Sue Heenan

Two-Center Evaluation of Dynamic Sentinel Node Biopsy for Squamous Cell Carcinoma of the Penis

PURPOSE Sentinel node biopsy is used to evaluate the nodal status of patients with clinically node-negative penile carcinoma. Its use is not widespread, and the majority of patients with clinically node-negative disease undergo an elective inguinal lymph node dissection. Reservations about the use of sentinel node biopsy include the fact that most current results come from one institution and the supposedly long learning curve associated with the procedure. The purpose of this study was to address these issues by analyzing results from two centers and by evaluating the learning curve. PATIENTS AND METHODS All patients undergoing sentinel node biopsy for penile carcinoma at two centers were included. The sentinel node identification rate, false-negative rate, and morbidity of the procedure were calculated. RESULTS from the first 30 procedures were assessed for a potential learning curve. Results A total of 323 patients with penile squamous cell carcinoma, which included 611 clinically node-negative groins, were scheduled for sentinel node biopsy. A sentinel node was found in 572 of the 592 groins (97%) that proceeded to sentinel node biopsy. In 79 groins, a sentinel node was positive for tumor. Six inguinal node recurrences occurred after a negative sentinel node procedure, all within 15 months after sentinel node biopsy. The combined false-negative rate was 7%. Complications occurred in 4.7% of explored groins. None of the false-negative procedures occurred in the initial 30 procedures. CONCLUSION Sentinel node biopsy is a suitable procedure to stage clinically node-negative penile cancer, and it has a low complication rate. No learning curve was demonstrated in this study.

Dynamic sentinel lymph node biopsy in patients with invasive squamous cell carcinoma of the penis: a prospective study of the long-term outcome of 500 inguinal basins assessed at a single institution.

BACKGROUND Dynamic sentinel node biopsy (DSNB) in combination with ultrasound scan (USS) has been the technique of choice at our centre since 2004 for the assessment of nonpalpable inguinal lymph nodes (cN0) in patients with squamous cell carcinoma of the penis (SCCp). Sensitivity and false-negative rates may vary depending on whether results are reported per patient or per node basin, and with or without USS. OBJECTIVE To determine the long-term outcome of patients undergoing DSNB and USS-guided fine-needle aspiration cytology (FNAC) in our cohort of newly diagnosed cN0 SCCp patients, as well as to analyse any variation in sensitivity of the procedure. DESIGN, SETTING, AND PARTICIPANTS A series of consecutive patients with newly diagnosed SCCp, over a 6-yr period (2004-2010), were analysed prospectively with a minimum follow-up period of 21 mo. All patients had definitive histology of ≥ T1G2 and nonpalpable nodes in one or both inguinal basins. Patients with persistent or untreated local disease were excluded from the study. INTERVENTION All eligible patients had DSNB and USS with or without FNAC of cN0 groins. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was no nodal disease recurrence on follow-up. The secondary end point was complications after DSNB. Sensitivity of the procedure was calculated per node basin, per patient, with DSNB alone, and with USS with DSNB combined. RESULTS AND LIMITATIONS Five hundred inguinal basins in 264 patients underwent USS with or without FNAC and DSNB. Seventy-three positive inguinal basins (14.6%) in 59 patients (22.3%) were identified. Four inguinal basins in four patients were confirmed false negative at 5, 8, 12, and 18 mo. Two inguinal basins had positive USS and FNAC and negative DSNB results. Sensitivity of DSNB with USS, with and without FNAC, per inguinal basin was 95% and per patient was 94%. Sensitivity of DSNB alone per inguinal basin and per patient was 92% and 91%, respectively. The DSNB morbidity rate was 7.6%. CONCLUSIONS DSNB in combination with USS has excellent performance characteristics to stage patients with cN0 SCCp, with a 5% false-negative rate per node basin and a 6% false-negative rate per patient.

Is Routine Postoperative Diuresis Renography Indicated in All Adult Patients After Pyeloplasty for Ureteropelvic Junction Obstruction

