Sentinel Lymph Node Sampling Research Articles

Ultrasound guided infiltration of local anaesthesia in medically unfit patients allows adequate wide local excision and sentinel node sampling

Objective: To determine the advantages and limitations of a combined stereotaxic fine-needle aspiration biopsy and needle-core biopsy in the diagnosis of 353 nonpalpable breast lesions with special attention given to the collection of follow-up data. Methods and material: 353 nonpalpable breast lesions underwent ‘one pass’ stereotaxic fine-needle aspiration (21 gauge needle) and needle-core biopsy (18 gauge needle) at our institution from January 1990 to October 1993. Stereotaxic biopsies were carried out by means of an ‘add-on unit’. Surgical biopsy was usually recommended for highly suspicious radiologic patterns and/or needle biopsy reports classified as atypical or malignant. In all other cases mammographic follow-up was advised at 6 months and then annually for 3 years. The data were collected retrospectively during September 1995 (theoretical average follow-up of greater than 3 years). Results: Following the combined needle biopsy technique procedure, surgery was recommended for 83 lesions. Fifty-four cancers were associated to these suspicious lesions. Because of changing radiological or clinical pattern during follow-up (mean follow-up: 22 months), 11 cancers were detected among the 270 lesions initially considered not to need surgery. Forty-three percent of the 65 malignant lesions were initially read as having less than highly suspicious mammographic features. There was no significant difference between the sensitivity and the specificity of one pass fine-needle aspiration biopsy (57% and 96% respectively) and needle-core biopsy (60% and 97% respectively), but noncontributive samples were not included in the false negative diagnoses and atypical samples were included in the true positive diagnoses. Of the 11 missed cancers, nine were manifested initially by clusters of calcifications. Our diagnostic approach was significantly less sensitive (P = 0.006) and less specific (P = 0.032) in cases of clusters of calcifications (31% false negative diagnoses) than in cases of soft-tissue masses (5.5% false negative diagnoses). In this study, an average delay in diagnosis of 22 months was responsible for a significantly increased percentage of axillary node positive invasive cancer (P < 0.001) and six of the 11 missed cancers were palpable at the time of the delayed diagnosis. For the nine cancers initially manifested by calcifications, the 22 months delay in diagnosis was responsible for a nonsignificant increase of microinvasive type at the expense of carcinoma in situ. Conclusion: Our enthusiasm with the sensitivity of this double stereotaxic needle sampling has been tempered by the results of this reanalysis in the light of a mean theoretical follow-up of three years. Our diagnostic approach was adequate in the presence of soft-tissue masses but not valid in the presence of clustered calcifications. When dealing with calcifications, multiple samplings must be done in order to improve the sensitivity of the diagnosis. Furthermore, this study does not favour the theory that the majority of mammographically detected cancers are indolent and highlights the poor sensitivity of the mammographic follow-up of nonpalpable lesions.

Sentinel node sampling in stage I non-small cell lung cancer

Sentinel node sampling in stage I non-small cell lung cancer

Predicting Nodal Status Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging in Patients With Locally Advanced Breast Cancer Undergoing Neoadjuvant Chemotherapy With and Without Sequential Trastuzumab

Dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) is a reliable and accurate method for monitoring primary tumor response in the breast and can be used as a surrogate to predict final axillary nodal status. Retrospective study (October 1, 2004, through February 28, 2006) of 46 patients with clinically staged locally advanced breast cancer. Comprehensive cancer center. Forty-six patients with locally advanced breast cancer. Neoadjuvant chemotherapy (NAC), DCE-MRI, mastectomy and lumpectomy, and axillary lymph node dissection. The DCE-MRI results and pathologic response of the breast and axillary lymph nodes. Forty-six patients underwent NAC with doxorubicin hydrochloride and cyclophosphamide, followed by paclitaxel and carboplatin, with or without trastuzumab based on human epidermal growth factor receptor 2 (HER2/neu) status. Twenty-one patients (46%) had a complete pathologic response. For the HER2/neu-positive patients, the complete pathologic response rate was 70% (14/20). The accuracy, sensitivity, and specificity of the primary tumor response in predicting the axillary nodal status were 78%, 88%, and 72%, respectively. The accuracy, sensitivity, and specificity of the DCE-MRI-measured response in the primary tumor in predicting axillary nodal status were 74%, 62%, and 82%, respectively. For the HER2/neu-positive patients, the accuracy, sensitivity, and specificity improved to 80%, 75%, and 82%, respectively. The results of DCE-MRI of the primary tumor can be predictive of axillary nodal status, especially in patients receiving trastuzumab who are HER2/neu positive. The HER2/neu-positive patients with a complete clinical response on DCE-MRI are highly unlikely to benefit from an axillary lymph node dissection. For HER2/neu-negative patients, sentinel lymph node sampling is warranted.

Is the clinical staging system a good choice in the staging of vulvar malignancies?

Dear Sir, We have read the article by Sergi Vidal-Sicart and coworkers [1] entitled “Validation and application of the sentinel lymph node concept in malignant vulvar tumours”, published in the March 2007 issue of the European Journal of Nuclear Medicine and Molecular Imaging. We agree with the authors that sentinel lymph node (SLN) identification permits the accurate pathological examination of regional nodes and could reduce the high morbidity of current surgical treatment in vulvar tumour patients. The results are impressive; however, there are some controversies in the explanation for the tumour stage in SLN-positive cases. The clinical stage of vulvar cancers is at least III when lymph node positivity is found. In the publication of Sergi Vidal-Sicart, however, there are ten patients listed with positive SLN, classified as stage Ib or II. During the past 5 years our team has been involved in the development and application of the method of SLN sampling in vulvar neoplasms to determine the level of progression of the disease. Our preliminary results suggest that sentinel node scintigraphy is a reliable method in early vulvar carcinoma and melanoma [2]. An occasional survey was written by us on the comparison of the TNM and clinical (FIGO) staging systems in different gynaecological malignancies. In 1969 FIGO introduced a staging system for vulvar cancer based on the TNM classification, utilising the clinical assessment of tumour size, tumour site, status of the regional lymph nodes and a limited search for distant metastases. The most serious drawback of this staging system was the inaccuracy of clinical assessment in determining groin node status, especially given that microscopic metastases may be present in clinically normal nodes and cancer-free nodes may be enlarged by inflammation [3]. The TNM system is a dual system distinguishing between a clinical (pretreatment) classification (TNM or cTNM) and a pathological (post-surgical histopathological) classification (pTNM). Thus, in TNM, each patient is staged clinically as well as pathologically. We should realise that not only surgical and pathological, but also clinical staging is important. We should continue to rely upon clinical staging when planning treatment and making prognostic assessments [4]. In the case of vulvar carcinoma, the TNM staging system is obviously superior to clinical (FIGO) staging. Of all the gynaecological malignancies, vulvar carcinoma is the one for which the SLN concept is most relevant. We suggest that in publications dealing with SLN investigations, TNM staging should be preferred over clinical staging. Eur J Nucl Med Mol Imaging (2007) 34:1878–1879 DOI 10.1007/s00259-007-0511-5

