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Article of the Week: DSNB for Penile Cancer

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

 

Dynamic sentinel lymph node biopsy for penile cancer: a comparison between 1- and 2-day protocols

Panagiotis Dimopoulos*, Panagiotis Christopoulos*, Sam Shilito, Zara Gall*, Brian Murby§, David Ashworth§, Ben Taylor, Bernadette Carrington, Jonathan Shanks**, Noel Clarke*, Vijay Ramani*, Nigel Parr*, Maurice Lau* and Vijay Sangar*

 

Departments of *Urology, §Nuclear Medicine, Radiology , **Pathology, The Christie Hospital, ManchesterMedical School, University of Manchester, Manchester, and Department of Urology, Royal Bolton Hospital, Bolton Lancashire, UK

Objective

To determine the outcome of clinically negative node (cN0) patients with penile cancer undergoing dynamic sentinel node biopsy (DSNB), comparing the results of a 1- and 2-day protocol that can be used as a minimal invasive procedure for staging of penile cancer.

Patients and Methods

This is a retrospective analysis of 151 cN0 patients who underwent DSNB from 2008 to 2013 for newly diagnosed penile cancer. Data were analysed per groin and separated into groups according to the protocol followed. The comparison of the two protocols involved the number of nodes excised, γ-counts, false-negative rates (FNR), and complication rates (Clavien–Dindo grading system).

JuneAOTW3

Results

In all, 280 groins from 151 patients underwent DSNB after a negative ultrasound ± fine-needle aspiration cytology. The 1-day protocol was performed in 65 groins and the 2-day protocol in 215. Statistically significantly more nodes were harvested with the 1-day protocol (1.92/groin) compared with the 2-day protocol (1.60/groin). The FNRs were 0%, 6.8% and 5.1%, for the 1-day protocol, 2-day protocol, and overall, respectively. Morbidity of the DSNB was 21.4% for all groins, and 26.2% and 20.1% for the 1-day and 2-day protocols, respectively. Most of the complications were of Clavien–Dindo Grade 1–2.

Conclusions

DSNB is safe for staging patients with penile cancer. There is a trend towards a 1-day protocol having a lower FNR than a 2-day protocol, albeit at the expense of a slightly higher complication rate.

Editorial: One Day Protocol for Early Penile Cancer – The Way to Go

The present article by Dimopoulos et al. [1] has some useful lessons on the development of new services. The authors have kept a detailed database of all patients going through their super-regional network, and have designed the protocol around the patient, whereby the primary and regional lymph nodes are dealt with in one visit. Previously, bilateral inguinal lymph node dissection (ILND) was so fraught with complications that it would not be combined routinely with organ-sparing surgery of the penis [2]; however, the significantly lower complication rate of dynamic sentinel node biopsy (DSNB) has allowed the more streamlined approach. The ‘only handle it once’ (OHIO) philosophy is surely not only preferable for the patient, but also reduces the risk of patients not receiving ideal management. In most cases, a biopsy at the time of presentation, along with physical examination/imaging, can determine those requiring DSNB instead of waiting for final pathology from the primary tumour. The controversy surrounding DSNB compared with ILND has been the false-negative rates. The pioneering group from the Netherlands reported four deaths in six patients with false-negative results [3]. In the present paper, the overall false-negative rate was 5.8%, but the smaller and newer cohort of patients underwent a same-day protocol and had zero false-negatives. This may be attributable to the fact that biopsies were taken from a total sample of 65 or that slightly more nodes were taken in this group. We expect the one-day protocol to become standard, and future independent reports will be welcome. Should there truly be a 0% false-negative rate then the controversy is resolved and prophylactic ILND will become a historical procedure. Finally, the lower morbidity of the present study cohort allowed the authors to move the intermediate-risk group from surveillance to nodal biopsy, which proved justified because some of these cases had micrometastatic disease. We congratulate the group for their scientific approach to improving the quality of care for patients and for bringing their data to publication.

