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

New histological risk grading system for prediction of lymph node metastasis in patients with penile cancer

Inguinal lymph node surgery is a standard treatment for penile cancer patients with intermediate or high risk for lymph node metastasis (LNM) according to European Association of Urology (EAU) risk grading. We are proposing a more objective histological prognostic grading system for inguinal LNM in these patients. We assessed worst pattern of invasion, lymphocytic host response, lymphovascular invasion, and perineural invasion in a population-based cohort of 306 penile cancer patients. Patients were classified into low, intermediate, and high risk for inguinal LNM. There was a significant association both between risk groups and pT stage (p < 0.001) and between risk groups and LNM. Univariate logistic regression showed 25.43 times higher odds of LNM for patients in the intermediate risk group compared with the low risk group (odds ratio (OR) 25.43; 95% confidence interval (CI): 5.94-108.97) and a 177.13 times higher odds in the high risk group compared to the low risk group (OR 177.13; 95% CI: 40.09-782.51). When comparing our histological risk grading with the EAU grading, we found a higher sensitivity, of 51.28% (95% CI: 45.68-56.88) versus 37.09% (95% CI: 31.68-42.50), as well as a higher area under the curve (0.86; 95% CI: 0.81-0.89; versus 0.65; 95% CI: 0.58-0.71) with our grading system. While our grading classified 111 patients as low risk, only 31 were considered low risk for LNM according to the EAU risk classification. The new histological risk grading system shows a higher sensitivity and includes a higher number of patients in the low risk group in whom lymph node surgery could be avoided, reducing morbidity and costs.

New EAU/ASCO guideline recommendations on sentinel node biopsy for penile cancer and remaining challenges from a nuclear medicine perspective

INTRODUCTION

The European Association of Urology (EAU) and the American Society of Clinical Oncology (ASCO) recently issued updated guidelines on penile cancer, emphasising dynamic sentinel node biopsy (DSNB) as the preferred method for surgical staging among patients with invasive penile tumours and no palpable inguinal lymphadenopathy. This paper outlines the rationale behind this new recommendation and describes remaining challenges, as well as strategies for promoting DSNB worldwide.

MAIN TEXT

DSNB offers high diagnostic accuracy with the lowest postoperative complications compared to open or minimally invasive inguinal lymph node dissection (ILND), prompting its preference in the new guidelines. Nevertheless, despite its advantages, there are challenges hampering the widespread adoption of DSNB. This includes the false-negative rate associated with DSNB and the potential negative impact on patient outcome. To address this issue, improvements should be made in several areas, including refining the timing and interpretation of the lymphoscintigraphy and the single photon emission computed tomography/computed tomography images. In addition, the quantity of tracer employed and choice of the injection site for the radiopharmaceutical should be optimised. Finally, limiting the removal of nodes without tracer activity during surgery may help minimise complication rates.

CONCLUSION

Over the years, DSNB has evolved significantly, related to the dedicated efforts and innovations in nuclear medicine and subsequent clinical studies validating its efficacy. It is now strongly recommended for surgical staging among selected penile cancer patients. To optimise DSNB further, multidisciplinary collaborative research is required to improve SN identification for better diagnostic accuracy and fewer complications.

Penile cancer: long-term infectious and thromboembolic complications following lymph node dissection - a population-based study (Sweden)

PURPOSE

To assess the long-term risks of infectious and thromboembolic events following inguinal (ILND) and pelvic (PLND) lymph node dissection in men with penile cancer.

MATERIAL AND METHODS

A total of 364 men subjected to ILND with or without PLND for penile cancer between 2000 and 2012 were identified in the Swedish National Penile Cancer Register. Each patient was matched based on age and county of residence with six penile cancer-free men. The Swedish Cancer Register and other population-based registers were used to retrieve information on treatment and hospitalisation for selected infectious and thromboembolic events. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox proportional hazard models with multiple imputation.

RESULTS

The risk of infectious events remained increased for more than five years postoperatively in men with penile cancer compared with matched controls. The palpable nodal disease was the only predictor of these events, with risk increasing with the cN stage. The HR at one, three and five years and six months postoperatively was 8.60 (95% CI 5.16-14.34), 4.02 (95% CI 2.65-6.09) and 1.93 (95% CI 1.11-3.38), respectively. An increased risk of thromboembolic events persisted for three years postoperatively. The HR at one and three years postoperatively was 13.51 (95% CI 6.53-27.93) and 2.12 (95% CI 1.07-4.20). The results correspond well with the over-prescription of anticoagulants observed during this period. An association with bulky disease (cN3) was observed.

CONCLUSIONS

Lymph node dissection for penile cancer is associated with an increased risk of infectious and thromboembolic events. The findings of this population-based study show that the risks of these events remain increased more than five years for infectious and three years for thromboembolic events. Improved awareness of long-term complications following ILND is of importance both among patients and care givers to ensure early detection and treatment.