The role of radiotherapy in treating small early invasive breast cancer

The aim of the study was to identify if radiotherapy can be safely avoided in a selected subgroup of largely screening detected small invasive breast cancer. One hundred and eighty-eight patients with node negative invasive early breast cancer < or =1cm (< or =T1b) treated in our centre between 1990 and 2004 were retrospectively followed for local, regional and distant recurrences. Treatment involved adequate local excision by breast conserving surgery (BCS). Axillary staging was performed by a four node axillary sampling until 2000, following which sentinel lymph node sampling was employed. All sections were assessed histologically by haematoxylin and eosin stained sections. The inked margins were reported as being involved, close and clear. Radiotherapy (RT) was employed only if the resected margins were inadequate, and in those with involved axillary nodes who refused further completion axillary clearance. Ninety-four patients (Group A) had BCS alone and 79 patients (Group B) had both BCS and RT. There was no ipsilateral breast tumour recurrence (IBTR) in 88 patients in Group A, corresponding to an actuarial freedom from IBTR of 96%, 91% and 88.1% at 5 years, 8 years and 9 years. In Group B, there was no IBTR in 75 patients corresponding to an actuarial freedom from IBTR of 97%, 94.9% and 90.6% at 5 years, 8 years and 10 years. Our experience over 14 years has shown that it is possible to safely avoid radiotherapy in a selected subgroup of small invasive breast cancer.

Prospective Randomized Study Comparing Sentinel Lymph Node Evaluation With Standard Pathologic Evaluation for the Staging of Colon Carcinoma

The principal role of sentinel lymph node (SLN) sampling and ultrastaging in colon cancer is enhanced staging accuracy. The utility of this technique for patients with colon cancer remains controversial. This multicenter randomized trial was conducted to determine if focused assessment of the SLN with step sectioning and immunohistochemistry (IHC) enhances the ability to stage the regional nodal basin over conventional histopathology in patients with resectable colon cancer. Between August 2002 and April 2006 we randomly assigned 161 patients with stage I-III colon cancer to standard histopathologic evaluation or SLN mapping (ex vivo, subserosal, peritumoral, 1% isosulfan blue dye) and ultrastaging with pan-cytokeratin IHC in conjunction with standard histopathology. SLN-positive disease was defined as individual tumor cells or cell aggregates identified by hematoxylin and eosin (H&E) and/or IHC. Primary end point was the rate of nodal upstaging. Significant nodal upstaging was identified with SLN ultrastaging (Control vs. SLN: 38.7% vs. 57.3%, P = 0.019). When SLNs with cell aggregates < or =0.2 mm in size were excluded, no statistically significant difference in node-positive rate was apparent between the control and SLN arms (38.7% vs. 39.0%, P = 0.97). However, a 10.7% (6/56) nodal upstaging was identified by evaluation of H&E stained step sections of SLNs among study arm patients who would have otherwise been staged node-negative (N0) by conventional pathologic assessment alone. SLN mapping, step sectioning, and immunohistochemistry (IHC) identifies small volume nodal disease and improves staging in patients with resectable colon cancer. A prospective trial is ongoing to determine the clinical significance of colon cancer micrometastasis in sentinel lymph nodes.

Sentinel node sampling limits lymphadenectomy in stage I non-small cell lung cancer

It is controversial whether a systematic mediastinal lymph node dissection (MLND) needs to be performed in all patients with stage I lung cancer. The present study was done to examine the new sentinel lymph nodes hypothesis based on the lobe of the primary tumor. In our first study, the lymph node (LN) metastases were assessed in 291 stage I non-small cell lung cancer (NSCLC) patients who had a major lung resection with a systematic mediastinal lymph node dissection. We evaluated the validity of using our new sentinel lymph nodes method based on the lobe of the primary tumor as follows: the pretracheal (#3), tracheobronchial (#4), and hilar nodes (#10) for right upper lobe tumors; #4, subcarinal (#7), and #10 for middle lobe tumors; the subaortic (#5), paraaortic (#6), and #10 for left upper lobe tumors; and the #7, #10, and interlobar nodes (#11) for tumors in either lower lobes. In the second study, we performed a lobectomy with new sentinel node sampling in 64 patients with preoperative complications. If all of the sampling nodes showed no metastases on frozen section diagnosis, systematic node dissections were not performed. Six of 291 patients in the first study had skip metastases that did not involve the new sentinel nodes; 5 of the 6 patients had macroscopic pleural invasion. Thus, we defined pleural invasion as an exclusion criterion for the second study. In the second study, the median follow-up time was 39 months. Metastatic lymph nodes were detected in 11 of 64 patients. Fifty-three patients (83%) had no metastasis in the sampled nodes, and, therefore, a mediastinal lymph node dissection was not done. The morbidity rate in the sampling group was 36%, and there was no mortality. In the sampling group, local recurrences were observed in two patients, distant metastases in eight, and carcinomatous pleuritis in one; the overall 5-year survival rate was 82%. We found that it is possible to perform a less invasive lymphadenectomy for patients with stage I lung cancer using intra-operative sampling of new sentinel lymph nodes.