Paul K. Hegarty and Peter E. Lonergan
Urology, National Penile Cancer Centre, Mater Misericordiae University Hospital, Dublin, Ireland

 

References

 

1 Dimopoulos P, Christopoulos P, Shilito S et al. Dynamic sentinel lymph node biopsy for penile cancer: a comparison between 1- and 2-day protocols. BJU Int 2016; 117: 8906

 

2 Hegarty PK, Eardley I, Heidenreich A et al. Penile cancer: Organ-sparing techniques. BJU Int 2014; 114: 799805

 

3 Kroon BK, Horenblas S, Meinhardt W et al. Dynaminc sentinel node biopsy in penile cancer: evaluation of 10 years experience. Eur Urol 2005; 47: 6016

 

Seizure with left hemiparesis complicating a percutaneous transthoracic needle biopsy

Air embolism is a rare unpredictable complication after CT guided tranthoracic needle biopsy of lung masses but potentially fatal if not managed correctly and urgently. We present a case of cerebral air embolism following lung nodule biopsy manifested by seizure and left hemiparesis. The patient had a full recovery following 100% oxygenotherapy.

Authors: Maalouly, Rina Antou ; Tannouri, Fadi; Mattar, Hanna; Kassis, Antoine

Corresponding Author: Maalouly, Rina Antoun

 

Introduction
Computed tomography guided percutaneous transthoracic needle biopsy (PTNB) of lung lesions isa well established diagnostic procedure for the evaluation of lung masses. It provides high diagnostic accuracy with excellent sensitivity and specificity (>90%) in the diagnosis of lung cancer, metastasis or benign lesions.
As for all interventional procedures, some complications may occur. The most frequent ones for PTNB are pneumothorax (27%), haemorrhage (11%) and haemoptysis (7%). A rare but not to miss fatal complication is systemic air embolus, occurring at a rate of 0.07%1.
We present a case of cerebral air embolism clinically manifested by complete disorientation, hemiparesis, convulsion and loss of consciousness in a 53 year old male just after a CT guided lung biopsy. The patient had a full recovery after 100% oxygentherapy.

Case report
A 53 year old male patient diagnosed with testicular cancer (Non SeminomatousGerminal Cell Tumor) surgically treated 4 years previous to presentation, was admitted for follow up. A chest CT scan (5mm thicknesscomputed tomography; Prospeed GE Medical System) showed a new, well-margined 0.8 cm nodule at the apex of the left lower lobe. Findings were suggestive of a secondary lesion and a CT guided biopsy was requested for diagnosis as both testicular tumourmarkers, α-foetoprotein and βHCG, were negative.
After signing the informed consent, the biopsy was performed under local anaesthesia, with the patient inthe left lateral decubitusposition. A 15 cm; 18 G automated cutting needle was inserted into the lesion with a single step approach during a single breath hold. Within the procedure the patient was totally co-operative; he didn’t cough or breath inappropriately (fig 1). The needle was removed during a second breath hold.

053 F1

Just after the completion of the nodule biopsy, the patient developed a generalized tonico-clonic seizure then became unresponsive. Immediate resuscitation was started;a100% oxygen mask ventilation was placed and the cardiac arrest team was called. The patient regained consciousness, with persistent somnolence and left hemiplegia. An urgent brain CT scan performed without IV contrast administration revealed no abnormalities, but as the clinical course suggested a serious injury, a brain MRI was performed 1 hour later. This revealed a tiny cortical infarction in the area of the right posterior cerebral artery demonstrated on the Diffusion Weighted Images (fig 2). The patient had a full recovery after 100% oxygentherapy. No hyperbaric oxygen treatment was needed.

053 F2

The histopathologic exam confirmed the metastatic nature of the lung nodule consistent with the primary NSGCT.

