Sentinel Node Identification with Hybrid Tracer-guided and Conventional Dynamic Sentinel Node Biopsy in Penile Cancer: A Prospective Study in 130 Patients from the Two National Referral Centres in Sweden

Bimodal inguinal sentinel lymph node imaging using a radiation-free fluorescent magnetic hybrid tracer in penile cancer patients

Invasive lymph node (LN) staging is crucial for survival in penile cancer (PeCa) patients. To lower patient morbidity associated with radical inguinal lymphadenectomy, sentinel node biopsy (SNB) is recommended. Application of conventional radioactive/fluorescent tracers for sentinel node (SN) labelling is limited to centers with nuclear medicine or lacks pre-operative imaging. We introduce a radiation-free fluorescent magnetic hybrid tracer for bimodal inguinal SN imaging in PeCa patients. In three consecutive PeCa patients, the fluorescent magnetic hybrid tracer (50 µl indocyanine green, 5 mg/ml, in 1 ml superparamagnetic iron oxide nanoparticles) was peritumorally injected. SNs were visualized by magnetic resonance imaging (MRI). Intra-operatively, SNs were detected using a handheld magnetometer and a fluorescence camera. Concordance was determined between MRI and magnetometer-guided SNB and between magnetic and fluorescent SN labelling. MRI revealed 29 SNs (median 4.5, range 0-8 SNs/groin). Twenty-five LNs (median 4.5, range 0-9 LNs/groin) were resected, including 16 magnetically active and 17 fluorescent SNs (median 3, range 0-6 SNs/groin, either mode). MRI and magnetometer-guided SNB had 66% concordance, magnetic and fluorescence SN labelling 96%. The diagnostic accuracy of our approach has to be evaluated in larger patient cohorts. Our radiation-free SNB technique is feasible without the need for nuclear medicine, its associated additional effort and regulations.

French AFU Cancer Committee Guidelines-Update 2024-2026: Penile cancer

OBJECTIVE

Update of the recommendations for the management of penile lesions.

MATERIALS AND METHODS

Comprehensive PubMed review from 2022 of the literature on the diagnosis, treatment and follow-up of penile tumours. The level of evidence of the studies was assessed.

RESULTS

A total of 95% of infiltrating penile cancers are squamous cell carcinomas, one-third of which are related to human papillomavirus (HPV) infection. Clinical examination can reveal the size of the lesion, its location, its proximity to the urethral meatus and its infiltration depth. Urinary and sexual function should be assessed. Magnetic resonance imaging (MRI) is the gold standard for local assessment. Penile tumours are classified as low-risk (≤pT1a and well-differentiated G1), intermediate-risk (pT1a G2) or high-risk (≥pT1b, G3, or sarcomatoid contingent). Lymph node assessment in penile cancer is fundamental. The sentinel node technique is recommended for the evaluation of cN0 patients with tumours of intermediate risk or higher. 18FDG PET is recommended for cN+ patients. Surgery is the standard treatment locally and depends on the size, location and grade of the tumour. Topical treatment or brachytherapy may be indicated in some cases. Radical inguinal curettage (RIC) is recommended for stages cN1/cN2. Neoadjuvant chemotherapy is recommended for patients with cN3-stage lesions, combined with RIC in responders. Metastatic forms may be treated with palliative chemotherapy and immunotherapy as part of a clinical trial.

CONCLUSION

The treatment of penile cancer is essentially surgery, with or without chemotherapy in the case of lymph node involvement. The main prognostic factor is lymph node involvement, which justifies early diagnostic and therapeutic management of the inguinal areas.

Indocyanine green and methylene blue dye guided sentinel lymph node biopsy in patients with penile cancer (PeCa): results of 50 inguinal basins assessed at a single institution in India

AIM

The primary aim of this study was to validate the reliability, sensitivity and safety profile of novel combination of ICG- methylene blue dye as an SN tracer for PeCa.

METHODS

This is a validation and non-randomised prospective observational study involving 25 patients (50 inguinal basins) who underwent SLNB where in ICG and methylene blue were used for localisation. The patients with clinically node negative groins were recruited in the study. SNs were identified intraoperatively using near infrared fluorescence imaging (NIRF Imaging system, SPY-PHI, Stryker, Sweden) and blue dye. The numbers of SNs identified by each tracer and the rates of complications and nodal recurrence during the followup.

