Sentinel lymph node dissection for prostate cancer: experience with more than 1,000 patients

PURPOSE: We determined the incidence of positive pelvic lymph nodes in men undergoing radical retropubic prostatectomy and describe the correlation with prostate specific antigen, histological grade and stage. We examined whether tumor cells are localized in the sentinel nodes only or also in other nonsentinel lymph nodes. MATERIALS AND METHODS: A total of 1,055 men with prostate cancer underwent radio guided pelvic lymph node dissection and radical retropubic prostatectomy. In men with prostate specific antigen 20 ng/ml or less and biopsy Gleason score 7 or less only sentinel nodes were removed. In men with prostate specific antigen more than 20 ng/ml or Gleason score greater than 7 extended pelvic lymph node dissection was also performed. RESULTS: Positive lymph nodes were found in 207 men (19.6%). In 63.3% of the men these lymph nodes were detected outside of the region of standard lymphadenectomy. The percent of patients with positive nodes was greater than predicted by currently used nomograms. The higher the preoperative prostate specific antigen, pathological stage and grade, the greater the percent of men with positive sentinel and nonsentinel lymph nodes (p<0.001). CONCLUSIONS: When deciding on pelvic lymph node dissection, sentinel or extended lymphadenectomy should be performed since more than half of patients have positive nodes outside of the region of standard lymphadenectomy. In cases of positive sentinel nodes extended lymph node dissection should be performed since tumor cells are also detectable in nonsentinel lymph nodes.     

Lymphadenectomy in bladder cancer: How high is “high enough”?

PURPOSE: The role of a regional lymphadenectomy in the surgical treatment of high-grade, invasive transitional cell carcinoma of the bladder has evolved over the last several decades. Although the application of a lymphadenectomy for bladder cancer is not significantly debated, the absolute extent or level of proximal dissection of the lymphadenectomy remains a controversial issue. MATERIAL AND METHODS: A review of the literature should help elucidate the rationale and extent of an appropriate lymphadenectomy in patients undergoing radical cystectomy for bladder cancer. Various surgical issues of lymphadenectomy as well as prognostic factors in patients undergoing radical cystectomy for bladder cancer are examined. RESULTS: A growing body of evidence, spanning from early autopsy and cadaveric studies to recent retrospective series and multicenter prospective trials, suggests that an extended lymph node dissection (cephalad extent to include the common iliac arteries) may provide not only prognostic information but also provide a therapeutic benefit for both patients with lymph node-positive and lymph node-negative disease undergoing radical cystectomy for bladder cancer. Although the absolute boundaries of the lymphadenectomy remain a subject of controversy, historical reports confirmed by recent lymphatic mapping studies suggest the inclusion of the common iliac as well as possibly presacral nodes in the routine lymphadenectomy for transitional cell carcinoma of the bladder. The need to extend the dissection higher to include the distal para-aortic and paracaval lymph nodes may be important in select individuals but remains more controversial. The extent of the primary bladder tumor (p-stage), number of lymph nodes removed, the lymph node tumor burden (tumor volume), and lymph node density (number of lymph nodes involved/number of lymph nodes removed) are all important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases. Systemic adjuvant chemotherapy remains a mainstay of treatment of patients with lymph node metastases. CONCLUSIONS: Radical cystectomy with an appropriately performed lymphadenectomy provides the best survival outcomes and lowest local recurrence rates. Although the absolute limits of the lymph node dissection remain to be determined, evidence supports a more extended lymphadenectomy to include the common iliac vessels and presacral lymph nodes at cystectomy in patients who are appropriate surgical candidates. When feasible, adjuvant chemotherapy is warranted in patients with positive nodal metastasis.     