Discussion
Percutaneous transthoracic needle biopsy is nowadays a ‘must’ procedure for evaluating lung lesions. Air embolism is a rare unpredictable complication but potentially fatal. The incidence of a systemic air embolism is probably underestimateddue to asymptomatic patients. Different studies suggested that air embolism induces endothelial damage, activating a thrombo-inflammatory process responsible of micro thrombus creation2.
Once in the vascular circulation, the gas follows the blood flow until it get blocked in the small vessels. Even a small air volume can occlude distal arteries. The clinical symptoms depend primarily on the territory of the microvascular obstruction. In fact, the presence of air within the spinal cord arteries is responsible foran electrical discharge sensation in the legs facilitated by the prone position, as these arteries arise from the intercostal or lumbar arteries themselves arising from the posterior and postero-lateral wall of the aorta3.If an air embolism reached the coronary arteries, arrhythmia, ischaemia and myocardial infarction could occur.Whereas, if it reached the cerebral arteries,focal neurologic deficit, hemiplegia, seizures, coma and even death were probable.
There are mainly three possible ways for air to be introduced into the pulmonary venous system during PTNB4. Air may enter directly through the needle tip placed into a pulmonary vein with an open ended base to the atmospheric pressure, which exceeds the pulmonary venous pressure during deep inspiration. In our case, this is not possible since no coaxial needle was used. Also, a needle may simultaneously penetrate an air containing space nearby a pulmonary vein, since coughing orvalsalvamanoeuvre may increase the airway pressure, facilitating the aspiration of air into the pulmonary vein5, 6. Again our patient was very compliant to our requests- he didn’t cough during the procedure but a valsalva cannot be ruled out. Finally, a communication between the bronchus and a pulmonary vein may be responsible of air passage.If a transient fistula is created when the needle is passing through the lung parenchyma, intraalveolar or intrabronchial air might be introduced into the pulmonary vein. This mechanism could have taken place in our case.
The clinical diagnosis is based on the sudden neurologic and/or cardiovascular symptoms occurring just after the biopsy. Computed tomography may confirm the diagnosis, showing air bubbles in the coronary arteries, the cerebral circulation, the cardiac cavities or the aorta. Once the diagnosis is suspected, immediate treatment by a 100% Oxygen mask and transfer to a hyperbaric air Oxygen chamber is crucial,in order to reduce the gas bubble size replacing nitrogen with Oxygen, and restoring circulation and tissue oxygenation7.
Unfortunately, our institution does not possess a hyperbaric oxygen treatment and the patient was not transferred to another institution for this treatment, given the rapid favorable progress-probably due to the very small gas volume embolism, and rapid commencement of 100% oxygenation.
Although air embolism is a rare complication associated with PTNB, it has been reported previously. Interventional radiology services should consider having in place a clinical protocol applicable toPTNB, to handle this very rare but life threatening complication of arterial air embolism, thereby optimisingoutcome , since the histopathologic nature of such nodule in such categories of patients is the key point for the subsequent management.

References
1- Sinner WN. Complications of percutaneous transthoracic needle aspiration biopsy. ActaRadiolDiag 1976; 17: 813-28
2- HsiDH, ThompsonTN, FreatherA, et al. Simultaneous coronary and cerebral air embolism after CT-guided core needle biopsy of the lung. Tex Heart Enst J. 2008; 35(4): 472-474.
3- Muth CM, Shank ES. Gas Embolism. N Engl J Med 2000; 342:476-482
4- Hiraki T, Fujiwara H, Sakurai J, et al. Non fatal systemic air embolism complicating percutaneous CT-guided transthoracic needle biopsy: four cases from a single institution. Chest 2007; 132: 684 – 690
5- Wescott JL. Air embolism complicating percutaneous needle biopsy of the lung. Chest 1973; 63: 108 – 110
6- Baker BK, Awwad EE. Computed tomography of fatal cerebral air embolism following percutaneous aspiration biopsy of the lung. J comput Assist Tomogr 1988; 12: 1082 – 1083
7- Lattin G, O’Brien W Sr, Mc Cray B, et al. Massive systemic air embolism treated with hyperbaric oxygen therapy following CT-guided transthoracic needle biopsy of a pulmonary nodule. J VascIntervRadiol 2006; 17: 1355-1358

Date added to bjui.org: 09/11/2012

DOI: 10.1002/BJUIw-2012-053-web

 

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