Morbidity and risk factors for complications of inguinal lymph node dissection in penile cancer

PURPOSE

To assess the morbidity of inguinal lymph node dissection (ILND) in penile cancer, then to compare this morbidity with that of ILND performed in the context of skin cancer treatment.

METHODS

We retrospectively included all patients having undergone ILND between 1 January 2004 and 31 December 2019 in our centre's urology department in the context of treatment of penile cancer or skin cancer. Postoperative complications were reported in accordance with the Clavien-Dindo classification system.

RESULTS

Two hundred forty-two ILNDs were performed in 122 patients with penile cancer and 56 ILNDs were performed in 56 patients with skin cancer. The most common early complication was postoperative fluid collection (lymphocele or haematoma), which complicated 44% of ILNDs overall and 60% of radical lymphadenectomies. The most common late complication was leg lymphoedema, found in up to 36% of radical lymphadenectomies. Major complications (grade ≥ III) were very rare (4% of radical lymphadenectomies). Radical lymphadenectomies resulted in significantly more cases of postoperative fluid collection, skin necrosis and dehiscence, as well as leg lymphoedema, than modified lymphadenectomy techniques. Two factors significantly increasing postoperative morbidity were demonstrated: ASA score = 3 (OR = 3.09) and operating time (OR = 1.01).

CONCLUSION

ILNDs are morbid surgical procedures for which the indications must be well defined. However, the complications are almost exclusively minor, for a major oncological benefit.

The Acute Complications After Surgery for Penile Carcinoma and Strategies for Their Management: A Systematic Review of the Literature

OBJECTIVES

To investigate the contemporary rates of 30-day complications after surgery for penile cancer and to discuss the currently used preventative and therapeutic practices aimed at mitigation of these postoperative adverse events.

DATA SOURCES

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed, and studies reporting on the contemporary rates, nature, or management of acute complications following primary penile surgery or inguinal lymph node dissection for penile cancer were abstracted. Medline (PubMed) and EMBASE libraries were used to retrieve the articles published between January 1984 and December 2021 (n = 170 articles). Ultimately, 38 articles were included. The primary outcome of interest was 30-day (acute) postoperative complications, stratified by those associated with treatment of the primary penile lesion and those with inguinal lymph node dissection. Risk of bias assessment was undertaken. Special attention was paid to studies reporting management strategies for these complications.

CONCLUSION

This comprehensive review revealed that the quality of existing studies reporting on complications is poor and the risk of bias is high. Within these studies, the rates of acute complications following primary penile surgery and inguinal lymph node dissection ranged between 0% and 29.4% and 6% and 90%, respectively. More than 50% of these complications were wound related. Over the past two decades, several studies have reported on improved surgical techniques and protocolized postsurgical care pathways. Although the newer techniques have been associated with improved outcomes, the absolute rates of complications have remained high even in the most contemporary series. Therefore, there is an urgent need for health care providers and stakeholders to reach consensus regarding preoperative workup and medical optimization goals, stage appropriate therapies, and postoperative care pathways, as has been done for other malignancies associated with high morbidity.

IMPLICATIONS FOR NURSING PRACTICE

Penile cancer is a disease of the elderly, and surgical management of the primary lesion or the groins is associated with a high rate of complications. Most complications are wound related. Meticulous surgical technique and careful postoperative monitoring with early intervention are keys to mitigating surgery-related morbidity. However, equally important is dissemination and adoption of these principles by all health care workers universally.

Radioisotope-Guided Sentinel Lymph Node Biopsy in Penile Cancer: A Long-Term Follow-Up Study

Lymph node (LN) management is critical for survival in patients with penile cancer. However, radical inguinal lymphadenectomy carries a high risk of postoperative complications such as lymphedema, lymphocele, wound infection, and skin necrosis. The European Association of Urology guidelines therefore recommend invasive LN staging by modified inguinal lymphadenectomy or dynamic sentinel node biopsy (DSNB) in clinically node-negative patients (cN0) with intermediate- and high-risk tumors (≥ T1G2). However, the timing of DSNB (simultaneous vs. subsequent to partial or total penile resection) is controversial and the low incidence of penile cancer means that data on the long-term outcomes of DSNB are limited. The present study aimed to analyze the reliability and morbidity of DSNB in patients with penile cancer during long-term follow-up. This retrospective study included 41 patients (76 groins) who underwent radioisotope-guided DSNB simultaneously or secondarily after penile surgery from June 2004 to November 2018. In total, 193 sentinel LNs (SLNs) and 39 non-SLNs were removed. The median number of dissected LNs was 2.5 (interquartile range 2-4). Histopathological analysis showed that five of the 76 groins (6.6%) contained metastases. None of the non-SLNs were tumor-positive. In accordance with the guidelines, all inguinal regions with positive SLNs underwent secondary radical inguinal lymphadenectomy, which revealed three additional metastases in one groin. Regional LN recurrence was detected in three patients (four groins) during a median follow-up of 70 months, including two patients in whom DSNB had been performed secondarily after repetitive penile tumor resections. DSNB-related complications occurred in 15.8% of groins. Most complications were mild (Clavien-Dindo grade I; 50%) or moderate (II; 25%), and invasive intervention was only required in 3.9% of groins (IIIa: n = 1; IIIb: n = 2). In summary, this study suggests that the current radioisotope-guided DSNB procedure may reduce the complication rate of inguinal lymphadenectomy in patients with cN0 penile cancer. However, DSNB and penile surgery should be performed simultaneously to minimize the false-negative rate. Recent advances, such as new tracers and imaging techniques, may help to reduce the false-negative rate of DSNB further.

