Modified Technique of Radical Inguinal Lymphadenectomy for Penile Carcinoma: Morbidity and Outcome

Inguinal Lymphadenectomy for Penile Cancer: An Interim Report from a Trial Comparing Open Versus Videoendoscopic Surgery Using a Within-patient Design

Background and objective

Nodal metastasis is a major survival and prognostic factor in penile cancer (PeCa). Thus, accurate staging, prognosis, and treatment selection require adequate inguinal lymphadenectomy (ILND). ILND surgery should balance oncologic rigor with morbidity and postoperative complications. Our aim was to compare the feasibility and safety of open ILND (OILND) and videoendoscopic ILND (VEILND) in patients with PeCa.

Methods

We conducted a single-center randomized trial with a within-patient design between October 2019 and April 2023. Patients who were undergoing either staging or radical ILND for PeCa were included and randomized to receive either OILND or VEILND on one side, with the other technique then used on the contralateral side. The trial was approved by the local ethics committee and was registered on ClinicalTrials.gov (NCT05887921). The primary outcome was the safety of VEILND. Secondary outcomes included intraoperative and postoperative morbidity rates and surgical outcomes for the two procedures, as well as oncological outcomes according to survival estimates.

Key findings and limitations

We included 14 patients in the study. Median follow-up was 12 mo (interquartile range [IQR] 12-17). There were no significant differences in operative time and the number of lymph nodes removed between OILND and VEILND. However, the median time to drain removal was significantly shorter in the VEILND group (15 d, IQR 13-17, 95% confidence interval [CI] 12-17) than in the OILND group (27 d, IQR 20-41, 95% CI 24-31; p = 0.025). No intraoperative complications were observed, but postoperative complications occurred in three cases (21.4%, 95% CI 8.4-37.8%) in the VEILND group and eight (57.1%, 95% CI 18.6-54.3%) in the OILND group (p = 0.032).

Conclusions and clinical implications

VEILND represents a safe technique to consider for either staging or curative intent in PeCa and seems to have an advantage over OILND in terms of morbidity. Further high-powered studies are warranted to confirm these preliminary results.

Patient summary

We compared the outcomes of two different surgical techniques to remove lymph nodes in patients with penile cancer. We found that a video-assisted keyhole surgery approach seems to result in a lower rate of complications than after open surgery.

Regional lymph node mapping in patients with penile cancer undergoing radical inguinal lymph node dissection - a retrospective cohort study

BACKGROUND

Radical inguinal lymph node dissection (rILND) is the most available treatment to cure penile cancer (PC) with limited inguinal-confined disease. However, guidelines regarding acceptable boundaries of rILND are controversial, and consensus is lacking. The authors aimed to standardize the surgical boundaries of rILND with definite pathological evidence and explore the distribution pattern of inguinal lymph nodes (ILNs) in PC.

METHODS

A total of 414 PC patients from two centers who underwent rILND were enrolled. The ILN distribution was divided into seven zones anatomically for pathological examination. Student's t test and Kaplan-Meier survival analysis were used.

RESULTS

ILNs displayed a funnel-shaped distribution with high density in superior regions. ILNs and metastatic nodes are present anywhere within the radical boundaries. Positive ILNs were mainly concentrated in zone I (51.7%) and zone II (41.3%), but there were 8.7% and 12.3% in inferior zones V and VI, respectively, and 7.1% in the deep ILNs. More importantly, a single positive ILN and first-station positive zone was detected in all seven regions. Single positive ILNs were located in zones I through VI in 40.4%, 23.6%, 6.7%, 18.0%, 4.5%, and 1.1%, respectively, and 5.6% presented deep ILN metastasis directly.

CONCLUSIONS

The authors established a detailed ILN distribution map and displayed lymphatic drainage patterns with definite pathological evidence using a large cohort of PC patients. Single positive ILNs and first-station metastatic zones were observed in any region, even directly with deep ILN metastasis. Only rILND can ensure tumor-free resection without the omission of positive nodes.

Management of Lymph Node-positive Penile Cancer: A Systematic Review

CONTEXT

Lymph node (LN) involvement in penile cancer is associated with poor survival. Early diagnosis and management significantly impact survival, with multimodal treatment approaches often considered in advanced disease.

OBJECTIVE

To assess the clinical effectiveness of treatment options available for the management of inguinal and pelvic lymphadenopathy in men with penile cancer.

EVIDENCE ACQUISITION

EMBASE, MEDLINE, the Cochrane Database of Systematic Reviews, and other databases were searched from 1990 to July 2022. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), and case series (CSs) were included.

EVIDENCE SYNTHESIS

We identified 107 studies, involving 9582 patients from two RCTs, 28 NRCSs, and 77 CSs. The quality of evidence is considered poor. Surgery is the mainstay of LN disease management, with early inguinal LN dissection (ILND) associated with better outcomes. Videoendoscopic ILND may offer comparable survival outcomes to open ILND with lower wound-related morbidity. Ipsilateral pelvic LN dissection (PLND) in N2-3 cases improves overall survival in comparison to no pelvic surgery. Neoadjuvant chemotherapy in N2-3 disease showed a pathological complete response rate of 13% and an objective response rate of 51%. Adjuvant radiotherapy may benefit pN2-3 but not pN1 disease. Adjuvant chemoradiotherapy may provide a small survival benefit in N3 disease. Adjuvant radiotherapy and chemotherapy improve outcomes after PLND for pelvic LN metastases.

CONCLUSIONS

Early LND improves survival in nodal disease in penile cancer. Multimodal treatments may provide additional benefit in pN2-3 cases; however, data are limited. Therefore, individualised management of patients with nodal disease should be discussed in a multidisciplinary team setting.

PATIENT SUMMARY

Spread of penile cancer to the lymph nodes is best managed with surgery, which improves survival and has curative potential. Supplementary treatment, including the use of chemotherapy and/or radiotherapy, may further improve survival in advanced disease. Patients with penile cancer with lymph node involvement should be treated by a multidisciplinary team.

Long-term follow-up of comparative study of open and endoscopic lymphadenectomy in patients with penile carcinoma

BACKGROUND

Penile carcinoma is an uncommon cancer that develops in the penis tissue. The standard surgical method to manage regional lymph nodes after local excision is radical inguinal lymphadenectomy, but it has a high rate of complications. The objective of this retrospective study was to compare the long-term outcomes of endoscopic inguinal lymphadenectomy and open inguinal lymphadenectomy in patients with penile carcinoma.

METHODS

The study included patients diagnosed with penile carcinoma who underwent open inguinal lymphadenectomy (n = 23) or endoscopic inguinal lymphadenectomy (n = 27) at a single hospital between January 2013 and January 2021. Operation time, blood loss, drainage, hospital stay, postoperative complications, and survival rates were assessed and compared between the two groups.

