Early experience in intermediate-risk penile cancer with sentinel node identification using the gamma probe

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.

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.

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.

DNA topoisomerase I and IIalpha expression in penile carcinomas: assessing potential tumour chemosensitivity

OBJECTIVE

To examine the tissue expression of DNA topoisomerase I (Topo I) and IIalpha (Topo II), to pursue the possibility of future chemotherapy regimens for squamous cell carcinoma of the penis (SCCP), as high expression of Topo I might indicate sensitivity to the camptothecins, whereas high Topo II might indicate sensitivity to etoposide.

PATIENTS AND METHODS

In all, 73 patients with SCCP were reviewed and then tissue samples microarrayed. These were then stained with immunohistochemistry for Topo I, Topo II and Ki-67. Tumour stage, grade and type were available.

RESULTS

Topo II showed a strong positive correlation with the proliferation index as measured by Ki-67 (P < 0.001) but no correlation with Topo I. There were also strong correlations between tumour grade and Ki-67, and Topo II expression (both P < 0.001). Tumour type was also strongly correlated with Topo II and Ki-67 expression, with the highest expression in basaloid carcinomas and the lowest in verrucous carcinomas. However, Topo I expression was not correlated with any other tumour variable.

CONCLUSION

The expression of Topo I is grade- and type-independent, and chemotherapy using the camptothecins is unlikely to be effective. The strong positivity of Topo II in high-grade and basaloid SCCPs suggests that treatment with etoposide or other Topo II 'poisons' might be a better target for future clinical trials.

[Frozen section in urological oncology]

The indications of Frozen section diagnosis (FS) in surgery due to urologic neoplasia are quite specific, and this explains the fact that they amount to a mere 7.3% of the FSs performed in general hospitals. This also makes the knowledge of their usefulness necessary, and thus we are submitting the present review. Generally speaking, FS is not warranted to identify the nature of a tumoral mass, with the following exceptions: (1) Renal masses of a doubtf ul parenchymal origin, or in the urinary tract: (2) Intesticular neoplasias,when the possibility of a conservative treatment arises; (3) Determination of the presence of a prostate adenocarcinoma in an organ donor with high serum PSA; but even in these circumstances its need is widely controversial. Intraoperative determination of surgical margins is particularly useful in: (1) Partial nephrectomies (it may be limited to inspection after dyeing the margin with Indian ink--bed freezing is very seldom needed); (2) Urethral margins in women with total cystectomies and orthotopic substitution; (3) In partial penectomies (always studying the urethral margin and the cavernosal and spongIosal corpora margins). The study of the nodes is a widely debated issue, and except for those cases in which unexpectedly increased node size is found, systematic FS is indicated neither of the bladder nor of the prostate. The situation regarding penis carcinoma is different, as in the groups with intermediate and high risk of node metastasis, even though there is around 16%-18% of false negatives FS is recommended, particularly of radioisotope-marked sentinel nodes.

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.

[Lymphadenectomy of the inguinal region and pelvis]

The draining lymph nodes of extra-abdominal tumors and malignant lesions of the lower extremity are located in the groin and iliac region. Malignancies with lymphatic drainage into this region include tumors of the anorectum, penis and vulva, skin (melanoma, squamous cell carcinoma), and soft tissue sarcomas. Current clinical research in biology, routes of lymphatic spread, and the possibility of marking the sentinel lymph node has directed lymphadenectomy strategy toward differential procedures, depending on the type of underlying malignancy. The spectrum of lymphadenectomy includes diagnostic lymph node removal of clinically enlarged nodes, removal of the sentinel node, and radical lymphadenectomy. Lymphadenectomy can also be indicated as a palliative procedure. The indications also depend on the type of tumor, previous treatment, and disease prognosis. This review presents the current state of indications and surgical techniques of inguinal and iliacal lymphadenectomy.

Sentinel Lymph Node Biopsy in Cutaneous Squamous Cell Carcinoma: A Systematic Review of the English Literature

BACKGROUND

Although most cutaneous squamous cell carcinoma (SCC) is curable by a variety of treatment modalities, a small subset of tumors recur, metastasize, and result in death. Although risk factors for metastasis have been described, there are little data available on appropriate workup and staging of patients with high-risk SCC.

OBJECTIVE

We reviewed reported cases and case series of SCC in which sentinel lymph node biopsy (SLNB) was performed to determine whether further research is warranted in developing SLNB as a staging tool for patients with high-risk SCC.

METHODS

The English medical literature was reviewed for reports of SLNB in patients with cutaneous SCC. Data from anogenital and nonanogenital cases were collected and analyzed separately. The percentage of cases with a positive sentinel lymph node (SLN) was calculated. False negative and nondetection rates were tabulated. Rates of local recurrence, nodal and distant metastasis, and disease-specific death were reported.

