Diagnostic Value, Oncologic Outcomes, and Safety Profile of Image-Guided Surgery Technologies During Robot-Assisted Lymph Node Dissection with Sentinel Node Biopsy for Prostate Cancer

Abstract

Rationale: Despite good sensitivity and negative predictive value, the implementation of sentinel node biopsy (SNB) in robot-assisted radical prostatectomy (RARP) with extended pelvic lymph node dissection (ePLND) for prostate cancer (PCa) is still controversial.Based on this premise, we aimed to define the added value of SNB (with different tracer modalities) to ePLND in the identification of nodal metastases. Complications rates and oncological outcomes were also assessed.Methods: From January 2006 to December 2019, prospectively collected data were retrospectively analyzed from a single institutional database regarding PCa patients all treated with RARP and ePLND with or without additional use of SNB, either with hybrid tracer indocyanine green (ICG)-99m Tc-nanocolloid (ICG-99mTc-nanocolloid) or free ICG.Multivariable logistic and Cox regression models tested the impact of adding SNB (either with hybrid tracer or free-ICG) on lymph nodal invasion detection, complications and oncological outcomes.Results: Overall, 1680 patients were included in the final analysis. 1,168 (69.5%) were in the non SNB-group, 161 (9.6%) in the ICG SNB-group and 351 (20.9%) patients in the Hybrid SNB-group. Hybrid SNB-group (OR 1.61, 95%CI 1.18-2.20, p=0.002) was an independent predictor of nodal involvement, while ICG SNB-group did not reach the independent predictor status when compared to non SNB group (OR 1.35, 95%CI 0.89-2.03, p=0.1). SNB techniques were not associated with higher rates of complications. Lastly, use of Hybrid SNB was associated with lower rates of biochemical recurrence (0.79, 95%CI 0.63-0.98) and of clinical recurrence (HR 0.76, p=0.035) compared to non SNB group. Conclusions:The implementation of hybrid sentinel node biopsy technique with ICG-99m Tc-nanocolloid in prostate cancer improves detection of positive nodes and potentially lowers recurrence rates with subsequent optimization of patient management, without harming patient safety.

Molecular Imaging in Primary Staging of Prostate Cancer Patients: Current Aspects and Future Trends

“…In addition, a significant number of patients may unnecessarily undergo invasive staging, which is associated with the risk of complications [ 225 , 240 ]. In a further aspect, due to the wide variation in lymphatic outflow, nodal metastases may appear beyond the standard lymphadenectomy templates (8–10% of cases) [ 230 , 231 ], which potentially leads to under-diagnosis and under-treatment. The therapeutic benefit of ePLND is also still debatable [ 241 ].…”

“…For precise LN staging, SLNB has also been successfully used in PCa, but it has not gained enough popularity. Although it demands additional equipment, expenditure and expertise, SLNB provides a higher detection rate [ 230 , 231 ]. Further randomized controlled trials are necessary to clarify its additional clinical value compared to the standard procedures.…”

“…In this regard, in a systematic review, Wit et al calculated the overall false-negative rate to be 4.8% (0–18.2%) [ 225 ]. Additionally, there is evidence that the hybrid tracer technique using indocyanine green- 99m Tc-nanocolloid improves the detection of SLNs [ 227 , 228 , 229 , 230 ]. On the other hand, studies showed that ePLND does not necessarily provide complete resection of involved LNs [ 230 , 231 ].…”

“…Additionally, there is evidence that the hybrid tracer technique using indocyanine green- 99m Tc-nanocolloid improves the detection of SLNs [ 227 , 228 , 229 , 230 ]. On the other hand, studies showed that ePLND does not necessarily provide complete resection of involved LNs [ 230 , 231 ]. Metastatic LNs were missed in approximately 8–10% of patients undergoing ePLND without SNB, mainly due to metastases outside the template surgery [ 230 , 231 ].…”

“…On the other hand, studies showed that ePLND does not necessarily provide complete resection of involved LNs [ 230 , 231 ]. Metastatic LNs were missed in approximately 8–10% of patients undergoing ePLND without SNB, mainly due to metastases outside the template surgery [ 230 , 231 ]. Importantly, large non-randomized studies indicated that the biochemical-free [ 230 , 232 ] and clinical-free [ 230 ] survival rates are higher in patients undergoing SLNB.…”