Evaluation of dynamic sentinel lymph node biopsy in patients with squamous cell carcinoma of the penis and palpable inguinal nodes

Value and efficiency of sentinel lymph node diagnostics in patients with penile carcinoma with palpable inguinal lymph nodes as a new multimodal, minimally invasive approach

PURPOSE

The international guidelines recommend sentinel lymph node biopsy (SLNB) for lymph node staging in penile cancer with non-palpable inguinal lymph nodes (LN) but it is not recommended with palpable inguinal LN. The aim of this study was to evaluate the reliability and morbidity of SLNB in combination with an ultrasound-guided resection of suspect inguinal LNs as a new multimodal, minimally invasive staging approach in these patients.

METHODS

We performed SLNB in 26 penile cancer patients with 42 palpable inguinal LNs. Prior to the combined staging procedures the patients underwent an ultrasound examination of the groins as well as planar lymphatic drainage scintigraphy and SPECT/CT scans. During the surgical procedure, the radioactive-labelled sentinel lymph nodes and, in addition, sonographically suspect LNs, were resected under ultrasound guidance. Follow-up screening was done by ultrasound examination of the groins according to the guidelines of the European Association of Urology.

RESULTS

Nineteen groins of 42 preoperatively palpable inguinal findings were histologically tumor-positive. SLNB alone showed lymphogenic metastases in 14 groins. Sonography revealed five further metastatic groins, which would not have been detected during SLNB due to a tumor-related blockage of lymphatic drainage or a so-called re-routing of the tracer. During follow-up, none of the 28 groins with tumor-negative LN status showed any LN recurrence in this combined investigation technique. The median follow-up period was 46 (24 to 92) months. Morbidity of this procedure was low at 4.76 % in relation to the number of groins resp. 7.69 % in relation to the number of patients.

CONCLUSIONS

The results show that this combined procedure is a reliable multimodal diagnostic approach for treatment of penile cancer patients with palpable inguinal LNs. It is associated with low morbidity rates. SLNB alone would lead to a significantly higher false-negative rate in these patients. The encouraging results of this work can extend the range of indications for nuclear medicine in the form of SLNB using radioactive tracers in this patient group.

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.

Risk Group Systems for Penile Cancer Management: A Study of 203 Patients With Invasive Squamous Cell Carcinoma

OBJECTIVE

To evaluate the accuracy of previously published risk group systems for predicting inguinal nodal metastases in patients with penile carcinoma.

MATERIALS AND METHODS

Two hundred three cases of invasive penile squamous cell carcinomas (SCC) were stratified using the following systems: Solsona et al (J Urol 2001;165:1509), Hungerhuber et al (Urology 2006;68:621), and the system proposed by the European Association of Urology (EAU; Eur Urol 2004;46:1). Receiver operating characteristic (ROC) analysis was carried out to compare accuracy in predicting final nodal status and cancer-related death.

RESULTS

Most of cases were pT2/pT3 high-grade tumors with a small percentage of low-grade pT1 carcinomas. The metastatic rates for the Solsona et al, EAU, and Hungerhuber et al systems in the high-risk category were 15 of 73 (21%), 16 of 103 (16%), and 10 of 35 (29%) in patients with clinically negative inguinal lymph nodes and 52 of 75 (69%), 55 of 93 (59%), and 34 of 47 (72%) in patients with palpable inguinal lymph nodes, respectively. Performance by ROC analysis showed a low accuracy for all stratification systems although the Solsona et al and the Hungerhuber et al systems performed better than the EAU system. Patients in intermediate-risk categories and with clinically palpable inguinal lymph nodes were more likely to have nodal metastasis than patients with clinically negative lymph nodes in the same category.

CONCLUSION

These stratification systems may be useful for patients with low-grade superficial tumors and less accurate for evaluating patients with high-grade locally advanced penile carcinomas. These data may be useful for therapeutic planning of patients with penile SCC.

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.

Update in the management of penile cancer

PURPOSE

The management of penile cancer has evolved as less invasive techniques are applied in the treatment of the primary tumor and inguinal lymph nodes.

MATERIALS AND METHODS

Herein we review the literature focusing on advances in the preservation of the phallus as well as less morbid procedures to evaluate and treat the groins.

RESULTS

Promising imaging modalities for staging are discussed. New techniques are described and tables provided for penile preservation. We also review the contemporary morbidity of modified surgical forms for evaluation of the inguinal nodes.

CONCLUSIONS

Advances in surgical technique have made phallic preservation possible in a greater number of primary penile cancers. The groins can be evaluated for metastasis with greater accuracy through new radiologic means as well as with less morbid modified surgical techniques.

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.

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.

Visualization of tumor blockage and rerouting of lymphatic drainage in penile cancer patients by use of SPECT/CT

The reliability of sentinel node biopsy is dependent on the accurate visualization and identification of the sentinel node(s). It has been suggested that extensive metastatic involvement of a sentinel node can lead to blocked inflow and rerouting of lymph fluid to a "neo-sentinel node" that may not yet contain tumor cells, causing a false-negative result. However, there is little evidence to support this hypothesis. Recently introduced hybrid SPECT/CT scanners provide both tomographic lymphoscintigraphy and anatomic detail. Such a scanner enabled the present study of the concept of tumor blockage and rerouting of lymphatic drainage in patients with palpable groin metastases.

METHODS

Seventeen patients with unilateral palpable and cytologically proven metastases in the groin underwent bilateral conventional lymphoscintigraphy and SPECT/CT before sentinel node biopsy of the contralateral groin. The pattern of lymphatic drainage in the 17 palpable groin metastases was evaluated for signs of tumor blockage or rerouting.

RESULTS

On the CT images, the palpable node metastases could be identified in all 17 groins. Four of the 17 palpable node metastases (24%) showed uptake of radioactivity on the SPECT/CT images. In 10 groins, rerouting of lymphatic drainage to a neo-sentinel node was seen; one neo-sentinel node was located in the contralateral groin. A complete absence of lymphatic drainage was seen in the remaining 3 groins.

CONCLUSION

The concept of tumor blockage and rerouting was visualized in 76% of the groins with palpable metastases. Precise physical examination and preoperative ultrasound with fine-needle aspiration cytology may identify nodes with considerable tumor invasion at an earlier stage and thereby reduce the incidence of false-negative results.

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.