RESULTS

Overall 137 SNs were identified intraoperatively. Among the 137 SNs excised fluorescence, blue dye and Combined (blue + green) identified 57(41.6%), 27 (19.7%), and 51 (37.2%), respectively. The average number of SLNs removed per patient was 5 (range, 1-11) with sentinel lymph nodes detection rate at 94% (47/50). Seven patients had malignancy on SLNB and underwent ipsilateral radical inguinal lymphadenectomy. One patient had false negative SN and positive node in modified inguinal lymphadenectomy specimen. No adverse events were observed in all cases.

CONCLUSION

The Novel combination of ICG fluorescence-Methylene blue dye technique is simple, reliable and safe. Moreover, it demonstrates a high SLN detection rate with a low false-negative rate, and it avoids radiation exposure.

New EAU/ASCO guideline recommendations on sentinel node biopsy for penile cancer and remaining challenges from a nuclear medicine perspective

INTRODUCTION

The European Association of Urology (EAU) and the American Society of Clinical Oncology (ASCO) recently issued updated guidelines on penile cancer, emphasising dynamic sentinel node biopsy (DSNB) as the preferred method for surgical staging among patients with invasive penile tumours and no palpable inguinal lymphadenopathy. This paper outlines the rationale behind this new recommendation and describes remaining challenges, as well as strategies for promoting DSNB worldwide.

MAIN TEXT

DSNB offers high diagnostic accuracy with the lowest postoperative complications compared to open or minimally invasive inguinal lymph node dissection (ILND), prompting its preference in the new guidelines. Nevertheless, despite its advantages, there are challenges hampering the widespread adoption of DSNB. This includes the false-negative rate associated with DSNB and the potential negative impact on patient outcome. To address this issue, improvements should be made in several areas, including refining the timing and interpretation of the lymphoscintigraphy and the single photon emission computed tomography/computed tomography images. In addition, the quantity of tracer employed and choice of the injection site for the radiopharmaceutical should be optimised. Finally, limiting the removal of nodes without tracer activity during surgery may help minimise complication rates.

CONCLUSION

Over the years, DSNB has evolved significantly, related to the dedicated efforts and innovations in nuclear medicine and subsequent clinical studies validating its efficacy. It is now strongly recommended for surgical staging among selected penile cancer patients. To optimise DSNB further, multidisciplinary collaborative research is required to improve SN identification for better diagnostic accuracy and fewer complications.

Systematic Review and Meta-analysis of Minimally Invasive Procedures for Surgical Inguinal Nodal Staging in Penile Carcinoma

CONTEXT

There are several procedures for surgical nodal staging in clinically node-negative (cN0) penile carcinoma.

OBJECTIVE

To evaluate the diagnostic accuracy, perioperative outcomes, and complications of minimally invasive surgical procedures for nodal staging in penile carcinoma.

EVIDENCE ACQUISITION

A systematic review of the Medline, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov was conducted. Published and ongoing studies reporting on the management of cN0 penile cancer were included without any design restriction. Outcomes included the false negative (FN) rate, the number of nodes removed, surgical time, and postoperative complications.

EVIDENCE SYNTHESIS

Forty-one studies were eligible for inclusion. Four studies comparing robot-assisted (RA-VEIL) and video-endoscopic inguinal lymphadenectomy (VEIL) to open inguinal lymph node dissection (ILND) were suitable for meta-analysis. A descriptive synthesis was performed for single-arm studies on modified open ILND, dynamic sentinel node biopsy (DSNB) with and without preoperative inguinal ultrasound (US), and fine-needle aspiration cytology (FNAC). DSNB with US + FNAC had lower FN rates (3.5-22% vs 0-42.9%) and complication rates (Clavien Dindo grade I-II: 1.1-20% vs 2.9-11.9%; grade III-V: 0-6.8% vs 0-9.4%) in comparison to DSNB alone. Favourable results were observed for VEIL/RA-VEIL over open ILND in terms of major complications (2-10.6% vs 6.9-40.6%; odds ratio [OR] 0.18; p < 0.01). Overall, VEIL/RA-VEIL had lower wound-related complication rates (OR 0.14; p < 0.01), including wound infections (OR 0.229; p < 0.01) and skin necrosis (OR 0.16; p < 0.01). The incidence of lymphatic complications varied between 20.6% and 49%.

