Management of Clinically Node Negative cN0 Patients

Additionally, in penile cancer, dynamic sentinel node biopsy with peritumour injection of 99mTc nanocolloid has already been investigated in clinically node-negative (cN0) patients with penile cancer. The technique has progressed from the original lymphangiography studies performed by Cabanas in 197735 to the modern day use, incorporating several modifications, to reduce the false-negative rates and therefore allowing it to mature into a reliable and safe method for assessing lymph node status in cN0 penile carcinoma patients.36 When compared with a historical series from the same institute, this nonrandomized group was reported to have less morbidity than with conventional radical inguinal lymphadenectomy.2 1 Kroon et al. evaluated the results of 10 years dynamic sentinel node biopsy experience in penile carcinoma, in 140 patients with clinically node-negative groins. Lymphoscintigraphy was performed after injection of 99mTc -nanocolloid around the primary tumor. The sentinel node was intraoperatively identified with the aid of patent blue dye and a gamma ray detection probe. Subsequent lymph node dissection was performed only if metastatic disease was identified in the sentinel lymph node. With a median follow-up of 52 months, they found that lymphoscintigraphy visualized at least one sentinel node in 138 patients. Sentinel node metastasis were found in 37 inguinal regions of 31 patients. The sentinel node was the only tumor-positive node in 78% (29/37) of the dissection speci mens. Complications occurred in only 8% of the operated groins. False-negative results were encountered in six patients resulting in a false-negative rate of 16%. Importantly, the 5-year disease-specific survival was 96% and 66% for patients with a tumor-negative sentinel node and tumor-positive sentinel node, respectively (p=0.001). They concluded that dynamic sentinel lymph node biopsy in penile carcinoma offered important diagnostic, prognostic, and therapeutic information at the cost of only minor morbidity. Subsequently, the same group explored the role of repeat dynamic sentinel-node biopsy in clinically node-negative patients with locally recurrent penile carcinoma after previous penile surgery and sentinel-node biopsy in 12 patients.37 They found that no sentinel nodes were seen on preoperative lymphoscintigraphy in the five groins that had previously been dissected. A sentinel node was visualized on lymphoscintigraphy in the remaining 19 undissected groins. In 15 of these groins (79%) the sentinel node was identified during surgery. Histopathological analysis showed involved sentinel nodes in four groins of three patients. Additional metastatic nodes were found in one completion inguinal lymph node dissection specimen. During a median follow-up of 32 months after the repeat sentinel node biopsy, one patient developed a groin recurrence 14 months after a tumor-negative sentinel node procedure. The conclusion from this study was that repeat dynamic sentinel node biopsy was feasible in clinically node-negative patients with locally recurrent penile carcinoma despite previous sentinel node biopsy.21

Patients undergoing inguinal lymph node dissections can suffer from troublesome lower limb lymphedema which is refractory to conservative treatment. However, the development of nanoparticles which encourage tissue regeneration will be invaluable in the management of lymphedema.

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