Limitations of radioguided surgery in high-risk prostate cancer

OBJECTIVES: To determine how many men with high-risk prostate cancer (prostate-specific antigen [PSA]>20 ng/ml or biopsy Gleason score 8-10) have positive lymph nodes (sentinel lymph nodes [SLNs] and nonsentinel lymph nodes [NSLNs]) and whether these positive nodes are localised in the region of SLN dissection or in other regions, too. METHODS: In 228 men with high-risk prostate cancer radical retropubic prostatectomy combined with radioguided pelvic lymph node dissection and extended lymphadenectomy were performed. Serial sections of the SLNs were analysed immunohistochemically. RESULTS: A median of 7 SLNs (mean, 7) and 11 NSLNs (mean, 11) were dissected per patient. Ninety-six of 228 men (42.1%) had lymph node metastases. Most men had positive lymph nodes along the internal iliac artery alone or in combination with other regions. Twenty-two men had only micrometastatic disease. In 94 of 96 men the SLNs were positive. Twenty-six of 96 men had also positive NSLNs. When SLNs and NSLNs were positive, in more than half the patients the NSLNs were localised outside the region of sentinel lymphadenectomy. CONCLUSIONS: The dissection of SLNs in prostate cancer has a high sensitivity in detecting positive nodes. When SLNs are negative, the other pelvic lymph nodes are also negative in a high percentage of men (sensitivity 97.1%). When the SLNs are positive, patients with high-risk disease also have a high incidence of positive NSLNs. Therefore, when it is aspired to remove all pelvic lymph node metastases sentinel and extended lymphadenectomy should be performed.     

Early stage prostatic cancer investigated by pelvic lymph node biopsy and bone marrow acid phosphatase

A prospective study was done to evaluate 47 patients with early stage prostatic cancer. Pelvic lymphadenectomy was combined with bone marrow acid phosphatase determination to evaluate early metastatic disease. Thirteen patients (28 per cent) had tumor in the pelvic lymph nodes. In no instance was the bone marrow acid phosphatase elevated to more than the normal value for serum by the substrate used. Combined high grade and stage tumors seemed to have an increased incidence of metastases to pelvic lymph nodes. A surprisingly high incidence of B1 lesions (5 of 21 patients or 24 per cent) had positive lymph nodes. Generally, the nodes were moderately well or well differentiated lesions. The metastases were unilateral, frequently microscopic only and involved 1 or only a few nodes. Pelvic lymphadenectomy seems to have a well defined role in the diagnostic study of early stage prostatic cancer, while bone marrow acid phosphatase determinations were of no value.     

Incidence of positive pelvic lymph nodes in patients with prostate cancer, a prostate-specific antigen (PSA) level of < or =10 ng/mL and biopsy Gleason score of < or =6, and their influence on PSA progression-free survival after radical prostatectomy

OBJECTIVE: To investigate how many men with low-risk prostate cancer had positive lymph nodes detected by radio-guided surgery and whether they had a higher biochemical relapse rate after radical prostatectomy, because in such patients most urologists dispense with operative lymph node staging, as nomograms indicate only a low percentage of lymph node metastases. PATIENTS AND METHODS: The study included 474 men with a prostate-specific antigen (PSA) level of < or = 10 ng/mL, biopsy Gleason score of < or = 6 and positive biopsies in one (group 1, 315 men) or both lobes (group 2, 159 men); follow-up data were available in 357 men. Men with adjuvant radiation or hormone therapy before the occurrence of biochemical relapse were excluded. RESULTS: Positive lymph nodes were detected in 17 men in group 1, and in 18 in group 2. In more than half of the patients (19/35) these nodes were found outside the region of standard lymphadenectomy. Men with node-positive disease had a higher biochemical relapse rate (P < 0.001). When the tumour was organ-confined and well differentiated in node-positive disease (Gleason score < or = 6) the biochemical relapse rate was lower than in men with higher tumour stage and grade. CONCLUSIONS: When dissecting pelvic lymph nodes, extended or sentinel lymphadenectomy should be preferred. Removing the diseased nodes could improve the PSA progression-free survival, especially in well differentiated organ-confined disease.     

