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Preoperative and Intraoperative Lymphatic Mapping for Radioguided Sentinel Node Biopsy in Cancers of the Male Reproductive System

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Atlas of Lymphoscintigraphy and Sentinel Node Mapping

Abstract

This chapter describes the principles of lymphatic mapping and sentinel lymph node biopsy for cancers of the male reproductive system, thus including penile, prostate, and testicular cancer. For all three malignancies, lymph node staging is of importance for both prognosis and therapeutic management. Although sentinel lymph node biopsies for penile and prostate cancer are validated procedures, the indications for the procedure in testis cancer are still debated. For testicular cancer, the sentinel lymph node procedure has been the object of several feasibility studies, but further validation studies are required to assess the clinical benefit of the approach. For all three applications, the procedure is based on the injection of a radiocolloid, followed by sequential lymphoscintigraphy. Sequential planar images are able to identify the lymph nodes draining directly from the tumor site, but give only limited information about the anatomical location. SPECT/CT enables exact preoperative anatomical localization of the sentinel lymph nodes and thereby aids the surgical procedure. The most frequently visualized lymphatic drainage pattern for penile cancer is bilateral drainage to both groins. In prostate cancer, the main draining lymph node basins generally follow the iliac vessels. Sentinel lymph nodes in testicular cancer are principally detected at paracaval, interaortocaval, para-aortic, or preaortic locations. Intraoperative sentinel lymph node detection in penile cancer is usually guided by a gamma ray detection probe and by using blue dye. For prostate cancer and testicular cancers, the surgical procedure has shifted from the initial open approach toward less invasive laparoscopic and robot-assisted techniques. Intraoperative spatial orientation using a laparoscopic gamma probe can sometimes be difficult, as a laparoscopic probe does not provide visual information and probe-guided detection is sometimes hindered by high background signals coming from the injection site. The intraoperative use of a portable gamma camera and emerging techniques such as near-infrared fluorescence imaging help to refine (laparoscopic) sentinel lymph node localization.

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Author information

Authors and Affiliations

  1. Department of Urology, Netherlands Cancer Institute, Amsterdam, Netherlands

    Hielke Martijn de Vries, Joost M. Blok, Hans N. Veerman, Florian van Beurden, Henk G. van der Poel & Oscar R. Brouwer

  2. Department of Radiology, Section of Nuclear Medicine and Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands

    Renato A. Valdés Olmos

Authors
  1. Hielke Martijn de Vries
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  2. Joost M. Blok
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  5. Henk G. van der Poel
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  6. Renato A. Valdés Olmos
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Corresponding author

Correspondence to Oscar R. Brouwer .

Editor information

Editors and Affiliations

  1. Regional Center of Nuclear Medicine Department of Translational Research and Advanced Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy

    Giuliano Mariani

  2. Nuclear Medicine Department, Hospital Clinic Barcelona, Barcelona, Catalonia, Spain

    Sergi Vidal-Sicart

  3. Department of Radiology Section of Nuclear Medicine and Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands

    Renato A. Valdés Olmos

Clinical Cases

Clinical Cases

Case 15.1: SLN Mapping in Penile Cancer with Bilateral Drainage to Both Groins

Renato A. Valdés Olmos Henk G. van der Poel Oscar R. Brouwer

Background Clinical Case

A 78-year-old man with penile carcinoma was referred for SLNB. During staging of both groins no lymph node abnormalities had been detected on physical examination and ultrasonography (clinical stage T1N0).

Planar Lymphoscintigraphy and SPECT/CT Imaging

In the afternoon before surgery a total of 110 MBq ICG-99mTc-nanocolloid was administered in three intradermal injections proximal to the primary tumor into the glans. Immediately after tracer administration, a dynamic study was acquired during 10 min with the patient in supine position using a dual-head gamma camera (Symbia T, Siemens, Erlangen, Germany) equipped with low-energy high-resolution collimators. Subsequently, 5-min planar static images were acquired at 15 min and 2 h postinjection. In addition, SPECT/CT imaging was acquired after the 2-h delayed planar imaging using the same gamma camera.

Fig. 15.11
figure 11

Anterior early (on the left) and delayed (on the right) planar images, displayed in superposition to anatomical models, showing bilateral drainage to both groins. Inguinal SLNs in the left groin become clear only on delayed images. On SPECT/CT (bottom) radioactive SLNs in both groins are located above the saphenofemoral junction corresponding on low-dose CT to normal-size lymph nodes in the so-called upper inguinal zones of Daseler (circles)

Full size image

Case 15.2: SLN Mapping in Recurrent Penile Carcinoma with Drainage to Iliac and Inguinal Lymph Nodes

Renato A. Valdés Olmos Henk G. van der Poel Oscar R. Brouwer

Background Clinical Case

A 57-year-old man with a squamous-cell penile carcinoma recurrence was referred for SLNB. The patient had undergone partial penis amputation 13 years earlier because of a primary penile carcinoma (cT2N0) with subsequent lymph node dissection of the right groin due to SLN metastases (pT2N1). The SLN of the left groin at that time was free of tumor and no further surgical intervention had been performed. Following confirmation of the recurrence, no lymph node abnormalities had been detected on palpation and ultrasonography.

