Beyond penile cancer, is there a role for sentinel node biopsy in urological malignancies?
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This review aims to discuss the current state-of-the-art of sentinel node (SN) mapping in urological malignancies. The principles and methodological aspects of lymphatic mapping and SN biopsy in urological malignancies are reviewed. Literature search was restricted to English language. The references of the retrieved articles were examined to identify additional articles. The review also includes meta-analyses published in the past 5 years. SN biopsy for penile cancer is recommended by the European Association of Urology as the preferred staging tool for clinically node-negative patients with at least T1G2 tumours (level of evidence 2a, Grade B). The feasibility of SN biopsy in prostate cancer has been repeatedly demonstrated and its potential value is increasingly being recognised. However, conclusive prospective clinical data as well as consensus on methodology and patient selection are still lacking. For bladder, renal and testicular cancer, only few studies have been published, and concerns around high false-negative rates remain. Throughout the years, the uro-oncological field has portrayed a pivotal role in the development of the SN concept. Recent advances such as hybrid tracers and novel intraoperative detection tools such as fluorescence and portable gamma imaging will hopefully encourage prospectively designed clinical trials which can further substantiate the potential of the SN approach in becoming an integral part of staging in urological malignancies beyond penile cancer.
KeywordsSentinel node Urology Urological malignancies Penile cancer Prostate cancer Bladder Renal cancer Testicular cancer Lymphatic drainage SPECT/CT
An extensive literature search was performed based on the following PubMed/MEDLINE medical subject headings: SN biopsy, lymphatic mapping, SPECT/CT, intraoperative SN detection, hybrid tracer, penile cancer, prostate cancer, bladder cancer, testicular cancer and renal cell carcinoma. The search was restricted to English language. The references of the retrieved articles were examined to identify additional articles. Meta-analyses published in the past 5 years were also included.
Evolution and guideline recommendations
Penile cancer is a relatively rare disease in the western world, with an incidence of approximately 1 per 1,00,000 . Penile cancer only rarely presents distant metastases without spreading via the lymphatic system to the inguinal regions first. As a consequence, the presence of lymph node involvement is the single most important prognostic factor for cancer-specific death . At present, currently available non-invasive staging techniques lack sufficient accuracy to reliably stage the nodal status in patient with penile cancer which is why surgical staging remains indispensable. However, a complete inguinal lymphadenectomy is associated with substantial morbidity. Since only 20–25 % of clinically node negative patients harbour occult nodal metastasis, performing a complete lymphadenectomy is unnecessary overtreatment in 75–80 % of patients . It is because of the abovementioned reasons that penile cancer has been an ideal model for the development of the SN concept. In 1977, it was the Paraguayan urologist Ramon Cabañas who was the first to publish a study using lymphangiograms to locate the primary draining lymph nodes followed by excision of these nodes . In other words, Cabañas was the first investigator to perform lymphatic mapping followed by SN biopsy. However, Cabañas described the SN as to be localised in a fixed, predetermined location, not taking into account possible individual variations in lymphatic drainage patterns. Furthermore, Cabañas did neither use blue dye, radiotracers, lymphoscintigraphy nor a gamma probe, which made his method difficult to reproduce. Approximately 15 years later, the SN concept re-emerged outside the field of urology when Morton et al. performed SN biopsy in melanoma patients using radiocolloid and blue dye to intraoperatively visualise the lymphatic vessels and subsequently localise the SN . This landmark study was the first to recognise variability in lymphatic drainage and SN location, which paved the way for further development of the approach. Based on this modernised concept, the SN procedure was re-introduced in uro-oncology in 1994 when Horenblas et al. initiated studies in the Netherlands applying the SN biopsy in its current form in penile cancer patients . Since then, the procedure has evolved into a reliable staging technique, with a low complication rate compared to (prophylactic) inguinal lymphadenectomy [10, 11, 12].