Technical management of inguinal lymph-nodes in penile cancer: open versus minimal invasive

Inguinal lymphadenectomy (ILND) remains the standard of care for patients with invasive squamous cell carcinoma of the penis, dictating patient prognosis, adjuvant therapies, and surveillance strategies. Importantly the performance of an ILND has been shown to improve cancer-specific outcomes, providing a modifiable factor for patients with an aggressive malignancy. Surprisingly, the procedure remains underutilized, mainly due to the high surgical morbidity associated with the procedure. The open lymphadenectomy technique has undergone several modifications over the last 30 years to minimize its associated surgical morbidity, but wound-related complications remain significant. Minimally invasive surgery (MIS) techniques have been recently introduced to help mitigate wound-related complications associated with open lymphadenectomy, with promising results. In this review, we highlight the importance of ILND, present a detail review of the surgical and oncological outcomes associated with open, laparoscopic and robotic ILND for patients with penile cancer.

Final results of the PräVAC trial: prevention of wound complications following inguinal lymph node dissection in patients with penile cancer using epidermal vacuum-assisted wound closure

PURPOSE

Inguinal lymphadenectomy in penile cancer is associated with a high rate of wound complications. The aim of this trial was to prospectively analyze the effect of an epidermal vacuum wound dressing on lymphorrhea, complications and reintervention in patients with inguinal lymphadenectomy for penile cancer.

PATIENTS AND METHODS

Prospective, multicenter, randomized, investigator-initiated study in two German university hospitals (2013-2017). Thirty-one patients with penile cancer and indication for bilateral inguinal lymph node dissection were included and randomized to conventional wound care on one side (CONV) versus epidermal vacuum wound dressing (VAC) on the other side.

RESULTS

A smaller cumulative drainage fluid volume until day 14 (CDF) compared to contralateral side was observed in 15 patients (CONV) vs. 16 patients (VAC), with a median CDF 230 ml (CONV) vs. 415 ml (VAC) and a median maximum daily fluid volume (MDFV) of 80 ml (CONV) vs. 110 ml (VAC). Median time of indwelling drainage: 7 days (CONV) vs. 8 days (VAC). All grade surgery-related complications were seen in 74% patients (CONV) vs. 74% patients (VAC); grade 3 complications in 3 patients (CONV) vs. 6 patients (VAC). Prolonged hospital stay occurred in 32% patients (CONV) vs. 48% patients (VAC); median hospital stay was 11.5 days. Reintervention due to complications occurred in 45% patients (CONV) vs. 42% patients (VAC).

CONCLUSIONS

In this prospective, randomized trial we could not observe a significant difference between epidermal vacuum treatment and conventional wound care.

External validation of nomogram to predict inguinal lymph node metastasis in patients with penile cancer and clinically negative lymph nodes

INTRODUCTION

Penile cancer (PC) occurs less frequently in Europe and in the United States than in South America and parts of Africa. Lymph node (LN) involvement is the most important prognostic factor, and inguinal LN (ILN) dissection can be curative; however, ILN dissection has high morbidity. A nomogram was previously developed based on clinicopathological features of PC to predict ILN metastases. Our objective was to conduct an external validation of the previously developed nomogram based on our population.

MATERIALS AND METHODS

We included men with cN0 ILNs who underwent ILN dissection for penile carcinoma between 2000 and 2014. We performed external validation of the nomogram considering three different external validation methods: k-fold, leave-oneout, and bootstrap. We also analyzed prognostic variables. Performance was quantified in terms of calibration and discrimination (receiver operator characteristic curve). A logistic regression model for positive ILNs was developed based on clinicopathological features of PC.