RESULTS

The two groups were comparable in terms of age, tumor size and stage, inguinal lymph nodes, and follow-up. The endoscopic group had significantly lower blood loss (27.1 ± 1.5 ml vs 55.0 ± 2.7 ml, P < 0.05), shorter drainage time and hospital stay (4.7 ± 1.1 days vs 8.1 ± 2.2 days, and 13.4 ± 1.0 days vs 19 ± 2.0 days, respectively, P < 0.05), and longer operation time compared to the open group (82.2 ± 4.3 min in endoscopic group vs 53.1 ± 2.2 min in open group, P < 0.05). There were significant differences in the incidence of incisional infection, necrosis, and lymphorrhagia in both groups (4 vs 0, 4 vs 0, and 2 vs 0, respectively, P < 0.05). The inguinal lymph node harvested was comparable between the two groups. The mean follow-up time was similar for both groups (60.4 ± 7.7 m vs 59.8 ± 7.3 m), and the recurrence mortality rates were not significantly different.

CONCLUSIONS

The study shows that both open and endoscopic methods work well for controlling penile carcinoma in the long term. But the endoscopic approach is better because it has fewer severe complications. So, the choice of surgery method might depend on factors like the surgeon's experience, what they like, and what resources are available.

Surgical templates for inguinal lymph node dissection in cN0 penile cancer: A comparative study

PURPOSE

Modified and superficial inguinal lymph node dissection (MILD and SILD) are the 2 widely used templates for surgical staging of clinically node negative (cN0) penile cancer (PeCa); however, no previous reports have compared their outcomes. We compared these 2 surgical templates for oncological outcomes and complications.

MATERIALS AND METHODS

We retrospectively reviewed records of cN0 PeCa patients who underwent MILD/SILD at our cancer care center from January 2013 to December 2019. Patients who developed a penile recurrence during follow up were excluded from analysis of oncological outcomes. The 2 groups (MILD and SILD) were compared for baseline clinico-pathological characteristics. The primary outcome was the groin recurrence free survival (gRFS). Secondary outcomes included the false negative rate (FNR) and disease free survival (DFS) for both templates and also the post-operative wound related complication.

RESULTS

Of the 146 patients with intermediate and high risk N0 PeCa, 74 (50.7%) and 72 (49.3%) underwent MILD and SILD respectively. The 2 groups were comparable with regards to the distribution of T stage, tumor grade and the proportion of intermediate and high-risk patients. At a median follow up of 34 months (47 for SILD and 23 for MILD), a total of 5 groin recurrences were encountered; all of them occurred in the MILD group. The gRFS and DFS for the MILD group was 93.2% and 91.8% respectively; while that for the SILD group was 100% and 94.4% respectively. Too few events had occurred to determine any statistically significant difference. The FNR for MILD and SILD was 26.3% and 0% respectively. The overall complication rate was significantly higher in the SILD group (46% vs 20.3%, p=0.001), especially for Clavien Dindo 3A complications.

CONCLUSION

MILD can fail to pick up micro-metastatic disease in a small proportion of cN0 PeCa patients, while SILD provides better oncological clearance with no groin recurrences. This oncological superiority comes at the cost of a higher incidence of wound-related complications.

Outcomes following radical inguinal lymphadenectomy for penile cancer using a fascial-sparing surgical technique

PURPOSE

To describe our surgical technique and report the oncological outcomes and complication rates using a fascial-sparing radical inguinal lymphadenectomy (RILND) technique for penile cancer patients with cN+ disease in the inguinal lymph nodes.

METHODS

Over a 10-year period, 660 fascial-sparing RILND procedures were performed in 421 patients across two specialist penile cancer centres. The technique used a subinguinal incision with an ellipse of skin excised over any palpable nodes. Identification and preservation of the Scarpa's and Camper's fascia was the first step. All superficial inguinal nodes were removed en bloc under this fascial layer with preservation of the subcutaneous veins and fascia lata. The saphenous vein was spared where possible. Patient characteristics, oncologic outcomes and perioperative morbidity were retrospectively collected and analysed. Kaplan-Meier curves estimated the cancer-specific survival (CSS) functions after the procedure.

RESULTS

Median (interquartile range, IQR) follow-up was 28 (14-90) months. A median (IQR) number of 8.0 (6.5-10.5) nodes were removed per groin. A total of 153 postoperative complications (36.1%) occurred, including 50 conservatively managed wound infections (11.9%), 21 cases of deep wound dehiscence (5.0%), 104 cases of lymphoedema (24.7%), 3 cases of deep vein thrombosis (0.7%), 1 case of pulmonary embolism (0.2%), and 1 case of postoperative sepsis (0.2%). The 3-year CSS was 86% (95%Confidence Interval [95% CI] 77-96), 83% (95% CI 72-92), 58% (95% CI 51-66), respectively, for the pN1, pN2 and pN3 patients (p < 0.001), compared to a 3-year CSS of 87% (95% CI 84-95) for the pN0 patients.

CONCLUSION

Fascial-sparing RILND offers excellent oncological outcomes whilst decreasing the morbidity rates. Patients with more advanced nodal involvement had poorer survival rates, emphasizing the need for adjuvant chemo-radiotherapy.

First-line programmed death receptor-1 (PD-1) inhibitor and epidermal growth factor receptor (EGFR) blockade, combined with platinum-based chemotherapy, for stage IV penile cancer

OBJECTIVES

To evaluate the anti-tumour activity and safety of anti-programmed death receptor-1 (PD-1) antibody plus epidermal growth factor receptor blockade combined with platinum-based chemotherapy (PEP) as first-line therapy for stage IV penile squamous cell carcinoma (PSCC).

PATIENTS AND METHODS

We conducted a retrospective review of 17 patients with stage IV PSCC undergoing first-line PEP at Sun Yat-sen University Cancer Center between January 2018 and September 2021. Clinical responses were assessed using the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.1. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Adverse events (AEs) were graded according to Common Terminology Criteria for Adverse Events version 5.0.

RESULTS

Of 17 patients who received first-line PEP, 13 were observed to have partial responses. Twelve patients subsequently received consolidated surgery. Nine of these achieved pN0 status, of whom six with locally advanced PSCC achieved pathological complete response. The median (range) follow-up time was 24.87 (3.63-29.40) months. Median PFS and median OS were not reached, with 2-year PFS and OS rates being 68.4% (95% confidence interval [CI] 48.7-96.1) and 62.9% (95% CI 41.6-95), respectively. Eight patients experienced Grade 3 or 4 treatment-related AEs. No Grade 5 AEs or death associated with treatment was observed.

CONCLUSIONS

Anti-PD-1 antibody plus epidermal growth factor receptor blockade and platinum-based chemotherapy showed promising anti-tumour activity, acceptable toxicity, and satisfying long-term survival for stage IV PSCC. Larger clinical trials are needed to validate our findings.

