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Püllen L, Costa PF, Darr C, Hess J, Kesch C, Rehme C, Wahl M, Yirga L, Reis H, Szarvas T, van Leeuwen FWB, Herrmann K, Hadaschik BA, Tschirdewahn S, Krafft U. Near-infrared fluorescence lymph node template region dissection plus backup lymphadenectomy in open radical cystectomy for bladder cancer using an innovative handheld device: A single center experience. J Surg Oncol 2024; 129:1325-1331. [PMID: 38583145 DOI: 10.1002/jso.27618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/10/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The extent of pelvic lymphadenectomy (PLND) as part of radical cystectomy (RC) for bladder cancer (BC) remains unclear. Sentinel-based and lymphangiographic approaches could lead to reduced morbidity without sacrificing oncologic safety. OBJECTIVE To evaluate the feasibility and diagnostic value of fluorescence-guided template sentinel region dissection (FTD) using a handheld near-infrared fluorescence (NIRF) camera in open radical cystectomy. DESIGN, SETTING, AND PARTICIPANTS After peritumoral cystoscopic injection of indocyanine green (ICG) 21 patients underwent open RC with FTD due to BC between June 2019 and June 2021. Intraoperatively, the FIS-00 Hamamatsu Photonics® NIRF camera was used to identify and resect fluorescent template sentinel regions (FTRs) followed by extended pelvic lymphadenectomy (ePLND) as oncological back-up. OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS Descriptive analysis of positive and negative results per template region. RESULTS AND LIMITATIONS FTRs were identified in all 21 cases. Median time (range) from ICG injection to fluorescence detection was 75 (55-125) minutes. On average (SD), 33.4 (9.6) lymph nodes were dissected per patient. Considering template regions as the basis of analysis, 67 (38.3%) of 175 resected regions were NIRF-positive, with 13 (7.4%) regions harboring lymph node metastases. We found no metastatic lymph nodes in NIRF-negative template regions. Outside the standard template, two NIRF-positive benign nodes were identified. CONCLUSION The concept of NIRF-guided FTD proved for this group all lymph node metastases to be found in NIRF-positive template regions. Pending validation in a larger collective, resection of approximately 40% of standard regions may be sufficient and may result in less morbidity.
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Affiliation(s)
- Lukas Püllen
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Pedro F Costa
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Nuclear Medicine, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
| | - Christopher Darr
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Jochen Hess
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Claudia Kesch
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Christian Rehme
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Milan Wahl
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Leubet Yirga
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Henning Reis
- Dr. Senckenberg Institute of Pathology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tibor Szarvas
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Dr. Senckenberg Institute of Pathology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Department of Urology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Fijs W B van Leeuwen
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Centre, Leiden University, Leiden, Netherlands
| | - Ken Herrmann
- German Cancer Consortium (DKTK), Heidelberg, Germany
- Department of Nuclear Medicine, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
| | - Boris A Hadaschik
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Stephan Tschirdewahn
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Ulrich Krafft
- Department of Urology, West German Cancer Center, University Duisburg Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Heidelberg, Germany
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Małkiewicz B, Jędrzejuk D, Gurwin A, Wilk K, Knecht-Gurwin K, Kiełb P, Krajewski W, Bolanowski M, Hałoń A, Szydełko T. Diagnostic Value of the Sentinel Lymph Node Technique in Patients with Muscle-Invasive Bladder Cancer. J Clin Med 2023; 12:jcm12093092. [PMID: 37176533 PMCID: PMC10179622 DOI: 10.3390/jcm12093092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The optimal limits of the bilateral pelvic lymph node dissection (PLND) template in bladder cancer treatment remain controversial. This study aimed to investigate whether radio-guided sentinel node (SLN) detection is a reliable technique for the perioperative localisation of potential lymphatic metastasis during cystectomy for muscle-invasive bladder cancer (MIBC). MATERIALS AND METHODS We studied 54 patients with pT2-pT4 MIBC who underwent cystectomy with extended PLND (ePLND) augmented by the SLN technique. The identification of SLN was performed by preoperative SPECT/CT hybrid lymphoscintigraphy using peritumoral injection of nanocolloid-Tc-99m, followed by intraoperative navigation with a handheld γ-probe. All nodal specimens were collected separately and then fixed in formalin, stained with haematoxylin and eosin, and examined by an experienced uropathologist. RESULTS A total of 1414 LNs were resected and examined for the presence of metastases. The mean number of harvested LNs was 26 (range: 11-50) per patient. In 51 of 54 patients, 192 SLNs were resected. In addition, 20/192 (10.4%) SLNs were located outside of the ePLND area. Overall, 72 metastatic LNs (LN+) were found in 22 of 54 patients (40.7%) and in 24/192 SLNs (12.5%). The SLN technique detected LN+ in 14 of 22 (64%) patients. The SLNs were the only sites of metastasis (SLN+ = LN+) in 6 of 22 (27.3%) LN+ patients, including two cases with foci located in the pararectal region. The diagnostic values for the sensitivity, specificity, positive predictive value, and false-negative rate for the SLN technique were 66.66%, 4.16%, 28.57%, and 33.33%, respectively. Extended lymphadenectomy and its combination with the SLN technique enabled the correct assessment in 96.3 and 100% of patients, respectively. CONCLUSIONS The combination of ePLND and SLN provides a better pN assessment compared to ePLND alone. Although the SLN technique has restrictions that limit its diagnostic value, its use as an addition to lymphadenectomy allows for the visualisation of nonstandard lymph drainage pathways that may be potential metastatic routes.