The introduction of SN biopsy has also led to a significant improvement in mortality of patients with penile cancer. A recent study evaluated the 5-year cancer-specific survival of patients with squamous cell carcinoma of the penis. They compared the 5-year cancer survival rate before and after the introduction of SN biopsy and found a statistically significant difference, 91 % compared to 82 % (p = 0.021). This finding is most likely due to the detection of microscopic disease by SNB, resulting in early lymph node dissection in patients with a tumour-positive SN .
SN biopsy for penile cancer entered the European Association of Urology guidelines in 2009 as the preferred staging tool for clinically node-negative patients (defined by ultrasound-guided fine needle cytology) with at least T1G2 tumours (level of evidence 2a, Grade B) and the procedure is now standard of care in many (specialised) centres .
As is customary for SN biopsy in melanoma and breast cancer, intraoperative SN detection is guided by a gamma-ray detection probe and blue dye. The entire (pre- and intraoperative) procedure can be performed in both 1- and 2-day protocols, although a 1-day protocol may yield lower false-negative rates . Proper pathological node examination is imperative to minimise false-negative results. As stated in the EAU guidelines, additional inguinal node dissection is recommended in all men with nodal metastases at SN biopsy .
Refinements and future prospects
Initially, the most significant drawback of SN biopsy for penile cancer was found to be a relatively high false-negative rate (22 %) . After analysis of the false-negative cases, several modifications were made to the procedure to decrease the false-negative rate and thus increase sensitivity: (1) histopathologic analysis was expanded with serial sectioning of the harvested SNs; (2) preoperative ultrasound of cN0 groins with fine needle aspiration cytology of suspicious lymph nodes was introduced and (3) exploration of the groin in the case of non-visualisation during scintigraphy was added, including intraoperative palpation of the wound to identify suspicious lymph nodes that failed to pick up any radiocolloid (due to tumour blockage) . Thanks to these modifications, the procedure has evolved into a reliable minimally invasive staging technique, with an associated sensitivity of 93–95 % and low morbidity in experienced centres [10, 26]. However, higher false-negative rates have also been reported, a recent study stating a figure as high as 15 % and a later meta-analysis showing pooled sensitivity rates of 88 % [27, 28]. Accurate staging with SN biopsy can only be achieved if all nodes on a direct drainage pathway from the tumour are harvested. If SNs are left behind, this constitutes one of the potential causes for false-negative results. The following developments have refined the procedure and, in time, may help minimise false-negative rates. Preoperative imaging using SPECT/CT was shown to improve inguinal detection of SN by providing superior 3D information on lymph node location as compared to conventional scintigraphy imaging [22, 23, 25]. The integration of a portable gamma camera during the intraoperative procedure may also increase the detection sensitivity, since it provides an intraoperative overview image of the radioactive SNs and enables post-excision confirmation of complete removal of all SNs . As mentioned before, the most widely used tracer for intraoperative optical detection of the SN and its afferent lymphatic duct is blue dye. The visualisation rate of lymph nodes with blue dye alone is between 55 and 70 % [29, 30]. In recent years, near-infared (NIR) imaging has become available as an additional optical guidance modality. Fluorescent tracers in the NIR spectrum of light provide the benefit of visualisation of lymph drainage without obscuring the surgical field in the white light surgical setting. Indocyanine green (ICG) is the most frequently used fluorescent dye that can be visualised using NIR imaging systems . When injected locally, ICG rapidly migrates through the lymphatic system enabling intraoperative visualisation of lymphatic ducts and nodes, yet these quick migrational properties may also result in a limited diagnostic time frame and the visualisation of higher echelon nodes . To solve this limitation, a recent development in penile cancer SN biopsy has been the introduction of a hybrid tracer molecule, comprised of the fluorescent dye ICG covalently attached to the 99mTc nanocolloid . This hybrid tracer molecule combines the properties of both modalities in one compound and can thus be used to provide both preoperative SPECT imaging and intraoperative fluorescence guidance during surgery . The tracer demonstrated favourable characteristics compared to blue dye, allowing intraoperative visualisation of 96.8 % of SNs compared to blue dye which stained just 55.7 % .
