Patients with penile carcinoma benefit from immediate resection of clinically occult lymph node metastases

Robotic-assisted endoscopic inguinal lymphadenectomy

INTRODUCTION

Open inguinal lymphadenectomy is a well-established therapeutic and diagnostic option for patients with invasive penile squamous cell carcinoma who are at risk of regional and distant metastases. We report the use of endoscopic robotic-assisted bilateral inguinal lymph node dissections in a patient with palpable inguinal nodes despite oral antibiotics.

TECHNIQUE

A 2-cm mid-thigh incision was made to develop a plane just deep to Camper's (fatty) fascia. Once a sufficient working space was created to place 3 robotic ports and 1 assistant port, subcutaneous gas was instilled, and the robotic device was docked and used to perform the dissection. The surgical approach replicated the principles of open techniques such that the contents of the femoral canal were dissected to the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially to include both superficial and deep lymph nodes in the dissection template.

CONCLUSIONS

To our knowledge, this is the first report of an endoscopic robotic-assisted inguinal lymph node dissection. A minimally invasive approach circumventing the need for thick skin flaps, the improved flexibility afforded by robotic instruments, and the improved magnification could decrease the morbidity associated with inguinal lymphadenectomy while maintaining oncologic principles.

Contemporary inguinal lymph node dissection: minimizing complications

OBJECTIVES

This review describes the morbidity of inguinal lymph node dissection (ILND) performed as part of the management of penile cancer as well as recent modifications that may reduce the incidence of complications.

METHODS

A review of the literature was conducted using Pubmed for studies reporting complication outcomes of ILND for penile cancer. Furthermore, our contemporary results and patient related morbidity associated with ILND performed for penile cancer are reported and compared with prior series.

RESULTS

A review of the literature over the past 25 years identified 27 manuscripts discussing complications of ILND in the context of penile cancer. ILND has traditionally been associated with an 80-100% risk of surgical morbidity, with skin necrosis, wound dehiscence, infection, and lymphedema the predominant findings. Recent technical modifications and management strategies have reduced the associated risks of this surgical procedure. Most recently, we report a 19 and 27% rate of minor and major complications, respectively, for a diagnostic ILND (i.e., superficial ILND alone in the absence of nodal metastasis) and a 29 and 24% rate of minor and major complications, respectively, for a therapeutic ILND (superficial/deep ILND and pelvic lymph node dissection in the presence of nodal metastasis). In contrast, among clinically node negative patients undergoing dynamic sentinel lymph node biopsy as a staging procedure, the reported complication rate was 7%.

CONCLUSIONS

The incorporation of novel management strategies and surgical modifications have resulted in decreasing peri-operative morbidity associated with inguinal staging and therapy.

Non-invasive and minimally invasive staging of regional lymph nodes in penile cancer

INTRODUCTION

The management of the regional lymph nodes in penile cancer patients, particularly when these lymph nodes are impalpable, remains controversial. Prophylactic bilateral inguinal lymphadenectomy is associated with high morbidity and is often unnecessary. However, there is no non-invasive or minimally invasive staging technique that can determine the lymph node status of penile cancer patients with 100% accuracy.

METHODS

We reviewed the current literature to examine the role of non-invasive and minimally invasive techniques for staging regional lymph nodes in penile cancer with particular reference to clinically impalpable disease.

RESULTS

Cross-sectional imaging (un-enhanced CT and MRI) modalities have a role in the assessment of patients with palpable inguinal basins and in locating distant metastases, but are unreliable in staging impalpable regional lymph nodes. The spatial resolution of lymphotropic nanoparticle enhanced MRI (LNMRI) and positron emission tomography (PET)/CT are limited to several millimetres and so these modalities cannot reliably detect micro-metastases (<2 mm). Ultrasound (US) and fine-needle aspiration cytology (FNAC) are indicated in staging palpable inguinal basins but are unreliable in isolation in the assessment of impalpable lymph nodes. They are, however, useful as an adjunct to dynamic sentinel lymph node biopsy (DSLNB) in lowering false-negative rates.

CONCLUSIONS

While we await staging modalities that can equal the results of DSLNB with fewer disadvantages, histological staging in the form of DSLNB remains the best minimally invasive staging modality we can offer at risk patients presenting with clinically node negative groins.

How accurate are present risk group assignment tools in penile cancer?

OBJECTIVES

To evaluate the accuracy of the predictive models available to estimate the risk of lymph node metastases and cancer-specific survival in patients with squamous cell carcinoma of the penis.

METHODS

A nonsystematic review of the literature was performed searching MEDLINE in January 2008.