RESULTS

A total of 607 patients with anogenital SCC and 85 patients with nonanogenital SCC were included in the analysis. A SLN could not be identified in 3% of anogenital and 4% of nonanogenital cases. SLNB was positive in 24% of anogenital and 21% of nonanogenital patients. False-negative rates as determined by completion lymphadenectomy were 4% (8/213) and 5% (1/20), respectively. Most false-negative results were reported in studies from 2000 or earlier in which the combination of radioisotope and blue dye was not used in the SLN localization process. Complications were reported rarely and were limited to hematoma, seroma, cutaneous lymphatic fistula, wound infection, and dehiscence.

CONCLUSIONS

Owing to the lack of controlled studies, it is premature to draw conclusions regarding the utility of SLNB in SCC. The available data, however, suggest that SLNB accurately diagnoses subclinical lymph node metastasis with few false-negative results and low morbidity. Controlled studies are needed to demonstrate whether early detection of subclinical nodal metastasis will lead to improved disease-free or overall survival for patients with high-risk SCC.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Lymphoscintigraphy in penile cancer: limited value of sentinel node biopsy in patients with clinically suspicious lymph nodes

The staging lymph node dissection in patients with penile carcinoma is accompanied with a high morbidity. As many patients are free of nodal metastases the lymphoscintigraphic sentinel node biopsy is supposed to minimize perioperative morbidity in these patients. In the current study the accuracy of the lymphoscintigraphic sentinel node biopsy was verified against the gold standard of radical inguinal dissection. In particular, patients with enlarged lymph nodes have also been included since one half of these patients is known to have histologically negative lymph nodes. Between 2000 and 2004 fifteen patients with penile carcinoma were elected to undergo bilateral groin dissection, thus 30 inguinal areas have been dissected. Nine patients have had clinically palpable nodes. All patients underwent lymphoscintigraphy after injection of Tc99-nanocolloid subcutaneously into the peritumoral area. Intraoperatively the sentinel nodes were identified with the aid of a gamma ray detection probe and excised. Afterwards a standard groin dissection was performed and the different lymph nodes were histopathologically assessed separately. In all patients lymph nodes with high radioactivity uptake were detected bilaterally. In 10 out of 30 inguinal areas histopathologically positive lymph nodes were present. In four of them the sentinel node was positive for tumor but in six dissection areas lymph node metastases were found despite a negative sentinel node. These patients had clinically palpable lymph nodes in their histologically positive inguinal regions. If no palpable nodes were present dynamic sentinel biopsy detected the positive nodes. The current study showed that dynamic sentinel node biopsy in patients with clinically suspicious lymph nodes is of low value for detection of lymphatic spread in penile cancer. Therefore the gold standard in these patients remains the radical groin dissection. However, dynamic sentinel node biospy is still a promising strategy to identify lymphatic spreading in clinically N0 patients and therefore to prevent unnecessary groin dissection.

Prognostic factors in node-positive carcinoma of the penis

BACKGROUND

Lymph node metastasis is the most important prognostic factor in patients with carcinoma of the penis. In this article, we have reviewed the outcome of the patients with pathologic node-positive carcinoma of the penis after groin dissection performed at the Cancer Institute (WIA) between 1987 and 1998.

METHODS

The case records of all patients who underwent groin dissection for carcinoma of the penis between 1987 and 1998 were analyzed.

RESULTS

Between 1987 and 1998, 128 patients underwent groin dissections for carcinoma of the penis at Cancer Institute (WIA), Chennai. Out of them, 102 patients had pathologic node-positive disease. The 5-year overall survival (OS) for these patients was 51.1%. Patients with metastasis only to inguinal nodes had a 5-year OS of 64.6% whereas none of the patients with pelvic nodal metastasis survived for 5 years. Among the pathologically node-positive patients, the factors adversely influencing survival on multivariate analysis were bilateral nodal metastases, number of positive inguinal nodes, pelvic nodal metastasis, and extranodal extension.

CONCLUSIONS

Groin dissection is an effective treatment for nodal metastasis from carcinoma of the penis. However, innovative approaches are needed for the subset of patients with dismal outlook.

Role of dynamic sentinel node biopsy in penile cancer: Our experience

BACKGROUND AND OBJECTIVES

We report our initial experience with a relatively new technique, the so-called "dynamic sentinel node biopsy", in patients with penile cancer.

METHODS

From January 2001 to February 2003, 17 consecutive patients with bilateral, clinically node negative penile cancer were enrolled. Dynamic sentinel node biopsy was followed by local excision of the primary lesion or penile amputation during the same session. Standard inguinal node dissection was performed 4 weeks after the first operation in all the patients.

