1. Management of Groin in Cancer of the Penis
Hemant B. Tongaonkar
Professor & Head Urologic Oncology Services Tata Memorial Hospital, Mumbai

2. Penile Cancer Presence and extent of inguinal nodal metastases
most important prognostic factor for survival

3. Penile Cancer Prolonged locoregional phase before mets occur
Superficial inguinal LN most frequent site of lymphatic mets
LN involvement generally stepwise
LN mets beyond pelvis considered distant
Lymphadenectomy can be curative & need not be treated as systemic disease

4. Penile cancer Problems in management of groin
LN mets single most imp prognostic parameter
10-20% have occult LN mets in patients with clinically negative groin
50% of patients with palpable groin nodes do not have metastasis
Clinical prediction of nodal spread unreliable & inaccurate

5. Penile Cancer Assessment of groin
Clinical examination
Lymphangiography
High resolution USG with FNAC
Fine needle aspiration cytology
Sentinel node biopsy with patent blue dye or lymphoscintigraphy
Histological evaluation at surgery is the Gold Standard

6. Penile Cancer: Management of Groin Nodes Crucial questions
Predictors of lymph node mets
Indications for lymphadenectomy
Prophylactic vs therapeutic
Extent of lymphadenectomy Superficial vs deep inguinal Inguinal or inguinopelvic Unilateral vs bilateral
No prospective or randomized trials

7. Inguinopelvic Lymphadenectomy Good Prognostic Factors
Minimal nodal disease (2 or less nodes)
Unilateral involvement
No extranodal extension
Absence of pelvic node metastases

8. Penile Cancer
Lymphadenectomy is indicated in patients with palpable inguinal lymphadenopathy that persists after treatment of the primary penile lesion following a course of antibiotic therapy
Srinivas 1987, Ornellas 1994

9. Penile Cancer Management of No groin
Early prophylactic lymphadenectomy
Versus
Surveillance (delayed lymphadenectomy)

10. Penile Cancer Early Prophylactic Lymphadenectomy for N0 Groin
Cure rate may be as high as 80%
Lymph node metastases in nearly 30%
Reluctance due to substantial morbidity
Less likely in prophylactic setting
Modified extent of dissection
Better surgical technique
Preservation of dermis, scarpa’s fascia & saphenous veins
Myocutaneous flap coverage

11. Early vs Delayed Lymphadenectomy Early better
Baker 1976 (n=37): 59% vs 61%
McDougal 1986 (n=23): 83% vs 36% (66% in patients with N1 with GND)
Fraley 1989, Johnson & Lo 1984, Lynch 1997, Ornellas 1999
Delayed LND unable to salvage relapses (Fossa 1987, Fraley 1989, Johnson 1984, Ravi 1993, Srinivas 1987)
Early prophylactic better than delayed therapeutic
“Window of opportunity”
Reluctance due to morbidity

12. Early vs Delayed Lymphadenectomy No difference
Ravi 1993: (n=371): 100% vs. 76% (NS)
Probably due to:
Patient selection
Strict follow up
Aggressive treatment at relapse
Can delayed therapeutic dissection reliably &
Effectively salvage inguinal recurrences?

13. N0 Groin: Treatment Options
Fine needle aspiration cytology
Isolated node biopsy
Sentinel node biopsy
Extended sentinel LN dissection
Intraoperative lymphatic mapping
Superficial dissection
Modified complete dissection
Is there a role for Spiral CT or PET scan?

14. Fine needle aspiration cytology
Requires pedal / penile lymphangiograhy for node localization & aspiration under fluoroscopy guidance
Multiple nodes to be sampled
Sensitivity 71% (Scappini 1986, Horenblas 1993)
Can provide useful information to plan therapy when +ve

15. Unreliable method: Not recommended
Sentinel Node Biopsy
Based on penile lymphangiographic studies of Cabanas (1977)
Accuracy questioned: False –ve 10=50% (Cabanas 1977, McDougal 1986, Fossa 1987)
Extended sentinel node biopsy: 25% false –ve
False –ve due to anatomic variation in position of sentinel node
Unreliable method: Not recommended

16. Intraoperative Lymphatic Mapping
Potential for precise localization of sentinel node
Intradermal inj of vital blue dye or Tc- labeled colloid adjacent to the lesion
Horenblas 11/55: All +ve False –ve in 3
Pettaway 3/20: All +ve No false –ve
Tanis (2002): 18/23 +ve detected (Sensitivity 78%)
Promising technique for early localization of nodal metastases
Long-term data needed

17. Superficial Inguinal LND
Removal of nodes superficial to fascia lata
If nodes +ve on FS: Complete inguino-pelvic LND
Rationale: No spread to deep inguinal nodes when superficial nodes –ve (Pompeo 1995, Parra 1996)
No clinical evidence of direct deep node mets when corporal invasion present

18. Complete Modified LND (Catalona 1988)
Smaller incision
Limited inguinal dissection (superficial + fossa ovalis)
Preservation of saphenous vein
Thicker skin flaps
No sartorius transposition
Identifies microscopic mets without morbidity
(Colberg 1997, Parra 1996)

19. Limited Inguinal LND: Advantages
Provides more information than does biopsy of a single node or group of nodes
Avoids missing the sentinel node by removing all potential first echelon nodes
Spares patients the morbid consequences associated with traditional LND
Can be performed by any surgeon

