World Journal of Urology

, Volume 29, Issue 6, pp 793–799 | Cite as

Intraoperative sentinel node identification and sampling in clinically node-negative renal cell carcinoma: initial experience in 20 patients

  • A. Bex
  • L. Vermeeren
  • W. Meinhardt
  • W. Prevoo
  • S. Horenblas
  • R. A. Valdés Olmos
Original Article



To apply single-photon emission computed tomography (SPECT) in combination with computed tomography (CT) for preoperative identification of sentinel lymph nodes (SNs) and to investigate surgical feasibility and safety of intraoperative sampling.


A retrospective combined interim analysis of 20 patients from two prospective trials who underwent injection of 99mTc-nanocolloid into the renal tumour for preoperative identification of SN with SPECT/CT and subsequent removal of the tumour and intraoperative sampling using a gamma probe and portable camera. Lymphadenectomy was completed locoregionally. Surgical approach, time, blood loss, intraoperative yield, Clavien complications and anatomical location of SN in correlation with preoperative imaging were evaluated.


SPECT/CT detected SN in 14/20 patients (70%), including 4 patients with non-visualisation on planar lymphoscintigraphy. Twenty-six SNs were seen: 17 para-aortic (including interaorto-caval), 4 retrocaval, 1 hilar, 1 celiac trunc, 1 internal mammary and 2 mediastinal and pleural. These latter 4 nodes were not harvested according to protocol. All other SNs, except for 2 weakly radioactive interaorto-caval nodes, were identified and excised with a mean additional time of 20 min. None of the removed SN and locoregional nodes was tumour-bearing.


Intraoperative SN identification and sampling in RCC with preoperative detection on SPECT/CT is surgically safe and feasible. SN from the kidney are mainly localised in the para-aortic region, but aberrant nodes receive direct drainage. Non-visualisation of SN appears in almost a third of the patients. Further studies are required to demonstrate whether accurate mapping of lymphatic drainage and extent of lymphatic spread may have diagnostic and therapeutic implications.