Prophylactic inguinal lymphadenectomy for high-risk cN0 penile cancer: The optimal surgical timing

Background

Few reports have investigated the oncologically safe timing of prophylactic inguinal lymphadenectomy for penile cancer patients with clinically normal inguinal lymph nodes (cN0), particularly those who received delayed surgical treatment.

Methods

The study included pT1aG2, pT1b-3G1-3 cN0M0 patients with penile cancer who received prophylactic bilateral inguinal lymph nodes dissection (ILND) at the Department of Urology of Tangdu Hospital between October 2002 and August 2019. Patients who received simultaneous resection of primary tumor and inguinal lymph nodes were assigned to the immediate group, while the rest were assigned to the delayed group. The optimal timing of lymphadenectomy was determined based on the time-dependent ROC curves. The disease-specific survival (DSS) was estimated based on the Kaplan-Meier curve. Cox regression analysis was used to evaluate the associations between DSS and the timing of lymphadenectomy and tumor characteristics. The analyses were repeated after stabilized inverse probability of treatment weighting adjustment.

Results

A total of 87 patients were enrolled in the study, 35 of them in the immediate group and 52 in the delayed group. The median (range) interval time between primary tumor resection and ILND of the delayed group was 85 (29-225) days. Multivariable Cox analysis demonstrated that immediate lymphadenectomy was associated with a significant survival benefit (HR, 0.11; 95% CI, 0.02-0.57; p = 0.009). An index of 3.5 months was determined as the optimal cut-point for dichotomization in the delayed group. In high-risk patients who received delayed surgical treatment, prophylactic inguinal lymphadenectomy within 3.5 months was associated with a significantly better DSS compared to dissection after 3.5months (77.8% and 0%, respectively; log-rank p<0.001).

Conclusions

Immediate and prophylactic inguinal lymphadenectomy in high-risk cN0 patients (pT1bG3 and all higher stage tumours) with penile cancer improves survival. For those patients at high risk who received delayed surgical treatment for any reason, within 3.5 months after resection of the primary tumor seems to be an oncologically safe window for prophylactic inguinal lymphadenectomy.

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.

Inguinal lymph node dissection in the era of minimally invasive surgical technology

BACKGROUND

Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications.

METHODS

The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020.

FINDINGS

There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

Minimally invasive evaluation of the clinically negative inguinal node in penile cancer: Dynamic sentinel node biopsy

The presence of lymph node metastasis is the most important prognostic factor in penile cancer (PeCa). Due to limited sensitivity of currently available imaging modalities, invasive staging approaches remain indispensable for adequate nodal staging. As an alternative to radical inguinal lymphadenectomy and with the aim to reduce morbidity, staging strategies such as modified lymphadenectomy and dynamic sentinel node biopsy (DSNB) have been introduced. Over the years, DSNB evolved into a safe and reliable staging technique when performed in high volume centers. Recent enhancements of the procedure such as Single-photon emission computed tomography/computed tomography (SPECT/CT) and the introduction of hybrid tracers have improved pre- and intraoperative sentinel node (SN) visualization. Other technologies such as superparamagnetic iron oxide nanoparticles could have a potential future role to further refine DSNB. Future efforts should be aimed at optimizing diagnostic accuracy whilst minimizing perioperative morbidity.

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.

A laparoscopic radical inguinal lymphadenectomy approach partly preserving great saphenous vein branches can benefit for patients with penile carcinoma

Background

Inguinal lymphadenectomy (iLAD) is effective for penile carcinoma treatment, but usually results in many complications. This study aims to clinically evaluate the feasibility and clinical significance of a laparoscopic radical iLAD approach partly preserving great saphenous vein branches for penile carcinoma patients.

Methods

A total of 48 patients with penile cancer who underwent laparoscopic radical iLAD with retention of the great saphenous vein in Henan Cancer Hospital from 2012 Jan to 2020 Dec were included in this study. Sixteen penile carcinoma patients who underwent laparoscopic radical iLAD preserving parts of superficial branches of the great saphenous vein were identified as the sparing group, and the matched 32 patients who incised those branches were identified as control group. This new procedure was performed by laparoscopy, preserving parts of superficial branches of the great saphenous vein, superficial lateral and medial femoral veins. Clinicopathological features and perioperative variables were recorded. Postoperative complications, including skin flap necrosis, lymphorrhagia, and lower extremity edema were analyzed retrospectively.

Results

We found that the operative time of the sparing group is significantly longer than the control group (p = 0.011). There was no statistical difference in intraoperative blood loss, the lymph node number per side, average time to remove the drainage tube and postoperative hospital stay between the two groups. Compared to the control group, the sparing group showed a significantly decreased incidence of lower extremity edema (p = 0.018). The preservation of parts of superficial branches of the great saphenous vein was mainly decreased the incidence of edema below ankle (p = 0.034).

Conclusions

This study demonstrated that the iLAD with preserving parts of superficial branches of the great saphenous vein, with a decreased incidence of postoperative complications, is a safe and feasible approach for penile cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01582-3.

Guia de cáncer de pene de la Sociedad Colombiana de Urología

El cáncer de pene tiene una incidencia de 1.11 por 100.000 habitantes en Colombia, representado en el 95% por carcinoma de células escamosas el cual representa una alta morbilidad y mortalidad, La Sociedad Colombiana de Urología realizo la adaptación de la guía de cáncer de pene para el año 2021 con revisión de la literatura, esta guía permite realizar una evaluación y tratamiento del cáncer de pene, en muchas ocasiones con el objetivo de preservación de órgano utilizando la ecografía como determinante para evaluar el compromiso de la lesión a las estructuras del pene, los estudios de extensión dependerán de hallazgos al examen físico como ganglios o compromiso local de la enfermedad, de acuerdo al tipo de lesión y su estadificación puede recibir terapia con agentes tópicos, radioterapia, cirugía láser, cirugía preservadora de órgano o penectomía total; La linfadenectomía inguinal permitirá mejorar la supervivencia en tumores de riesgo intermedio y alto (>pT1G2), posteriormente la quimioterapia adyuvante esta en el grupo de pacientes en el cual la intención sea curativa, aunque en terapia paliativa de segunda línea se encuentran los platinos y texanos como alternativa pero con pobre respuesta (<30%); los esquemas de seguimiento se realiza de acuerdo al estadio y el compromiso ganglionar. Al final se presentan los resultados de actividad sexual después de cirugía preservadora de órgano; Esta guía abarca la literatura actualizada del cáncer de pene, el cual es útil para el manejo por parte de los profesionales de salud del país.

Deep Inguinal Lymph Node Metastases Can Predict Pelvic Lymph Node Metastases and Prognosis in Penile Squamous Cell Carcinoma

OBJECTIVES

To evaluate the relationship between deep inguinal lymph node metastasis (ILNM) and pelvic lymph node metastasis (PLNM) and explore the prognostic value of deep ILNM in penile squamous cell carcinoma (PSCC).