Importance of sentinel lymph nodes in colorectal cancer: A pilot study

Accurate identification of lymph nodes involved in metastases is vitally important for predicting survival, and it facilitates decision making with regard to adjuvant therapy. The study described here, which was undertaken to evaluate the role of sentinel lymph node mapping in refining the staging of colorectal cancer, was performed prospectively in 19 patients with colorectal cancer who underwent surgery from January to July 2005. Sentinel lymph node sampling was performed during each operation with isosulfan blue dye. Additional immunohistochemical staining was performed only if the sentinel nodes were negative for metastasis. In 18 of 19 patients, at least 1 sentinel node was identified. In 5 of 18 patients, sentinel nodes were positive for metastasis, and in 3 of 5, the sentinel node was the only node containing metastasis that was detected by immunohistochemical staining. In 3 patients, metastases in nonsentinel lymph nodes were detected by hematoxylin and eosin staining; these were determined to be false-negative results. Upstaging associated with sentinel lymph node mapping may reveal disease that might otherwise remain undetected by conventional methods. Patients who are upstaged may benefit from adjuvant therapies that have been shown to improve survival.

Cancer canalaire in situ du sein avec micro-invasion. Place du ganglion sentinelle

Objectives To investigate the role of sentinel lymph node biopsy for microinvasive ductal carcinoma in situ of the breast. Patients and methods From January 2001 to January 2006, lymphatic mapping was performed using radiocolloid and/or blue dye technique. Full axillary lymph node dissection was accomplished systematically in 10 instances at the beginning of the study, and furthermore when the sentinel node was involved (macrometastatic or micrometastatic disease). Results Identification rate was 98% (40/41), the unsuccessful procedure occurred after incisional biopsy for diagnosis. The number of sentinel nodes removed was 2 in average (1–5). Sentinel node involvement was found in 10% of cases (4/40): 1 sentinel node macrometastasis pN 1, 2 sentinel node micrometastases determined by hematoxylin and eosin staining pN 1 (mi), 1 sentinel node micrometastasis detected only by immunohistochemical staining pN 0 (mi). Discussion and conclusion Sentinel lymph node sampling should not be currently applied for management of every ductal carcinoma in situ of the breast but a selective utilization is proposed in documented high risk subset of patients according to clinical, mammographic, and histologic features obtained by percutaneous biopsies. Ductal carcinoma in situ (DCIS) with proved or suspected microinvasion could be scheduled for sentinel node procedure a fortiori in cases undergoing mastectomy because of extensive DCIS before the occurrence of disturbances of lymphatic drainage induced by surgical breast dissection.

Current topics in melanoma

New approaches to melanoma are emerging. This review summarizes developments over the past 12 months. Surgical, chemotherapeutic, immunologic and targeted therapies for melanoma are evolving. Sentinel lymph node sampling is now accepted as the standard of care for patients with intermediate thickness primary melanomas. Temozolomide continues to be widely used as part of combination therapy, and recent evidence suggests that a combination of temozolomide and interferon-alpha may be superior to temozolomide alone. Meanwhile, temozolomide and thalidomide carries unacceptable thrombosis risk. In the area of immunotherapy, anti-CTLA-4 continues to show promise, but special attention must be paid to gastrointestinal toxicity. Interferon-alpha, in addition, has shown efficacy in the neoadjuvant setting with inflammatory infiltrates demonstrated in tumors. A better understanding of the complex genetic regulation of melanoma cell growth is emerging and this is expected to lead to the development of novel targeted therapies. Research is producing a more complete understanding of melanoma genetics and immune regulation. These are beginning to produce therapeutics that are impacting clinical practice.