RESULTS

Most of the authors select patients for early inguinal lymphadenectomy according to the pathologic extension of the primary tumor and its histologic grade, as recommended by the EAU Guidelines and the Solsona risk groups. Although the Solsona risk groups performed slightly better, both risk groups had low predictive accuracy. A nomogram including eight clinical and pathologic variables (tumor thickness, microscopic growth pattern, Broder's grade, presence of vascular or lymphatic embolization, infiltrations of the corpora cavernosa, corpus spongiosum or urethra, and the clinical stage of groin lymph nodes) was developed to estimate the risk of lymph node involvement at follow-up. Two nomograms are currently available able to estimate the 5-year cancer-specific survival probabilities of the patients. The first nomogram included the clinical lymph node stage and the same pathological variables of the primary tumor at penectomy, while the pathological stage of the lymph nodes replaced the clinical one in the second model. All the 3 nomograms had good prognostic accuracy.

CONCLUSIONS

Both the Solsona and EAU risk group assessment had low prognostic accuracy, although the Solsona risk groups performed slightly better. The nomograms designed to predict the risk of lymph node metastases showed and cancer-specific survival had good prognostic accuracy but their external validation is still lacking.

Recurrence patterns of squamous cell carcinoma of the penis: recommendations for follow-up based on a two-centre analysis of 700 patients

BACKGROUND

Current follow-up recommendations for patients with penile carcinoma are based on small numbers of patients.

OBJECTIVES

To give further insight into the recurrence patterns of penile carcinoma in different treatment settings and provide recommendations for follow up. DESIGNS, SETTING, AND PARTICIPANTS: In this retrospective study, we analysed 700 patients from two referral centres for penile carcinoma for recurrences.

MEASUREMENTS

Recurrences were categorized as local, regional, or distant. The rate of local recurrences was compared between patients undergoing penile-preserving treatments and partial/total amputation. Regional recurrences were compared between patients surgically staged as pN0 or pN+ and clinically node-negative (cN0) patients subjected to a wait-and-see policy. The total recurrence rate, type of recurrence, time to recurrence, and survival were calculated.

RESULTS AND LIMITATIONS

205 out of 700 patients (29.3%) had a recurrence, consisting of 18.6% local, 9.3% regional, and 1.4% distant recurrences. Of the recurrences, 92.2% occurred within 5 yr after primary treatment. All regional and distant recurrences occurred within 50 and 16 mo, respectively. The local recurrence rate was 27.7% after penile-preserving therapy and 5.3% after amputation. The regional recurrence rate was 2.3% in patients staged as pN0, 19.1% in patients staged as pN+, and 9.1% in patients undergoing a wait-and-see policy. The 5-yr disease-specific survival was 92% after a local recurrence and 32.7% after a regional recurrence. All patients with a distant recurrence died within 22 mo. Although the number of analysed patients is substantial, the results do not necessarily reflect those of other centres using different techniques for the management of penile carcinoma.

CONCLUSIONS

Patients undergoing penile-preserving therapy, patients surgically staged as pN+, and those undergoing a wait-and-see policy for the nodal status are at high risk of developing a recurrence. Follow-up recommendations are provided based on the risk and impact on survival of a recurrence.

Risk factors for lymph node metastasis in clinically node-negative penile cancer patients

OBJECTIVES

To analyze the effects of pathological T stage, grade, extent of surgery for primary tumor, and age group on the risk of developing lymph node metastasis in clinically node-negative penile cancer patients.

METHODS

We performed a retrospective analysis of 200 clinically node-negative penile cancer patients who were kept under surveillance, after treatment of the primary tumor in our institution. The primary outcome parameter was cytologically or histologically proven lymph node metastasis. Logistic regression analysis was used to compute odds ratios in univariate and multivariate settings.

RESULTS

Lymph node metastasis occurred in 31 patients at a median time of three months. Histological grade 3 and grade 2 tumors had a statistically significant increased odds ratio for lymph node metastasis, (7.1[P < 0.001] and 2.7 [P = 0.04], respectively), compared with grade 1 tumors. Although increasing pT stage was associated with increasing odds ratios, the differences were not statistically significant. Nor did the extent of surgery of the primary tumor or the age group significantly influence the risk of developing lymph node metastasis.

CONCLUSIONS

Histological grade is the most significant parameter influencing the risk of lymph node metastasis in clinically node-negative penile cancer patients on surveillance. Patients with grade 3 and grade 2 tumors may benefit from elective inguinal lymphadenectomy.

Preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging penile cancer: results with pathological correlation

PURPOSE

We assessed the sensitivity of preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging the inguinal region of patients with penile cancer and no palpable inguinal adenopathy.

MATERIALS AND METHODS

The records of 31 patients with invasive penile cancer and nonpalpable (29) or nonsuspicious (2) inguinal lymph nodes were reviewed. Preoperatively lymphoscintigraphy plus dynamic sentinel node biopsy with (99m)technetium labeled sulfur colloid and isosulfan blue dye was performed in 21 patients and dynamic sentinel node biopsy alone with blue dye only was done in 10. All patients underwent superficial lymph node dissection regardless of preoperative lymphoscintigraphy or dynamic sentinel node biopsy findings to establish pathological nodal status.