Planar Lymphoscintigraphy and SPECT/CT Imaging

In the afternoon before surgery a total of 100 MBq ICG-99mTc-nanocolloid was administered in three intradermal injections around the tumor recurrence following preparation with xylocaine 10% spray for local anesthesia. Immediately after tracer administration, a dynamic study was acquired during 10 min with the patient in supine position using a dual-head gamma camera (Symbia T, Siemens, Erlangen, Germany) equipped with low-energy high-resolution collimators. Subsequently, 5-min planar static images were acquired at 15 min and 2 h postinjection. In addition, SPECT/CT imaging was acquired after acquiring the delayed planar images using the same gamma camera.

Fig. 15.12
figure 12

Anterior static planar images displayed in superposition to anatomical models (upper row). Bilateral tracer migration to lymph nodes is only seen on delayed image (on the right) with a radioactive left lymph node near the penile injection site and a higher located node with a visible lymphatic duct in the right side. Note on SPECT/CT imaging (lower row) that the SLN in the right side is located in the vicinity of the external iliac artery (circles), whereas the SLN in the left side is located in the groin

Full size image

Case 15.3: SLN Mapping in Prostate Carcinoma with Bilateral Drainage to Pelvic Lymph Nodes

Renato A. Valdés Olmos Henk G. van der Poel Oscar R. Brouwer

Background Clinical Case

A 70-year-old man with confirmed carcinoma in the right lobe of the prostate on histopathology and Gleason 7 was referred for a SLN procedure with robot-assisted surgery. No lymph node abnormalities had been detected on radiological examination (clinical stage T2N0).

Planar Lymphoscintigraphy and SPECT/CT Imaging

The patient was planned for a 1-day SLN procedure. Early in the morning a total of 125 MBq ICG-99mTc-nanocolloid was administered in both lobes of the prostate by means of four injections guided by transrectal ultrasonography. Immediately after tracer administration, the patient was transferred to the department of nuclear medicine and a static image was acquired during 5 min with the patient in supine position using a dual-head gamma camera (Symbia T, Siemens, Erlangen, Germany) equipped with low-energy high-resolution collimators. Subsequently, delayed static images were acquired at 2 h postinjection. In addition, SPECT/CT imaging was acquired after acquiring the delayed planar images using the same gamma camera.

Fig. 15.13
figure 13

Static planar images (upper row) are displayed in superposition to anatomical models. On early anterior (first frame) and right lateral (second frame) views bilateral lymph node uptake is seen principally on the left side of the pelvis. Volume-rendering and cross-sectional SPECT/CT images (lower row) show four SLNs along the left internal and common iliac arteries, whereas on the right side of the pelvis the SLN is located medially from the right common iliac vessels

Full size image

Case 15.4: SLN Mapping in Prostate Carcinoma with Unilateral Drainage to a Pelvic Lymph Node

Renato A. Valdés Olmos Henk G. van der Poel Oscar R. Brouwer

Background Clinical Case

A 70-year-old man with confirmed carcinoma in both lobes of the prostate on histopathology was referred for a SLN procedure with robot-assisted surgery. No lymph node abnormalities had been detected on radiological examination (clinical stage T2N0).

Planar Lymphoscintigraphy and SPECT/CT Imaging

Since a 1-day SLN procedure had been planned, the patient received in the morning a total of 115 MBq ICG-99mTc-nanocolloid by means of four injections in both lobes of the prostate guided by transrectal ultrasonography. Immediately after tracer administration, the patient was moved to the department of nuclear medicine and static 5-min images were acquired at 15 min and 2 h postinjection with the patient in supine position using a dual-head gamma camera (Symbia T, Siemens, Erlangen, Germany) equipped with low-energy high-resolution collimators. Subsequently to delayed static images, SPECT/CT imaging was acquired using the same gamma camera.

Fig. 15.14
figure 14

Both early and delayed planar images (upper row), displayed in superposition to anatomical models, show migration of the tracer to the right side of the pelvis. Volume-rendering and cross-sectional SPECT/CT images (lower row) show one single SLN located laterally from the right common iliac vessels. The corresponding lymph node on low-dose CT (circle) is not enlarged

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Case 15.5: SLN Mapping in Prostate Carcinoma with Drainage to Presacral and Mesorectal Lymph Nodes

Renato A. Valdés Olmos Henk G. van der Poel Oscar R. Brouwer

Background Clinical Case

A 67-year-old man with carcinoma in both lobes of the prostate was referred for SLN procedure with robot-assisted surgery. No lymph node abnormalities had been detected on radiological examination (clinical stage T2N0).