MATERIALS AND METHODS

The records of 189 patients with ILNM treated for PSCC were analysed retrospectively. Logistic regression models were used to test for predictors of PLNM. Cox regression was performed in univariable and multivariable analyses of cancer-specific survival (CSS). CSS was compared using Kaplan-Meier analyses and log rank tests.

RESULTS

PLNM were observed in 53 cases (28.0%). According to logistic regression models, only deep ILNM (OR 9.72, p<0.001) and number (≥3) of metastatic inguinal lymph nodes (ILNs) (OR 2.36, p=0.03) were independent predictors of PLNM. The incidences of PLNM were 18% and 19% with negative deep ILNM and extranodal extension (ENE); and 76% and 42% with positive deep ILNM and ENE, respectively. The accuracy of deep ILNM, ENE, bilateral involvement and number (≥3) of ILNMs for predicting PLNM were 81.0%, 65.6%, 63.5% and 67.2%, respectively. The CSS was significantly different in patients with positive and negative deep ILNM (median 1.7 years vs not reached, p<0.01). Patients who presented with deep ILNM had worse CSS (median 3.8 years vs not reached, p<0.01) in those with negative PLNs.

CONCLUSIONS

Deep ILNM is the most accurate factor for predicting PLNM in PSCC according to our data. We recommend that patients with deep ILNM should be referred for pelvic lymph node dissection. Involvement of deep ILNs indicates poor prognosis. We propose that patients with metastases of deep ILNs may be staged as pN3.

[French ccAFU guidelines - update 2020-2022: penile cancer]

OBJECTIVE

- To update French oncology guidelines concerning penile cancer.

METHODS

- Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of testicular germ cell cancer to update previous guidelines. Level of evidence was evaluated according to AGREE-II.

RESULTS

- Epidermoid carcinoma is the most common penile cancer histology. Physical examination is mandatory to define local and inguinal nodal cancer stage. MRI with artificial erection can help to assess deep infiltration in cases of organ-sparing intention. Node negative patients (defined by palpation and imaging) will present micro nodal metastases in up to 25% of cases. Invasive lymph node assessment is thus advocated except for low risk patients. Sentinel node dynamic biopsy is the first line technique. Modified bilateral inguinal lymphadenectomy is an option with higher morbidity. 18-FDG-PET is recommended in patients with palpable nodes. Chest, abdominal and pelvis computerized tomography is an option. Fine needle aspiration (when positive) is an easy way to assess inguinal palpable node pathological involvement. Its results determine the type of lymphadenectomy to be performed (for diagnostic or curative purposes). Treatment is mostly surgical. Free margins status is essential, but it also has to be organ-sparing when possible. Brachytherapy and topic agents can cure in selected cases. Lymph node assessment should be synchronous to the removal of the tumour when possible. Limited inguinal lymph node involvement (pN1 stage) can be cured with the only lymphadenectomy. In case of larger lymph node stage, one should consider multidisciplinary treatment including chemotherapy and inclusion in a trial.

CONCLUSIONS

- Penile cancer needs demanding surgery to be cured, surrounded by chemotherapy in node positive patients. Lymph nodes involvement is a major prognostic factor. Thus, inguinal node assessment cannot be neglected.

Penile cancer in Ireland - A national review

OBJECTIVE

Penile cancer is a rare malignancy, with a reported incidence of 1.5/100,000 males in the Republic of Ireland in 2015. The aim of this study was to perform the first national review and to evaluate clinicopathological factors affecting survival.

SUBJECTS AND METHODS

All cases of penile cancer in Ireland between 1995 and 2010 were identified through the National Cancer Registry Ireland (NCRI) and analysed to identify factors affecting survival.

RESULTS

360 cases of penile cancer were identified, with a mean age at diagnosis of 65.5 years and 88% (n = 315) of cases occurred in those over 50. 91% (n = 328) of cases were squamous cell carcinomas (SCC). The majority of patients were treated surgically (n = 289), with 57% (n = 206) and 24% (n = 87) undergoing partial penectomy and total penectomy respectively. Only 18% (n = 65) received radiotherapy, and 8% (n = 27) received chemotherapy. Mean overall survival (OS) was 113 months, and five year disease specific survival (DSS) was 70% (95%CI: 59.1-77.8%). Age at diagnosis, nodal status and presence of metastatic disease were independent prognostic markers on multivariate analysis.

CONCLUSION

This study represents the first national review of penile cancer in Ireland. The annual incidence and survival rates are comparable to European figures, though superior DSS has previously been reported from our institution, highlighting the role for centralisation of care in Ireland.

LEVEL OF EVIDENCE

2b.

Prognostic Factors in Penile Cancer: Should We Avoid Inguinal Lymph Node Staging?

INTRODUCTION

Penile cancer (PC) is a rare neoplasm, mostly in developed countries. Herewith, we evaluate the main prognostic factors of patients with PC undergoing surgery.

METHODS

This is a retrospective analysis of prognostic factors of overall survival in 65 patients with PC treated at a tertiary referral center over the last 15 years (2004-2018).

RESULTS

Almost half (48%) of the patients were diagnosed at an advanced local stage pT3/4. Thirty-eight (58%) patients underwent inguinal lymphadenectomy, and 25 (66%) were negative for lymph node (LN) invasion. Overall survival was 80% at a median follow-up of 31 months. In the multivariate analysis, the main factors of poor prognosis were nodal staging (pN) (p = 0.008) and perineural invasion (p = 0.023). The presence of LN metastasis and perineural invasion in the primary tumor increased the risk of death by 29 (hazard ratio 29.0, 95% confidence interval 2.4-354.2) and 13 (hazard ratio 12.7, 95% confidence interval 1.4-112.0) times, respectively.

DISCUSSION/CONCLUSION

Late diagnosis of PC has a negative impact on overall survival, as nodal invasion correlates with survival. Despite the high number of negative inguinal lymphadenectomy, we continue to advocate aggressive surgical treatment of this disease due to the poor prognosis associated with LN metastasis.

Molecular stratification by BCL2A1 and AIM2 provides additional prognostic value in penile squamous cell carcinoma

Background: Lymph node metastasis is the most unfavorable prognostic factor of penile squamous cell carcinoma (PSCC). However, patients with the same lymph node status have different outcomes, and molecular classifiers for precise prognostic assessments are lacking.

Methods: Comprehensive genomic profiling and high-content proliferation screening were performed in eight PSCC and normal tissue pairs and in cell lines. BCL2A1 and AIM2 were selected and further evaluated by qPCR and Western blot. The clinical relevance and prognostic value of the target genes were validated via immunohistochemistry in a cohort of 220 PSCC patients with a defined pN stage. Finally, the biological functions and molecular mechanisms of BCL2A1 and AIM2 were investigated in vitro and in vivo.