Concept and potential indications
Prostate cancer is the most frequent urogenital malignancy and the second most common cause of death by cancer in males . Since prostate cancer may initially metastasize to the lymph nodes, lymph node staging is important for both prognosis and therapeutic management. For instance, the presence of lymph node metastases can disqualify patients from local therapy with curative intent, such as radical prostatectomy or external beam radiation therapy, and result in treatment with androgen-deprivation therapy instead . Therefore, accurate lymph node staging in prostate cancer is imperative. To date, none of the available non-invasive diagnostic imaging modalities provide a reliable assessment of lymph node (micro) metastases; this is the principal reason why open or laparoscopic lymphadenectomy is still considered the gold standard for regional lymph node staging. Predictive nomograms are generally used to define the indication for a nodal dissection [37, 38, 39, 40], and European guidelines recommend nodal dissection when nomograms predict a risk of more than 5 % on the presence of nodal metastases (intermediate and high-risk patients) [35, 37].
When performing a lymphadenectomy, an extended pelvic lymph node dissection template is advised, because dissection limited to the obturator fossa misses approximately 50 % of metastases . Apart from its role in discriminating N0 from N1 patients, recent retrospective data suggest that an extended lymphadenectomy also has therapeutic value: in >300 pN1 prostate cancer patients, removal of less than 14 nodes resulted in poorer outcome when compared to removal of more lymph nodes . On the other hand, an extended nodal dissection is associated with considerable morbidity, and complications of the procedure are strongly correlated with the number of nodes removed, ranging from 10.5 % for 1–5 lymph nodes to 24.3 % when dissection includes more than 20 lymph nodes .
Despite extended nodal dissection, pelvic recurrences do occur, and the false-negative rate of extended pelvic nodal dissection for prostate cancer was estimated to be around 12.5 % [43, 44]. This can potentially be explained by the finding that tumour-positive (sentinel) nodes may be present outside the extended pelvic node dissection template in >5 % of patients. With the aim to “remove the nodes that count, rather than count the nodes that don’t” , SN biopsy has emerged as an alternative staging procedure. The potential advantages of SN biopsy are a lower incidence of complications and the possibility of identifying tumour-draining lymph nodes outside the field of an extended lymphadenectomy . If the goal is to remove as many (tumour-positive) nodes as possible to maximise a potential therapeutic effect, SN biopsy may be combined with an extended lymph node dissection [47, 48].
SN biopsy is generally reserved for patients in the intermediate-risk group (clinical stage T2b-c, PSA 10–20 ng/mL, Gleason 7) where it can identify lymph node metastases in 20 % of patients on average. Nevertheless, SN biopsy has been able to identify metastases in as many as 7–10 % of patients with more favourable risk factors . In the intermediate-risk group, a pooled sensitivity rate of 95 % can be reached as reported by meta-analyses [49, 50]. The sensitivity appears to decrease to 76 % in high-risk patients .
As mentioned above, the presence of tumour-bearing lymph node(s) may influence the choice between local (curative) treatment of the prostate or hormonal therapy in patients in the intermediate-risk group. Another possible indication is to select patients who are eligible for salvage treatment of the prostate (in case of biochemical recurrence after local treatment). Selecting these patients is challenged by the fact that the usual parameters to stratify patients in risk groups do not apply to patients with intraprostatic recurrence. Since salvage treatment of the prostate may result in serious complications, it should only be considered when the prostate is actually the only tumour-bearing site .
At present, the European Association of Urology guidelines deem the SN procedure in prostate cancer at an experimental state due to lack of larger prospective studies and higher level of evidence. Nevertheless, guidelines acknowledge the potential role of the SN approach in defining lymph node dissection templates .
Tracer injection to identify SNs in prostate cancer is different compared to the technique used with other malignancies where the location of the primary tumour is often visible or palpable. In those cases, a well-directed peri- or intratumoural injection can be placed to observe the lymphatic drainage of the tumour. In prostate cancer, however, it is not known from which part of the organ the metastatic spread originates. Therefore, the aim of lymphatic mapping in prostate cancer has traditionally been to visualise all primarily draining lymph nodes (SNs).