CONCLUSIONS

Of all the surgical staging options, DSNB with inguinal US + FNAC had the lowest complication rates and high diagnostic accuracy, especially when performed in high-volume centres. If DSNB is not available, favourable results were also found for VEIL/RA-VEIL over open ILND. Lymphatic-related complications were comparable across open and video-endoscopic ILND.

PATIENT SUMMARY

We reviewed studies on different surgical approaches for assessing lymph node involvement in cases with penile cancer. The results show that a technique called dynamic sentinel node biopsy with ultrasound guidance and fine-needle sampling has high diagnostic accuracy and low complication rates. For lymph node dissection in penile cancer cases, a minimally invasive approach may offer favourable postoperative outcomes.

Performance of indocyanine green in sentinel lymph node mapping and lymph node metastasis in penile cancer: systematic review, meta-analysis, and single-center experience

PURPOSE

The aim of this study was to investigate the overall sensitivity and specificity of indocyanine green (ICG)-near-infrared (NIR) fluorescence imaging in the detection of sentinel lymph node metastasis (SLNM) in penile cancer.

METHODS

We searched PubMed, Embase, Web of Science, Scopus, and the Cochrane Library databases to identify manuscripts where ICG was intravenously administered prior to or during penile cancer surgery, with no restriction on language or publication status. The results extracted are presented as forest plots.

RESULTS

Seven studies were included in the analysis. The median sensitivity and specificity of ICG-NIR imaging for SLNM detection were 100 and 4%, respectively; the pooled sensitivity was 100.0% (95% confidence interval [CI] 97.0-100.0) and specificity was 2.0% (95% CI 1.0-3.0). There was no significant difference in the diagnostic results between different injection sites and doses in each experimental group.

CONCLUSION

To our knowledge, this meta-analysis is the first to summarize the diagnostic performance of ICG-NIR imaging for SLNM detection in penile cancer. ICG is sensitive in the imaging of SLN tissue, which can consequently improve the accuracy of lymph node detection. However, the specificity is very low.

Role of Sentinel Lymph Node Biopsy for Skin Cancer Based on Clinical Studies

The sentinel lymph node is the first lymph node from the primary tumor. Sentinel lymph node biopsy (SLNB) is a surgical procedure that can detect occult nodal metastasis with relatively low morbidity. It may also have a therapeutic effect via regional disease control. The Multicenter Selective Lymphadenectomy-I (MSLT-I) trial revealed a prognostic benefit from SLNB in melanoma patients. However, it remains unclear whether there is a prognostic benefit from SLNB in patients with nonmelanoma skin cancer owing to a lack of randomized prospective studies. Nevertheless, SLNB provides important information about nodal status, which is one of the strongest factors to predict prognosis and may guide additional nodal treatment. Currently, SLNB is widely used in the management of not only patients with melanoma but also those with nonmelanoma skin cancer. However, the utilization and outcomes of SLNB differ among skin cancers. In addition, SLNB is not recommended for routine use in all patients with skin cancer. In this review, we provide a summary of the role of SLNB and of the indications for SLNB in each skin cancer based on previously published articles.

Exploring the Applications of Indocyanine Green in Robot-Assisted Urological Surgery: A Comprehensive Review of Fluorescence-Guided Techniques

This comprehensive review aims to explore the applications of indocyanine green (ICG) in robot-assisted urological surgery through a detailed examination of fluorescence-guided techniques. An extensive literature search was conducted in PubMed/MEDLINE, EMBASE and Scopus, using keywords such as "indocyanine green," "ICG", "NIRF", "Near Infrared Fluorescence", "robot-assisted", and "urology". Additional suitable articles were collected by manually cross-referencing the bibliography of previously selected papers. The integration of the Firefly^® technology in the Da Vinci^® robotic system has opened new avenues for the advancement and exploration of different urological procedures. ICG is a fluorophore widely used in near-infrared fluorescence-guided techniques. The synergistic combination of intraoperative support, safety profiles and widespread availability comprises an additional asset that empowers ICG-guided robotic surgery. This overview of the current state of the art illustrates the potential advantages and broad applications of combining ICG-fluorescence guidance with robotic-assisted urological surgery.