OBJECTIVE To determine if routine follow-up diuresis renography is indicated in all adult patients after pyeloplasty for ureteropelvic junction obstruction (UPJO). METHODS A multicenter retrospective analysis was conducted in adults who underwent pyeloplasty for symptomatic UPJO between January 2002 and August 2012. Patients with unilateral UPJO demonstrated on diuresis renography, treated with pyeloplasty, and aged >18 years at time of surgery were included in the study. Patients with contralateral renal abnormalities, genitourinary anomalies, and those who declined renography during follow-up were excluded. All eligible patients underwent diuresis renography approximately 3 months postoperatively. Minimal follow-up was 12 months. Patients were divided into 2 groups: patients with persistent pain at 3 months after pyeloplasty and patients who became asymptomatic. Treatment failures in each cohort were identified. Comparisons were performed using the Fisher exact test. RESULTS A total of 100 pyeloplasties were performed. Of them, 90 were eligible for the study. Mean age was 40 years. Mean follow-up was 21 months. Seventy-three patients (81.1%) became pain free after pyeloplasty. One patient (1.4%) had worsening of differential renal function despite unobstructed drainage on diuresis renogram. None of the patients in the asymptomatic cohort was identified to have unequivocal drainage obstruction on postoperative renogram. Seventeen patients (18.9%) remained symptomatic with pain at 3 months after pyeloplasty; 3 (17.6%) of those patients with loin pain after pyeloplasty were confirmed to have persistent obstructed drainage postoperatively on diuresis renogram (P <.001). All 3 patients required insertion of ureteric stents and/or revision surgery (P <.007). CONCLUSION In our series, adult patients who became pain free after unilateral pyeloplasty for UPJO did not have persistent obstruction of renal drainage on renography. Routine diuresis renogram to assess drainage and differential renal function in patients who become pain free after pyeloplasty for UPJO may not be necessary. If objective evidence of postoperative outcome is required, then a single renogram at 3 months is recommended.

Venous thromboembolism at time of diagnosis of ovarian cancer: Survival differs in symptomatic and asymptomatic cases

OBJECTIVES To determine the impact on survival of symptomatic and asymptomatic venous thromboembolism (VTE) at time of diagnosis of primary ovarian malignancy. MATERIALS AND METHODS The clinical records of 397 consecutive cases of primary ovarian malignancy were studied. Clinical, pathological and survival data were obtained. RESULTS AND CONCLUSIONS Of 397 cases, 19 (4.8%) were found to have VTE at diagnosis, of which 63.2% (n=12) were asymptomatic. VTE was significantly associated with reduced overall median survival (28 vs. 45 months, p=0.004). Decreased survival was associated with symptomatic VTE compared to patients with asymptomatic VTE (21 vs. 36 months, p=0.02) whose survival was similar to that of patients without VTE. Decreased survival remained significant in symptomatic patients after controlling for stage of disease at diagnosis, cytoreductive status and adjuvant chemotherapy use. Overall these data suggest for the first time that symptomatic but not asymptomatic VTE prior to primary treatment of ovarian cancer is an independent adverse prognostic factor.

517 Dynamic sentinel lymph node biopsy in patients with invasive squamous cell carcinoma of the penis: A prospective study of the outcome of 500 inguinal basins assessed in a single institution

Background: Dynamic sentinel node biopsy (DSNB) in combination with ultrasound scan (USS) has been the technique of choice at our centre since 2004 for the assessment of nonpalpable inguinal lymph nodes (cN0) in patients with squamous cell carcinoma of the penis (SCCp). Sensitivity and false-negative rates may vary depending on whether results are reported per patient or per node basin, and with or without USS. Objective: To determine the long-term outcome of patients undergoing DSNB and USSguided fine-needle aspiration cytology (FNAC) in our cohort of newly diagnosed cN0 SCCp patients, as well as to analyse any variation in sensitivity of the procedure. Design, setting, and participants: A series of consecutive patients with newly diagnosed SCCp, over a 6-yr period (2004–2010), were analysed prospectively with a minimum follow-up period of 21 mo. All patients had definitive histology of T1G2 and nonpalpable nodes in one or both inguinal basins. Patients with persistent or untreated local disease were excluded from the study. Intervention: All eligible patients had DSNB and USS with or without FNAC of cN0 groins. Outcome measurements and statistical analysis: The primary end point was no nodal disease recurrence on follow-up. The secondary end point was complications after DSNB. Sensitivity of the procedure was calculated per node basin, per patient, with DSNB alone, and with USS with DSNB combined. Results and limitations: Five hundred inguinal basins in 264 patients underwent USS with or without FNAC and DSNB. Seventy-three positive inguinal basins (14.6%) in 59 patients (22.3%) were identified. Four inguinal basins in four patients were confirmed false negative at 5, 8, 12, and 18 mo. Two inguinal basins had positive USS and FNAC and negative DSNB results. Sensitivity of DSNB with USS, with and without FNAC, per inguinal basin was 95% and per patient was 94%. Sensitivity of DSNB alone per inguinal basin and per patient was 92% and 91%, respectively. The DSNB morbidity rate was 7.6%. Conclusions: DSNB in combination with USS has excellent performance characteristics to stage patients with cN0 SCCp, with a 5% false-negative rate per node basin and a 6% false-negative rate per patient.