RESULTS

We analyzed 65 men who underwent ILN dissection (cN0). The mean age was 56.8 years. Of 65 men, 24 (36.9%) presented with positive LNs. A median 21 ILNs were removed. Considering the three different methods used, we concluded that the previously developed nomogram was not suitable for our sample.

CONCLUSIONS

In our study, the previously developed nomogram that was applied to our population had low accuracy and low precision for correctly identifying patients with PC who have positive ILNs.

Current controversies and developments on the role of lymphadenectomy for penile cancer

Penile squamous cell carcinoma is a rare cancer in men. The main prognosticators of survival for penile cancer patients remain the presence and the extent of lymph node metastasis. While radical inguinal lymphadenectomy has been the cornerstone of regional lymph node management for many years, it is still associated with significant morbidity and psychological distress. Recent developments in penile squamous cell carcinoma management have been met with some controversy in the urologic oncology community. Herein, we review the current controversies and developments on the role of inguinal lymphadenectomy for penile cancer.

Sentinel node biopsy and lymphatic mapping in penile and prostate cancer

BACKGROUND

Nodal metastases are linked to poor outcome in men with penile or prostate cancer. Early detection and resection are important for staging and for the prognosis. However, lymphadenectomy is associated with morbidity and may miss metastases when performed solely on the basis of anatomical templates.

METHODS

In this article we describe the technique and benefits of sentinel node biopsy (SNB) and provide a review of the literature.

RESULTS

Dynamic sentinel node techniques using both radioactive and optical (hybrid) tracers have been proven effective in penile cancer. For prostate cancer, SNB added to extended nodal dissection may further tailor dissection to the highly variable lymphatic drainage patterns in the pelvis. The sensitivity of SNB was found to be superior to conventional imaging methods; however, false-negative SNB procedures can occur and a complementary extensive lymphadenectomy is required to remove additional positive nodes that were not detected in the SNB template.

CONCLUSION

SNB is a standard method for early detection of nodal metastases in penile cancer and provides superior diagnostic accuracy to conventional imaging modalities in prostate cancer.

Prospective study comparing video-endoscopic radical inguinal lymph node dissection (VEILND) with open radical ILND (OILND) for penile cancer over an 8-year period

OBJECTIVE

To compare the complications and oncological outcomes between video-endoscopic inguinal lymph node dissection (VEILND) and open ILND (OILND) in men with carcinoma of the penis.

PATIENTS AND METHODS

A prospectively collected institutional database was used to determine the outcomes in 42 consecutive patients undergoing ILND between 2008 and 2015 in a centre for treating penile cancer. Before 2013 all procedures were OILNDs. Since 2013 we have performed VEILND on all patients in need of ILND. The wound-related and non-wound-related complications, length of stay, and oncological safety between OILND and VEILND groups were compared. The mean duration of follow-up was 71 months for OILND and 16 months for the VEILND groups.

RESULTS

In the study period 42 patients underwent 68 ILNDs (OILND 35, VEILND 33). The patients' demographics, primary stage and grade, and indications were comparable in both groups. There were no intraoperative complications in either group. The wound complication rate was significantly lower in the VEILND group at 6% compared to 68% in the OILND group. Lymphocoele rates were similar in both the groups (27% and 20%). The VEILND group had a better or the same lymph node yield, mean number of positive lymph nodes, and lymph node density confirming oncological safety. There were no groin recurrences in either group of patients. VEILND significantly reduced the mean length of stay by 4.8 days (P < 0.001).

CONCLUSION

VEILND is an oncologically safe procedure with considerably low morbidity and reduced length of stay, at a mean (range) follow-up of 16 (4-35) months.

Sentinel lymph node biopsy in renal malignancy: The past, present and future

Sentinel lymph node biopsy (SLNB) is now an established technique in penile and pelvic cancers, resulting in a lower mortality and morbidity when compared with the traditional lymph node dissection. In renal cancer however, despite some early successes for the SLNB technique, paucity of data remains a problem, thus lymph node dissection and extended lymph node dissection remain the management of choice in clinically node positive patients, with surveillance of lymph nodes in those who are clinically node negative. SLNB is a rapidly evolving technique and the introduction of new techniques such as near infra-red fluorescence optical imaging agents and positron emission tomography/computed tomography scans, may improve sensitivity. Evidence in support of this has already been recorded in bladder and prostate cancer. Although the lack of large multi-centre studies and issues around false negativity currently prevent its widespread use, with evolving techniques improving accuracy and the support of large-scale studies, SLNB does have the potential to become an integral part of staging in renal malignancy.

Role of dynamic sentinel node biopsy in carcinoma penis with or without palpable nodes

Introduction:

We aimed to evaluate the role of dynamic sentinel node biopsy (DSLNB) in patients diagnosed with carcinoma penis and clinically N0 disease using superficial inguinal dissection as the standard staging modality.