RESULTS

Pre-operative lymphoscintigraphy revealed no sentinel nodes in 1, unilateral sentinel nodes in 5, and bilateral in 11 patients. Metastases were noted in 5 out of 16 patients (31.25%), bilaterally in 3 of them. Among the five patients with sentinel node metastasis, this was the only tumor positive lymph node in one patient. In all cases with negative dynamic sentinel node biopsy, no metastatic nodes were found at the following inguinal node dissection. Therefore, the technique showed a 100% negative predictive value and an 88% sensitivity.

CONCLUSIONS

We believe that dynamic sentinel node biopsy is a minimally invasive procedure that can be easily performed. The goal is to offer the possibility of less extensive surgery for selected low risk patients.

Radiation doses to staff involved in sentinel node operations for breast cancer

BACKGROUND

The use of radioactive compounds for sentinel node biopsy is now a generally accepted part of the surgical treatment of breast cancer and melanoma, with the risk of radiation exposure to the operating team. The aim of this investigation was to study the levels of this exposure in relation to the permissible radiation dose limits.

METHODS

The radiation exposure to the hands and bodies of the operating surgeons (the 'risk persons') was measured by thermoluminescent dosimeters in 79 operations and to the pathologists handling the specimens in 17 cases. Radioactivity and dose rate measurement from tumours and breast specimens were also performed.

RESULTS

During an operation the mean skin dose (+/-SD) to the thermoluminescent dosimeters placed at the hand and the abdominal wall were 0.04 +/- 0.04 mSv (79 operations) and 0.01 +/- 0.02 mSv (67 operations) respectively. For the pathologist, the mean hand dose per operation was below the detection limit (17 operations). Correlation between the measured dose rate and the radioactive content of the tumours was 0.998.

CONCLUSIONS

The radiation exposure to the staff involved in sentinel node (SN) biopsy for breast cancer using radioactive labelled tracers will be considerably below the permissible limits, even with high numbers of SN biopsy procedures. Pregnant staff members should participate in <100 SN operations.

Prepubic Sentinel Node Location in Penile Carcinoma

An unusual sentinel node location in a patient with penile carcinoma is described. The preoperative lymphoscintigram showed a prepubic sentinel node. The node could be harvested during surgery. This case illustrates one of the advantages of lymphatic mapping in penile carcinoma: preoperative lymphoscintigraphy can identify lymph nodes outside the usual nodal basins.

Lymphadenektomie beim Peniskarzinom

Lymphadenectomy is an essential part of diagnosis and treatment of the squamous cell carcinoma of the penis. Lymphadenectomy is performed depending on various characteristics of penile cancer such as depth of invasion, tumor grade, invasion into the corpora cavernosa, invasion into vascular and lymphatic vessels. In case the inguinal lymphnodes are not palpable a modified lymphadenectomy is indicated. The limits of lymphadenectomy are extended to the radical type of dissection when the frozen section indicates cancer. Inguinal lymphadenectomy is always performed on both sides. Are more than 2 nodes positive the lymphnodes in the true pelvis have to be resected as well. The dynamic sentinel lymphnode dissection may replace the modified approach in case randomized prospective studies will confirm the initial positive results and morbidity can be reduced as well. The immediate lymphadenectomy is superior to the delayed lymphadenectomy (palpable nodes during followup) in terms of local recurrence and survival. According to the risk profile patients with palpable inguinal lymphnodes can be initially managed conservatively. In case the lymphnodes remain palpable, lymphadenectomy is indicated. In this situation it is reasonable to perform imaging studies of the pelvis and abdomen for adequate planning of the surgical approach. Neoadjuvant chemotherapy is reasonable for patients with bulky nodes fixed to the skin or fascia because this improves respectability, freedom from local recurrence and increases survival. Adjuvant chemo- and/or radio-therapy are reserved for extended disease or palliative situations.

Intraoperative Frozen Section Diagnosis in Urological Oncology

The intraoperative frozen sections are indicated if the pathological findings change the surgical procedure. In urological oncology is not recommended, as a general attitude, in the tumor diagnosis/staging during the surgery. The assessment of the surgical margins is recommended in partial surgical resections but the literature discourages its systematic use in the radical surgical resections. The assessment of the lymph nodes is specially indicated in the penile cancer with intermediate or high risk and non-palpable nodes, and is debated its utility in non-palpable lymph nodes of cystectomies and prostatectomies.

Dynamic sentinel node biopsy in penile carcinoma: evaluation of 10 years experience

PURPOSE

The aim of this study was to evaluate the results of 10 years dynamic sentinel node biopsy experience in penile carcinoma at our institute.

