Management of Groin in Cancer of the Penis

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Management of Groin in Cancer of the Penis

• Hemant B. Tongaonkar
• Professor Head Urologic
  Oncology Services Tata Memorial
  Hospital, Mumbai

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Penile Cancer

• Presence and extent of inguinal nodal metastases
• most important prognostic factor for survival

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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
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)
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Penile CancerCorporal 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)
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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
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)
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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