Management of Groin in Cancer of the Penis

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

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Penile cancerProblems 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

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Penile CancerAssessment 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

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Penile Cancer Management of Groin NodesCrucial
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
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Inguinopelvic LymphadenectomyGood Prognostic
Factors

• Minimal nodal disease (2 or less nodes)
• Unilateral involvement
• No extranodal extension
• Absence of pelvic node metastases

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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

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Penile CancerManagement of No groin

• Early prophylactic lymphadenectomy
• Versus
• Surveillance (delayed lymphadenectomy)

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Penile CancerEarly 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, scarpas fascia
  saphenous veins
• Myocutaneous flap coverage

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Early vs Delayed LymphadenectomyEarly better

• Baker 1976 (n37) 59 vs 61
• McDougal 1986 (n23) 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
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Early vs Delayed LymphadenectomyNo difference

• Ravi 1993 (n371) 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?
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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?

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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

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Sentinel Node Biopsy

• Based on penile lymphangiographic studies of
  Cabanas (1977)
• Accuracy questioned False ve 1050 (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

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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

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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

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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)
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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

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Penile CancerPredictors of lymph node metastases

• Tumour histology
• Corporal invasion
• Urethral involvement
• Tumour grade
• Lymphatic vascular invasion
• DNA ploidy

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Penile CancerLN mets in stage T1 G1-2 cancers
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Penile CancerCorporal Invasion vs. LN Mets
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Penile CancerRisk Grouping for Inguinal Nodal
Metastases

• Low risk
• Tis / Ta
• T1 Grade I-II
• No vascular invasion
• lt10 LN mets
• Surveillance

• High risk
• T2-T3
• Grade III
• Vascular invasion
• Non-compliance
• gt50 LN mets
• Early lymphadenectomy

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Penile Cancer N0 High Risk GroupGoals 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

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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

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Cancer PenisManagement 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

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Resectable Inguinal Lymphadenopathy

• Complete inguinopelvic lymphadenectomy
• Therapeutic value justifies morbidity
• Goals
• To eradicate all cancer
• To cover the vasculature
• To ensure rapid wound healing

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LymphadenectomyUnilateral 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 gt12 mo

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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
• gt3 ve 57

• Although overall survival 10, occasional
• long-term survivals reported

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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

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Inguinopelvic LymphadenectomyPathologic criteria
for long-term survival

• Minimal nodal metastases (upto 2)
• Unilateral involvement
• No extranodal extension
• Absence of pelvic node metastases

80 five year survival
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Penile CancerPelvic LN Mets vs. Survival
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Cancer PenisSubstratification 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)

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Inguinopelvic LymphadenectomyIndications for
adjuvant therapy

• gt2 metastatic inguinal nodes
• Extranodal extension of disease
• Pelvic lymph node metastases

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Penile CancerManagement of fixed nodes

• Neoadjuvant chemo surgery in responders
• Palliative chemotherapy
• Chemotherapy radiation therapy

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Complications of lymphadenectomy

• Persistent lymphorrhoea
• Wound breakdown, necrosis, infection
• Lymphocyst
• Femoral blowout
• Lymphangitis
• Lymphoedema of lower extremity

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Cancer PenisMeasures to reduce morbidity of GND

• Choice of incision
• Downscaling of template
• Saphenous vein sparing
• Reconstructive techniques
• Lymphovenous shunts

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Tensor fascia lata myocutaneous flap
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Measures to reduce morbidity of GNDTMH
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

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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