Sentinel lymph node mapping in post chemotherapy nonseminoma testicular cancer patients undergoing retroperitoneal lymph node dissection: A series of nine cases

Document Type : Original Article


1 Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2 Kidney transplantation complications research center, Mashhad University of Medical Sciences, Mashhad, Iran


Objective(s): Testicular germ cell cancers are the most common solid malignancy among young men at the age ranging between 14 and 35 years. In this study, we evaluated the feasibility of sentinel lymph node mapping using intraoperative injection of radiotracer in nonseminomatous testicular cancer patients with history of orchiectomy who were candidate for retroperitoneal lymph node dissection (RPLND) in post-chemotherapy setting.
Methods: Nine consecutive cases were included in the study. Technetium-99m-labelled phytate was injected in two divided doses in the stump of the spermatic cord, through transabdominal approach. A hand-held gamma probe was used for radio-guided retroperitoneal sentinel lymph node detection intraoperatively and confirming the location of the sentinel lymph nodes.
Results: Detection rate and the false negative rate were estimated as the main indices. The detection rate was 6/9 (66%) and the false negative rate was 0/2 (0%). Location of the dissected sentinel lymph nodes were interaortocaval (2 patients), internal iliac (1 patient), external iliac (1 patient), common iliac (2 patients), and paraaortic (1 patient).
Conclusion: Sentinel lymph node mapping technique seems to be feasible and promising in post chemotherapy non-seminoma testis cancer patients who are candidate for RPLND; however, further larger studies are needed to increase and standardize the detection rate. 