RESULTS

Six of 32 groins that showed drainage on preoperative lymphoscintigraphy had inguinal node metastasis, as did 1 of 10 that was drainage negative. The sensitivity of preoperative lymphoscintigraphy drainage for cancer detection was 86%. Using dynamic sentinel node biopsy with blue dye plus radiotracer 5 sentinel lymph nodes were positive for cancer, although 2 false-negative results were obtained. Thus, the sensitivity of dynamic sentinel node biopsy per groin for cancer detection was 71%.

CONCLUSIONS

In our experience preoperative lymphoscintigraphy and dynamic sentinel node biopsy as currently performed remain insufficient for detecting occult inguinal disease. Superficial lymph node dissection remains the gold standard for detecting inguinal microscopic metastasis in select patients.

Evaluation of dynamic lymphoscintigraphy and sentinel lymph-node biopsy for detecting occult metastases in patients with penile squamous cell carcinoma

OBJECTIVE

To evaluate the introduction of dynamic lymphoscintigraphy and sentinel lymph-node (SLN) biopsy (used to detect occult lymph node metastases in patients with penile cancer and clinically impalpable inguinal lymph nodes at presentation) at a UK tertiary referral centre for penile cancer.

PATIENTS AND METHODS

In all, 75 patients with penile squamous cell carcinoma of stage T1, grade > or = 2, and unilateral or bilateral impalpable groin nodes, were prospectively enrolled over a 2-year period. Patients underwent lymphoscintigraphy with (99m)technetium-labelled nanocolloid which was injected intradermally around the tumour or into the distal penile shaft skin. Four hours later, the SLN(s) were identified during surgery using a hand-held gamma-probe and intradermal injections with blue dye. Completion lymph node dissection was subsequently used in patients with tumour-positive SLNs.

RESULTS

In all, 255 SLNs were removed from 143 groins; all excised nodes had taken up the radioactive marker, and the blue dye was evident in 87%. Eighteen of 75 (24%) patients and 21 of 143 groins (15%) had a tumour-positive SLN. All but one patient went on to completion lymph node dissection. Three of these 18 (17%) had further disease in other than SLNs. Six of 143 (4%) groins developed minor complications. One false-negative result was reported at a median (range) follow-up of 11 (2-24) months.

CONCLUSION

This technique is feasible for managing penile cancer in a UK tertiary referral centre. The initial results suggest that it can accurately identify the SLN(s), which can then be removed for pathological review with minimal morbidity.

Long-term follow-up after laser therapy for penile carcinoma

OBJECTIVES

Although in many cases of penile carcinoma, laser therapy has become the standard treatment, opinion still differs regarding the risks related to the relatively high rate of recurrence that accompanies this form of treatment. In this study, we reviewed the results of neodymium:yttrium-aluminum-garnet laser treatment of 44 consecutive patients with penile carcinoma in our institution from 1986 to 2003.

METHODS

We created five groups, on the basis of the T stage and grade of the tumor. Of the 44 patients, 21 had Stage T1, 17 had Stage T2, and 6 had carcinoma in situ.

RESULTS

Local disease recurrence (in the treated area) occurred in 48% of the treated patients, and in 20% of the patients, the first recurrence was elsewhere on the glans penis. These were subsequently treated by laser therapy or partial amputation. In 10 cases, nodal metastases were found. Eight of these cases were Stage T2. Our results suggest a stronger prognostic role for the primary T stage of the tumor than for the tumor grade, with respect to the risk of nodal metastasis.

CONCLUSIONS

From the high recurrence rate in our series, we decided to perform a wider initial laser excision and to diminish the number of retreatments to less than three. We also now believe that laser therapy is best for Stage Tis and T1 tumors exclusively. Only selected patients with T2 tumors should be treated in combination with early lymph node resection.

Video endoscopic inguinal lymphadenectomy: a new minimally invasive procedure for radical management of inguinal nodes in patients with penile squamous cell carcinoma

PURPOSE

Video endoscopic inguinal lymphadenectomy is a recently described lymphadenectomy with the same template of the open technique but performed with laparoscopic instruments under video guidance. It was developed to decrease procedure related morbidity while maintaining good oncological results. We report our initial results in a trial comparing video endoscopic inguinal lymphadenectomy with standard inguinal lymphadenectomy.

MATERIALS AND METHODS

From 2003 to 2005, 10 patients with penile carcinoma who were at high risk for inguinal metastases underwent bilateral inguinal lymphadenectomy. We performed standard lymphadenectomy in 1 limb and video endoscopic inguinal lymphadenectomy on the contralateral side. Perioperative results and followup data were compared.