Planar Lymphoscintigraphy and SPECT/CT Imaging

The procedure was based on a 1-day SLN procedure. Early in the morning the patient received a total of 120 MBq ICG-99mTc-nanocolloid by means of four injections in both lobes of the prostate guided by transrectal ultrasonography. Immediately after tracer administration, the patient was moved to the department of nuclear medicine and static 5-min images were acquired at 15 min and 2 h postinjection with the patient in supine position using a dual-head gamma camera (Symbia T, Siemens, Erlangen, Germany) equipped with low-energy high-resolution collimators. Subsequently to delayed static imaging, SPECT/CT imaging was acquired using the same gamma camera.

Fig. 15.15
figure 15

Both early and delayed planar images (first two images in upper row), displayed in superposition to anatomical models, show delayed migration of the tracer to both sides of the pelvis. On volume-rendering SPECT/CT (last frame in upper row) the drainage becomes clearer, with visualization of three SLNs. Cross-sectional SPECT/CT images (lower row) show presacral and mesorectal SLNs. These radioactive nodes correspond to normal-size lymph nodes on low-dose CT (circles)

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Case 15.6: SLN Mapping in Left Testicular Cancer with Unilateral Drainage to Para-aortic, Funicular, Iliac, and Inguinal Lymph Nodes

Renato A. Valdés Olmos Henk G. van der Poel Oscar R. Brouwer

Background Clinical Case

A 35-year-old man with left testicle cancer was referred for SLN procedure. No lymph node abnormalities had been detected on radiological examination (clinical stage I).

Planar Lymphoscintigraphy and SPECT/CT Imaging

The day before surgery the patient received a total of 100 MBq ICG-99mTc-nanocolloid by means of a single injection in the left testicle in the proximity of the primary tumor following funicular block with 2% lidocaine. Immediately after tracer administration, a dynamic study was started during 10 min. Subsequently, static 5-min images were acquired at 15 min and 2 h postinjection with the patient in supine position using a dual-head gamma camera (Symbia T, Siemens, Erlangen, Germany) equipped with low-energy high-resolution collimators. Subsequently to delayed static images, SPECT/CT imaging was acquired using the same gamma camera.

Fig. 15.16
figure 16

Anterior planar images (first two images in upper row) are displayed in superposition to anatomical figures. Early static image (on the left) shows migration of the tracer from the left testicle through a long lymphatic vessel whereas delayed lymph node uptake is observed (second image) at various levels of pelvis and abdomen. On volume-rendering SPECT/CT (lower row) superficial (left image) and deep (second image) are displayed. Cross-sectional SPECT/CT images (right column) show inguinal and external iliac (top) as well as obturator and funicular SLNs (middle images) whereas the most cranial located lymph node is para-aortic (bottom)

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Case 15.7: SLN Mapping in Right Testicular Cancer with Unilateral Drainage to Lymph Nodes Along the Vena Cava Inferior

Renato A. Valdés Olmos Henk G. van der Poel Oscar R. Brouwer

Background Clinical Case

A 46-year-old man with right testicular cancer was referred for SLN procedure. No lymph node abnormalities had been detected on radiological examination (clinical stage I).

Planar Lymphoscintigraphy and SPECT/CT Imaging

The day before surgery the patient received a total of 90 MBq 99mTc-nanocolloid by means of a single injection in the right testicle in the vicinity of the primary tumor following funicular block with 2% lidocaine. Immediately after tracer administration a dynamic study was started during 10 min. Subsequently, static 5-min images were acquired at 15 min and 2 h postinjection with the patient in supine position using a dual-head gamma camera (Symbia T, Siemens, Erlangen, Germany) equipped with low-energy high-resolution collimators. Subsequently to delayed static images, SPECT/CT imaging was acquired using the same gamma camera.

Fig. 15.17
figure 17

Anterior planar images (upper row) are displayed in superposition to anatomical models. Early static image (on the left) shows migration of the tracer from the right testicle through a long lymphatic vessel with uptake in two lymph nodes. Delayed planar image (on the right) shows increasing uptake in the first draining lymph nodes and in a second echelon more medially located. On SPECT/CT imaging (lower row) both SLNs are seen laterally from the vena cava inferior

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de Vries, H.M. et al. (2020). Preoperative and Intraoperative Lymphatic Mapping for Radioguided Sentinel Node Biopsy in Cancers of the Male Reproductive System. In: Mariani, G., Vidal-Sicart, S., Valdés Olmos, R. (eds) Atlas of Lymphoscintigraphy and Sentinel Node Mapping. Springer, Cham. https://doi.org/10.1007/978-3-030-45296-4_15

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