Most studies use a transperineal or transrectal tracer injection method which is generally guided by ultrasound. One study described intraoperative optical tracer injection transperitoneally but in general, preoperative injection is used [52, 53, 54]. When the transrectal injection route is used prophylactic antibiotics are given to prevent infections. Injections are traditionally placed in both lobes in the peripheral zone of the prostate, since this is where most tumours (approximately 80 %) reside. However, tracer distribution may show considerable variation, which was recently demonstrated by Buckle et al. . With the introduction of MRI-guided injection techniques, ongoing studies should reveal whether intratumoural injection is superior to several tracer depots within the entire prostate .
The most frequently used radiopharmaceutical in Europe has been 99mTc-nanocolloid. However, technetium-99m can also be bound to sulphur or phytate as used in other continents [57, 58]. In literature studies particle sizes vary (80–1500 nm) as well as the amount of radioactivity injected (60–250 MBq) . The particle concentration also appears to be important, and the use of a reduced labelling dilution volume (0.4 mL 99mTc per 0.2 mg nanocolloid) yields more visualised SNs with higher radioactivity count rates . No comparative studies are available on the optimal dose and injection volume as of yet.
Lymphoscintigraphy is mostly acquired 15 min after radiocolloid administration, which visualises the first draining lymph nodes in almost 88 % of cases . Delayed imaging may be performed 2–4 h after injection (increasing the visualization rate to 90–95 %). Comparing the early and delayed images enables differentiation of second-echelon lymph nodes from SNs. Additional hybrid imaging with SPECT/CT enables anatomical localisation of SNs which can aid in planning the surgical procedure . SPECT/CT was shown to increase the SN visualisation rate from 91 % for planar scintigraphy to 98 %. SPECT/CT also depicted more SN than planar images (average 4.3 versus 2.2 SNs) in 46 patients; 44 % of the SNs containing metastases were visualised only by SPECT/CT .
Intraoperatively, the radioactive SNs can be detected with a gamma-ray detection probe. Both open and laparoscopic approaches have been extensively studied in prostate cancer although there is a shift toward the less invasive laparoscopic and robot-assisted techniques [48, 62, 63].
Review of the results
The SN procedure for prostate cancer was introduced by the Augsburg group in 1999 . SN biopsy was based on an open surgery approach with the use of a gamma probe to guide detection of the radioactive sentinel nodes. Initially, to evaluate the sensitivity of the procedure, an extended lymph node dissection was performed (common iliac, external iliac, obturator, internal iliac and presacral regions). After the initial feasibility report, the studied cohort was gradually expanded to a total of 638 patients, demonstrating an overall sensitivity of 97 % . The most frequently occurring SN location was the internal iliac region (32 %), followed by the external iliac region (29 %) and obturator fossa (26 %, Fig. 1). The pioneering Augsburg group laid the groundwork for others to explore the SN approach for prostate cancer, reporting varying outcomes. In total, over 7000 cases were reported in the literature [66, 67, 68]. Overall, the median number of excised SNs was 6 (range 2–26) per patient. The SN detection rate ranged 76–100 % [46, 52, 54, 66, 67, 69, 70, 71, 72, 73, 74, 75]. In 4.1–25 % of patients, SNs outside the extended dissection template were found, whereas 3.5–17 % of patients with positive LNs had SN metastases outside the extended dissection template. In these studies, the median percentage of patients with positive LNs was 20.4 % (range 4.7–50) with a false-negative rate of 1 % (range 0–20), respectively, [44, 46, 52, 57, 64, 67, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82]. The largest study was performed by Holl et al. and published in 2009. Out of more than 2000 patients evaluated, only 11 false-negative cases (5.5 %) were reported . A recent meta-analysis reported a pooled detection rate of 94 % (89–96.6 %) and a pooled sensitivity rate of 95 % (92–97 %) . The potential advantages of the SN approach are a lower incidence of complications and the possibility of identifying tumour-draining lymph nodes outside the extended dissection field. Despite the relatively high sensitivity rates reported throughout the years, the routine use of SN biopsy in prostate cancer is still topic of debate as high level evidence from large prospective studies is still lacking. Recently, a large study by Abdollah et al. reported that removing a higher number of (tumour-positive) lymph nodes may improve cancer-specific survival rates . This might support combining extended lymphadenectomy with SN mapping to prevent missing potentially relevant nodes which reside outside the extended dissection field.