进展期胃癌以术中淋巴显影为指导的D2根治术

目的 比较进展期胃癌在D2基础上以术中淋巴显影为指导的个体化清扫与常规D2根治术的淋巴结清扫效果.方法 20例进展期胃癌患者术中在肿瘤周围注射纳米炭混悬液者为纳米炭组,在D2根治术的基础上以黑染淋巴结为指导进行个体化清扫.21例常规行D2根治术的进展期胃癌为对照组,比较两组清扫淋巴结的数目及淋巴结转移情况、纳米炭组淋巴结黑染情况,并观察其副作用及并发症.结果 纳米炭组平均清扫淋巴结(35.1±13.4)枚/例,高于对照组的(26.2±7.8)枚/例,两者相比差异有统计学意义(t=2.126,P=0.034),主要体现在N2、N3淋巴结的清扫;纳米炭组淋巴结黑染率为52.7%,黑染淋巴结中发生转移的阳性率(27.6%)高于未黑染淋巴结(10.8%)及对照组(16.9%),差异均有统计学意义(x2=6.034,P=0.016;x2=5.142,P=0.023);纳米炭组术后1例发生输入襻梗阻.结论 在D2根治术的基础上以术中淋巴显影技术为指导对进展期胃癌进行淋巴结清扫,能增加淋巴结清扫的效率.     

Influence of the size and the localization of metastases in melanoma sentinel lymph nodes on the results of lymphadenectomy

AIM: Thirty-five cases of lymphadenectomy carried out in the context of positive sentinel lymph node for malignant melanoma have been reviewed to assess the prognostic value of certain metastatic charachteristics. We have checked wether the type (macro or micrometastasis) and localisation (subcapsular or intraparenchymal) in the sentinel lymph node had predictive value for the lymphadenectomy outcome and evolution of the case. MATERIAL AND METHODS: The retrospective study relates to 35 cases (with an average 2 years history) taken from a total of 87 sentinel lymph node protocols; average age 46.5 years, Breslow 2.5 mm with an history of 25 months. RESULTS: Among the 35 positive sentinel lymph nodes we have 19 cases (54.2%) of micrometastasis. Among the 35 lymphadenectomy 5 cases (14.28%) turned out positive, 3 of which concerned micrometastatic sentinel lymph nodes. In our cohort the micrometastatic nature of sentinel lymph nodes did not have statistically significant impact upon the lymphadenectomy result but showed more favourable short-term evolution with 68.42% metastatic free evolution as against 43.75% in case of initial macrometastasis. The subcapsular localisation of micrometastasis equally represents a factor of improved prognosis (69.2% of metastatic free evolution against of 30.8% in the case of intraparenchymal localistion). CONCLUSION: Unfortunately, none of the studied criteria justifies a modification of our present clinical attitude whereby a systematic lymphadenectomy in cases of positive sentinel lymph nodes is performed, whatever the type or localisation of the relevant metastases.     

Adjuvant chemotherapy after radical resection of squamous cell carcinoma in the thoracic esophagus: who benefits? A retrospective study

BACKGROUND: A definitive combined modality therapy superior to surgery alone has not yet been found for esophageal cancer. This retrospective study investigated the impact of postoperative adjuvant chemotherapy in patients who underwent curative (R0) esophagectomy with radical lymphadenectomy. STUDY DESIGN: Two hundred and eleven patients with a squamous cell carcinoma in the thoracic esophagus who underwent transthoracic curative (R0) esophagectomy with radical lymphadenectomy, such as 3-field lymphadenectomy or total 2-field lymphadenectomy, between 1988 and 2000, were retrospectively reviewed. Ninety-four patients received postoperative chemotherapy - 2 courses of cisplatin (CDDP) plus fluorouracil (5-FU) or vindesine (VDS) - while the other 117 patients received surgery alone. The overall survival rate was compared between the two groups after being stratified by the numbers of the metastasis- positive lymph nodes. RESULTS: Only in the subgroup of patients with 8 or more lymph nodes metastasis- positive, the surgery-with-postoperative-chemotherapy group had a significantly better survival than the surgery-alone group. No significant difference was found in survival between the two groups in any other stratified subgroup. CONCLUSIONS: Postoperative adjuvant chemotherapy following curative (R0) esophagectomy with radical lymphadenectomy such as 3-field lymphadenectomy or total 2-field lymphadenectomy provided a benefit only in patients having metastasis in a large number - 8 or more - lymph nodes.     