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Affiliation(s)
- Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556 Wrocław, Poland
| | - Diana Jędrzejuk
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, 50-367 Wrocław, Poland
| | - Adam Gurwin
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556 Wrocław, Poland
| | - Karol Wilk
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556 Wrocław, Poland
| | - Klaudia Knecht-Gurwin
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Paweł Kiełb
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556 Wrocław, Poland
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556 Wrocław, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, 50-367 Wrocław, Poland
| | - Agnieszka Hałoń
- Department of Clinical and Experimental Pathology, Wrocław Medical University, 50-556 Wrocław, Poland
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-556 Wrocław, Poland
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Rietbergen DD, van Gennep EJ, KleinJan GH, Donswijk M, Valdés Olmos RA, van Rhijn BW, van der Poel HG, van Leeuwen FW. Evaluation of the Hybrid Tracer Indocyanine Green- 99m Tc-Nanocolloid for Sentinel Node Biopsy in Bladder Cancer-A Prospective Pilot Study. Clin Nucl Med 2022; 47:774-780. [PMID: 35713891 PMCID: PMC9351699 DOI: 10.1097/rlu.0000000000004301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022]
Abstract
RATIONALE In muscle-invasive bladder cancer (MIBC), lymph node invasion has proven to be an independent predictor of disease recurrence and cancer-specific survival. We evaluated the feasibility of targeting the sentinel node (SN) for biopsy in MIBC patients using the hybrid tracer indocyanine green (ICG)- 99m Tc-nanocolloid for simultaneous radioguidance and fluorescence guidance. METHODS Twenty histologically confirmed cN0M0 MIBC patients (mean age, 63.3 years; range, 30-82 years), scheduled for radical cystectomy with SN biopsy and extended pelvic lymph node dissection (ePLND), were prospectively included. Twelve patients were operated on following neoadjuvant chemotherapy. The patients received lymphoscintigraphy as well as SPECT/CT after 4 transurethral injections of ICG- 99m Tc-nanocolloid (mean, 208 MBq; range, 172-229 MBq) around the tumor/scar in the detrusor muscle of the bladder on the day before radical cystectomy. Sentinel node resection was performed under radioguidance and fluorescence guidance. RESULTS Nineteen patients could be analyzed. On preoperative imaging, SNs could be identified in 10 patients (53%; mean, 1.6 SN/patient), which revealed drainage pathways outside the ePLND in 20% of the patients. Interesting to note is that 2 patients (10%) with preoperative nonvisualization displayed fluorescent and radioactive SNs during surgery. Location of the primary tumor near the left lateral side of the bladder seemed to be a factor for nonvisualization. Nodal harvesting with ePLND varied among patients (mean, 23.3). Histopathology confirmed tumor-positive nodes in 4 (21%) of all patients. In the 2 patients where an SN could be identified, the ePLND specimens were tumor-negative. All patients with tumor-positive nodes had advanced disease (stage III). CONCLUSION Sentinel node biopsy in bladder cancer using the hybrid tracer ICG- 99m Tc-nanocolloid is feasible, and preoperative imaging is predictive for the ability to perform SN biopsy in 83% of the patients who displayed an SN. In patients with a successful preoperative SN mapping using lymphoscintigraphy and SPECT/CT, the intraoperative SN guidance and detection were effective, even outside the ePLND area. As such, this study underscores the critical role that preoperative imaging plays in challenging image-guided surgery applications.
