Development and Validation of a Nomogram for the Prediction of Inguinal Lymph Node Metastasis Extranodal Extension in Penile Cancer

Preoperative platelet-to-lymphocyte ratio as a predictor of inguinal lymph node metastasis in penile cancer

BACKGROUND

Penile cancer (PC) is a rare malignancy with poor prognosis. To date, reliable preoperative biomarkers for lymph node status and prognosis are still lacking. This study aims to explore the potential role of preoperative platelet-to-lymphocyte ratio (PLR) as a predictor of inguinal lymph node invasion in PC patients.

METHODS

Retrospective analysis was conducted on anamnestic, clinical, and laboratory data of PC patients who underwent surgical treatment between January 2016 and October 2023. Inguinal lymphadenectomy was performed as per EAU guidelines. PLR, calculated as the ratio between platelet-to-lymphocyte values obtained from preoperative blood analyses, was assessed within 30 days before surgery. Patients were categorized into pN- (no lymph node metastasis) and pN+ (lymph node metastasis confirmed pathologically). Statistical analyses included Kruskal-Wallis and Mann-Whitney U tests, univariate logistic regression, and ROC curve analysis with Youden index, assuming p<0.05 as statistically significant.

RESULTS

Overall, 60 PC patients were retrospectively involved in the study. A total of 36 (60%) patients reported ILN metastases, confirmed by inguinal lymphadenectomy (pN+), while no ILN metastases (pN-) were reported in 24 (40%) patients. The AUC for predicting ILN metastasis by preoperative PLR was 0.71 (p=0.014). According to the ROC curve analysis and the Youden Index, a cut-off for PLR was set at 122.4. On Univariable logistic regression analysis, the presence of T stage ≥ 2 (OR = 3.21; 95% CI: 1.43-7.47, p=0.011), lymphovascular invasion (OR = 3.78; 95% CI: 1.56-5.90, p=0.003), clinical node-positive disease (OR = 19.86; 95% CI: 5.91-41.03, p<0.001) and PLR ratio > 122.4 (OR = 7.22; 95% CI: 1.41-22.71, p=0.0148) were independent predictors of pN+ disease.

CONCLUSIONS

The current study confirms the relationship between cancer and inflammation. When elevated preoperatively, PLR may be associated with inguinal lymph node invasion in PC patients.

French AFU Cancer Committee Guidelines-Update 2024-2026: Penile cancer

OBJECTIVE

Update of the recommendations for the management of penile lesions.

MATERIALS AND METHODS

Comprehensive PubMed review from 2022 of the literature on the diagnosis, treatment and follow-up of penile tumours. The level of evidence of the studies was assessed.

RESULTS

A total of 95% of infiltrating penile cancers are squamous cell carcinomas, one-third of which are related to human papillomavirus (HPV) infection. Clinical examination can reveal the size of the lesion, its location, its proximity to the urethral meatus and its infiltration depth. Urinary and sexual function should be assessed. Magnetic resonance imaging (MRI) is the gold standard for local assessment. Penile tumours are classified as low-risk (≤pT1a and well-differentiated G1), intermediate-risk (pT1a G2) or high-risk (≥pT1b, G3, or sarcomatoid contingent). Lymph node assessment in penile cancer is fundamental. The sentinel node technique is recommended for the evaluation of cN0 patients with tumours of intermediate risk or higher. 18FDG PET is recommended for cN+ patients. Surgery is the standard treatment locally and depends on the size, location and grade of the tumour. Topical treatment or brachytherapy may be indicated in some cases. Radical inguinal curettage (RIC) is recommended for stages cN1/cN2. Neoadjuvant chemotherapy is recommended for patients with cN3-stage lesions, combined with RIC in responders. Metastatic forms may be treated with palliative chemotherapy and immunotherapy as part of a clinical trial.

CONCLUSION

The treatment of penile cancer is essentially surgery, with or without chemotherapy in the case of lymph node involvement. The main prognostic factor is lymph node involvement, which justifies early diagnostic and therapeutic management of the inguinal areas.

Prognostic Markers and Trials in Penile Cancer

New tumor biomarkers open the potential for designing personalized therapy for penile squamous cell carcinoma. Despite the initial promising results of some biomarkers, controversy remains due to contradictory studies. Further robust research work is required before incorporating biomarkers in the personalized management of penile cancer. This narrative review aims to highlight some of the most commonly and recently investigated biomarkers of penile cancer and to summarize the ongoing registered clinical trials for the management of penile cancer patients.

Prognostic Significance of Systemic Inflammation Markers in Testicular and Penile Cancer: A Narrative Review of Current Literature

In contemporary clinical practice, biomarkers are indispensable in the assessment and management of oncological patients. Although established serum tumor markers (beta human chorionic gonadotropin (bHCG), alpha fetoprotein (AFP), and lactate dehydrogenase (LDH)) have an indisputably important role in the management of patients with testicular cancer (TC), the application of these tumor markers may be accompanied with certain limitations, implying the need for additional biomarkers. Contrary to TC, there is a lack of established serological biomarkers for penile cancer (PC) and the management of this urological malignancy is based on multiple clinicopathological parameters. Therefore, the identification and rigorous analytical and clinical validation of reliable biomarkers are considered pivotal for improving PC management. Inflammation may be associated with all stages of oncogenesis, from initial neoplastic transformation to angiogenesis, tissue invasion, and metastasis. Accordingly, an array of inflammation-related indices have gained increasing attention as emerging predictors of oncological outcomes. The clinical usefulness of systemic inflammation markers was reported in many urological and non-urological malignancies. The aim of this narrative review is to summarize current scientific data regarding the prognostic and predictive significance of systemic inflammation markers in TC and PC patients.

French AFU Cancer Committee Guidelines - Update 2022-2024: penile cancer

OBJECTIVE

To update French oncology guidelines concerning penile cancer.

METHODS

Comprehensive Medline search between 2020 and 2022 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 organsparing 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.

Development and Verification of Prognostic Nomogram for Penile Cancer Based on the SEER Database

Aim

We aimed to establish a prognostic nomogram for penile cancer (PC) patients based on the Surveillance, Epidemiology, and End Results Program (SEER) database.

Methods

Data from 1643 patients between 2010 and 2015 were downloaded and extracted from the SEER database. They were randomly divided into the development group (70%) and the verification group (30%), and then, univariate and multivariate Cox proportional hazards regression, respectively, was used to explore the possible risk factors of PC. The factors significantly related to overall survival (OS) and cancer-specific survival (CSS) were used to establish the nomogram, which was assessed via the concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve. An internal validation was conducted to test the accuracy and effectiveness of the nomogram. Kaplan–Meier calculation was used to predict the further OS and CSS status of these patients.

Results

On multivariate Cox proportional hazards regression, the independent prognostic risk factors associated with OS were age, race, marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type, with a moderate C-index of 0.737 (95% confidence interval (CI): 0.713–0.760) and 0.766 (95% CI: 0.731–0.801) in the development and verification groups, respectively. The areas under the ROC (AUC) of 3- and 5-year OS were 0.749 and 0.770, respectively. While marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type were significantly linked to PC patients' CSS, which have better C-index of 0.802 (95% confidence interval (CI): 0.771–0.833) and 0.82 (95% CI: 0.775–0.865) in the development and verification groups, and the AUC of 3- and 5-year CSS were 0.766 and 0.787. Both of the survival calibration curves of 3- and 5-year OS and CSS brought out a high consistency.

Conclusion

Our study produced a satisfactory nomogram revealing the survival of PC patients, which could be helpful for clinicians to assess the situation of PC patients and to implement further treatment.