Materials and Methods:

Twenty consecutive men (40 groins) with carcinoma penis having clinically N0 status were enrolled in the study. Patients underwent DSLNB if fine needle aspiration cytology from the groin nodes was negative, followed by injection of radiocolloid and blue dye. The sentinel lymph node(s) were harvested. The inguinal incision was then extended and a modified superficial inguinal dissection was performed and all nodes were labeled separately and sent for frozen section. A completion deep inguinal with pelvic dissection was performed if any of the nodes were reported positive for malignancy.

Results:

The median age of the patients was 52.5 years. Ten patients were smokers. Phimosis was present in five patients. Lesions were present over the glans penis and shaft in 18 and two patients, respectively. Wide local excision, partial penectomy and total penectomy were performed in one, 15 and four patients, respectively. Clinically palpable nodes were found in 19 groins. Median follow-up was 26 months. Nodes were positive in 10 groins. DSLNB missed the sentinel node in one groin. The accuracy and false-negative rate of DSLNB was 97.5% and 10%, respectively.

Conclusion:

DSLNB is a useful and reliable technique to identify the involved node(s) in patients diagnosed as having carcinoma penis with clinical N0 status (with or without palpable nodes). It helps to avoid the morbidity associated with a staging inguinal dissection in these patients.

Dynamic sentinel node biopsy in penile cancer: initial experiences at a Swedish referral centre

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? According to the current European Association of Urology Guidelines, dynamic sentinel node biopsy is the recommended approach to assess lymph node status in men with cN0 intermediate and high risk penile cancer. Nevertheless, most encouraging results derive from a limited number of studies. The present study shows a false-negative rate of 15%, comparable with or better than several previous studies. Nevertheless, the aim should be a false-negative rate of no more than 5%. We conclude that increased overall experience and the use of the complete modern dynamic sentinel node biopsy protocol are paramount to improve results.

OBJECTIVE

•  To evaluate the false-negative rate and complication rate of dynamic sentinel node biopsy (DSNB) in penile cancer.

PATIENTS AND METHODS

•  In this retrospective study, 58 unilaterally or bilaterally clinically lymph node negative (cN0) patients with penile cancer (57 squamous cell carcinomas and one malignant melanoma), scheduled for DSNB at the Örebro University Hospital, Sweden, between 1999 and 2011, were analysed. •  Preoperative ultrasonography and fine-needle aspiration cytology of suspicious nodes were not introduced until 2008. •  Patients were assessed by lymphoscintigraphy using (99m) technetium nanocolloid on the day before surgery and the dissection of sentinel nodes was aided by the lymphoscintigraphic images and intraoperative detection of radiotracer and patent blue dye. •  The false-negative rate and complication rate were calculated per groin.

RESULTS

•  Of the 58 patients, 32 (55%) underwent preoperative ultrasonography. •  Two patients had positive fine-needle aspiration cytology and discontinued further DSNB protocol. Of the remaining 56 patients, all but one were bilaterally cN0 and hence 111 cN0 groins were assessed by lymphoscintigraphy. •  In the 55 bilaterally cN0 patients, lymphoscintigraphy visualized a bilateral sentinel node in 34 (62%). •  At surgery, all excised sentinel nodes were radioactive while 43% were additionally blue. In total, at least one sentinel node was harvested in 96 (86%) of the DSNB staged groins. •  A positive sentinel node was found in 11 groins (bilaterally in three patients). During a median follow-up of 21 months, two false-negative cases emerged, producing a false-negative rate of 15%. Both false-negative cases occurred during the first half of the study. The complication rate was 10%. The majority of complications were minor and transient.

CONCLUSIONS

•  DSNB is a minimally invasive staging tool in men with cN0 penile cancer, enabling early detection of metastatic disease and thus optimal care. •  Our false-negative rate of 15% is comparable or even favourable in comparison with several previous studies, but far from the 5% or less that we aim for. The complication rate found is somewhat higher than previously reported. •  With increased overall experience and the continued use of the complete DSNB protocol, we believe our results will improve and the complication rate will decrease.

Accuracy of sentinel lymph node biopsy for inguinal lymph node staging of penile squamous cell carcinoma: systematic review and meta-analysis of the literature

PURPOSE

Sentinel lymph node biopsy is emerging as a promising method for inguinal lymph node staging of penile squamous cell carcinoma. In the current systematic review we evaluated the accuracy of sentinel lymph node biopsy for inguinal lymph node staging of penile squamous cell carcinoma and studied possible influential factors.

MATERIALS AND METHODS

MEDLINE®, Scopus®, ISI®, Ovid SP®, Springer, ScienceDirect® and Google™ Scholar were searched by the key words "(penile OR penis) AND sentinel". No date or language limitation was imposed on the search and meeting abstracts were not excluded from analysis. A random effects model was used for statistical pooling.