Refinements and future prospects
Accurate localisation of SNs in the pelvis can be challenging. The introduction of SPECT/CT has refined preoperative lymphatic mapping by allowing exact pinpointing of the localisation of the SNs and providing anatomical reference points whilst planning the surgical procedure. SPECT/CT was shown to be able to identify SNs outside the extended dissection in 31 % of cases [46, 61]. The aberrantly located SNs were located proximal to the most distal part of the aorta, in the vicinity of the common iliac artery (above the crossing of the ureter), around the inferior mesenteric vessels, in the perivesical area and near the umbilical ligament.
Another recent development is the use of ultrasmall superparamagnetic nanoparticle MRI [89, 90, 91]. A handheld magnetometer was used to detect intra-prostatically injected superparamagnetic iron oxide in 20 men with prostate cancer. Metastases were found only in lymph nodes detected using the magnetometer and identified as SNs in this analysis . The role of this new approach for intraoperative detection of lymphatic drainage patterns holds promise but needs further evaluation.
In the United States, bladder cancer is the fourth most common type of cancer in men and the ninth most common cancer in women . Lymph node metastases are common in patients with (muscle-invasive) bladder cancer, and the presence of lymph node metastases, their number and the volume of involved nodes are strongly associated with survival [93, 94]. Therefore, dissection of tumour-positive nodes may confer a survival benefit in patients with muscle-invasive bladder cancer with lymph node metastases, which is supported by studies comparing different historical cohorts indicating a therapeutic effect of extended lymphadenectomy [93, 95]. In addition, survival may also be increased by treating node-positive patients with systemic chemotherapy, in either a neoadjuvant or adjuvant setting . These reasons underline the importance of accurate lymph node staging in bladder cancer patients. To date, the value of pelvic lymphadenectomy is undisputed for muscle-invasive bladder cancer. However, controversy exists on the extent of lymphadenectomy and the minimum number of nodes required for adequate lymphadenectomy, since lymph drainage from the bladder shows a wide variation and contralateral drainage is frequent [97, 98, 99, 100] Moreover, single node metastasis may occur outside the known and accepted templates (e.g., along the common iliac and presacral areas) [100, 101, 102]. A LN mapping study using SPECT/CT after radiocolloid administration in 60 patients showed radioactive nodes in the external iliac (30 %), the obturator fossa (25 %), the internal iliac (26 %), the common iliac (15 %) and the para-aortic/paracaval (4 %) region . This means that extended nodal dissection would have included 92 % of the active nodes, and a more limited resection of external and obturator template would have only included 50 % of the radioactive lymph nodes . SN biopsy may provide a minimally invasive technique with the ability to identify potential tumour-positive nodes outside the field of extended lymphadenectomy. Interestingly, even extended lymphadenectomy followed by histologic examination may have its limits as approximately one-third of patients with pathologically staged pN0 bladder cancer show micro-metastases in LNs when molecular tools are used for staging [103, 104, 105]. Consequently, there might also be a role for SN mapping as a tool to improve nodal staging by selecting lymph nodes for ultrastaging, e.g., using serial sectioning and additional immunohistochemistry or reverse transcriptase (RT)‐PCR [106, 107]. Last, one report has proposed the use of SN biopsy to harvest T-cells for immunotherapy for bladder cancer .