P68 Comparison of early postoperative axillary morbidity between sentinel lymph node biopsy and conventional axillary lymph node dissection

Background: Sentinel lymph node biopsy (SNB) is a relatively accurate diagnostic method of axillary lymph node metastastic status and diminishes the magnitude of surgically related side effects. The aim of the study is to compare the magnitude of axillary morbidity differences between conventional axillary lymph node dissection and SNB in the early postoperative period. Methods: We performed a prospective case control study of breast cancer patients who underwent operation at Asan Medical Center between July 1, 2005, and August 20, 2005. At postoperative 5 days, we evaluated the range of motion in both shoulders, arm circumference 10 cm above and below both elbows, and upper arm power. We evaluated subjective axillary morbidity such as upper arm edema, upper arm paresthesia, and axillary pain with a visual analogue scale (VAS). Group I (n = 28) underwent sentinel lymph node biopsy or sentinel lymph node biopsy and sampling. Group II (n = 38) underwent conventional axillary lymph node dissection. We compared axillary morbidity between groups. Results: The range of shoulder flexion in Group II was significantly decreased (p < 0.021) and lower arm circumference was significantly increased (p < 0.046). The degree of limitation of arm motion was significantly more than in Group II (p < 0.05). There was no difference between patients who underwent sentinel lymph node biopsy and sentinel lymph node biopsy with sampling in arm edema, axillary pain, range of shoulder motion, or paresthesia of upper arm. Conclusion: Sentinel lymph node biopsy was more effective than conventional axillary lymph node dissection in decreasing early postoperative axillary morbidity. Lymph node sampling did not affect postoperative axillary morbidity of sentinel lymph node biopsy. Long-term follow up remains to be investigated.

Sentinel Lymph Node Sampling and Analysis in Colon Cancer: What Is the Question?

Sentinel Lymph Node Sampling and Analysis in Colon Cancer: What Is the Question?

Malignant eccrine spiradenoma of the vulva: a case report and review of the literature

Malignant eccrine spiradenoma is a rare skin tumor of sweat gland origin. We present the first reported case of this tumor in the female genitalia. Due to the rarity of this tumor, there has yet to be an established standard of care. The present case is that of a 41-year-old woman with malignant eccrine spiradenoma of the periclitoral region. She had an 18-month history of a recurrent, painful mass adjacent to the clitoris. Her diagnosis was made after excision of the cystic tumor. The patient then underwent a partial radical vulvectomy with bilateral sentinel lymph node sampling. As malignant eccrine spiradenoma is a rare tumor, no standard care exists for treatment and postoperative management. Based on our review of the literature, wide local excision appears to be the preferred initial treatment. Furthermore, adjuvant chemotherapy and/or radiation does not seem to improve survival in patients with advanced or recurrent cancer. Although lymph node sampling and/or lymphadenectomy is frequently reported in the treatment of this tumor, hematogenous metastasis can also occur. Therefore, these patients require close postoperative follow-up for recurrent disease.

Prognostic Factors and New Methods in Cervical Carcinoma

Cervical cancer is the third most common gynecologic malignancy in the United States. Despite the relatively good prognosis of early-stage tumors, a significant portion of patients die of locally recurrent or metastatic disease. To better determine the risk of tumors, various prognostic factors have been established. This paper reviews the traditional clinicopathologic and histopathologic prognostic factors such as International Federation of Gynecology and Obstetrics (FIGO) stage, tumor volume, lymphovascular invasion, and lymph node metastasis, including sentinel lymph node sampling, and briefly discusses the available data regarding some of the recently identified pathophysiologic and molecular prognostic factors, such as tumor hypoxia, angiogenesis and lymphangiogenesis. In addition to their value in predicting response to treatment and patient outcome, the study of these mechanisms also leads to a better understanding of the biology of cervix carcinoma and may result in the development of novel therapeutic methods.