Results: BCL2A1 and AIM2 were both upregulated in PSCC tissues and associated mostly with cell proliferation. Staining for either BCL2A1 or AIM2 revealed that both are correlated with pN status, extranodal extension, clinical stage and cancer-specific survival (CSS). Compared to patients who are single-positive or double-negative for BCL2A1 and AIM2, those overexpressing both genes had a higher risk of tumor progression and the poorest survival in the pN0 (5-year CSS: 63.3% vs. 94.9% and 100.0%, respectively, p = 0.000) and pN+ subsets (5-year CSS: 24.1% vs. 45.7% and 55.1%, respectively, p = 0.035). Molecular biofunction and mechanistic studies demonstrated that BCL2A1 and AIM2 knockdown inhibited tumorigenesis via the AIM2/NF-κB/BCL2A1/MAPK/c-Myc signaling pathway.

Conclusions: BCL2A1 and AIM2 promote PSCC progression. Integrating BCL2A1 and AIM2 as novel molecular classifiers with pN stage provides additional information for the prognosis and treatment of PSCC patients.

Progress on Management of Penile Cancer in 2020

OPINION STATEMENT

Management of penile cancer represents a challenge to urologic oncologists due to the disease's rarity and sparse data in the literature. Squamous cell carcinoma represents the most common histologic subtype of penile cancer. Penile cancer has a disastrous effect on patients' psychological and physical health. Penile cancer accounts for approximately 1% of cancer deaths in the USA annually. However, in recent years, the management of penile cancer has achieved marked progress in both diagnostic and therapeutic approaches with the intent to avoid radical surgeries. The traditional total penile amputation has been replaced by penile preserving procedures in many patients. Nowadays, total penile amputation (total penectomy) is preserved only for patients with proximal lesions. The introduction of minimally invasive surgical techniques in the management of penile cancer-infiltrated lymph nodes has been reported. Given the dismal prognosis with conventional cytotoxic therapies, new systemic therapies have been investigated in patients with locally advanced or metastatic penile cancer. Multiple studies have shown promising outcomes. All these efforts have resulted in a remarkable improvement in patient quality of life. The objectives of our review are to update clinicians on the advances in the management of penile cancer and to summarize the recent guidelines and recommendations.

Current management and future perspectives of penile cancer: An updated review

Penile cancer (PeCa) is a rare disease worldwide, accounting for less than one percent of all malignancies in men. It usually presents as a painless ulcer or lump on the head of the penis. Squamous cell carcinoma represents the most common histological subtype of PeCa, with pathogenesis intimately linked to chronic Human Papilloma Virus (HPV) infection. Surgery is the cornerstone for the treatment of primary PeCa with potential mutilating outcome depending on the nodal extension of the disease. However, in case of extensive lymph node involvement, multidisciplinary treatment including perioperative chemotherapy and inclusion in clinical trial should be considered. To date, advanced or metastatic disease still have poor prognosis and are a therapeutic challenge with limited options, highlighting the need of new treatments and further investigations. Growing efforts to identify molecular alterations, understand the role of HPV and characterize immune contexture have expanded over the past years, providing further perspectives in prognostication, predictive biomarkers and therapeutic intervention. In this review, we provide an updated overview of current management of PeCa focusing on perioperative strategy. We discuss about new insights of the biology of PeCa and comment future directions in the field.

Utility of Minimally Invasive Technology for Inguinal Lymph Node Dissection in Penile Cancer

Our aim is to review the benefits as well as techniques, surgical outcomes, and complications of minimally invasive inguinal lymph node dissection (ILND) for penile cancer. The PubMed, Wiley Online Library, and Science Direct databases were reviewed in March 2020 for relevant studies limited to those published in English and within 2000–2020. Thirty-one articles describing minimally invasive ILND were identified for review. ILND has an important role in both staging and treatment of penile cancer. Minimally invasive technologies have been utilized to perform ILND in penile cancer patients with non-palpable inguinal lymph nodes and intermediate to high-risk primary tumors or patients with unilateral palpable non-fixed inguinal lymph nodes measuring less than 4 cm, including videoscopic endoscopic inguinal lymphadenectomy (VEIL) and robotic videoscopic endoscopic inguinal lymphadenectomy (RVEIL). Current data suggest that VEIL and RVEIL are feasible and safe with minimal intra-operative complications. Perhaps the strongest appeal for the use of minimally-invasive approaches is their faster post-operative recovery and less post-operative complications. As a result, patients can tolerate this procedure better and surgeons can offer surgery to patients who otherwise would not be a candidate or personally willing to undergo surgery. When compared to open technique, VEIL and RVEIL have similar dissected nodal count, a surrogate metric for oncological adequacy, and a none-inferior inguinal recurrence rate. Larger randomized studies are encouraged to investigate long-term outcome and survival rates using these minimally-invasive techniques for ILND.

Prognostic significance of common preoperative laboratory variables in penile squamous cell carcinoma

OBJECTIVE

To investigate the predictive value of common preoperative laboratory variables in patients undergoing bilateral inguinal lymph node dissection surgery for penile squamous cell carcinoma.

METHODS

We retrospectively analyzed the records of 228 patients who had bilateral inguinal lymph node dissection for penile squamous cell carcinoma to assess the following clinical factors: preoperative laboratory measurements, white blood cell count, platelet count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, serum calcium, total protein, globulin, pathological factors and survival rates after surgery.

RESULTS

The percentage of positive lymph nodes was 52.6%. Univariate analysis showed that the tumor stage and grade, the presence of metastasis, white blood cell count, platelet count, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and globulin were significantly associated with the disease-specific survival (all P < 0.05). At multivariate analysis, only the neutrophil-to-lymphocyte ratio had an independent effect (hazard ratio 2.131; P = 0.035). The predictive accuracy of the neutrophil-to-lymphocyte ratio was the best among the laboratory variables. The predictive accuracy of the basic pathological factors was significantly increased by incorporating the neutrophil-to-lymphocyte ratio prognosticator.

CONCLUSION

The neutrophil-to-lymphocyte ratio before inguinal lymph node dissection might be useful for predicting the prognosis of patients with penile squamous cell carcinoma.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020: tumeurs du pénis French ccAFU guidelines — Update 2018—2020: Penile cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.008. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.008. That newer version of the text should be used when citing the article.