RESULTS

No intraoperative complications occurred. Mean operative time was 92 and 126 minutes for open and endoscopic surgery, respectively (p=0.00002). Despite the small number of patients we noted a decrease in cutaneous complications with video endoscopic inguinal lymphadenectomy (0% vs 50%, p=0.017) and a trend toward decreased overall morbidity with this endoscopic technique (20% vs 70%, p=0.059). The mean number of retrieved and positive lymph nodes were similar for the 2 techniques. At a mean followup of 18.7 months (range 12 to 31) no signs of recurrence or disease progression were noted. In the postoperative period 9 of the 10 patients identified video endoscopic inguinal lymphadenectomy as the preferred technique in terms of surgical morbidity.

CONCLUSIONS

Video endoscopic inguinal lymphadenectomy is a safe and feasible technique in patients with penile carcinoma and nonpalpable nodes. These preliminary results suggest that video endoscopic inguinal lymphadenectomy may decrease postoperative morbidity without compromising oncological control. Future studies should include the bilateral procedure, longer term followup and a greater number of patients.

Penile Carcinoma: The Role of Koilocytosis in Groin Metastasis and the Association With Disease Specific Survival

PURPOSE

We evaluated the influence of koilocytosis, and other clinical and pathological variables in the risk of groin metastasis and death in penile cancer patients.

MATERIALS AND METHODS

From January 1994 to January 2004, 172 patients with squamous cell carcinoma of the penis were treated at a single cancer center. Of these patients 144 were retrospectively studied to analyze prognostic factors and establish the role of koilocytosis in penile cancer. Univariate and multivariate analyses were performed, and Kaplan-Meier survival curves were generated.

RESULTS

A total of 102 patients (71%) underwent groin dissection, of whom 84 (58.3%) had inguinal metastasis. Koilocytosis was present in 91 patients (63.1%) and it was associated with low and moderate primary tumor grade on univariate analysis (p = 0.0005). Although koilocytosis statistically correlated with Jackson stage (p = 0.017) and tumor grade (p = 0.002), it had no impact on disease specific survival (p = 0.912). Metastatic inguinal disease correlated with patient age, Jackson and disease specific survival. Only Jackson stage and inguinal relapse after groin dissection influenced overall survival on multivariate analysis (each p = 0.001).

CONCLUSIONS

According to all studied variables only patient age and Jackson stage correlated with an increased risk of groin disease. Koilocytosis was rarely found in high grade penile tumors and it did not correlate with a high risk of metastatic groin disease or death.

Pelvic Lymph Node Dissection for Penile Carcinoma: Extent of Inguinal Lymph Node Involvement as an Indicator for Pelvic Lymph Node Involvement and Survival

PURPOSE

We identified pathological parameters of inguinal lymph node involvement with the aim of predicting pelvic lymph node involvement and survival.

MATERIALS AND METHODS

A total of 308 patients with penile carcinoma and adequate followup were included in this study. The outcome of 102 patients who underwent lymphadenectomy for lymph node metastases was analyzed further. Histopathological characteristics of the regional lymph nodes were reviewed including unilateral or bilateral involvement, the number of involved nodes, pathological tumor grade of the involved nodes, and the presence of extracapsular growth.

RESULTS

Tumor grade of the involved inguinal lymph nodes (OR 6.0, 95% CI 1.2-30.3) and the number of involved nodes (2 or less vs more than 2) (OR 12.1, 95% CI 3.0-48.1) were independent prognostic factors for pelvic lymph node involvement. Extracapsular growth (OR 2.3, 95% CI 1.1-4.8), bilateral inguinal involvement OR 3.4, 95% CI 1.2-9.4) and pelvic lymph node involvement (OR 3.1, 95% CI 1.4-6.6) were independent prognostic factors for disease specific survival.

CONCLUSIONS

Patients with only 1 or 2 inguinal lymph nodes involved without extracapsular growth and no poorly differentiated tumor within these nodes are at low risk of pelvic lymph node involvement and have a good prognosis with a 5-year survival rate of approximately 90%. Pelvic lymph node dissection seems to be unnecessary in these cases.

Reconstructive surgery for invasive squamous carcinoma of the glans penis

OBJECTIVES

We present medium-term outcome data for patients with invasive penile cancer treated with glansectomy and reconstruction with a split-thickness skin graft.

METHODS

A series of consecutive patients referred with penile malignancies over a 6-yr period were analyzed prospectively. A dedicated histopathologist reviewed all the specimens. After clinical staging, patients with tumours confined to the glans were offered glansectomy.

RESULTS

A total of 72 patients (32% of patients, 31% of procedures) underwent glansectomy for penile carcinoma. Of these, 65 patients were new diagnoses and seven were recurrences after radiotherapy. The mean follow-up period was 27 mo (range: 4-68 mo). There have been three late local recurrences (4%).