20. Penile Cancer Predictors of lymph node metastases
Tumour histology
Corporal invasion
Urethral involvement
Tumour grade
Lymphatic & vascular invasion
DNA ploidy

21. Penile Cancer LN mets in stage T1 G1-2 cancers
Author
Stage/Grade N
% LN mets
Fraley
T1G1 19
1 (5.2%)
Theodorescu 8
2 (25%)
Solsona
T1G1-2 23
1 (4.3%)
McDougal 24
1 (4%)
Heyns 91
5 (6%) 17
1 (6%)
Total
182
11 (6%)

22. Penile Cancer Corporal Invasion vs. LN Mets
Author N
+ve nodes
McDougal 23
11 (48%)
Fraley 29
26 (90%)
Theodorescu 18
12 (67%)
Villavicencio 37
14 (38%)
Lopes 44
28 (64%)
Heyns 32
15 (47%)
Solsona 42
27 (64%)
Total
225
133 (59%)

23. Penile Cancer Risk Grouping for Inguinal Nodal Metastases
Low risk
Tis / Ta
T1 Grade I-II
No vascular invasion
<10% LN mets
Surveillance
High risk
T2-T3
Grade III
Vascular invasion
Non-compliance
>50% LN mets
Early lymphadenectomy

24. Penile Cancer: N0 High Risk Group Goals of Treatment
To determine whether occult metastases exist in inguinal nodes
To maximise detection & treatment for those with proven nodal metastases
To limit treatment morbidity in those with histologically negative nodes

25. Management: High risk patients
Bilateral N0 groin
Bilateral superficial or modified inguinal LND
Node -ve Unilat +ve Bilat +ve
Conclude Unilat inguino Bilat inguino-
pelvic LND pelvic LND

26. Cancer Penis Management of N+ groin
Surgical treatment recommended for operable inguinal metastatic disease
Most patients with inguinal LN mets will die if untreated.
20-67% patients with metastatic inguinal LN disease free 5 years after LND. Better survival 82-88% with single / limited mets

27. Resectable Inguinal Lymphadenopathy
Complete inguinopelvic lymphadenectomy
Therapeutic value justifies morbidity
Goals:
To eradicate all cancer
To cover the vasculature
To ensure rapid wound healing

28. Lymphadenectomy Unilateral vs. Bilateral
Anatomic crossover well-established & bilateral drainage a rule (Lymphangiography & IOLM studies)
Synchronous: Contralateral nodes in 50% (Ekstrom 58) Bilateral LND must Contralateral side: Superficial – FS
Metachronous: Unilateral may be justified if RFS >12 mo

29. Should pelvic lymphadenectomy be performed in patients with positive inguinal nodes?
Pelvic LN mets related to inguinal LN mets (Ravi 1993, Srinivas 1987, Kamat 1993)
Inguinal nodes Pelvic nodes
-ve -ve
1-3 +ve 22%
>3 +ve 57%
Although overall survival 10%, occasional
long-term survivals reported

30. Pelvic Lymphadenectomy
Staging tool
Identifies patients likely to benefit from adjuvant chemo
Adds to locoregional control
No additional morbidity
If pre-op pelvic node identified : NACT followed by surgery in responders
Value of pelvic LND unproven
Patients with minimal inguinal disease & limited pelvic LN mets may benefit

31. Inguinopelvic Lymphadenectomy Pathologic criteria for long-term survival
Minimal nodal metastases (upto 2)
Unilateral involvement
No extranodal extension
Absence of pelvic node metastases
80% five year survival

32. Penile Cancer Pelvic LN Mets vs. Survival
Author
Pts with +ve LN
5 yr survival
Dekernion 2
1 (50%)
Horenblas
Srinivas 11
Pow-Sang 3
2 (66%)
Kamat 6
2 (33%)
Ravi 30
Total 54
5 (10%)

33. Cancer Penis Substratification of LN vs survival
Survival with metastatic inguinal LN 20-25%
Survival related to : No. of metastatic nodes Bilaterality Level of metastatic nodes Perinodal extension
(Srinivas 1989, Tongaonkar 1992)

34. Inguinopelvic Lymphadenectomy Indications for adjuvant therapy
>2 metastatic inguinal nodes
Extranodal extension of disease
Pelvic lymph node metastases

35. Penile Cancer Management of fixed nodes
Neoadjuvant chemo + surgery in responders
Palliative chemotherapy
Chemotherapy + radiation therapy

36. Complications of lymphadenectomy
Persistent lymphorrhoea
Wound breakdown, necrosis, infection
Lymphocyst
Femoral blowout
Lymphangitis
Lymphoedema of lower extremity

37. Cancer Penis Measures to reduce morbidity of GND
Choice of incision
Downscaling of template
Saphenous vein sparing
Reconstructive techniques
Lymphovenous shunts

38. Tensor fascia lata myocutaneous flap

39. Measures to reduce morbidity of GND TMH experience (n = 100)
Elective excision of skin overlying the lymph node area
Reconstruction with TFL or anterolateral thigh flap
Significant reduction in early & late morbidity
? Improved disease control

40. Penile Cancer: Conclusions
Uncommon disease
No systematic study & complete absence of RCTs
Small no of patients over a long time
Poor decision making, treatment delays, poor compliance to treatment & follow up
RCTs to develop guidelines essential