Penilecancer-management of Groin

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Management of Groin inCancer of the Penis

Hemant B. Tongaonkar

Professor & Head

Urologic Oncology Services

Tata Memorial Hospital, Mumbai



Penile Cancer

Presence and extent of inguinal nodal

metastases

most important prognostic factor for survival



Penile Cancer

Prolonged locoregional phase before mets

occur

Superficial inguinal LN most frequent siteof lymphatic mets

LN involvement generally stepwise

LN mets beyond pelvis considered distant

Lymphadenectomy can be curative & need

not be treated as systemic disease



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



Penile Cancer

Assessment of groin

Clinical examination

Lymphangiography

High resolution USG with FNAC Fine needle aspiration cytology

Sentinel node biopsy with patent bluedye or lymphoscintigraphy

Histological evaluation at surgery is theGold Standard



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 inguinopelvicUnilateral vs bilateral

No prospective or randomized trials



Inguinopelvic Lymphadenectomy

Good Prognostic Factors

Minimal nodal disease (2 or less nodes)

Unilateral involvement

No extranodal extension

Absence of pelvic node metastases



Lymphadenectomy is indicated in patients

with palpable inguinal lymphadenopathythat persists after treatment of the primary

penile lesion following a course of

antibiotic therapy

Srinivas 1987, Ornellas 1994

Penile Cancer



Penile Cancer

Management of No groin

Early prophylactic lymphadenectomy

Versus

Surveillance (delayed lymphadenectomy)



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



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

³Window of opportunity´

Reluctance due to morbidity



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?



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 PETscan?



Fine needle aspiration cytology

Requires pedal / penile lymphangiograhyfor node localization & aspiration under

fluoroscopy guidance Multiple nodes to be sampled

Sensitivity 71% (Scappini 1986, Horenblas1993)

Can provide useful information to plantherapy when +ve



Sentinel Node Biopsy

Based on penile lymphangiographicstudies of Cabanas (1977)

Accuracy questioned: False ±ve 10=50%

(Cabanas 1977, McDougal 1986, Fossa1987)

Extended sentinel node biopsy: 25% false ±ve

False ±ve due to anatomic variation inposition of sentinel node

Unreliable method: Not recommended



Intraoperative Lymphatic Mapping

Potential for precise localization of sentinelnode

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 (Sensitivity78%)

Promising technique for early localization of nodal metastases

Long-term data needed



Superficial Inguinal LND

Removal of nodes superficial to fascia lata

If nodes +ve on FS: Complete inguino-

pelvic LND

Rationale: No spread to deep inguinalnodes when superficial nodes ±ve(Pompeo 1995, Parra 1996)

No clinical evidence of direct deep nodemets when corporal invasion present



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)



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



Penile Cancer

Predictors of lymph node metastases

Tumour histology

Corporal invasion Urethral involvement

Tumour grade

Lymphatic & vascular invasion DNA ploidy



Penile Cancer

LN mets in stage T1 G1-2 cancers

Author Stage/Grade N % LN mets

Fraley T1G1 19 1 (5.2%)

Theodorescu T1G1 8 2 (25%)

Solsona T1G1-2 23 1 (4.3%)

McDougal T1G1-2 24 1 (4%)

Heyns T1G1-2 91 5 (6%)Solsona T1G1 17 1 (6%)

Total 182 11 (6%)



Penile Cancer

Corporal Invasion vs. LN MetsAuthor 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%)



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



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



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



Cancer Penis

Management of N+ groin

Surgical treatment recommended for

operable inguinal metastatic disease

Most patients with inguinal LN metswill die if untreated.

20-67% patients with metastatic

inguinal LN disease free 5 years after LND. Better survival 82-88% with

single / limited mets



Resectable Inguinal Lymphadenopathy

Complete inguinopelvic lymphadenectomy

Therapeutic value justifies morbidity

Goals:

± To eradicate all cancer

± To cover the vasculature

± To ensure rapid wound healing



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



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



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




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



Penile Cancer

Pelvic LN Mets vs. Survival

Author Pts with +ve LN 5 yr survival

Dekernion 2 1 (50%)Horenblas 2 0

Srinivas 11 0

Pow-Sang 3 2 (66%)

Kamat 6 2 (33%)

Ravi 30 0

Total 54 5 (10%)



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)




Indications for adjuvant therapy

>2 metastatic inguinal nodes

Extranodal extension of disease

Pelvic lymph node metastases



Penile Cancer

Management of fixed nodes

Neoadjuvant chemo + surgery in

responders

Palliative chemotherapy

Chemotherapy + radiation therapy



Complications of lymphadenectomy

Persistent lymphorrhoea

Wound breakdown, necrosis,infection

Lymphocyst

Femoral blowout Lymphangitis

Lymphoedema of lower extremity



Cancer Penis

Measures to reduce morbidity of GND

Choice of incision

Downscaling of template

Saphenous vein sparing

Reconstructive techniques

Lymphovenous shunts



Tensor fascia lata myocutaneous flap



Measures to reduce morbidity of GND

TMH experience (n = 100)

Elective excision of skin overlying the lymphnode area

Reconstruction with TFL or anterolateral

thigh flap

Significant reduction in early & late morbidity

? Improved disease control



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

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Penilecancer-management of Groin