CONCLUSION

Glansectomy appears to be an oncologically safe and effective procedure for patients with glans-confined squamous cell tumours. It preserves maximum phallic length and results in a very satisfactory cosmetic penile appearance after reconstruction.

Reliability and safety of current dynamic sentinel node biopsy for penile carcinoma

OBJECTIVES

Dynamic sentinel node biopsy (DSNB) has been performed at our department since 1994 to assess status of inguinal lymph nodes of clinically node-negative (cN0) patients with penile carcinoma. Over time, several modifications were made to reduce the false-negative rate and thus increase sensitivity. We compared the false-negative and complication rates of the current procedure, as performed at our institute since 2001, with the prior procedures.

MATERIALS AND METHODS

The patients who underwent DSNB for penile carcinoma in the period from 1994 until July 2004 were divided into two cohorts: cohort A: patients treated from 1994 until 2001; cohort B: patients treated from 2001 until 2004. Cohort A consisted of 92 patients, in whom 157 groins were explored. Cohort B consisted of 58 patients, with a total of 105 explored groins. Medians for follow-up in cohorts A and B were 83 (range: 24-130) and 30 (range: 24-49) mo, respectively. The false-negative and complication rates were determined in both cohorts.

RESULTS

In cohort A, 21 of 157 explored groins contained tumour-positive sentinel nodes, and five false-negative procedures were encountered, resulting in a false-negative rate of 19.2%. In cohort B, 20 of 105 explored groins contained tumour-positive sentinel nodes, and one procedure was false-negative. The false-negative rate was 4.8%. The rate of complications dropped from 10.2% in cohort A to 5.7% in cohort B. All complications were minor and transient.

CONCLUSIONS

The false-negative and complication rates of DSNB have decreased since the procedure was modified. The current procedure has false-negative and complication rates of 4.8% and 5.7%, respectively. DSNB has matured into a reliable and safe method for assessing status of lymph nodes in cN0 penile carcinoma patients.

Revisión de los tumores epidermoides de pene

OBJECTIVES

To study the characteristics and evolution of the epidermoid penis tumours.

MATERIAL AND METHODS

It was carried out a retrospective study on the epidermoid penis tumours treated in our center between 1981 and 2005.

RESULTS

16 tumours penis epidermoides were diagnosed. The average age of the patients was of 71.7 years (interval between 54 and 90 years). In 80% of the cases they are diagnosed in advanced stadiums (T3 and T4). The most habitual presentation forms are the ulcerous lesions (53%) and papilar (33%). The average diameter of the lesion was 2.3 cm, and the most frequent localization the glands (53%) and balano prepucial (33%). They were carried out 7 local scissions, 8 partial penectomies, one total penectomy, and an local scission pluslocal treatment with 5-fluoracile. With a follow-up of 24 months 5 relapses took place, mainly in patients subjected to local excision of the lesion (p = 0.06 log-rank test).

CONCLUSIONS

The epidermoid carcinoma of the penis is a tumoral lesion characteristic of advanced ages that is diagnosed later and treated in not very aggressive way. Therefore it is frequent the advanced stadiums and the tumour relapses.

Der Einfluss des T-Stadiums auf das Metastasierungsrisiko des Peniskarzinoms: T1 vs. T2

BACKGROUND

Controversies persist over the therapeutic approach to T1 penile carcinoma, particularly in patients with negative inguinal lymph nodes. Available data on lymph nodes metastases (LNM) in T1 carcinoma are contradictory. The aim of this study was to evaluate the metastatic risk of T1 carcinoma and to compare it with that of T2 carcinoma.

MATERIAL AND METHODS

A total of 37 patients (pts) with T1 or T2 tumors were reviewed. Assessment of the inguinal lymph node condition was based on node dissection in 29 pts and surveillance in eight pts (mean 62 months, range 22-162).

RESULTS

Grading was classified as good (G1), moderate (G2) and poor (G3) in seven, 26 and four pts, respectively. Tumor stage was T1 in 21 and T2 in 16 pts. LNM were observed in eight of 21 T1 (38%) and six of 16 T2 tumors (38%). No G1 and all G3 tumors developed LNM independently of tumor stage. Ten of the 26 G2 carcinomas (38%) harboured LNM and seven of these pts (70%) had a T1 tumor.

CONCLUSIONS

According to our data, the metastatic potential of T1 penile carcinoma has been underestimated in the recent literature. Tumor grading has a substantially stronger impact on the metastatic risk in T1 and T2 penile carcinoma than tumor stage, indicating a surgical lymph node staging starting at the pT1G2 stage.

External-beam radiotherapy in T1-2 N0 penile carcinoma

AIMS

To review the outcome of 41 patients with invasive carcinoma of the penis treated with external-beam radiotherapy using a consistent technique and dose.

MATERIALS AND METHODS

Forty-one patients with carcinoma of the penis treated at Christie Hospital, Manchester, UK, between 1995 and 2000 were reviewed retrospectively. Radiotherapy was delivered using 4 MV linear accelerators with a dose of 50 Gy or 52.5 Gy in 16 fractions over 22 days.