PATIENTS AND METHODS

140 patients with clinically node-negative groins were prospectively included. Lymphoscintigraphy was performed after injection of 99mTechnetium-nanocolloid around the primary tumour. The sentinel node was intraoperatively identified with the aid of patent blue dye and a gamma ray detection probe. Lymph node dissection was performed only if sentinel node metastasis was found. Median follow-up was 52 months (range 5-129).

RESULTS

Lymphoscintigraphy visualized at least 1 sentinel node in 138 patients. Sentinel node metastasis was found in 37 inguinal regions of 31 patients. The sentinel node was the only tumour-positive node in 78% (29/37) of the dissection specimens. Complications occurred in 8% (17/206) of the operated groins. False-negative results were encountered in 6 patients resulting in a false-negative rate of 16% (6/37 patients). 5-year disease-specific survival was 96% and 66% for patients with a tumour-negative sentinel node and tumour-positive sentinel node, respectively (p=0.001).

CONCLUSION

Dynamic sentinel node biopsy in penile carcinoma is of important diagnostic, prognostic, and therapeutic value at the cost of only minor morbidity.

Advanced penile carcinoma

PURPOSE

In the United States penile carcinoma is an uncommon malignancy that represents only 0.4% of all male malignancies and 2% to 4% of genitourinary malignancies. Of penile cancer cases 30% are diagnosed with advanced disease. Improved understanding of the natural history, appropriate and accurate staging, and tailored, less morbid lymphadenectomy have led to improved survival and decreased the adverse effects of therapy. However, the management of advanced penile carcinoma remains a challenge to urological, medical and radiation oncologists. The rarity and paucity of well designed clinical studies of medical and/or surgical therapy for advanced penile cancer have hampered progress in the treatment of this disease. However, there is clear evidence that identifies active chemotherapy and radiation treatments. This review aims to provide the treating physician with an overview of available data for surgical, chemotherapeutic and radiation treatments, and provide guidelines for appropriate patient selection for these therapies.

MATERIALS AND METHODS

We performed a detailed review of the available literature regarding advanced penile carcinoma to include its etiology, epidemiology, natural history, staging classification and treatment.

RESULTS

Penile carcinoma typically spreads along an echelon of nodal pathways that permits fairly accurate staging. Prognosis correlates well with clinical nodal status and grade, and the TNM classification developed by the UICC should be uniformly used by clinicians. Treatment recommendations are tightly associated with disease stage. Although tailored lymphadenectomy as currently recommended has greatly decreased morbidity, improved staging accuracy and improved treatment results, controversies still exist regarding the need for lymphadenectomy in patients with impalpable lymph node (cN0) disease, and the role and timing of pelvic lymphadenectomy. There is evidence of modest activity for chemotherapy in advanced penile carcinoma. Active agents include cisplatin, bleomycin and methotrexate. Combination chemotherapy regimens with promising activity and toxicity profiles include cisplatin and 5-fluorouracil, and vincristine, bleomycin and methotrexate. Radiation in combination with surgery and/or chemotherapy in advanced disease have also demonstrated activity.

CONCLUSIONS

The natural history of penile carcinoma and its proclivity to spread via regional lymphatics has been well defined. This understanding has led to the development of effective locoregional treatment strategies. Penile carcinoma is sensitive to radiation and certain chemotherapeutic agents. A threshold volume of nodal metastases is associated with significant mortality. The optimal application of these strategies remains to be determined. Improvements in survival and quality of life likely require the incorporation of multiple modalities into the treatment of advanced penile carcinoma. A multi-institutional, international effort is essential to perform appropriately powered clinical trials to advance the standard of care in this rare disease.

Squamous cell carcinoma antigen: a role in the early identification of nodal metastases in men with squamous cell carcinoma of the penis

OBJECTIVE

To evaluate whether serum squamous cell carcinoma antigen (SCCAg) measurements may be of use in identifying nodal metastases in patients with SCC of the penis after treating the primary tumour.

PATIENTS AND METHODS

The levels of SCCAg were analysed in 11 men with penile SCC between 1994 and 2001.

RESULTS

An elevated SCCAg level had a sensitivity of 57% (95% confidence interval, CI, 18-90%) and a specificity of 100% (CI 40-100%) for nodal metastases. Levels of SCCAg increased exponentially in patients who developed nodal metastases after treatment of the primary tumour, and were elevated before clinical or radiological evidence of nodal disease.

CONCLUSION

Either the absolute level or the rate of rise of SCCAg may be a useful tool with which to follow patients after excision of the primary tumour. It may be more sensitive than computed tomography and magnetic resonance imaging in detecting recurrence, but further evaluation is needed.