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 lymph node imaging in urologic oncology

Lymph node (LN) metastases in urological malignancies correlate with poor oncological outcomes. Accurate LN staging is of great importance since patients can benefit from an optimal staging, accordingly aligned therapy and more radical treatments. Current conventional cross-sectional imaging modalities [e.g., computed tomography (CT) and magnetic resonance imaging (MRI)] are not accurate enough to reliably detect early LN metastases as they rely on size criteria. Radical lymphadenectomy, the surgical removal of regional LNs, is the gold standard of invasive LN staging. The LN dissection is guided by anatomic considerations of lymphatic drainage pathways of the primary tumor. Selection of patients for lymphadenectomy heavily relies on preoperative risk stratification and nomograms and, as a result a considerable number of patients unnecessarily undergo invasive staging with associated morbidity. On the other hand, due to individual variability in lymphatic drainage, LN metastases can occur outside of standard lymphadenectomy templates leading to potential understaging and undertreatment. In theory, metastases from the primary tumor need to pass through the chain of LNs, where the initial node is defined as the sentinel LN. In theory, identifying and removing this LN could lead to accurate assessment of metastatic status. Radiotracers and more recently fluorescent dyes and superparamagnetic iron oxide nanoparticles (SPION) are injected into the primary tumor or peritumoral and the sentinel LNs are identified intraoperatively by a gamma probe, fluorescent camera or a handheld magnetometer. Preoperative imaging [e.g., single-photon emission computed tomography (SPECT)/CT or MRI] after tracer injection can further improve preoperative planning of LN dissection. While sentinel LN biopsy is an accepted and widely used approach in melanoma and breast cancer staging, its use in urological malignancies is still limited. Most data published so far is in penile cancer staging since this cancer has a typical echelon-based lymphatic metastasizing pattern. More recent data is encouraging with low false-negative rates, but its use is limited to centers with high expertise. Current guidelines recommend sentinel LN biopsy as an accepted alternative to modified inguinal lymphadenectomy in patients with pT1G2 disease and non-palpable inguinal LNs. In prostate cancer, a high diagnostic accuracy could be demonstrated for the sentinel approach. Nevertheless, due to lack of data or high false-negative rates in other urological malignancies, sentinel LN biopsy is still considered experimental in other urological malignancies. More high-level evidence and longitudinal data is needed to determine its final value in those malignancies. In this manuscript, we will review sentinel node imaging for urologic malignancies.

Radical Videoscopic Inguinal Lymphadenectomies: A Matched Pair Analysis

OBJECTIVE

To evaluate the modifications and feasibility of radical videoscopic inguinal lymphadenectomy (VIL).

PATIENTS AND METHODS

From January 2010 to December 2017, more than 200 patients who have underwent bilateral radical inguinal lymphadenectomy for penile cancer in Sun Yat-Sen University Cancer Center. And there were 33 patients who received radical VIL and 174 patients who received open inguinal lymphadenectomy (OIL). According to similar factors of age, body mass index, T stage, and N stage, two matched groups were created with a rate of 1:2, one group received VIL, and another group received OIL. The numbers of harvested lymph nodes, operating times, and complications were compared between the two groups. Descriptive statistical analyses, t tests, chi-square tests, and rank sum tests were performed.

RESULTS

In total, 93 patients were selected, including 31 patients who underwent bilateral VIL and 62 who underwent OIL. The numbers of harvested lymph nodes did not differ significantly (p = 0.983), the operating time was longer for the VIL than the open lymphadenectomy (p < 0.01), and the morbidity was lower among the VIL than the open lymphadenectomy.

CONCLUSIONS

Modified radical VIL is feasible, practical, and results in reduced morbidity. The dissecting field and the defined plane were critical to these modifications.

Elevated serum LAMC2 is associated with lymph node metastasis and predicts poor prognosis in penile squamous cell carcinoma

Purpose

Molecular biomarkers, especially serologic factors, have been widely applied in cancer diagnosis and patient follow-up. However, there are few valuable prognostic factors in penile squamous cell carcinoma (PSCC). Here, the authors investigated whether laminin gamma 2 (LAMC2) expression, especially serum LAMC2 (sLAMC2) level, was a suitable prognostic factor that could aid in the prediction of survival in PSCC.

Patients and methods

This study included 114 PSCC patients. Reverse transcription-quantitative polymerase chain reaction, Western blotting, and immunohistochemistry were performed to detect LAMC2 expression; enzyme-linked immunosorbent assays were used to test sLAMC2 concentration; and a Transwell assay and an in vivo experiment in nude mice were used to test PSCC cell migration, invasion, and metastasis. The chi-squared test was used to analyze the association between LAMC2 level and clinical parameters, the Cox proportional hazards regression model was used to evaluate the hazard ratio for death, and Kaplan–Meier analysis with a log-rank test was used for the survival analysis.

Results

LAMC2 was overexpressed in PSCC tissues, and the LAMC2 expression level was higher in metastatic lymph node (LN) tissues than in primary cancer tissues; moreover, the LAMC2 levels in primary cancer tissues and sLAMC2 were higher in patients with LN metastasis than in those without LN metastasis. Upregulated LAMC2 facilitated the migration, invasion, and epithelial-to-mesenchymal transition of PSCC cells in vitro and promoted LN metastasis of PSCC cells in nude mice. Elevated LAMC2 levels were strongly correlated with advanced clinicopathologic parameters, especially LN metastasis, in PSCC patients and predicted shorter disease-specific survival. The predictive value of sLAMC2 is superior to that of C-reactive protein and squamous cell carcinoma antigen previously reported in PSCC patients, and a stratification analysis revealed that the level of sLAMC2 had a higher predictive value for disease-specific survival in early penile cancer (especially at the N_0/X stage) than in later-stage penile cancer.

Conclusion

These findings suggest that sLAMC2 is a potential serologic prognostic marker in PSCC and could aid in risk stratification in early-stage PSCC patients.

Robotic-assisted inguinal lymphadenectomy: a systematic review

BACKGROUND

Lymphadenectomy represents the standard treatment for various types of cancer. The introduction of robotics in lymph node dissection may have an important impact on post-lymphadenectomy complications.

METHODS

A systematic literature review was performed.

RESULTS

In our review, robotic inguinal lymphadenectomy was performed on 51 patients. Penile squamous cell carcinoma was the most common histological type of the primary neoplasia. No intra-operative complications were reported. One case of conversion to open was reported. The mean duration of hospitalization was 2 days. The duration of drainage ranged from 7 to 72 days. The most common postoperative complications were lymphocele (13.7%), lymphedema (7.8%), cellulitis (7.8%), seroma (3.9%), abscess (3.9%), wound breakdown/wound infection (3.9%), sepsis (1.9%), prolonged lymphorrhea (1 out of 51 patients, 1.9%) and skin necrosis (1 out of 51 patients, 1.9%).

CONCLUSIONS

Until now there has not been sufficient evidence regarding the role of robotics in groin lymph node dissection, though this approach appears to be safe and oncologically effective, with morbidity rates relatively lower compared to open surgery.

