Dynamic sentinel lymph node biopsy

Penile cancer is a disease that can be treated with surgery. The usual site of spread is to the lymph nodes in the groins. The surgery you would usually undergo involves removal of the penile tumour and in some cases the lymph nodes in the groins. The lymph nodes are examined under a microscope in the laboratory and from this we are able to ensure that the cancer has not spread to the groin areas.

The standard surgery to remove the lymph nodes from the groin can result in complications such as wound infection and leg swelling (lymphoedema), in addition to reduced mobility whilst the wound heals.

Dynamic sentinel lymph node biopsy is an improved method of detecting whether the nodes in the groin are involved with the tumour and can minimise the extent of groin surgery that is needed, and consequently the potential complications. A dynamic sentinel node biopsy uses a small dose of radioactive material into the sentinel lymph nodes and pictures are taken to detect the location of the sentinel node. If the result of these biopsies is negative, it means you will avoid having to undergo extensive surgery to remove the lymph nodes.

All treatments and procedures have risks and we will talk to you about the risks of dynamic sentinel node biopsy.

When you are admitted to hospital, you will have your scan in the Nuclear Medicine department. There is a possibility of discomfort at the time of the initial injection for this scan, although local anaesthetic will be used in the area to minimise this. An injection of dye is administered into the penis and you will then be observed closely for any reaction. However, in our experience the risk of the injection causing an allergic reaction or later long-term problems is extremely low and is no more a risk than having a normal chest X-ray.

During surgery, whilst you are asleep under a general anaesthetic, you will have an injection of blue dye. This blue dye may make your urine blue-green-coloured and make your skin turn a bluish colour temporarily after your operation.

• Pain
  You may experience some discomfort following your operation. Please take your painkillers regularly as prescribed on the packet. Do not exceed the stated dose. This discomfort will settle down after a few weeks. but if it does not, please contact your doctor.
• Bleeding
  You should not experience any major bleeding. It is normal for there to be a spot of blood on the dressing. This can be stopped by applying pressure to the area. Use a clean piece of gauze and press firmly on the wound site for about 10 minutes. If bleeding does not stop, seek medical advice.
• Swelling and bruising
  You may experience some bruising to the wound site. You may also notice some swelling in the groin area. This is usually an accumulation of lymphatic fluid and will settle down as your lymphatic system takes up this drainage. Please contact your nurse specialist with any concerns or if this area becomes red, hot to touch or has a discharge from the wound, as this may signify infection.
• Need for further surgery
  Dynamic sentinel node biopsies involve removing the main draining lymph node in each groin. Should this show evidence of cancer, your medical team will recommend further surgery to remove a ‘packet’ of lymph nodes in your groin to ensure that there are no further cancer cells remaining.

There are a number of factors that affect the chances of suffering complications from anaesthesia; these may include age, weight, smoking, lifestyle and the general state of your health. Your anaesthetist and/or your surgeon can provide further details. The following information on risks is provided by the Royal College of Anaesthetists:

Very common (1 in 10) and common (1 in 100) side effects

• feeling sick and vomiting after surgery
• sore throat
• dizziness, blurred vision
• headache
• itching
• aches, pains and backache
• pain during injection of drugs
• bruising and soreness
• confusion or memory loss

Uncommon (1 in 1,000) side effects and complications

• chest infection
• bladder problems
• muscle pains
• slow breathing (depressed respiration)
• damage to the teeth, lips or tongue
• an existing medical condition getting worse
• awareness (becoming conscious during operation).

Rare (1 in 10, 000) or very rare (1 in 100, 000 or less) complications

• damage to the eyes
• serious allergy to drugs
• nerve damage
• death
• equipment failure.

Death from anaesthesia is very rare, and is usually caused by a combination of four or five complications together. In the UK, there are approximately about five deaths for every million anaesthetics.

This is not something we would recommend. Scans such as CT, MRI and ultrasound are not accurate enough in excluding cancer spread to your groins. The only way to be sure that cancer has not spread to your groins is using surgery. Sentinel node surgery is the least invasive of the different surgical approaches.