Sentinel node Lymph node dissection Renal cell cancer Kidney cancer 


Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Blom JH, van Poppel H, Marechal JM (2009) Radical nephrectomy with and without lymph-node dissection: final results of European organization for research and treatment of cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 55:28–34PubMedCrossRefGoogle Scholar
  2. 2.
    Freedland SJ, deKernion JB (2003) Role of lymphadenectomy for patients undergoing radical nephrectomy for renal cell carcinoma. Rev Urol 5:191–195PubMedGoogle Scholar
  3. 3.
    Phillips CK, Taneja SS (2004) The role of lymphadenectomy in the surgical management of renal cell carcinoma. Urol Oncol 22:214–223PubMedCrossRefGoogle Scholar
  4. 4.
    Pantuck AJ, Zisman A, Dorey F et al (2003) Renal cell carcinoma with retroperitoneal lymph nodes. Impact on survival and benefits of immunotherapy. Cancer 97:2995–3002PubMedCrossRefGoogle Scholar
  5. 5.
    Pantuck AJ, Zisman A, Dorey F et al (2003) Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection. J Urol 169:2076–2083PubMedCrossRefGoogle Scholar
  6. 6.
    Hellsten S, Berge T, Linell F (1983) Clinically unrecognised renal carcinoma: aspects of tumour morphology, lymphatic and haematogenous metastatic spread. Br J Urol 55:166–170PubMedCrossRefGoogle Scholar
  7. 7.
    Johnsen JA, Hellsten S (1997) Lymphatogenous spread of renal cell carcinoma: an autopsy study. J Urol 157:450–453PubMedCrossRefGoogle Scholar
  8. 8.
    Matsuyama H, Hirata H, Korenaga Y et al (2005) Clinical significance of lymph node dissection in renal cell carcinoma. Scand J Urol Nephrol 39:30–35PubMedCrossRefGoogle Scholar
  9. 9.
    Hashimoto K, Hisasue S, Yanase M et al (2005) Tumour size and regional lymph node metastasis in patients with M0 renal cell carcinoma: analysis in those having regional lymph node dissection. Hinyokika Kiyo 51:621–625PubMedGoogle Scholar
  10. 10.
    Hadley DA, Stephenson RA, Samlowski WE, Dechet CB (2010) Patterns of enlarged lymph nodes in patients with metastatic renal cell carcinoma. Urol Oncol Epub ahead of printGoogle Scholar
  11. 11.
    Bex A, Vermeeren L, de Windt G, Prevoo W, Horenblas S, Olmos RA (2010) Feasibility of sentinel node detection in renal cell carcinoma: a pilot study. Eur J Nucl Med Mol Imaging 37:1117–1123PubMedCrossRefGoogle Scholar
  12. 12.
    Vermeeren L, Valdés Olmos RA, Meinhardt W et al (2009) Intra-operative radioguidance with a portable gamma camera: a novel technique for laparoscopic sentinel node localisation in urological malignancies. Eur J Nucl Med Mol Imaging 36:1029–1036PubMedCrossRefGoogle Scholar
  13. 13.
    Parker AE (1935) Studies on the main posterior lymph channels of the abdomen and their connections with the lymphatics of the genito-urinary system. Am J Anat 56:409CrossRefGoogle Scholar
  14. 14.
    Terrone C, Guercio S, De Luca S (2003) The number of lymph nodes examined and staging accuracy in renal cell carcinoma. BJU Int 91:37–40PubMedCrossRefGoogle Scholar
  15. 15.
    Saitoh H, Nakayama M, Nakamura K, Satoh T (1982) Distant metastasis of renal adenocarcinoma in nephrectomized cases. J Urol 127:1092–1095PubMedGoogle Scholar
  16. 16.
    Hulten L, Rosencrantz M, Seeman T, Wahlqvist L, Ahren C (1969) Occurrence and localization of lymph node metastases in renal carcinoma. Scand J Urol Nephrol 3:129–133PubMedCrossRefGoogle Scholar
  17. 17.
    Assouad J, Riquet M, Foucault C, Hidden G, Delmas V (2006) Renal lymphatic drainage and thoracic duct connections: implications for cancer spread. Lymphology 39:26–32PubMedGoogle Scholar
  18. 18.
    Assouad J, Riquet M, Berna P, Danel C (2007) Intrapulmonary lymph node metastasis and renal cell carcinoma. Eur J Cardiothorac Surg 31:132–134PubMedCrossRefGoogle Scholar
  19. 19.
    Mahon TG, Libshitz HI (1992) Mediastinal metastases of infradiaphragmatic malignancies. Eur J Radiol 15:130–134PubMedCrossRefGoogle Scholar
  20. 20.
    Riquet M, Le Pimpec Barthes F, Souilamas R, Hidden G (2002) Thoracic duct tributaries from intrathoracic organs. Ann Thorac Surg 73:892–898PubMedCrossRefGoogle Scholar
  21. 21.
    Wright FW (1977) Enlarged hilar and mediastinal nodes (and especially lower right hilar node enlargement) as a sign of metastasis of a renal tumour. Clin Radiol 28:431–436PubMedCrossRefGoogle Scholar
  22. 22.
    Kang DE, White RL Jr, Zuger JH, Sasser HC, Teigland CM (2004) Clinical use of fluorodeoxyglucose F 18 positron emission tomography for detection of renal cell carcinoma. J Urol 171:1806–1809PubMedCrossRefGoogle Scholar
  23. 23.
    Guimaraes AR, Tabatabei S, Dahl D, McDougal WS, Weissleder R, Harisinghani MG (2008) Pilot study evaluating use of lymphotrophic nanoparticle-enhanced magnetic resonance imaging for assessing lymph nodes in renal cell cancer. Urology 71:708–712PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • A. Bex
    • 1
  • L. Vermeeren
    • 2
  • W. Meinhardt
    • 1
  • W. Prevoo
    • 3
  • S. Horenblas
    • 1
  • R. A. Valdés Olmos
    • 2
  1. 1.Division of Surgical Oncology, Department of UrologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands
  2. 2.Department of Nuclear MedicineThe Netherlands Cancer InstituteAmsterdamThe Netherlands
  3. 3.Department of RadiologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands

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