Validation of predictors for lymph node status in penile cancer: Results from a population-based cohort

INTRODUCTION

The ability to predict lymph node (LN) status is essential in the management of men with localized squamous cell carcinoma (SCC) of the penis. There has been limited external validation of available risk stratification tools, particularly in routine clinical care. The objective of this study was to evaluate the predictive variables of LN metastases within a large population-based cohort of patients.

METHODS

In this population-based cohort study, surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients who were diagnosed with penile cancer in Ontario, Canada. Multivariable analyses were performed to evaluate predictive variables for LN involvement. Three contemporary risk stratification schemes used to predict LN status were analyzed by logistic regression.

RESULTS

The study included 380 localized penile SCC cases treated between 2000 and 2010. Sixty-three (17%) had pathologically confirmed LN metastases. Among these, 35 (56%) were diagnosed within three months of the initial penile SCC diagnosis and these patients had a worse five-year disease-specific survival (43%; 95% confidence interval [CI] 26-64) compared to patients who were diagnosed at a delayed LN dissection. On multivariable analysis, age (odds ratio [OR] 0.68; 95% CI 0.52-0.88), pathological stage (≥pT1b; OR 3.32; 95% CI 1.38-8.01), and tumour grade (Grade 2 OR 2.98; 95% CI 1.26-7.62; Grade 3 OR 3.97; 95% CI 1.32-11.9) were associated with an increased risk of LN metastases. Candidate risk stratification schemes demonstrated moderate to good property, with C-statistics ranging from 0.662-0.747.

CONCLUSIONS

Using a population-based cohort of penile cancer patients with a relatively low proportion of patients with pathologically confirmed LN involvement, we confirm and externally validate the importance of age, stage, and grade of the primary tumour in predicting nodal status.

Proposal for reclassification of N staging system in penile cancer patients, based on number of positive lymph nodes

In the present study, we aim to compare the rationality of proposed N classification based on the number of metastatic lymph nodes (LNs) with the current one. A total of 509 penile cancer patients at our institute were analyzed. Univariable and multivariable statistical analyses were used to assess cancer-specific survival (CSS) in 2 staging systems. Harrell's concordance index was applied to evaluate predictive accuracy of the current and proposed N classification in predicting CSS. We propose a new classification: pN1 (metastasis in 1-2 regional LNs), pN2 (metastasis in 3 regional LNs, or 3 or fewer regional lymph nodes with extranodal extension), and pN3 (metastasis in 4 or more regional LNs). According to the current and proposed N classification, the 5-year CSS of penile cancer patients with pN1, pN2 and pN3 was 85.8%, 39.0%, and 19.7%; and with pN1, pN2 and pN3 was 79.8%, 39.3% and 15.3%, which almost all showed significant difference (P < .001, P = .259) (P < .001, P < .001). Multivariable predictive accuracy of the proposed and current N staging was 76.48% and 70.92% (5.56% gain; P < .001). With a multivariable model of clinical features, both current (hazard ratio [HR], 7.761, 10.612; P < .001, P < .001) and proposed N stages (HR, 3.792, 3.971; P < .001, P < .001) exhibited independent effects on survival. The proposed N classification is superior to the current one, which is simpler and provides more accurate prognosis.

Management of penile cancer in a Singapore tertiary hospital

Objectives

To present our experience of managing penile squamous cell carcinoma (SCC) in a tertiary hospital in Singapore and to evaluate the prognostic value of the inflammatory markers neutrophil–lymphocyte ratio (NLR) and lymphocyte–monocyte ratio (LMR).

Patients and methods

We reviewed our prospectively maintained Institutional Review Board-approved urological cancer database to identify men treated for penile SCC at our centre between January 2007 and December 2015. For all the patients identified, we collected epidemiological and clinical data.

Results

In all, 39 patients were identified who were treated for penile SCC in our centre. The median [interquartile range (IQR)] follow-up was 34 (16.5–66) months. Although very few (23%) of our patients with high-risk clinical node-negative underwent prophylactic inguinal lymph node dissection (ILND), they still had excellent 5-year recurrence-free survival (RFS; 90%) and cancer-specific survival (CSS; 90%). At multivariate analysis, higher N stage was significantly associated with worse RFS and CSS. Patients with a high NLR (≥2.8) had significantly higher T-stage (P = 0.006) and worse CSS (P < 0.001) than those with a low NLR. Patients with a low LMR (<3.3) had significantly higher T-stage (P = 0.013) and worse RFS (P = 0.009) and CSS (P < 0.022) than those with a high LMR.

Conclusions

Although very few of our patients with intermediate- and high-risk clinical node-negative SCC underwent prophylactic ILND, they still had excellent 5-year RFS and CSS. However, survival was poor in patients with node-positive disease. The pre-treatment NLR and LMR could serve as biomarkers to predict the prognosis of patients with penile cancer.

Technical considerations to minimize complications of inguinal lymph node dissection

Penile cancer is a rare malignancy with a high propensity for regional dissemination. Current guidelines recommend inguinal lymphadenectomy in patients with penile cancer for palpable inguinal lymph nodes or in certain cases of nonpalpable inguinal lymph nodes. For many years, this procedure was performed with a traditional open approach and carried significant morbidity due to severe lymphedema, flap necrosis, wound infections, and seroma formation. The evolution of inguinal lymphadenectomy surgery for patients with penile cancer to a more minimally invasive approach has greatly reduced the morbidity of the procedure. Complications of inguinal lymphadenectomy can be minimized with modifications in surgical approach with the use of endoscopic, robotic, and various reconstructive methods. This review focuses on various intraoperative techniques to reduce morbidity in inguinal lymphadenectomies for penile cancer.

More precise prediction in Chinese patients with penile squamous cell carcinoma: protein kinase CK2α catalytic subunit (CK2α) as a poor prognosticator

Purpose

In this study, we assess the CK2α expression in human penile squamous cell carcinoma (SCC) and its clinical significance.

Methods

A total of 157 human penile SCC tissue samples were immunohistochemically analyzed. In addition, 12 human penile SCC and adjacent normal tissues were examined for CK2α protein and mRNA expression by Western blotting and real-time quantitative PCR, respectively. Survival was analyzed using the Kaplan-Meier test and the log-rank test. Multivariate Cox proportional hazard regression analysis was performed to determine the impacts of CK2α expression and the clinicopathological features on patient disease-specific survival (DSS). Likelihood ratios (LRs), Akaike information criterion (AIC) values, and concordance indexes (C-indexes) were investigated to evaluate the accuracies of the factors. Bootstrap-corrected C-indexes were used for internal validation (with sampling 1000 times).