Lymph node counts in indians in relation to lymphadenectomy for carcinoma of the oesophagus and stomach

OBJECTIVE: Systemic lymphadenectomy for carcinoma of the oesophagus and stomach is increasingly accepted as effective surgical treatment. A review of available literature reveals a great variety in the number of lymph nodes removed during standard lymphadenectomy. The present study was conducted to find the normal number of lymph nodes in the Indian population in relation to lymphadenectomy for oesophageal and gastric carcinoma. METHODS: Lymph nodes situated at stations 1-16, relevant to lymphadenectomy for gastric cancer, were removed by lymph node dissection according to the recommendations of the Japanese Research Society for Gastric Cancer and those at the 22 stations, relevant to lymphadenectomy in oesophageal cancer, were removed according to the International Society for Diseases of the Esophagus recommendations in 10 cadavers without a history of any abdominal pathology or haematological lymphatic disease. Nodes were cleared by dissolving fatty tissue. All lymph nodes were histologically confirmed and the diameter of each lymph node was recorded. RESULTS: An average of 52.0 nodes (range, 37-78 nodes) was found at Stations 1-16, while an average of 183.6 nodes (range, 118-234 nodes) was found at the 22 stations. These numbers are higher than those in the literature. CONCLUSION: This anatomical study addresses the dual issues of determining the number of dissectable lymph nodes in a particular population as well as assessing the quality of nodal dissection by providing quantitative surgical guidelines.     

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目的 探讨中下段直肠癌侧方淋巴结转移规律及影响因素。方法 对1995－2000年行侧方淋巴结清扫的105例直肠癌病人进行回顾性分析。结果 中下段直肠癌侧方转移率为21％，肿瘤的大小、部位、病理分型、分化程度及浸润深度是影响侧方转移的重要因素。在侧方淋巴结转移阳性病人中，单纯闭孔及髂内淋巴结转移阳性病人占54．5％，单纯髂外及髂总淋巴结转移阳性病人为18．1％。侧方淋巴结转移阴性病人术后局部复发率为6．7％，阳性病人为36．3％。行侧方清扫局部复发率较传统术式由17．6％降至11．4％。侧方转移阴性病人平均生存期为88个月，阳性病人为37个月，二者差异有显著性。结论 侧方淋巴转移是中下段直肠癌淋巴转移的重要途径。闭孔和髂内淋巴结是侧方淋巴结清扫中需要着重清扫的部位。侧方淋巴清扫较传统术式可明显降低局部复发率。     

Feasibility of a randomized trial of extended lymphadenectomy for pancreatic cancer