RESULTS

A total of 17 studies suitable for meta-analysis were detected. Three articles had 2 different subgroups of patients and each subgroup was considered as a separate study. Overall 18 studies (including the subgroups) were used for detection rate meta-analysis and 19 for sensitivity meta-analysis. The pooled detection rate was 88.3% (95% CI 81.9-92.6). Pooled detection rate of 90.1% (95% CI 83.6-94.1) was calculated for the studies using blue dye and radiotracer. The pooled sensitivity was 88% (95% CI 83-92). The highest pooled sensitivity (92% [95% CI 86-96]) was in the studies using radiotracer and blue dye, and recruiting only cN0 cases.

CONCLUSIONS

Sentinel lymph node mapping in penile squamous cell carcinoma is a method with a high detection rate and sensitivity. Using radiotracer and blue dye for sentinel lymph node mapping and including only cN0 disease ensures the highest detection rate and sensitivity.

Controversies in ilioinguinal lymphadenectomy

Patients with penile cancer who are proven to have negative inguinal lymph nodes have an excellent prognosis. Furthermore, patients with small-volume inguinal node involvement can often be cured by surgery alone. Lymphadenectomy has clear survival benefits for patients when applied to those with lymph node metastasis. However, the current morbidity of the standard technique of lymphadenectomy is an impediment to its universal application, and innovative strategies to reduce the morbidity of staging/treatment that do not compromise oncologic control must be developed and standardized. The optimal integration of multimodality therapy to improve survival in advanced disease will occur only through collaborative studies between centers with significant patient volume, which would be facilitated through the development of regional referral centers.

[Treatment of lymph nodes in epidermoid carcinoma of the penis: review of literature by the Committee of Cancerology of the French Association of Urology-External Genital Organs Group (CCAFU-OGE)]

INTRODUCTION

Invasive lymph nodes are an independent factor of prognosis and essential for the survival of patients with cancer of the penis. The aim of this article is to analyse published research results on the diagnosis and treatment of lymph nodes in cancer of the penis.

MATERIAL AND METHOD

Bibliographic research on Medline was carried out using the terms penile carcinoma, lymph node dissection, lymphadenectomy, survival, chemotherapy and radiotherapy.

RESULTS

The risk of lymph node metastasis depends on the stage of the primitive tumour, its histological grade, the presence of venous and lymphatic embolus and the presence of palpable lymph nodes (classification into risk groups by the European Association of Urology [EAU]). A diagnosis of suspected adenopathy based on clinical examination associated with FNA biopsy is essential. No medical imaging (tomodensitometry, NMR, PET-scan) has proven to be superior to clinical examination. The search for the sentinel lymph node although interesting remains to be defined, especially in patients who have no palpated adenopathy but are at risk of metastasis. Not only is surgery on inguinal lymph nodes the only reliable way of confirming an invasive metastatic lymph node, it also plays a therapeutic and prognostic role for patients who have a tumour of the penis which risks spreading to lymph nodes (intermediate or high risk according to EAU). The act should always be two-fold. The type of dissection is in function with the clinical examination: a radical inguinal dissection is recommended in the case of palpated adenopathy and a modified inguinal dissection is recommended if there is no palpated adenopathy, this should be radicalised in the case of metastatic adenopathy on histological examination. Neo-adjuvant or adjuvant chemotherapy would appear to play a interesting role when combined with surgery for certain patients without there being currently being precise consensus because of the lack of documented cases. The same goes for external radiotherapy on inguinal lymph nodes which seems to play a role in local controls of the lymph node disease though increases morbidity risks of surgical intervention.

CONCLUSION

Lymph node dissection alone has a therapeutic role in patients who have reached metastasis of lymph nodes (stage pN1). However, it remains insufficient for patients who have metastatic infiltration of more than 2 lymph nodes (stage > or =pN2). Consequently, it would seem important to develop multimodal approaches in the treatment of these patients in order to increase the rate of response to treatment.

Value of frozen section analysis of enlarged lymph nodes during radical nephrectomy for renal cell carcinoma

OBJECTIVES

To avoid unnecessary lymphadenectomy for renal cell cancer (RCC) in patients with retroperitoneal enlarged lymph nodes (ELNs).

METHODS

Frozen section examination (FSE) of ELNs was used to evaluate the lymphatic status. In the present study, 114 patients with RCC underwent FSE of ELNs and concurrent regional lymphadenectomy. The results of FSE were compared with the final histopathologic results of lymphadenectomy. Some clinical tumor characteristics were also considered to improve the evaluation effect of the FSE. Multiple regression analysis was applied to define the independent risk factors for lymphatic metastasis.