Results

A significant difference in the distribution of CK2α was observed between the normal and penile carcinoma tissues (P<0.001). CK2α expression was associated with the pathological T and N stages in the penile cancer tissues (P<0.001). High CK2α expression was with significantly poorer DSS compared with low expression one (P<0.001). Western blotting and real-time quantitative PCR also confirmed that CK2α expression was increased in the penile cancer tissues. In multivariate Cox regression analysis, CK2α overexpression still was one of independent prognostic factors for penile SCC (P=0.005). The predictive accuracy of CK2α was verified by analysis of the C-indexes.

Conclusion

High protein kinase CK2α expression is associated with several prognostic factors and is thus a significant indicator of poor prognosis for penile cancer.

Lower Extremity Lymphedema Management after Gynecologic Cancer Surgery: A Review of Current Management Strategies

Lymphedema can be described as an accumulation of protein-rich fluid in interstitial spaces. It affects patients in multiple aspects. Gynecologic cancer survivors might experience lower extremity lymphedema after cancer surgery or treatment. In literature, most of the studies have been performed on upper extremity lymphedema. As gynecologic cancer malignancies have increased in the recent years, treatment options and related complications have been gaining attention in studies. In this manner, this review focused on the management of lower extremity lymphedema after gynecologic surgery. Studies indicated that the incidence of lower extremity lymphedema ranges between 2.4% and 41% after pelvic lymph node dissection in patients with gynecologic malignancies. Thus, management of lower extremity lymphedema in patients after gynecologic cancer surgery is an important issue. Complex decongestive therapy method is still the gold standard of lymphedema management. Controlling, evaluating, and preventing the risk factors are also substantial points; hence, it is very important to provide accurate knowledge in the management of lower extremity lymphedema.

Minimally Invasive Inguinal Lymphadenectomy in the Management of Penile Carcinoma

OBJECTIVE

To report and analyze the outcomes of endoscopic inguinal lymph node dissection (E-ILND), inclusive of video endoscopic ILND (VEIL) and robotic-assisted ILND (RAIL) approaches, in the largest reported series to date.

MATERIALS AND METHODS

We retrospectively identified men with penile cancer who underwent E-ILND. Nodal resection volume, perioperative parameters, and postoperative complications were assessed and analyzed. A subset analysis of complications by tumor and operative characteristics was performed to determine the impact of these variables on complication rates.

RESULTS

A total of 34 E-ILND, comprising 7 VEIL and 27 RAIL limbs, were performed. Median nodal yield was 10.0 (interquartile range [IQR] 6.0-12.5) in all E-ILND limbs and 8.0 (IQR 13.0-23.0) in RAIL limbs. Median length of stay was 1 day (range 1-3) following E-ILND and RAIL procedures. The saphenous vein was spared in 57% (4/7) of VEIL and 100% (27/27) of RAIL limbs. Postoperative complications occurred in 33% (6/18) of E-ILND, including 21% (3/14) of RAIL patients. Median follow-up was 5.5 months (IQR 3.0-10.8), during which time 3 patients developed regional or distant metastases at a median duration of 1.7 months (IQR 0.9-3.9).

CONCLUSION

E-ILND is feasible from a technical standpoint, and our results demonstrate that lymph node counts are comparable with an open approach. Importantly, E-ILND has the potential to reduce complication rates and time to convalescence when compared with open ILND.

[CCAFU french national guidelines 2016-2018 on penile cancer]

INTRODUCTION

The aim of this work is to establish guidelines proposed by the external genital organ group of the CCAFU for the diagnosis, treatment and follow-up of penile cancer.

MATERIAL AND METHODS

The multidisciplinary working party studied 2013 guidelines exhaustively reviewed the literature, and evaluated references and their level of proof in order to attribute grades of recommandation.

RESULTS

The most common histological type is squamous cell carcinoma. Clinical examination of the penis is usually sufficient to access local extension. It can be completed by MRI to assess deeper extension. Physical examination of both groins must evaluate inguinal regional lymph nodes involvement. In the presence of palpable lymph nodes, abdomen and pelvis computed tomography and ¹⁸F-FDG PET-CT are recommended. Sentinel lymph node biopsy is recommended in the case of penile cancer with high risk of lymph node extension with no palpable lymph nodes. Treatment of the primary tumour is usually surgical. It must be as conservative as possible while ensuring negative surgical margins. Brachytherapy or local treatment can be proposed in some cases. Bilateral inguinal lymph node areas must be systematically treated. Inguinal lymphadenectomy alone has a curative role in patients with metastatic invasion of a single node (stage pN1). In the case of more extensive lymph node involvement, multimodal management combining chemotherapy, surgery, and possibly radiotherapy has to be considered.

CONCLUSIONS

The treatment of penile cancer is usually surgical possibly in combination with chemotherapy in the presence of lymph node extension. The main prognostic factor is lymph node involvement, requiring appropriate management at the time of diagnosis.x © 2016 Elsevier Masson SAS. All rights reserved.

Factors associated with regional recurrence after lymph node dissection for penile squamous cell carcinoma

OBJECTIVE

To identify factors associated with regional recurrence after lymph node dissection (LND) for squamous cell carcinoma (SCC) to determine which patients might benefit from adjuvant therapy.

PATIENTS AND METHODS

Men who underwent LND for penile SCC from 1977 to 2014 were identified from an institutional database. Kaplan-Meier curves estimated recurrence-free survival (RFS) calculated from the date of LND. Cox regression models evaluated the association between RFS and patient and tumour characteristics.

RESULTS

In all, 182 men who underwent LND for penile SCC were identified. The median patient age was 62 years and the median follow-up was 4.2 years. After LND 34 men had regional recurrence, of which 24 developed isolated regional recurrences without distant metastasis. The median RFS was 5.7 months, and the 3-year RFS rate was 70%. On univariate analysis, lymphovascular invasion, clinical and pathological nodal stage, pathological inguinal laterality, pelvic nodal involvement, lymph node density ≥5.2%, ≥3 pathologically involved lymph nodes, and extranodal extension (ENE) were associated with worse RFS (all P < 0.05). On multivariate analysis, clinical N3 disease [adjusted hazard ratio (AHR)] 3.53, 95% confidence interval (CI) 1.68-7.45; P = 0.001), ≥3 pathologically involved lymph nodes (AHR 3.78, 95% CI 2.12-6.65; P < 0.001), and ENE (AHR 3.32, 95% CI 1.93-5.76; P < 0.001) were associated with worse RFS. The 3-year RFS for patients with cN0, cN1, cN2, and cN3 disease was 91.7%, 64.5%, 54.7%, and 38.3%, respectively. For men with ≥3 involved nodes, the 3-year RFS was 17% vs 82.4% in men with <3 involved nodes. The 3-year RFS was 29.7% in men with ENE and 85.7% in men without ENE.

CONCLUSION

The presence of clinical N3 disease, ≥3 pathologically involved lymph nodes, and ENE was associated with worse RFS. As regional recurrence portends a dismal prognosis with few salvage options, adjuvant therapies should be developed for men with the aforementioned adverse factors.