Is There Clinical Value to Sentinel Lymph Node Sampling in Colon Cancer?

The well-established concept of sentinel lymph node (SLN) sampling for malignancies is based on the orderly and sequential flowoflymphaticfluidfromthesiteoftheprimarytumorthrough the lymphatic vessels and lymph nodes within the draining lymphatic basin. It is accepted that the lymphatic dissemination of tumor cells follows this pattern, with the additional supposition that the tumor cells will be effectively filtered out in the lymph nodes in the drainage basin. When this concept applies, localization, removal, and pathologic analysis of SLNs provides important staging and prognostic information regarding lymphatic dissemination of the primary tumor. The accuracy and advantages of SLN sampling for malignancies of the integumentary system (principally melanoma and breast cancer) have been well documented in multiple trials since Morton’s original report on SLN biopsy for malignant melanoma in 1992. 1

Analysis of Micrometastatic Disease in Sentinel Lymph Nodes From Resectable Colon Cancer: Results of Cancer and Leukemia Group B Trial 80001

To determine whether sentinel lymph node (LN) sampling (SLNS) could reduce the number of nodes required to characterize micrometastatic disease (MMD) in patients with potentially curable colon cancer. Cancer and Leukemia Group B 80001 was a study to determine whether SLNS could identify a subset of LNs that predicted the status of the nodal basin for resectable colon cancer and, therefore, could be extensively evaluated for the presence of micrometastases. Patients enrolled onto this study underwent SLNS after injection of 1% isosulfan blue, and both sentinel nodes (SNs) and non-SNs obtained during primary tumor resection were sectioned at multiple levels and stained using anti-carcinoembryonic antigen and anticytokeratin antibodies. Using standard histopathology, SNs failed to predict the presence of nodal disease in 13 (54%) of 24 node-positive patients. Immunostains were performed for patients whose LNs were negative by standard histopathology. Depending on the immunohistochemical criteria used to assign LN positivity, SN examination resulted in either an unacceptably high false-positive rate (20%) or a low sensitivity for detection of MMD (40%). By examining both SNs and non-SNs, this multi-institutional study showed that SNs did not accurately predict the presence of either conventionally defined nodal metastases or MMD. As a result, SLNS is not a useful technique for the study of MMD in patients with colon cancer.

Sentinel node biopsy and head and neck tumors—Where do we stand today?

Sentinel lymph node sampling may be studied profitably in series of patients with 1 tumor type, such as breast carcinoma, in 1 anatomic locale. The present work analyzes the efficacy of sentinel node sampling in a pathologically diverse group of lesions from an anatomically diverse region such as the head and neck; however, there are risks conflating the findings in different tumors with radically different behaviors, in the process producing muddled data. This report reviews the head and neck experience with sentinel sampling and concludes that certain tumor types that have a known propensity for aggressive behavior are the best candidates for trials employing sentinel node sampling; candidates include many cutaneous melanomas of the head and neck, oropharyngeal squamous carcinomas, and selected thyroid carcinomas. Despite the growing popularity of sentinel node sampling in a variety of regions of the body, however, at this juncture this technique remains an investigational procedure, pending demonstration of a tangible improvement in patient outcome through its use. It is recommended that studies of the efficacy of this technique strive, whenever possible, to segregate results of different tumor types in different head and neck locales from one another so as to produce more focused findings for discrete types of malignancies, and not group together tumor types that may in reality exhibit different biological behaviors.