RESULTS

The distribution of patients according to stage was T1=37, T2=4, N0=40, N3=1. Median follow-up was 4.5 years. The local control rate was 62%, nodal relapse-free rate of 88%, relapse-free rate of 51% and overall survival of 88% at 5 years. All recurrences were salvaged by surgery. Penile ulceration occurred in 8% and urethral stenosis requiring dilatation in 29%. There were no penectomies for penile necrosis.

CONCLUSION

EBXRT may be offered for T1-2 cancer of the penis with close surveillance to detect local recurrences early for salvage surgery without jeopardising overall survival. It remains an alternative option to penis-preserving surgery and should be discussed in a multidisciplinary setting and with the patient.

Predicting Regional Lymph Node Metastasis in Chinese Patients With Penile Squamous Cell Carcinoma: The Role of Histopathological Classification, Tumor Stage and Depth of Invasion

PURPOSE

We determined whether histological factors of primary penile squamous cell carcinoma could predict the risk of regional lymph node metastasis.

MATERIALS AND METHODS

The clinical records of 72 consecutive Chinese patients with squamous cell carcinoma of the penis were analyzed retrospectively. Of the patients 58 underwent bilateral inguinal lymph node dissection, of whom 9 also underwent unilateral or bilateral pelvic lymph node dissection. Primary lesions were evaluated according to recently revised standards. The variables recorded were histopathological classification, histological grade, pathological tumor stage, invasion depth, vascular invasion, and the number and position of metastatic lymph nodes.

RESULTS

No patients with verrucous carcinoma had regional lymph node metastasis. However, 100% of patients with basaloid, 33.3% with warty and 30% with typical squamous cell carcinoma had lymph node metastasis (p = 0.002). The rate of lymph node metastasis was 18.8% in patients with pT1, as compared with 53.1% in patients with pT2 or pT3 (p = 0.004). The mean depth of invasion was 9.3 (range 2 to 22) vs 3.2 mm (range 1 to 6) in patients with and without lymph node metastasis, respectively (p < 0.001).

CONCLUSIONS

Histopathological classification, pathological tumor stage and depth of invasion of the primary lesion are significant predictors of regional lymph node metastasis in Chinese patients with penile squamous cell carcinoma. Combining these predictors can be used to select patients who are the best candidates for regional lymphadenectomy.

Reproducibility of lymphoscintigraphy for lymphatic mapping in patients with penile carcinoma

PURPOSE

We evaluated the reproducibility of lymphoscintigraphy in the assessment of the location and number of sentinel nodes in patients with penile carcinoma.

MATERIALS AND METHODS

A total of 20 patients were prospectively included in analysis. Lymphoscintigraphy was performed after intradermal injection of technetium nanocolloid around the tumor or excision scar. We performed 10-minute anterior dynamic imaging, and static anterior and lateral images were obtained at 30 minutes and 2 hours. The following day scintigraphy was repeated after a second injection of the radiolabeled colloid given in an identical fashion, preceded by acquisition of a starting image. An observer evaluated the paired images and count rates were calculated from the images.

RESULTS

At least 1 sentinel node was visualized in all patients on the first lymphoscintigram. A total of 56 sentinel nodes were seen in 38 basins. Drainage to both groins was seen in 18 patients. In 1 of these patients drainage to the prepubic area was also observed. There were 2 patients with drainage to 1 groin. The second lymphoscintigram revealed the same drainage pattern in all patients- the same number of nodal basins and number of sentinel nodes were visualized at identical locations. All hotspots that were visualized during the first lymphoscintigram showed an unequivocal increase in radioactivity after repeat injection. Thus, the reproducibility of penile lymphoscintigraphy was 100% (95% CI 85%-100%). The Pearson correlation coefficient of the paired count rates was 0.69 (p <0.0001).

CONCLUSIONS

Results of lymphoscintigraphy in patients with penile carcinoma are highly reproducible for assessment of the number and location of sentinel nodes.

Risk stratification in penile carcinoma: 25-Year experience with surgical inguinal lymph node staging

OBJECTIVES

In penile carcinoma, the most reliable staging method for lymph node involvement remains radical dissection with its associated high morbidity. However, the patient's prognosis is closely associated with lymph node status, and radical dissection is potentially curative. We report our experience with surgical lymph node staging and evaluate which group of patients could be assigned to a wait-and-see strategy or dynamic sentinel node biopsy and which group should undergo groin dissection.

METHODS

From 1979 to 2004, 56 consecutive patients with penile cancer underwent surgical inguinal lymph node staging. On the basis of the histopathologic results, we defined risk stratification into low, high, and intermediate-risk groups according to the clinical examination findings, stage, and grade.

