND) during robot-assisted laparoscopic prostatectomy (RALP) demonstrate significant variability. The purpose of the study was to compare PLND outcomes in patients at risk for lymph node involvement (LNI) who were undergoing radical prostatectomy (RP) by different surgeons and surgical approaches. Institutional policy initiated on January 1, 2010, mandated that all patients undergoing RP receive a standardized PLND with inclusion of the hypogastric region when predicted risk of LNI was ≥ 2%. We analyzed the outcomes of consecutive patients meeting these criteria from January 1 to September 1, 2010 by surgeons and surgical approach. All patients underwent RP; surgical approach (open radical retropubic [ORP], laparoscopic [LRP], RALP) was selected by the consulting surgeon. Differences in lymph node yield (LNY) between surgeons and surgical approaches were compared using multivariable linear regression with adjustment for clinical stage, biopsy Gleason grade, prostate-specific antigen (PSA) level, and age. Of 330 patients (126 ORP, 78 LRP, 126 RALP), 323 (98%) underwent PLND. There were no significant differences in characteristics between approaches, but the nomogram probability of LNI was slightly greater for ORP than RALP (P=0.04). LNY was high (18 nodes) by all approaches; more nodes were removed by ORP and LRP (median 20, 19, respectively) than RALP (16) after adjusting for stage, grade, PSA level, and age (P=0.015). Rates of LNI were high (14%) with no difference between approaches when adjusted for nomogram probability of LNI (P=0.15). Variation in median LNY among individual surgeons was considerable for all three approaches (11-28) (P=0.005) and was much greater than the variability by approach. PLND, including hypogastric nodal packet, can be performed by any surgical approach, with slightly different yields but similar pathologic outcomes. Individual surgeon commitment to PLND may be more important than approach.

912 ROBOTIC LIMITED AND EXTENDED PELVIC LYMPHADENECTOMY FOR PROSTATE CANCER

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy II1 Apr 2010912 ROBOTIC LIMITED AND EXTENDED PELVIC LYMPHADENECTOMY FOR PROSTATE CANCER Hugh Lavery and Ronney Abaza Hugh LaveryHugh Lavery More articles by this author and Ronney AbazaRonney Abaza More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1668AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The optimal extent of lymphadenectomy for prostate cancer is unknown. More extensive dissections have shown increased overall nodal yields as well as more frequent identification of positive nodes. With the advent of robot-assisted laparoscopic prostatectomy (RALP), the ability to achieve adequate lymph node dissections with this approach has been questioned with many series reporting lower nodal yields than historical series or lower nodal positivity than expected based upon the biology of the disease. We reviewed our experience with both extended (ePLND) and limited pelvic lymphadenectomy (PLND) to determine nodal yield, complications, and rate of node positivity. METHODS We reviewed 250 consecutive RALP procedures with PLND from Feb 2008 to Jan 2009 by a single surgeon (RA). Nodal packets were dissected en bloc and nodes counted before paraffin-embedding to prevent double counting from cutting of nodes. Pathology processing was without knowledge of the study. ¡°Low-risk¡± patients underwent a limited PLND including the external iliac and obturator lymph nodes. An extended dissection was performed in ¡°high-risk¡± patients with preoperative PSA >10ng/dl, cT3 disease, Gleason ¡Ý8, or cancer in ¡Ý50% of biopsy tissue extending the template to all nodes medial to the genitofemoral nerve including the hypogastric nodes and common iliac nodes up to the crossing of the ureter. Patient and pathologic outcomes were evaluated. RESULTS Of 250 patients, 173 underwent limited PLND while 77 underwent ePLND. Mean nodal yield for all patients was 11 nodes, with 8.6 and 16.4 nodes for limited and extended PLND, respectively. A total of 17 (7%) node-positive (N+) patients were identified overall, with 2 (1.1%) in the limited group and 15 (19.5%) in the ePLND group. Of the 183 organ-confined (OC) tumors, only 1 was N+ (0.5%), compared to 16 of 67 (24%) non-OC tumors. Complications of the lymphadenectomy included four symptomatic lymphoceles requiring percutaneous drainage, one ureteral injury requiring a temporary stent, and one transient obturator nerve palsy for an overall complication rate of 2.4% (0.5% of limited and 8% of ePLND). CONCLUSIONS Pelvic lymphadenectomy for prostate cancer can be adequately performed in robot-assisted laparoscopic fashion with nodal yields and rate of positivity comparable to published open surgical series. The role of limited PLND remains unclear, but ePLND appears warranted for high risk cancers. Columbus, OH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byAbaza R, Dangle P, Gong M, Bahnson R and Pohar K (2018) Quality of Lymphadenectomy is Equivalent With Robotic and Open Cystectomy Using an Extended TemplateJournal of Urology, VOL. 187, NO. 4, (1200-1205), Online publication date: 1-Apr-2012. Volume 183Issue 4SApril 2010Page: e356 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hugh Lavery More articles by this author Ronney Abaza More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effect of Healthcare Provider Characteristics on Nodal Yield at Radical Cystectomy

Current evidence suggests that patient outcomes after radical cystectomy are dependent on nodal yield, even in cases of node-negative disease. We hypothesized that the final lymph node (LN) counts would be associated with the service provider (surgeon, pathologist) and the level of experience of the provider's assistant. We reviewed a series of 89 consecutive patients who had undergone cystectomy from 2001 to 2005 for the effect of provider factors on LN counts. The effect of the surgeon was assessed on an individual basis and the effect of the pathologist was determined according to the uropathologic subspecialization. Provider assistant experience was classified according to the training level of the surgical assistant and the caseload volume of the pathology assistant. Multivariate linear regression analysis, controlling for patient factors, number of nodal packets, and margin status, was used to determine the provider factors associated with the final nodal counts. The median number of LNs harvested was 14 per patient. On univariate analyses, the individual surgeon and the number of nodal packets submitted were significantly associated with nodal yield (P <0.001 for both). Surgical margin status was also significant (P = 0.003), with fewer LNs collected from those with margin-positive disease. On multivariate linear regression analysis, only surgeon (P = 0.01) and number of packets (P < 0.001; with more LNs taken with more packets) remained statistically significant. The results of our study have shown that the nodal yield from radical cystectomy is dependent on surgeon-specific factors (the number of packets submitted and the operating surgeon). The patient or pathology service providers did not influence the ultimate LN counts.

Ultrasound-guided contrast-enhanced sentinel node biopsy of the head and neck in a porcine model

To test the feasibility of contrast-enhanced ultrasound (CEUS)-guided sentinel lymph node biopsy (SNB) of the head and neck in a porcine model. In this prospective, nonrandomized study, methylene blue and Sonazoid were injected into the lateral tongue or floor of mouth (FOM) of four swine. Real-time CEUS was used to identify contrast in the lymphatic channels flowing to the sentinel lymph node (SLN). Endoscopic or open SNB was performed. Neck dissection was then performed, and the residual nodal packet was examined for remaining contrast-enhancing or blue dye-stained nodes. In all eight procedures, the SLN was visualized with ultrasound and blue dye. Seven procedures identified a single SLN, and one identified two SLNs. Subsequent neck dissections revealed no other nodes containing methylene blue or contrast in the nodal specimen or operative bed. CEUS-guided SNB of the head and neck in swine is feasible, with success comparable to blue dye-guided SNB. This technique may offer several advantages over traditional techniques, and warrants further study.