Low Value of [18F]-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography in Primary Staging of Early-Stage Cervical Cancer Before Radical Hysterectomy

The role of positron emission tomography (PET) with [18F]-fluoro-2-deoxy-D-glucose (FDG) in early-stage cervical cancer is unclear. We aimed to investigate the clinical benefit of FDG-PET in primary staging before radical hysterectomy and pelvic lymphadenectomy (RH-PLND). Patients with untreated stage IA2 to IIA adenocarcinoma (AD) or adenosquamous carcinoma (ASC) or nonbulky (< or = 4 cm) squamous cell carcinoma cervical cancer with magnetic resonance imaging (MRI) -defined negative nodal metastasis were enrolled onto a prospective study with a two-stage design. All patients had a preoperative dual-phase FDG-PET, technetium-99m-sulfur colloid lymphoscintigraphy, and intraoperative sentinel lymph node (LN) detection at RH-PLND. The gold standard of LN metastasis is histologic. A sample size of 120 patients was calculated to fit study aims (diagnostic efficacy of PET and sentinel LN sampling). An interim analysis was performed when 60 patients were accrued, which led to the current report. There were 36 SCCs, 20 ADs, and four ASCs. Of the 60 patients, 10 (16.7%) had pelvic LN metastases, and one (1.7%) had para-aortic LN (PALN) metastasis histologically. FDG-PET detected the single PALN metastasis (one of one patient) but detected only one (10%) of the 10 pelvic LN metastases. The PET false-negative pelvic LN micrometastases measured a median of 4.0 x 3.0 mm (range, 0.5 x 0.5 to 7 x 6 mm). The second stage of this trial will be continued without PET. This study shows that dual-phase FDG-PET has little value in primary, nonbulky, stage IA2 to IIA and MRI-defined, LN-negative cervical cancer.

Malignant eccrine spiradenoma of the vulva: a case report and review of the literature

Malignant eccrine spiradenoma is a rare skin tumor of sweat gland origin. We present the first reported case of this tumor in the female genitalia. Due to the rarity of this tumor, there has yet to be an established standard of care. The present case is that of a 41-year-old woman with malignant eccrine spiradenoma of the periclitoral region. She had an 18-month history of a recurrent, painful mass adjacent to the clitoris. Her diagnosis was made after excision of the cystic tumor. The patient then underwent a partial radical vulvectomy with bilateral sentinel lymph node sampling. As malignant eccrine spiradenoma is a rare tumor, no standard care exists for treatment and postoperative management. Based on our review of the literature, wide local excision appears to be the preferred initial treatment. Furthermore, adjuvant chemotherapy and/or radiation does not seem to improve survival in patients with advanced or recurrent cancer. Although lymph node sampling and/or lymphadenectomy is frequently reported in the treatment of this tumor, hematogenous metastasis can also occur. Therefore, these patients require close postoperative follow-up for recurrent disease.

Diagnosing metastatic disease in inguinal nodes in penile cancer: Do we have a test and the evidence?

Nodal metastasis is the most important prognostic factor in carcinoma of the penis. Clinical examination is inaccurate for diagnosing nodal involvement. Routine prophylactic block dissection carries a high risk of morbidity and a small but definite incidence of mortality. Procedures such as fine needle aspiration cytology with or without imaging guidance, anatomic sentinel node sampling, medial inguinal lymph node biopsy and dynamic sentinel node mapping, have all been tried, of which the last has proved most useful. Newer investigations like lymphotropic nano-particle enhanced MRI, squamous cell carcinoma antigen estimation and DNA flow cytometry are still experimental. It appears that in spite of numerous tests available for diagnosing metastatic disease in nodes before it becomes clinically apparent, the only test which currently holds promise is dynamic sentinel node mapping using radio isotopes with or without intraoperative colored dye, to identify the draining nodes for sampling. The only other alternative may be to recommend prophylactic node dissection in all T2, T3 or T4 patients or in all patients with Grade 2 or 3 T1 tumors, in whom the risk of nodal metastases is very high.