Editing Penile Cancer: Squamous Penile Cancer (section)

==== <span style="color:#ff0000">Clinically negative groins</span> ====
* '''<span style="color:#ff0000">≈20% of patients with clinically nonpalpable inguinal nodes harbor occult metastases</span>'''
**Cross-sectional imaging studies such as CT and magnetic resonance imaging (MRI) are unable to accurately detect these cases and are only largely used to assess for the presence of pelvic lymph node involvement
**'''Immediate resection of clinically occult lymph node metastases is associated with improved survival when compared with delayed resection of involved nodes at the time of clinical detection'''
* '''<span style="color:#ff0000">Surgical staging</span>'''
**'''<span style="color:#ff0000">Indications</span>'''
***'''<span style="color:#ff0000">Recommended (1):</span>'''
****'''<span style="color:#ff0000">High-risk tumor (≥pT1b)</span>'''
***'''<span style="color:#ff0000">Optional (1):</span>'''
****'''<span style="color:#ff0000">T1a G2 disease</span>'''
*****'''<span style="color:#ff0000">Surveillance is an alternative to surgical staging with patients willing to comply with strict follow-up</span>'''
**'''<span style="color:#ff0000">Options (2)</span>'''
**#'''<span style="color:#ff0000">Dynamic sentinel node biopsy (DNSB) (preferred)[https://pubmed.ncbi.nlm.nih.gov/36906413/]</span>'''
**#* Sentinel lymph node biopsy is the technique to remove nodes that are first affected by the spread of metastatic disease.
**#**Based on the assumption that penile cancer cells will initially spread unilaterally or bilaterally to a single inguinal lymph node before disseminating to adjoining lymph nodes and that this sentinel lymph node can have a variable position among individuals
**#***The theory is that certain cancers typically do not spread to other lymph nodes without the necessary and stepwise involvement of the sentinel node first.
**#***The concept of orderly lymphatic progression of metastatic cells from the primary tumor to the sentinel node seems to be likely with regard to squamous cell carcinoma of the penis.
**#*Technique
**#**Inguinal ultrasound and fine-needle aspiration (FNA) cytology of suspect lymph nodes has been added as a preliminary step before lymphoscintigraphy. Patients with abnormal nodes on ultrasound undergo FNA, and only patients with negative FNA findings proceed to scintigraphy and DSNB.
**#*** Patients with positive FNA findings undergo inguinal lymph node dissection.
**#**DNSB involves preoperative lymphoscintigraphy using technetium-99m nanocolloid, preoperative patent blue dye injection, and intraoperative guidance with a gamma ray detection probe to visualize the individual drainage pattern and accurately identify the sentinel node, which is subsequently resected
**#*'''Advantages'''
**#**'''Significantly less morbid than modified inguinal lymph node dissection or a standard lymphadenectomy'''
**#***Can serve as an intermediary between noninvasive imaging modalities and surgical resection when identifying those patients with clinically negative groins who would benefit from inguinal lymphadenectomy
**#*'''Disadvantages'''
**#** '''Widespread use of DSNB remains limited and generally restricted to high-volume centers'''
**#***Dedicated experience is needed to gain optimal results
**#**** Should be performed with the goal of a false-negative rate at ≤5%
**#****Methods to increase the accuracy of DNSB (4):
**#***# Preoperative inguinal US with needle biopsy of any suspicious nodes
**#***# Routine inguinal exploration even in the absence of radiotracer visualization
**#***# Intraoperative palpation of the wound for abnormal nodes
**#***# Extended pathologic analysis of any excised lymph nodes
**#* '''Follow-up'''
**#** '''Strict follow-up is necessary to identify recurrences that can be managed surgically and potentially salvaged.'''
**#** '''It is important to stress that DSNB remains a diagnostic procedure, allowing some men to avoid a therapeutic IFLND.'''
**#*** '''Those with a positive DSNB should proceed to a full therapeutic lymphadenectomy. It is not appropriate for palpable lymphadenopathy and applies only to clinically negative nodes'''.
**#*** '''In patients with palpable lymphadenopathy'''
**#'''<span style="color:#ff0000">Bilateral inguinal lymph node dissection (ILND)</span>'''
**#*'''Lymphatic spread of penile carcinoma can be unilateral or bilateral to the inguinal lymph nodes'''
**#*Approaches (2):
**#**Open
**#**Video-endoscopic surgery