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Affiliation(s)
- Daphne D.D. Rietbergen
- From the Interventional Molecular Imaging Laboratory, Department of Radiology
- Nuclear Medicine Section, Department of Radiology
| | | | | | | | - Renato A. Valdés Olmos
- From the Interventional Molecular Imaging Laboratory, Department of Radiology
- Nuclear Medicine Section, Department of Radiology
| | | | | | - Fijs W.B. van Leeuwen
- From the Interventional Molecular Imaging Laboratory, Department of Radiology
- Department of Urology, Leiden University Medical Center, Leiden
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Methods of Sentinel Lymph Node Detection and Management in Urinary Bladder Cancer—A Narrative Review. Curr Oncol 2022; 29:1335-1348. [PMID: 35323314 PMCID: PMC8947662 DOI: 10.3390/curroncol29030114] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Detection of lymph node status in bladder cancer significantly impacts clinical decisions regarding its management. There is a wide range of detection modalities for this task, including lymphoscintigraphy, computed tomography, magnetic resonance imaging, single-photon emission computed tomography, positron emission tomography, and fluoroscopy. We aimed to study the pre- and intraoperative detection modalities of sentinel lymph nodes in urinary bladder cancer. Method: This narrative review was performed by searching the PubMed and EMBASE libraries using the following search terms: (“Transitional cell carcinoma of the bladder” OR “urothelial cancer” OR “urinary bladder cancer” OR “bladder cancer”) AND ((“sentinel lymph node”) OR (“lymphatic mapping”) OR (“lymphoscintigraphy”) OR (“lymphangiography”) OR (“lymph node metastases”)). Studies analysing the effectiveness and outcomes of sentinel lymph node detection in bladder cancer were included, while non-English language, duplicates, and non-article studies were excluded. After analysing the libraries and a further manual search of bibliographies, 31 studies were included in this paper. We followed the RAMESES publication standard for narrative reviews to produce this paper. Results: Of the 31 studies included, 7 studies included multiple detection methods; 5 studies included lymphoscintigraphy; 5 studies included computed tomography and/or single-photon emission computed tomography; 5 studies included fluoroscopy; 4 studies included magnetic resonance imaging; and 5 studies included positron emission tomography. Discussion: Anatomical, radioactive, and functional detection modalities have been studied independently and in combination. The consensus is that preoperative detection with imaging helps guide surgical management and intraoperative detection methods help capture any lymph nodes that may have been missed. Each of these types of detection represent their own set of benefits and drawbacks, but there is currently limited evidence to support any change in overall practice to replace conventional staging.
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Challenging Visualization of Sentinel Lymph Nodes in Upper Urinary Tract Urothelial Carcinoma. J Clin Med 2021; 10:jcm10235465. [PMID: 34884167 PMCID: PMC8658349 DOI: 10.3390/jcm10235465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/14/2021] [Accepted: 11/20/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose: The purpose of this study was to assess the possibility of detecting sentinel lymph nodes (SLNs) and to perform analysis of lymphatic outflow in patients with suspicion of upper tract urothelial carcinoma (UTUC) with the use of a radioisotope-based technique. Methods: During 2018–2021, a prospective study was conducted on 19 patients with the suspicion of UTUC and for whom diagnostic ureterorenoscopy (URS) was planned. Technetium-99m (99mTc) nanocolloid radioactive tracer injection and a tumor biopsy were performed for staging procedures. Three-dimensional (3D) reconstruction and fusion of images were performed for better localization of lymph nodes (LNs). Detection of SLNs and the analysis of the radiotracer outflow was conducted with the use of single-photon emission-computed tomography/computed tomography (SPECT/CT) lymphangiography. Results: The mean age of the patients was 73.4 years; 7 (36%) were male. Pathological staging from the biopsy was T0—8 (42%), Ta—7 (36%), T1—4 (21%). SLNs were detected in two of 19 cases (10%). In one patient a single SLN (5.3%) was visualized, and in another case (5.3%), multiple (double) radioactive lymph nodes were visualized. In 17 out of the 19 (89.5%) cases, no lymphatic outflow was observed, and out of these five cases (26.3%) of gravitational leakage of injected radiotracer to the retroperitoneal space was noted. Conclusions: We demonstrated that detection of SLNs in the upper urinary tract is possible yet challenging. Radiotracer injection in the upper urinary tract during ureterorenoscopy is difficult to perform, and the expected result of injection is unsatisfactory. Lymphatic outflow from the tumor site to the first LNs in our studied group of patients is visible in 10.5% of cases. SPECT/CT lymphangiography in cases of UTUC may provide valuable information about a patient’s individual anatomy of the lymphatic system and the position of the first lymph nodes draining lymph with potential metastatic cells from the tumor.
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