HYPOTHESIS: The required sample size of a prospective randomized trial comparing standard pancreaticoduodenectomy with pancreaticoduodenectomy plus extended lymphadenectomy for pancreatic adenocarcinoma is prohibitively large, making such a trial infeasible. DESIGN: Retrospective cohort study. SETTING: Comprehensive cancer center. PATIENTS: We identified 158 patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with separate pathologic analysis of second-echelon lymph nodes, defined as lymph nodes along the proximal hepatic artery and/or the great vessels. MAIN OUTCOME MEASURES: To estimate the sample size required for a randomized trial, we devised a biostatistical model with the following assumptions: extended lymphadenectomy can benefit only patients who (1) actually have disease removed from second-echelon nodes, (2) have microscopically negative (R0) primary tumor resection margins, and (3) do not have visceral metastatic (M0) disease. RESULTS: Seventy-six patients (48.1%) had negative first- and second-echelon lymph nodes, 65 (41.1%) had positive first-echelon and negative second-echelon lymph nodes, and 17 (10.8%) had positive first- and second-echelon lymph nodes. Patients with positive second-echelon lymph nodes had an R0 resection rate of 47.1%. At a median follow-up of 65.1 months, 4 patients with positive second-echelon lymph nodes were alive, but 3 had recurrent disease. This implies that only 1 patient (5.9%) with positive second-echelon lymph nodes may have had true M0 disease. Therefore, only 0.3% of patients (10.8% with positive second-echelon lymph nodes x 47.1% with R0 resection x 5.9% with M0 disease) may achieve a survival benefit from extended lymphadenectomy. A randomized trial of standard pancreaticoduodenectomy vs pancreaticoduodenectomy with extended lymphadenectomy would require 202 000 patients in each study arm to detect such a small difference. CONCLUSIONS: Definitive evaluation of the potential benefits of extended lymphadenectomy would require a prohibitively large sample size. Adequately powered randomized trials to address the potential benefit of extended lymphadenectomy are infeasible.     

Extent of pelvic lymphadenectomy and its impact on outcome in patients diagnosed with bladder cancer: analysis of data from the Surveillance,Epidemiology and End Results Program data base

PURPOSE: The benefit of pelvic lymphadenectomy in patients with bladder cancer remains controversial. We analyzed the impact of lymphadenectomy on disease specific survival in a population based sample of patients with bladder cancer who underwent radical cystectomy. MATERIALS AND METHODS: Analysis included data on 1,923 patients who underwent radical cystectomy for bladder cancer between 1988 and 1996 obtained from the Surveillance, Epidemiology and End Results program cancer registry. We analyzed the impact of the number of lymph nodes examined, number of positive lymph nodes and ratio of positive-to-total number of lymph nodes resected on disease specific and overall survival independent of patient age, gender, stage, race, radiation and chemotherapy. RESULTS: Median followup in cystectomy cases was 63.5 months (range 0 to 131). Patients with 0 to 3 lymph nodes examined were at significantly higher risk of death from bladder cancer than those with greater than 3 (HR 1 to 1.2 versus 0.41 to 0.58). Patients with stages I/in situ, III and IV disease benefited from more extensive lymphadenectomy. In stage IV cases, while the total number of positive lymph nodes removed did not correlate with increased survival, the proportion of excised lymph nodes positive for metastatic bladder cancer tended to correlate with the risk of death from the disease. CONCLUSIONS: These results indicate significantly increased survival rates after cystectomy in patients with bladder cancer diagnosed with stages III or IV disease who have relatively more lymph nodes examined, suggesting that even some with higher stage disease may benefit from extended pelvic lymphadenectomy at cystectomy.     

Muskelinvasives Urothelkarzinom der Harnblase

Detection of metastases in lymph nodes is an important prognostic factor for progression-free survival in bladder cancer patients. Patients undergoing radical cystectomy with pelvic lymphadenectomy are randomized in the LEA study (AUO AB 25/02) into two groups receiving standard (obturator and external nodes) or extended lymphadenectomy (complete pelvic nodes up to the inferior mesenteric artery).The aim of this study is the detection of lymph node metastases that are not identified with classic pathological methods using RT-PCR as a highly sensitive and specific method. For detection of occult disseminated tumor cells we analyze the expression of the tumor markers cytokeratin 20 (CK-20), uroplakin II (UP II), mucin 2 (MUC2), and mucin 7 (MUC7).We examined 315 lymph nodes from 19 cystectomy patients for the expression of CK-20. In 93 lymph nodes CK-20 expression was detected whereas only 18 lymph nodes were histopathologically positive. More than one third of CK-20-positive lymph node metastases were located outside the standard lymphadenectomy field. We did not detect any skip lesions. Follow-up data will validate if there is a correlation between detection of occult disseminated tumor cells and progression-free survival.     