The concept of SN biopsy was introduced to bladder cancer in 2001 . Methodologically, various tracer injection techniques have been investigated, since both intraoperative and transurethral injection may yield different draining patterns [100, 110]. The recommended method is injection via a transurethral approach into the detrusor muscle, in four different sites adjacent to the visible bladder tumour . In a recent study by Schaafsma et al. comparing the different injection techniques, cystoscopic injection with distension of the bladder also appeared to be optimal, allowing for detection of the SN in 11 out of 12 patients in this group (92 % detection rate). However, in this study only ICG was used and no preoperative lymphatic imaging was possible . Most studies exploring SN mapping in bladder cancer used radioactive colloids and lymphoscintigraphy using a similar injection technique [100, 109, 113]. The use of radiocolloids also allows for preoperative SPECT/CT, which can provide a useful road map to guide urologists during the operation . Intraoperative SN identification has mostly been performed in an open surgery setting guided by gamma-probes (and followed by extended pelvic lymphadenectomy). However, with the advent of minimally invasive (laparoscopic/robot-assisted) approaches, newer techniques for intraoperative SN detection such as the use of a portable gamma camera and NIR fluorescence imaging have also emerged [72, 82, 112, 115].
Taken together, the available studies report SN detection rates ranging from 81 to 92 %. Initial validation studies reported false-negative rates as high as 19 % . These numbers form the basis of the persisting concerns around SN biopsy for bladder cancer as stated in the EAU guidelines , yet the numbers are comparable with the initial experiences in penile cancer, and more recent studies have shown higher sensitivity rates . Nevertheless, the relatively high false-negative rates, the complexity of injection and additional need of an extended nodal dissection may explain the limited use of the SN procedure for bladder cancer management. Although SN biopsy for bladder cancer is still in the early development phase, new technologies such as portable gamma cameras, intraoperative navigation and hybrid/NIR fluorescent tracers may provide more insights into actual lymphatic drainage patterns and in turn, help reduce the number of false-negatives cases.
Renal cell cancer
Renal cell cancer (RCC) is the 8th most common malignancy in Europe and the incidence is rising . The management of early stage RCC has traditionally been surgical, and nephrectomy or nephron-sparing strategies are often curative at this stage of the disease . Even when patients present with metastases, nephrectomy and metastasectomy may be beneficial in selected cases [119, 120]. Metastatic spread has been shown to have a high correlation with tumour size and the widespread use of ultrasound examination of the abdomen and increasing use of whole-body screening (with CT or MRI) has led to more small renal tumours being diagnosed [121, 122, 123]. This stage shift may result in an increasing number of patients with early lymph node metastases, who, in contrast to historical data, may benefit from removal of these lesions [124, 125]. SN biopsy could have both a prognostic and therapeutic role in identifying and removing nodal disease in patients without distant metastases. Another reason for the interest in RCC SNs is the possibility within these nodes to harvest T-lymphocytes for preparation and reinjection for the novel approach of autologous adoptive immunotherapy . In addition, the introduction of targeted agents has revived interest in adjuvant treatment concepts which also warrants accurate lymph node staging .
Since RCC has a well-recognised haematogenous spread and an unpredictable lymphatic drainage, the role of lymph node dissection in RCC remains controversial . The general notion is that the draining lymph nodes from RCC are in the hilar region, branching off into the paracaval, inter-aortocaval or para-aortic retroperitoneal lymph nodes (depending on the tumour side). However, the lymphatic drainage of renal tumours may not always follow the known pattern, as has frequently been found for other tumour entities . SN mapping offers the opportunity to identify such aberrant lymphatic drainage patterns in RCC.
Testicular cancer is the most frequent malignancy in young men, and the incidence has risen by almost 100 % in the past 20 years. At the time of diagnosis, approximately two-thirds of patients have clinical stage I disease . The management of regional lymph nodes in stage I testicular cancer generally consists of a surveillance policy with intensive, frequent follow-up visits and costly examinations since occult metastases are present in less than 20 % of patients. The SN approach could potentially aid in selecting patients with lymph node metastases so that they can be treated at an early stage, while preventing unnecessary treatment for those patients without metastases. Furthermore, this could potentially save CT scans (and radiation exposure) for 80 % of patients with stage I cancer and reduce the number of patients maintained in follow-up.
In spite of the fact that SN biopsy for testicular cancer was shown to be feasible, large-scale randomised clinical studies to validate and assess the added benefit of the approach are still lacking. This may be partially due to the fact that patients are usually referred to tertiary/specialised centres after orchidectomy has already been performed, thus after removal of the potential injection site. More importantly, the need for improvement of staging in stage I testicular cancer is not pressing, with 5- and 10-year overall cancer-specific survival rates approaching 100 % . On top of this, the use of adjuvant chemo and radiotherapy in case of suspected lymphatic dissemination at follow-up achieve very low recurrence rates and chemo-sensitivity among relapse patients is high, which is why SN biopsy does not currently have a role in lymph node mapping in testicular cancer in the EAU guidelines .
