Potential advantage of studying the lymphatic drainage by sentinel node technique and SPECT-CT image fusion for pelvic irradiation of prostate cancer

Purpose: This study aims to investigate the in vivo drainage of lymphatic spread by using the sentinel node (SN) technique and single-photon emission computed tomography (SPECT)-computed tomography (CT) image fusion, and to analyze the impact of such information on conformal pelvic irradiation. Methods and Materials: Twenty-three prostate cancer patients, candidates for radical prostatectomy already included in a trial studying the SN technique, were enrolled. CT and SPECT images were obtained after intraprostate injection of 115 MBq of 99mTc-nanocolloid, allowing identification of SN and other pelvic lymph nodes. Target and nontarget structures, including lymph nodes identified by SPECT, were drawn on SPECT-CT fusion images. A three-dimensional conformal treatment plan was performed for each patient. Results: Single-photon emission computed tomography lymph nodal uptake was detected in 20 of 23 cases (87%). The SN was inside the pelvic clinical target volume (CTV2) in 16 of 20 cases (80%) and received no less than the prescribed dose in 17 of 20 cases (85%). The most frequent locations of SN outside the CTV2 were the common iliac and presacral lymph nodes. Sixteen of the 32 other lymph nodes (50%) identified by SPECT were found outside the CTV2. Overall, the SN and other intrapelvic lymph nodes identified by SPECT were not included in the CTV2 in 5 of 20 (25%) patients. Conclusions: The study of lymphatic drainage can contribute to a better knowledge of the in vivo potential pattern of lymph node metastasis in prostate cancer and can lead to a modification of treatment volume with consequent optimization of pelvic irradiation.