髂腹股沟淋巴清扫对阴茎癌的治疗意义(附63例报告)

目的 探讨腹股沟淋巴结活检脑髂腹肌沟淋巴清扫在阴茎癌治疗中的作用.方法 报告1982年1月１９９７年７月收治的６３例陈茎癌的临床资料,在节切除阴茎原发病灶同时行无选择性双侧腹股沟淋巴结活检,并对淋巴结活检阳性者行双侧髂腹股沟淋巴清扫术。结果 １１例（１５侧）淋巴结活检阳性,１例假阴性。淋巴清扫后,原活检阴性侧髂腹股沟未见淋巴转移,阳性侧有１例,存在Ｃｌｏｑｕｅｔ淋巴结转移。结论 在切除阴茎癌肿的同时应作双     

What are the benefits of extended dissection of the regional renal lymph nodes in the therapy of renal cell carcinoma

In a prospective study of 511 patients we compared the data of 320 who underwent systematically extended dissection of the regional lymph nodes with data of 191 who underwent only facultative dissection of the lymph nodes, which means that no lymph nodes had been removed or only a few were taken for staging purposes. Only patients without distant metastases and who were less than 72 years old were included. All patients were treated with a transabdominal approach. The incidence of positive nodes in the patients with systematically extended lymphadenectomy was 17.5% and for patients with facultative lymphadenectomy it was 10%. Survival rates of patients with facultative lymphadenectomy were 58% after 5 years and 40.9% after 10 years, compared to 66% and 56.1%, respectively, for patients with systematically extended lymphadenectomy (p less than 0.01). Patients with stage pT1-2 (Robson stage I) and pT3aN0M0 (Robson stage II) tumor obviously had the highest benefits with extended lymphadenectomy. Operative mortality was less than 1% after systematically extended lymphadenectomy and 3.8% after facultative lymphadenectomy. We conclude from our data that the systematic and extended lymphadenectomy improves the prognosis of patients with renal cell carcinoma without any additional operative risks.     

Lateral lymphadenectomy in the treatment of rectal carcinoma

The aim of this work is to present existence of the lateral lymphatic spread of metastases in patients with Dukes C low rectal carcinoma (60% of all patients), located at or bellow peritoneal reflexion. Prospective clinical investigation analyzed the group of 64 patients (32 underwent lateral lymphadenectomy and 32 didn't), all treated at Ist Surgical Clinic, Clinical Center of Serbia. Lateral lymphatic spread of metastases was proven by frozen section in 8 cases, so extensive lateral lymphadenectomy was performed. In the group of patients who underwent lateral lymphadenectomy, positive lymph nodes were registered in 18 patients (56.2%); in group of patients operated without lateral lymphadenectomy, metastatic lymph nodes were registered in 12 patients (37.5%). According to results of this investigation, method of lateral lymphadenectomy, as well as extensive lateral lymphadenectomy, is significant for exact determination of postoperative stage of the disease. Also, there is a significant increase in number of patients with Dukes C stage of the disease. In those patients, mesorectectomy alone is not sufficient.     

Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis

PURPOSE: Lymphadenectomy for prostate cancer is limited to obturator and external iliac lymph nodes, although the internal lymph nodes represent the primary landing zone of lymphatic drainage. We performed anatomically adequate extended pelvic lymphadenectomy to assess the incidence of lymph node metastasis in cases of clinically localized prostate cancer. MATERIALS AND METHODS: A total of 103 consecutive patients underwent extended pelvic lymphadenectomy at radical retropubic prostatectomy comprising 9 selective fields, namely the external iliac, internal iliac, obturator and common iliac lymph nodes bilaterally, and the presacral lymph nodes. Histopathological findings were compared with serum prostate specific antigen (PSA), histopathological stage, preoperative biopsy and postoperative prostatectomy Gleason score. Extended pelvic lymphadenectomy was compared with radical retropubic prostatectomy and standard lymphadenectomy in 100 consecutive patients in terms of complications, the number of lymph nodes dissected and operative time. RESULTS: There were no significant differences in age, preoperative PSA or mean biopsy Gleason score in patients who underwent extended pelvic and standard lymphadenectomy. Metastases were diagnosed in 27 of the 103 patients (26.2%) who underwent the extended procedure. A mean of 28 lymph nodes (range 21 to 42) were dissected. Metastases were identified in the internal iliac and presacral regions despite negative obturator lymph nodes. Of the 27 patients 1 to 3 lymph nodes involved with metastasis were detected in 15, 9 and 1, respectively. In 26 of the 27 patients (95.8%) with lymph node metastasis PSA was greater than 10.5 ng./ml. and preoperative biopsy Gleason sum was 7 or greater. A low risk of 2% for lymph node disease was noted in patients with serum PSA less than 10.5 ng./ml. and biopsy Gleason sum less than 7. There were no significant differences in regard to intraoperative and postoperative complications, lymphocele formation or blood loss in the 2 groups. CONCLUSIONS: Extended pelvic lymphadenectomy is associated with a high rate of lymph node metastasis outside of the fields of standard lymphadenectomy in cases of clinically localized prostate cancer. Lymphadenectomy including the internal iliac lymph nodes should be performed in all patients with prostate cancer who are at high risk for lymph node involvement, as indicated by PSA greater than 10.5 ng./ml. and biopsy Gleason sum 7 or greater. In the low risk group pelvic lymphadenectomy can be omitted.     

Radioisotope guided pelvic lymph node dissection for prostate cancer

PURPOSE: The localization of lymph node metastases in prostate cancer varies enormously. Due to high morbidity complete pelvic lymphadenectomy is often decreased to modified staging lymphadenectomy, resulting in loss of sensitivity for detecting micrometastases. Based on the promising results of intraoperative gamma probe application for identifying sentinel lymph nodes in malignant melanoma, breast and penis cancer, we identified sentinel lymph nodes in prostate cancer using a comparable technique. MATERIALS AND METHODS: In 117 patients 99mtechnetium nanocolloid was transrectally injected directly into the prostate under ultrasound guidance 1 day before pelvic lymphadenectomy. Thereafter dynamic lymphoscintigraphy was done. Initially lymph nodes identified as sentinel lymph nodes by the gamma probe were removed and subsequently modified pelvic lymphadenectomy was performed. RESULTS: Lymphatic metastasis was detected in 28 cases. An average of 4 sentinel lymph nodes were identified per patient in 25 of 27 patients with micrometastasis, of which those in 24 contained micrometastasis for 96% sensitivity. In contrast, sensitivity of modified pelvic lymphadenectomy was 81.5%. In 16 patients only sentinel lymph nodes were positive. An average of 21.8 lymph nodes (range 10 to 51) was dissected per patient at pelvic lymphadenectomy. Lymph node metastasis was noted in 6 of the 46 patients with a prostate specific antigen between 4 and 10 ng./ml. and in 8 of the 64 with a stage pT2 tumor. CONCLUSIONS: Our study shows individual variability of lymphatic drainage of the prostate and limited sensitivity for detecting positive lymph nodes when the pelvic dissection area is limited. Furthermore, our experience implies that the identification of sentinel lymph nodes is feasible, not only in breast cancer and malignant melanoma, but also in prostate cancer using a comparable technique.     