Throughout the years, the uro-oncological field has portrayed a pivotal role in the development of the SN concept, resulting in a well-established role of SN biopsy in penile cancer. Although its feasibility in prostate cancer has repeatedly been demonstrated and its potential value is increasingly being recognised, conclusive prospective clinical data as well as consensus on methodology and patient selection is still lacking. For bladder, renal and testicular cancer, only few studies have been published and concerns around high false-negative rates remain. Recent advances such as hybrid tracers and novel intraoperative detection tools such as fluorescence- and portable gamma imaging will hopefully encourage prospectively designed clinical trials which can substantiate the potential of the SN approach in becoming an integral part of staging in urological malignancies.
Compliance with ethical standards
Conflict of interest
All authors declare that they have no conflict of interest.
This work does not involve human participants and/or animals.
- 15.Horenblas S, Bin K Kroon, Olmos RAV, Nieweg OE (2008) Dynamic Sentinel Lymph Node Biopsy in Penile Carcinoma. In: Radioguided surgery. Springer, New York, pp 111–119Google Scholar
- 34.Brouwer OR, Buckle T, Vermeeren L et al (2012) Comparing the hybrid fluorescent-radioactive tracer indocyanine green-99mTc-nanocolloid with 99mTc-nanocolloid for sentinel node identification: a validation study using lymphoscintigraphy and SPECT/CT. J Nucl Med 53:1034–1040. doi: 10.2967/jnumed.112.103127 PubMedCrossRefGoogle Scholar
- 36.Meinhardt W (2007) Sentinel node evaluation in prostate cancer. EAU-EBU Update Series 5:223–231Google Scholar
- 37.Briganti A, Chun FK-H, Salonia A et al (2006) Validation of a nomogram predicting the probability of lymph node invasion based on the extent of pelvic lymphadenectomy in patients with clinically localized prostate cancer. Brit J Urol Int 98:788–793. doi: 10.1111/j.1464-410X.2006.06318.x CrossRefGoogle Scholar
- 45.van der Poel HG, van den Berg NS, KleinJan GH, van Leeuwen FWB (2014) Reply from authors re: francesco Montorsi, Giorgio Gandaglia. Sentinel node biopsy for prostate cancer: a useless surgical exercise? Eur urol 2014; 66:999–1000: Removing nodes that count rather than counting nodes that don’t. Eur Urol 66:1000–1001. doi: 10.1016/j.eururo.2014.10.005 PubMedCrossRefGoogle Scholar
- 50.van der Poel HG, Leijte J, Horenblas S (2016) Radioguided sentinel lymph node biopsy and lymphatic mapping in urogenital malignancies. In: Radioguided surgery. Springer, New York, pp 227–247Google Scholar
- 54.Manny TB, Patel M, Hemal AK (2014) Fluorescence-enhanced robotic radical prostatectomy using real-time lymphangiography and tissue marking with percutaneous injection of unconjugated indocyanine green: the initial clinical experience in 50 patients. Eur Urol 65:1162–1168. doi: 10.1016/j.eururo.2013.11.017 PubMedCrossRefGoogle Scholar
- 56.Hansen N, Patruno G, Wadhwa K et al (2016) Magnetic resonance and ultrasound image fusion supported transperineal prostate biopsy using the ginsburg protocol: technique, learning points, and biopsy results. Eur Urol. doi: 10.1016/j.eururo.2016.02.064 (Epub ahead of print)
- 60.Vermeeren L, Muller SH, Meinhardt W, Valdés-Olmos RA (2010) Optimizing the colloid particle concentration for improved preoperative and intraoperative image-guided detection of sentinel nodes in prostate cancer. Eur J Nucl Med Mol Imaging 37:1328–1334. doi: 10.1007/s00259-010-1410-8 PubMedCrossRefGoogle Scholar