RESULTS

Tumor stage (P = 0.019) and tumor grade (P <0.001) correlated significantly with lymph node status. Stratification into low (pT1G1, pT1G2), high (all G3 tumors), and intermediate-risk (all others) groups found 7.7% of low-risk patients with metastases. In the intermediate and high-risk groups, 28.6% and 75.0% had nodal metastases, respectively. Correlation with nodal involvement according to risk group was R2 = 0.608 (P <0.001).

CONCLUSIONS

Risk stratification might enable a modified staging strategy for lymph node status according to stage, grade, and clinical examination findings. Highly motivated low-risk patients could be included in a surveillance program; however, high-risk patients should undergo bilateral inguinal dissection. Dynamic sentinel lymph node biopsy might be encouraged for intermediate-risk patients in the future.

Size of Metastasis in the Sentinel Node Predicts Additional Nodal Involvement in Penile Carcinoma

PURPOSE

The majority of patients with penile cancer with a tumor positive sentinel node do not benefit from complementary lymph node dissection because of absent additional involved nodes. We analyzed factors that may determine the involvement of additional nodes.

MATERIALS AND METHODS

A total of 158 patients with clinically node negative penile carcinoma underwent sentinel node biopsy. Complementary inguinal lymph node dissection was performed when the sentinel node was tumor positive. The size of the sentinel node metastasis was measured and classified as micrometastasis--2 mm or less, or macrometastasis--more than 2 mm. Sentinel and dissection specimen nodes were step-sectioned. Factors were analyzed for their association with additional nodal involvement, including stage, diameter, grade, absence or presence of vascular invasion of the primary tumor, and sentinel node metastasis size.

RESULTS

Tumor positive sentinel nodes were found in 46 groins and complementary lymph node dissection was performed. Nine of these 46 groins (20%) contained additional involved lymph nodes. On univariate and multivariate analyses the size of the sentinel node metastasis proved to be the only significant prognostic variable for additional lymph node involvement (each p = 0.02). None of the 15 groins with only micrometastasis in the sentinel node contained additional involved nodes.

CONCLUSIONS

In penile carcinoma additional nodal involvement was related to the size of the metastasis in the sentinel node. Sentinel node micrometastasis was not associated with other involved lymph nodes. This finding suggests that these patients can be spared complementary lymph node dissection.

Nomogram Predictive of Cancer Specific Survival in Patients Undergoing Partial or Total Amputation for Squamous Cell Carcinoma of the Penis

PURPOSE

We created the first nomograms to predict cancer specific survival probabilities of patients with squamous cell carcinoma of the penis, clustering prognostic information from the most commonly used clinical and pathological variables.

MATERIALS AND METHODS

We retrospectively collected clinical and pathological data from 175 patients who had undergone surgery for squamous cell carcinoma of the penis from 1980 to 2002 at 11 urological centers in northeastern Italy. A logistic regression model was used to construct the nomogram.

RESULTS

At a median followup of 24 months, 101 patients (57.7%) were alive and disease-free while 74 (42.3%) died of penile cancer. According to multivariate analyses, 2 models predictive of cancer specific survival probability were generated. The first model was based on the pathological findings of the primary tumor after penectomy and on the clinical stage of groin lymph nodes, while the second model included the pathological data of the primary tumor and groin lymph nodes. The concordance index was 0.728 for the first model and 0.747 for the second. Calibration appeared to be good in both models.

CONCLUSIONS

In this article we propose 2 models to predict the 5-year cancer specific survival probabilities of patients with squamous cell carcinoma of the penis. Both models showed good discriminating power and calibration in predicting patient 5-year cancer specific survival. These nomograms could improve the quality of prognostic data provided to patients and support physicians in planning treatment.

Fine-needle aspiration cytology predicts inguinal lymph node metastasis without antibiotic pretreatment in penile carcinoma

OBJECTIVE

To evaluate the accuracy of fine-needle aspiration (FNA) cytology of palpable inguinal lymphadenopathy before definitive management of the primary tumour, in predicting inguinal lymph node (LN) metastasis in men with primary squamous cell carcinoma (SCC) of the penis.

PATIENTS AND METHODS

Sixteen men with primary SCC of the penis and palpable inguinal lymphadenopathy (unilateral or bilateral) were treated by primary resection and bilateral inguinal LN dissection. FNA cytology was analysed for 25 palpable inguinal LNs at the time of penile biopsy. The sensitivity, specificity and accuracy of FNA cytology was compared with the histological findings from surgical LN clearance.

RESULTS

The 25 FNAs were without complication and without evidence of implantation of metastasis in the needle tracts; 14 FNA samples were positive for metastasis, 10 were negative, and one was inconclusive. From the histological assessment of the surgical inguinal LN specimens, FNA cytology had a sensitivity of 93%, and specificity of 91% in predicting metastatic disease.

