To review the management and clinical outcomes of uni- or bilateral non-visualization of inguinal lymph nodes following dynamic sentinel lymph node biopsy (DSNB) in patients diagnosed with penile cancer and clinically impalpable inguinal lymph nodes (cN0). An additional objective was to develop an algorithm for the management of patients in which non-visualisation occurs.
This is a retrospective observational study over a period of 4 years comprising 166 patients with penile squamous cell carcinoma undergoing DSNB and followed up for a minimum of 6 months. All cases diagnosed with uni- or bilateral non-visualisation of sentinel nodes in this cohort were identified from a penile cancer database. The management of the inguinal lymph nodes following non-visualisation and the oncological outcomes including local and regional recurrence rates were documented.
Out of 166 consecutive patients undergoing DSNB, 20 (12%) patients had unilateral non-visualisation following injection of intradermal (99m) Tc. Of these 20 patients, 7 underwent repeat DSNB at a later date with 6 having successful visualisation. One patient had persistent non-visualisation and proceeded to a superficial modified inguinal lymphadenectomy (SML). None of these patients experienced recurrence at follow-up. A further seven patients underwent modified SML with on table frozen section analysis of the lymph node packet; none of these patients were found to have micrometastatic disease in the inguinal lymph nodes although one patient developed metastatic inguinal node disease at a later date. Six patients elected to undergo clinical surveillance and have remained disease free.
Patients with impalpable inguinal lymph nodes undergoing DSNB with ≥ T1G2 disease should ideally have bilateral visualisation of the sentinel lymph nodes reflecting the drainage pattern from the primary tumour. In this series, 12% of patients were found to have unilateral non-visualisation following DSNB. Patients offered a repeat DSNB at a later date, were successful in localising the sentinel node in 86% of cases. Patients with favourable histological parameters can be placed on clinical surveillance. Those with high-risk disease can be offered a repeat DSNB procedure on the proviso that a SML may be carried out if there is repeated non-visualisation. Larger cohorts are required in order to validate this proposed algorithm. This article is protected by copyright. All rights reserved.
BJU international. 2016 Oct 15 [Epub ahead of print]
Varun Sahdev, Maarten Albersen, Michelle Christodoulidou, Arie Parnham, Peter Malone, Raj Nigam, Jamshed Bomanji, Asif Muneer
Department of Urology, University College London Hospitals NHS Foundation Trust, 235 Euston Road, NW12BU., Department of Urology, University College London Hospitals NHS Foundation Trust, 235 Euston Road, NW12BU. .