Sentinel-Lymphadenektomie beim Prostatakarzinom

There is no consensus on which prostate cancer patients should undergo lymph node removal and which lymph nodes should be included. Therefore, most clinicians rely on nomograms and dispense with lymph node dissection in patients with low-risk disease. Meanwhile, there are some studies which prove that there are also lymph node metastases in patients with low-risk prostate cancer and that lymph node metastases are predominantly localized outside the region of standard lymphadenectomy. In more than 800 men we could show that lymph node metastases were found more often than shown in the Partin tables. These lymph node metastases were detected by sentinel lymph node dissection outside the region of standard and extended lymphadenectomy. Because of insufficient preoperative diagnostics it is unclear which patients have positive lymph nodes. Therefore, it is useful to perform lymph node dissection in every patient. Men with positive nodes could have a better prognosis, when sentinel and extended lymph node dissection are performed.     

Risk factors for patients with pelvic lymph node metastases following radical cystectomy with en bloc pelvic lymphadenectomy: concept of lymph node density

PURPOSE: We evaluated the clinical outcomes and risk factors for progression in a large cohort of patients with lymph node metastases following en bloc radical cystectomy and bilateral pelvic lymphadenectomy. MATERIALS AND METHODS: From July 1971 through December 1997, 1,054 patients underwent radical cystectomy and bilateral pelvic-iliac lymphadenectomy for high grade, invasive transitional cell carcinoma of the bladder. Of these patients 244 (23%) with a median age of 66 years (range 36 to 90) had pathological lymph node metastases. Overall 139 of the 244 patients (57%) received some form of chemotherapy. At a median followup of greater than 10 years (range 0 to 28) outcomes data were analyzed in univariate analysis according to tumor grade, carcinoma in situ, primary bladder tumor stage, pathological subgroups, total number of lymph nodes removed and involved with tumor, and lymph node density (total number of positive lymph nodes/total number removed). In addition, the form of urinary diversion and the administration of chemotherapy were also evaluated. Multivariate analysis was then performed to analyze these variables independently. RESULTS: The incidence of positive lymph nodes increased with higher p stage and pathological subgroups. Of 669 patients 75 (11%) with organ confined primary tumors and 169 of 385 (44%) with extravesical tumor extension had involved lymph nodes. The median number of lymph nodes removed in the 244 lymph node positive cases was 30 (range 1 to 96), while the median number of positive lymph nodes was 2 (range 1 to 63). Overall recurrence-free survival at 5 and 10 years for the 244 patients with lymph node positive disease was 35% and 34%, respectively. Patients with lymph node positive disease and an organ confined primary bladder tumor had significantly improved 10-year recurrence-free survival compared with those with extravesical tumor extension (44% vs 30%, p = 0.003). The total number of lymph nodes removed at surgery was also prognostic. Patients with 15 or less lymph nodes removed had 25% 10-year recurrence-free survival compared with 36% when greater than 15 lymph nodes were removed. Recurrence-free survival at 10 years for patients with 8 or less positive lymph nodes was significantly higher than in those with greater than 8 positive lymph nodes (40% vs 10%, p <0.001). The novel concept of lymph node density was also a significant prognostic factor. Patients with a lymph node density of 20% or less had 43% 10-year recurrence-free survival compared with only 17% survival at 10 years when lymph node density was greater than 20% (p <0.001). On multivariate analysis the total number of lymph nodes involved, pathological subgroups of the primary bladder tumor, lymph node density and adjuvant chemotherapy remained significant and independent risk factors for recurrence-free and overall survival. CONCLUSIONS: Patients with lymph node tumor involvement following radical cystectomy may be stratified into high risk groups based on the primary bladder tumor, pathological subgroup, number of lymph nodes removed and total number of lymph nodes involved. Lymph node density, which is a novel prognostic indicator, may better stratify lymph node positive cases because this concept collectively accounts for the total number of positive lymph nodes (tumor burden) and the total number of lymph nodes removed (extent of lymphadenectomy). Future staging systems and the application of adjuvant therapies in clinical trials should consider applying lymph node density to help standardize this high risk group of patients following radical cystectomy.