RESULTS

The final histopathologic results indicated that 36 patients (31.6%) had nodal metastases. In these 36 patients, the FSE of ELNs revealed positive findings in 32 patients and negative findings in 4 patients. The sensitivity, specificity, concordance, and false-negative rate of FSE was 88.9%, 100%, 96.5%, and 11.1%, respectively. Multivariate analysis revealed that distant metastasis and high T stage (T3-T4) were independent risk factors for lymphatic metastasis. When FSE indicated negative results, no nodal metastases were found (64 patients) without these 2 risk factors.

CONCLUSIONS

ELNs in patients with RCC do not necessarily indicate metastatic disease, and more than one half of ELNs were benign. FSE of ELNs can be used to evaluate the lymphatic status. Using the findings from FSE and the clinical characteristics of the primary tumor, we can avoid unnecessary lymphadenectomy in patients with retroperitoneal ELNs.

Lymphadenectomy in the surgical management of penile cancer

CONTEXT

Uncertainty remains about the extent and indications for inguinal lymphadenectomy in penile cancer, a procedure known for relatively high morbidity. Several attempts have been made to develop strategies which can improve the diagnostic quality and reduce the morbidity of the management of inguinal lymph nodes in penile cancer.

OBJECTIVE

To analyse the existing published data on the surgical management of inguinal nodes in penile cancer regarding morbidity and survival.

EVIDENCE ACQUISITION

A Medline search was performed of the English-language literature (1966-September 2008) using the MeSH terms penile carcinoma, lymph node dissection, lymphadenectomy, and complications.

EVIDENCE SYNTHESIS

Lymph node metastases are frequent in penile cancer, even in early pT1G2 stages. Since the results of systemic treatment of advanced penile cancer are disappointing, complete dissection of all involved lymph nodes is highly recommended. The extent of lymph node dissection should be adapted to clinical stage, as this corresponds to metastatic spread. For low-risk patients (pTis, pTa, and pT1G1) without palpable lymph nodes and with good compliance, a surveillance strategy may be chosen. For all other patients without palpable lymph nodes (including intermediate risk pT1G2 disease), a modified bilateral lymphadenectomy is recommended. An alternative to this is a dynamic sentinel lymph node biopsy in specialised centres. All patients with histologically proven lymph node metastases should undergo radical inguinal lymphadenectomy. Pelvic lymph node dissection should be done in all patients with more than two metastatic inguinal lymph nodes. In case of fixed inguinal lymph nodes, neoadjuvant chemotherapy is recommended, followed by node resection.

CONCLUSIONS

Lymphadenectomy is an integral part of the management of penile cancer, since early dissection of involved lymph nodes improves survival.

Sentinel lymph node biopsy using dynamic lymphoscintigraphy combined with ultrasound-guided fine needle aspiration in penile carcinoma

The purpose of this study was to assess the utility of sentinel lymph node lymphoscintigraphy (SLNL) and ultrasound-guided fine needle aspiration cytology (FNAC) in patients with penile carcinoma. A prospective study was undertaken of 64 patients with stage T1 (or greater) clinically N0 squamous cell carcinoma of the penis. Patients underwent SLNL and bilateral groin ultrasonography with or without FNAC. Following intradermal blue dye, patients underwent unilateral or bilateral sentinel lymph node excision biopsy (SNB). 17 patients had sentinel nodes that contained metastases (21 nodal basins). Lymphatic drainage was demonstrated in all patients by lymphoscintigraphy. Bilateral drainage was seen in 57/64 patients. 61/64 patients had ultrasonography of the inguinal basins on the same day as FNAC of 38 basins. FNAC showed malignancy in eight basins. FNAC was negative in six basins, which were subsequently shown to be positive following SNB. 82 inguinal basins did not warrant FNAC by ultrasound criteria, of which 5 contained metastases at SNB. The sensitivity and specificity of ultrasonography was 74% and 77%, respectively. The positive and negative predictive values were 37% and 94%, respectively. Two patients had a negative initial SNB; however, ultrasonography identified a metastatic node and re-evaluation of the sentinel node confirmed micro-metastases. There has been no evidence of recurrence in any patients with negative SNB (during 6-28 months' follow-up). In conclusion, when investigating clinically stage N0 penile cancer, the combination of SNB and groin ultrasonography, with or without FNAC, identifies accurately those with occult nodal metastases. Ultrasonography alone is not adequate as a staging technique, and SNB alone might miss between 5% and 10% of metastases.

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.

What next? Managing lymph nodes in men with penile cancer

The management of patients with squamous cell carcinoma of the penis is often daunting given its rarity and subsequent lack of high-level evidence to support our decision-making. This culminates in the complex surgical issues involving the management of the regional lymph nodes, which is of critical importance to both quantity and quality of life for these patients. This review aims to highlight the decisive issues surrounding the management of the pelvic and inguinal lymph nodes in the setting of squamous cell carcinoma of the penis, and to spotlight recently published information that adds credence to accepted management strategies of both the clinically positive and negative groin after successful management of the primary lesion.