  1. De Toni L, Šabovic I, Cosci I, Ghezzi M, Foresta C, Garolla A. Testicular cancer: Genes, environment, hormones. Frontiers in endocrinology 2019; 10408.
  2. Huyghe E, Matsuda T, Thonneau P. Increasing incidence of testicular cancer worldwide: a review. J Urol 2003; 170(1): 5-11.
  3. Suleyman N, Moghul M, Gowrie-Mohan S, Lane T, Vasdev N. Classification, Epidemio-logy and Therapies for Testicular Germ Cell Tumours. J Genit Syst Disor S 2016; 3(2): 2.
  4. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, Washington MK et al. AJCC Cancer Staging Manual. Springer 2017.
  5. Cheng L, Albers P, Berney DM, Feldman DR, Daugaard G, Gilligan T et al. Testicular cancer (Primer). Nat Rev Dis Primers 2018; 4(1): 29.
  6. Stephenson AJ, Bosl GJ, Motzer RJ, Kattan MW, Stasi J, Bajorin DF et al. Retroperitoneal lymph node dissection for nonsemino-matous germ cell testicular cancer: impact of patient selection factors on outcome. J Clin Oncol 2005; 23(12): 2781-2788.
  7. Stephenson A, Klein E. Surgical management of low-stage nonseminomatous germ cell testicular cancer. BJU Int 2009; 1041362-1368.
  8. Weissbach L, Bussar-Maatz R, Flechtner H, Pichlmeier U, Hartmann M, Keller L. RPLND or primary chemotherapy in clinical stage IIA/B nonseminomatous germ cell tumors? Results of a prospective multicenter trial including quality of life assessment. Eur Urol 2000; 37582-594.
  9. Heidenreich A, Pfister D Fau - Witthuhn R, Witthuhn R Fau - Thuer D, Thuer D Fau - Albers P, Albers P. Postchemotherapy retroperitoneal lymph node dissection in advanced testicular cancer: radical or modified template resection. Eur Urol 2009; 55(1): 217-224.
  10. Krege S, Beyer J Fau - Souchon R, Souchon R Fau - Albers P, Albers P Fau - Albrecht W, Albrecht W Fau - Algaba F, Algaba F Fau - Bamberg M et al. European consensus conference on diagnosis and treatment of germ cell cancer: a report of the second meeting of the European Germ Cell Cancer Consensus group (EGCCCG): part I. Eur Urol 2008; 53(3): 478-496.
  11. Cary C, Masterson TA, Bihrle R, Foster RS. Contemporary trends in postchemotherapy retroperitoneal lymph node dissection: additional procedures and perioperative complications. Urol Oncol 2015; 33(9): 389. e 315-389. e321.
  12. Ray S, Pierorazio PM, Allaf ME. Primary and post-chemotherapy robotic retroperitoneal lymph node dissection for testicular cancer: a review. Transl Androl Urol 2020; 9(2): 949.
  13. Javan H, Gholami H, Assadi M, Pakdel AF, Sadeghi R, Keshtgar M. The accuracy of sentinel node biopsy in breast cancer patients with the history of previous surgical biopsy of the primary lesion: systematic review and meta-analysis of the Eur J Surg Oncol 2012; 38(2): 95-109.
  14. Ansari M, Rad MA, Hassanzadeh M, Gholami H, Yousefi Z, Dabbagh VR et al. Sentinel node biopsy in endometrial cancer: systematic review and meta-analysis of the literature. Eur J Gynaecol Oncol 2013; 34(5): 387-401.
  15. Sadeghi R, Gholami H, Zakavi SR, Kakhki VR, Tabasi KT, Horenblas S. Accuracy of sentinel lymph node biopsy for inguinal lymph node staging of penile squamous cell carcinoma: systematic review and meta-analysis of the literature. J Urol 2012; 187(1): 25-31.
  16. Farazestanian M, Yousefi Z, Zarifmahmoudi L, Mofrad MH, Kadkhodayan S, Sadeghi R. Concordance between intracervical and fundal injections for sentinel node mapping in patients with endometrial cancer?: a study using intracervical radiotracer and fundal blue dye injections. Clin Nucl Med 2019; 44(3): e123-e127.
  17. Hassanzadeh M, Farahabadi EH, Yousefi Z, Kadkhodayan S, Zarifmahmoudi L, Sadeghi R. Lymphatic mapping and sentinel node biopsy in ovarian tumors: a study using intra-operative Tc-99m-Phytate and lymphoscintigraphy imaging. J Ovarian Res 2016; 9(1): 55.
  18. Sadeghi R, Asadi M, Treglia G, Zakavi SR, Fattahi A, Krag DN. Axillary concordance between superficial and deep sentinel node mapping material injections in breast cancer patients: systematic review and meta-analysis of the literature. Breast Cancer Res Treat 2014; 144(2): 213-222.
  19. Sadeghi R, Tabasi K, Bazaz S, Kakhki V, Massoom A, Gholami H et al. Sentinel node mapping in the prostate cancer: meta-analysis. In Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. Centre for Reviews and Dissemination (UK) 2011.
  20. Sadeghi R, Alesheikh G, Zakavi SR, Fattahi A, Abdollahi A, Assadi M et al. Added value of blue dye injection in sentinel node biopsy of breast cancer patients: do all patients need blue dye? Int J Surg 2014; 12(4): 325-328.
  21. Fattahi AS, Tavassoli A, Rohbakhshfar O, Sadeghi R, Abdollahi A, Forghani MN. Can methylene blue dye be used as an alternative to patent blue dye to find the sentinel lymph node in breast cancer surgery? J Res Med Sci 2014; 19(10): 918-922.
  22. Zarifmahmoudi L, Ghorbani H, Sadri K, Tavakkoli M, Keshvari M, Salehi M et al. Sentinel Node Biopsy in Urothelial Carcinoma of the Bladder: Systematic Review and Meta-Analysis. Urol Int 2019; 103(4): 373-382.
  23. Satoh M, Ito A, Arai Y. Laparoscopic Retroperitoneal Lymph Node Dissection: Extraperitoneal Approach. In Endo-urological Management of Urogenital Carcinoma. Springer 2006; 209-218.
  24. Gilligan T, Lin DW, Aggarwal R, Chism D, Cost N, Derweesh IH et al. Testicular cancer, version 2.2020, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 2019; 17(12): 1529-1554.
  25. Zarifmahmoudi L, Sadeghi R. Re: Radio-Guided Lymph Node Mapping in Bladder Cancer Using SPECT/CT and Intraoperative gamma-Probe Methods. Clin Nucl Med 2017; 42(4): 327.
  26. Sadeghi R. Sentinel node mapping diagnostic studies warrant a unique reporting criteria: comment on Xiong et al. systematic review. Eur J Surg Oncol 2014; 40(8): 1025-1026.
  27. Blok JM, Kerst JM, Vegt E, Brouwer OR, Meijer RP, Bosch JR et al. Sentinel node biopsy in clinical stage I testicular cancer enables early detection of occult metastatic disease. BJU international 2019; 124(3): 424-430.
  28. Kadkhodayan S, Hasanzadeh M, Treglia G, Azad A, Yousefi Z, Zarifmahmoudi L et al. Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature. Eur J Surg Oncol 2015; 41(1): 1-20.
  29. Kakhki VRD, Bagheri R, Tehranian S, Shojaei P, Gholami H, Sadeghi R et al. Accuracy of sentinel node biopsy in esophageal carcinoma: a systematic review and meta-analysis of the pertinent literature. Surgery today 2014; 44(4): 607-619.
  30. Sadeghi R, Forghani MN, Memar B, Mashhadi MTR, Kakhki VRD, Abdollahi A et al. How long the lymphoscintigraphy imaging should be continued for sentinel lymph node mapping? Ann Nucl Med 2009; 23(6): 507-510.
  31. Abdollahi A, Jangjoo A, Kakhki VD, Zakavi SR, Memar B, Forghani MN et al. Factors affecting sentinel lymph node detection failure in breast cancer patients using intradermal injection of the tracer. Rev Esp Med Nucl 2010; 29(2): 73-77.
  32. Aliakbarian M, Memar B, Jangjoo A, Zakavi SR, Kakhki VRD, Aryana K et al. Factors influencing the time of sentinel node visualization in breast cancer patients using intradermal injection of the radiotracer. Am J Surg 2011; 202(2): 199-202.
  33. Jangjoo A, Forghani MN, Mehrabibahar M, Sadeghi R. Anaphylaxis reaction of a breast cancer patient to methylene blue during breast surgery with sentinel node mapping. Acta Oncologica 2010; 49(6): 877-878.