For the type of cancer you have, this is the best approach for staging your lymph nodes. If you have low risk cancer, then simply examining your groins on a regular basis may be enough, but if your cancer has higher risk features, we may need to do more extensive lymph node sampling.

Your case will have been discussed in our multidisciplinary meeting, whereby a team of specialist doctors, oncologists, radiologists and a histopathologist (who examines the tissue samples) attend in order to agree the safest and most appropriate management for your care.

Other forms of imaging such as MR (X-Ray) scanning have not been fully tested in penile cancer as a method of detecting cancer spread.

If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak with a senior member of staff.

Prior to your surgery, you will attend an appointment at pre- assessment to assess your fitness for surgery. Here you will be advised of any medications that may require omitting prior to or on the day of your surgery. You will be expected to stop eating from midnight before the day of your operation. You may drink water until 6am unless advised differently.

You will be admitted via the surgical admissions lounge on the day of your surgery. Here you will be seen by your consultant who will consent you for your surgery. You may wish to bring a book or newspaper to read whilst waiting for your appointments. Should you be staying in overnight, you may wish to bring overnight clothes and toiletries.

You will be admitted to hospital on the day of surgery. You will be seen by the medical team in the morning to consent you for your surgery and you will be given some local anaesthetic gel. The doctor/nurse will explain the area of your penis where you should apply this one hour before your morning scan in nuclear medicine.

You will receive an appointment to attend the Nuclear Medicine department on the fifth floor at UCLH to have a scan the morning of your surgery.

This is called a dynamic sentinel node scan. It is used to detect the main lymph nodes in your groins which we think are the first nodes to be involved in the spread of your cancer. The scan involves having an injection of half a teaspoon of very mildly radioactive dye into three separate places around your penis, after applying local anaesthetic spray. We will then take a series of pictures, with a special camera that detects the radioactive material, over a period of approximately two hours. These pictures will show the site of the sentinel node on each side of the groin. This site, in each groin, will be marked on the skin with a pen and covered with a plaster. You may remain in the department for up to three hours.

On the afternoon of the day of surgery, you will have a general anaesthetic, and then a blue dye will be injected into the same three sites of the penis as in the morning. This will be done 10 minutes before the actual surgery, but while you are asleep. The dye will then be absorbed into the lymph nodes and will help us identify the sentinel lymph nodes.

Whilst you are asleep, we will use the pictures from the morning, the marks on your skin and also a smaller camera to detect the sentinel node/gland. A small skin incision will be used to remove this gland on each side of the groin. There will be no additional scars in the groins.

Sentinel node surgery takes about 45 minutes. You will then recover from the anaesthetic in the recovery room before returning to the ward.

If you live nearby, you may be able to be discharged on the same day as your surgery. If you live far away, you will remain in hospital for one night.

You will be asked to attend hospital for a routine appointment about two to three weeks after your surgery for your wound to be checked and to discuss the results of your biopsy and future management of your condition.

Keep your wound clean and dry. You will be discharged with a dressing covering the site if this is deemed to be necessary.

Otherwise, the wound site will be left exposed. You will be able to shower but please do not sit and soak in a bath until you are reviewed in clinic. Any stitches used are dissolvable. You will be discharged home with antibiotics and painkillers.

You may notice some swelling at the wound site over the first few weeks following your operation. This is normal. However, if you experience increased pain, redness, a discharge from the wound site or feel unwell, please contact your nurse specialist on the telephone number given below.

For out-of-hours emergencies, please attend your nearest Accident and Emergency Department (Casualty).

It would be ideal to wear loose clothing for four weeks. Avoid belts and tight trousers as this will increase the swelling you experience.

UCLH Macmillan Cancer Information Centre

Email: uclh.supportandinformation@nhs.net or the clinical nurse practitioner: uclh.andrologycancercns@nhs.net

Macmillan Cancer Support
www.macmillan.org.uk

Macmillan Helpline

Freefone helpline on 0808 8080 000

The helpline number is also free from these mobile phone networks: 3, EE, O2, Virgin and Vodafone (when calls are made from the UK).

Cancer Research UK

www.cancerresearch.org.uk

This website provides facts about cancer, including treatment choices.

Orchid

www.orchid-cancer.org.uk

Fighting male cancer

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