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.

Management of merkel cell carcinoma: the roles of lymphoscintigraphy, sentinel lymph node biopsy and adjuvant radiotherapy

BACKGROUND

Merkel cell carcinoma (MCC) is an uncommon, highly aggressive skin malignancy with a propensity to recur locally and regionally. However, its optimal treatment is uncertain. In this study, we aimed to assess the roles of lymphoscintigraphy and sentinel node (SN) biopsy, as well as radiotherapy, in the treatment of MCC.

PATIENTS AND METHODS

A retrospective analysis of 17 patients diagnosed with MCC (median age 74 years) over a 7-year period (median follow-up 16 months) was performed.

RESULTS

Of 11 patients. 3 had a positive SN biopsy and, despite adjuvant radiotherapy, 2 of these 3 developed regional lymph node (RLN) recurrence. Of the remaining 8 patients who had a negative SN biopsy, however, 5 also had RLN recurrences. There were 9 patients who received adjuvant radiotherapy (RT) to the primary site, with no in-field recurrences; and 8 who received RT to their RLN field, with only 2 developing regional nodal recurrences-both were SN biopsy positive. During the follow-up period, 2 patients died, only 1 due to MCC.

CONCLUSION

The results suggest that SN status may not be an accurate predictor of loco-regional recurrence in MCC. However, they strongly reinforce previous reports that radiotherapy, both locally and to regional nodes, provides effective infield disease control.

The isolated gamma probe technique for sentinel node penile carcinoma detection is unreliable

PURPOSE

Penile carcinoma is a common disease in northeast Brazil. This paper shows the results of the use of isolated gamma probe and discusses the incidence of false negative rates.

MATERIALS AND METHODS

From July 2000 to September 2003, 27 newly diagnosed penile carcinoma patients (T1, T2, N0) were included in this prospective study. The isolated gamma probe technique uses the sodium phytate technetium as a tracer and inguinal scanning with probe and after identified the lymph node it is removed. Lymphadenectomies were performed for positive inguinal lymph nodes metastasis.

RESULTS

There were 27 patients (mean age 59.6). Follow up was 37 months. Patients from country were 72% and illiterate or semi-illiterate were 56.7%. The tumors were mostly located in the glans (81.4%). They were T1, 52 % and T2, 48 %. 81.4% of the patients underwent partial penectomy, and 18.6% underwent postectomy and excision with wide margins. In 48% of the patients, the highest radioactive count rate was located on the left side, while in 41% was located on the right side. Only one patient had a positive pathological lymph node metastasis at the moment of the surgery. Additionally 3 patients became inguinal lymph node positive at the follow up. This date yielded a sensibility rate of 25% and a false-negative rate of 42.8%.

CONCLUSION

Isolated gamma probe technique for sentinel node penile carcinoma has a very low sensibility and a high false negative rate. Therefore it is highly advisable the addition of others methods such as lymphoscintigraphy, vital blue, ultrasonography and so on. The isolated gamma probe technique for sentinel node penile carcinoma detection is unreliable.

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.

Vacuum-assisted Closure versus Conventional Wound Care in the Treatment of Wound Failures Following Inguinal Lymphadenectomy for Penile Cancer: A Retrospective Study

OBJECTIVES

Impaired wound healing is a frequent event in inguinal surgery and very common after lymphadenectomy for penile cancer. Although vacuum therapy has been reported to expedite the healing of complex wound failures, vacuum-assisted closure (VAC) has been reported to be contraindicated in malignancy. In the present study we evaluated the use of VAC in the treatment of complex wound failures following inguinal lymphadenectomy for penile cancer in comparison to conventional wound care (CWC) implying debridement and saline-soaked gauze.

METHODS

We retrospectively identified six inguinal wounds following inguinal lymphadenectomy for penile cancer and subsequent use of VAC from 2003 to 2006 at our institution. Data on surgical interventions, complications, length of time required for closure, and outcome were compared to 10 inguinal defects treated with CWC between 2000 and 2003.

RESULTS

Wound volume was comparable for both groups. Wound breakdown occurred at a median of 7.4 d after inguinal lymphadenectomy and was treated by CWC for a mean of 69.8 d. In the VAC group, the median duration until complete closure was 38.9 d. Thus, VAC was shown to result in complete wound healing in less time (p<0.001). No local recurrence in the VAC group was noted despite positive lymph nodes.

CONCLUSIONS

VAC therapy is effective in complex inguinal wound failures following lymphadenectomy for penile cancer and appears to be superior to CWC. VAC seems to offer adequate safety concerning local recurrence.