CONCLUSION

FNA cytology of palpable inguinal lymphadenopathy before surgery for the primary tumour has a high sensitivity and specificity for metastatic penile cancer. This procedure permits early inguinal lymphadenectomy where appropriate without need for prolonged initial antibiotic treatment.

Dynamic sentinel node biopsy in clinically node-negative penile cancer versus radical inguinal lymphadenectomy: a comparative study

OBJECTIVES

To evaluate the reliability and morbidity of dynamic sentinel node biopsy compared with radical inguinal lymphadenectomy (RIL) in the treatment of selected patients with squamous cell penile carcinoma.

METHODS

We retrospectively considered patients with clinically node-negative Stage pT2-pT3 penile cancer. From 1994 to 2000, 48 patients (group 1, mean age 63 years) underwent penectomy and, after 4 weeks, prophylactic bilateral RIL. From 2001 to 2004, 22 patients (group 2, mean age 67 years) underwent penectomy and dynamic sentinel node biopsy. After 4 weeks, bilateral RIL was performed.

RESULTS

In group 1, nodal disease was found in 39.6% of the patients. Early complications occurred in 21 patients (47.5%), with the most common being seroma formation. Late complications occurred in 18 patients (37.5%), with the most common being leg edema. In group 2, preoperative lymphoscintigraphy revealed no sentinel nodes in 1 patient, unilateral sentinel nodes in 7, and bilateral nodes in 14. A total of 35 sentinel nodes were seen in 42 inguinal regions (mean 0.83), including 27 (77.2%) identified with the probe and blue dye and 8 (22.8%) located with the probe only. Metastases were noted in 8 (36.4%) of 22 patients, bilaterally in 4 of them. Early minor complications occurred in 3 patients (13.6%). The technique had an 89% negative predictive value and 90% sensitivity.

CONCLUSIONS

The results of this study have shown that dynamic sentinel node biopsy is a minimally invasive technique that is easy to perform, with similar results to those of RIL, but lower morbidity. This procedure offers the possibility of less-extensive surgery for clinically node-negative penile carcinoma.

Advances in the treatment of carcinoma of the penis

The aim of this article is to define the therapeutic advances in the treatment of penile cancer over the past 2 decades. A literature search was conducted for articles in which a major change in therapy was documented as beneficial. Case records were then reviewed in patients who underwent such procedures. Major advances have involved less disfiguring treatment of the primary lesion in selected cases and the recognition of improved survival by altering the timing of groin dissection for those at risk for metastatic disease.

What's new in the management of penile cancer?

PURPOSE OF REVIEW

Penile cancer is a rare disease. This has led to little in the way of therapeutic advances in the last two decades. Efforts have been made to minimize the use of disfiguring or morbid procedures in treating the primary tumor or managing the inguinal region. In addition, new insights have been gained into multimodal therapy for treating metastatic disease. We reviewed the literature published during the past two years to define the recent insights into the diagnosis and management of penile cancer.

RECENT FINDINGS

Surveillance, Epidemiology and End Results Program data revealed poor outcome among African-American patients compared with Caucasians with penile cancer. Risk factors, including human papilloma virus, HIV, and the practice of circumcision have been reassessed. To improve diagnosis and staging, new modifications in imaging have been developed including magnetic resonance imaging with artificial erection. In addition, the technique of dynamic sentinel node biopsy has been refined. Pathologic features of the primary tumor (i.e., stage, grade, vascular invasion) assist in identifying patients who would benefit from lymphadenectomy. Organ-sparing treatments using laser ablation and reconstructive procedures to preserve glans or phallus length have also been developed. Systemic chemotherapy regimens, including consolidative approaches with surgery or radiotherapy, are discussed for advanced penile cancer.

SUMMARY

Penile cancer remains a rare disease. Epidemiologic insights reveal provocative findings with respect to risk factors and racial differences in the outcome. Recent literature provides information that will aid urologists in (1) minimizing the need for disfiguring treatment of penile tumors in some patients and (2) reducing the number of unnecessary inguinal staging procedures in others. Novel systemic therapies that generate durable responses tested in multi-institutional treatment trials are needed.

Peniskarzinom — Nachsorge mit Konsequenz

Penile cancer is a rare tumor entity but penile carcinoma is characterized by a high recurrence rate regarding local, lymphatic, and hematogenous recurrence. The critical period for tumor recurrence is in the first 5 years. Therapeutic options for tumor recurrence can be differentiated by the type of recurrence and the preceding therapy. The prognosis of local or small lymphatic recurrence-if detected early and diligently diagnosed-can be improved significantly by radical surgery. On the other hand, systemic therapy of advanced lymphatic recurrences and hematogenous metastases will influence disease progression only marginally. Based on these considerations, the follow-up of penile cancer should be risk adapted but close as suggested by our algorithm. With a reduced, but close follow-up we can offer our patients aftercare with the consequence of improved prognosis.