- 69.Brenot-Rossi I, Rossi D, Esterni B et al (2008) Radioguided sentinel lymph node dissection in patients with localised prostate carcinoma: influence of the dose of radiolabelled colloid to avoid failure of the procedure. Eur J Nucl Med Mol Imaging 35:32–38. doi: 10.1007/s00259-007-0516-0 PubMedCrossRefGoogle Scholar
- 72.Inoue S, Shiina H, Mitsui Y, Yasumoto H (2013) Identification of lymphatic pathway involved in the spread of bladder cancer: evidence obtained from fluorescence navigation with intraoperatively injected indocyanine green. Can Urol Assoc J 7:E322–E328. doi: 10.5489/cuaj PubMedPubMedCentralCrossRefGoogle Scholar
- 73.Häcker A, Jeschke S, Leeb K et al (2006) Detection of pelvic lymph node metastases in patients with clinically localized prostate cancer: comparison of [18F]fluorocholine positron emission tomography-computerized tomography and laparoscopic radioisotope guided sentinel lymph node dissection. J Urol 176:2014–2018. doi: 10.1016/j.juro.2006.07.037 (discussion 2018–9) PubMedCrossRefGoogle Scholar
- 75.van der Poel HG, Buckle T, Brouwer OR et al (2011) Intraoperative laparoscopic fluorescence guidance to the sentinel lymph node in prostate cancer patients: clinical proof of concept of an integrated functional imaging approach using a multimodal tracer. Eur Urol 60:826–833. doi: 10.1016/j.eururo.2011.03.024 PubMedCrossRefGoogle Scholar
- 82.Vermeeren L, Valdés Olmos RA, Meinhardt W et al (2009) Intraoperative radioguidance with a portable gamma camera: a novel technique for laparoscopic sentinel node localisation in urological malignancies. Eur J Nucl Med Mol Imaging 36:1029–1036. doi: 10.1007/s00259-009-1100-6 PubMedCrossRefGoogle Scholar
- 91.Winter A, Woenkhaus J, Wawroschek F (2014) A novel method for intraoperative sentinel lymph node detection in prostate cancer patients using superparamagnetic iron oxide nanoparticles and a handheld magnetometer: the initial clinical experience. Ann Surg Oncol 21:4390–4396. doi: 10.1245/s10434-014-4024-8 PubMedPubMedCentralCrossRefGoogle Scholar
- 99.May M, Herrmann E, Bolenz C et al (2011) Association between the number of dissected lymph nodes during pelvic lymphadenectomy and cancer-specific survival in patients with lymph node-negative urothelial carcinoma of the bladder undergoing radical cystectomy. Ann Surg Oncol 18:2018–2025. doi: 10.1245/s10434-010-1538-6 PubMedCrossRefGoogle Scholar
- 102.Triantafyllou M, Studer UE, Birkhäuser FD et al (2013) Ultrasmall superparamagnetic particles of iron oxide allow for the detection of metastases in normal sized pelvic lymph nodes of patients with bladder and/or prostate cancer. Eur J Cancer 49:616–624. doi: 10.1016/j.ejca.2012.09.034 PubMedCrossRefGoogle Scholar
- 111.International Atomic Energy Agency IAEA (2014) GOSTT in malignancies of the kidney and bladder. In: Guided Intraoperative Scintigraphic Tumour Targeting (GOSTT): implementing advanced hybrid molecular imaging and non-imaging probes for advanced cancer management. Vienna, pp 239–254Google Scholar
- 115.Manny TB, Hemal AK (2014) Fluorescence-enhanced robotic radical cystectomy using unconjugated indocyanine green for pelvic lymphangiography, tumor marking, and mesenteric angiography: the initial clinical experience. Urology 83:824–830. doi: 10.1016/j.urology.2013.11.042 PubMedCrossRefGoogle Scholar
- 124.Blom JHM, van Poppel H, Maréchal JM et al (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 55:28–34. doi: 10.1016/j.eururo.2008.09.052 PubMedCrossRefGoogle Scholar
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