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The impact of drainage pathways on the detection of nodal metastases in prostate cancer: a phase II randomized comparison of intratumoral vs intraprostatic tracer injection for sentinel node detection

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Abstract

Introduction

Previous studies indicated that location and amount of detected sentinel lymph nodes (SLNs) in prostate cancer (PCa) are influenced where SLN-tracer is deposited within the prostate. To validate whether intratumoral (IT) tracer injection helps to increase identification of tumor-positive lymph nodes (LNs) better than intraprostatic (IP) tracer injection, a prospective randomized phase II trial was performed.

Methods

PCa patients with a > 5% risk of lymphatic involvement were randomized between ultrasound-guided transrectal injection of indocyanine green-[99mTc]Tc-nanocolloid in 2 depots of 1 mL in the tumor (n = 55, IT-group) or in 4 depots of 0.5 mL in the peripheral zone of the prostate (n = 58, IP-group). Preoperative lymphoscintigraphy and SPECT/CT were used to define the location of the SLNs. SLNs were dissected using combination of radio- and fluorescence-guidance, followed by extended pelvic LN dissection and robot-assisted radical prostatectomy. Outcome measurements were number of tumor-bearing SNs, tumor-bearing LNs, removed nodes, number of patients with nodal metastases, and metastasis-free survival (MFS) of 4–7-year follow-up data.

Results

IT-injection did not result in significant difference of removed SLNs (5.0 vs 6.0, p = 0.317) and histologically positive SLNs (28 vs 22, p = 0.571). However, in IT-group, the SLN-positive nodes were 73.7% of total positive nodes compared to 37.3% in IP-group (p = 0.015). Moreover, significantly more node-positive patients were found in IT-group (42% vs 24%, p = 0.045), which did not result in worse MFS. In two patients (3.6%) from whom the IT-tracer injection only partly covered intraprostatic tumor spread, nodal metastases in ePLND without tumor-positive SNs were yielded.

Conclusions

The percentage-positive SLNs found after IT-injection were significantly higher compared to IP-injection. Significantly more node-positive patients were found using IT-injection, which did not affect MFS. IT-injection failed to detect nodal metastases from non-index satellite lesions. Therefore, we suggest to combine IT- and IP-tracer injections in men with visible tumor on imaging.

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Funding

This work was partially supported by an ERC starting grant (2012–306890) and a NWO-TTW-VICI grant (TTW 16141).

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Authors and Affiliations

  1. Department of Urology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands

    Esther M. K. Wit, Florian van Beurden, Gijs H. Kleinjan, Nikolaos Grivas, Tessa Buckle, Fijs W. B. van Leeuwen & Henk G. van der Poel

  2. Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands

    Florian van Beurden, Gijs H. Kleinjan, Clarize M. de Korne, Tessa Buckle & Fijs W. B. van Leeuwen

  3. Department of Urology, Leiden University Medical Center, Leiden, The Netherlands

    Gijs H. Kleinjan

  4. Department of Urology, University General Hospital of Heraklion, University of Crete Medical School, Heraklion, Greece

    Nikolaos Grivas

  5. Department of Nuclear Medicine, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

    Maarten L. Donswijk

  6. Department of Pathology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

    Elise M. Bekers

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  1. Esther M. K. Wit
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Correspondence to Esther M. K. Wit.

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This article is part of the Topical Collection on Oncology - Genitourinary

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Wit, E.M.K., van Beurden, F., Kleinjan, G.H. et al. The impact of drainage pathways on the detection of nodal metastases in prostate cancer: a phase II randomized comparison of intratumoral vs intraprostatic tracer injection for sentinel node detection. Eur J Nucl Med Mol Imaging 49, 1743–1753 (2022). https://doi.org/10.1007/s00259-021-05580-0

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