Penile Cancer: Squamous Penile Cancer: Difference between revisions
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* '''<span style="color:#ff0000">Clinically negative groins</span>''' | * '''<span style="color:#ff0000">Clinically negative groins</span>''' | ||
** '''<span style="color:#ff0000">≈20% of patients with clinically nonpalpable inguinal nodes harbor occult metastases</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 | |||
** '''Patients with stage ≥pT2 have high risk of metastasis, patients with pTis, pTa, pT1, grade 1 tumours have low risk of metastasis''' | ** '''Patients with stage ≥pT2 have high risk of metastasis, patients with pTis, pTa, pT1, grade 1 tumours have low risk of metastasis''' | ||
*** '''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''' | *** '''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">Patients with high-risk disease (high-grade or ≥pT2) should undergo lymph node staging with | ** '''<span style="color:#ff0000">Patients with high-risk disease (high-grade or ≥pT2) should undergo lymph node staging with</span>''' | ||
*** '''Dynamic | ***'''<span style="color:#ff0000">Bilateral modified inguinal lymphadenectomy</span>''' | ||
**** Sentinel lymph node biopsy is the technique to remove nodes that are first affected by the spread of metastatic disease. | ****'''Lymphatic spread of penile carcinoma can be unilateral or bilateral to the inguinal lymph nodes''' | ||
***'''<span style="color:#ff0000">Dynamic sentinel node biopsy</span>''' | |||
**** A minimally invasive diagnostic tool which 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 | |||
****Dynamic sentinel lymph node biopsy is 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 | |||
****Sentinel lymph node biopsy is the technique to remove nodes that are first affected by the spread of metastatic disease. | |||
***** Objective is to reduce the false-negative rate of groin dissection | ***** Objective is to reduce the false-negative rate of groin dissection | ||
***** 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 theory is that certain cancers typically do not spread to other lymph nodes without the necessary and stepwise involvement of the sentinel node first. | ||
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****** '''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'''. | ****** '''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''' | ****** '''In patients with palpable lymphadenopathy''' | ||
*** | ***Alternatives | ||
**** | ****Inguinal staging procedure | ||
***** In patients with no evidence of palpable adenopathy who are selected to undergo inguinal procedures by virtue of adverse prognostic factors within the primary tumor, the goal is to define whether metastases exist with minimal morbidity. The gold-standard for detecting microscopic metastases is the superficial inguinal node dissection | ***** Begins with a superficial node dissection which involves removal of nodes superficial to fascia lata. | ||
**** | ****** In patients with no evidence of palpable adenopathy who are selected to undergo inguinal procedures by virtue of adverse prognostic factors within the primary tumor, the goal is to define whether metastases exist with minimal morbidity. The gold-standard for detecting microscopic metastases is the superficial inguinal node dissection | ||
***** | ***** Complete ilionguinal lymph node dissection (removal of those nodes deep to the fascia lata contained within the femoral triangle as well as the pelvic nodes) is then performed if the superficial nodes are positive at surgery by frozen-section analysis. | ||
***** Given morbidity of pelvic lymph node dissection, this can be spared in select patients with limited inguinal metastases | ****** Series have shown that in patients with negative superficial nodes, nodes deep to the fascia were always negative | ||
**** | ****** Given morbidity of pelvic lymph node dissection, this can be spared in select patients with limited inguinal metastases | ||
***** | ***** The superficial lymph node dissection should be bilateral | ||
****** | |||
******Lymph node dissection does not need to be bilateral if adenopathy is unilateral at recurrence (after treating primary tumour) | |||
* '''<span style="color:#ff0000">Palpable adenopathy</span>''' | * '''<span style="color:#ff0000">Palpable adenopathy</span>''' | ||
** '''Associated with metastasis in 43% of cases, secondary to inflammation in the remainder'''; can consider fine-needle aspiration to differentiate | ** '''Associated with metastasis in 43% of cases, secondary to inflammation in the remainder'''; can consider fine-needle aspiration to differentiate | ||
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*# '''Absence of pelvic nodal metastases (pN3)''' | *# '''Absence of pelvic nodal metastases (pN3)''' | ||
*## '''i.e. pN1, and lack of features associated with pN2 and pN3''' | *## '''i.e. pN1, and lack of features associated with pN2 and pN3''' | ||
* '''<span style="color:#ff0000">Indications for pelvic lymph node dissection in patients undergoing inguinal lymph node dissection for curative intent (no pelvic adenopathy) (2):</span>''' | * '''No anatomic or lymphangiographic studies demonstrating direct lymphatic drainage to the pelvic lymph nodes from the penis, which is evidenced by the lack of metastatic spread to the pelvic lymph nodes from a primary penile tumor in the absence of metastatic spread to the inguinal lymph nodes[https://link.springer.com/book/10.1007/978-3-319-60858-7]''' | ||
*'''<span style="color:#ff0000">Indications for pelvic lymph node dissection in patients undergoing inguinal lymph node dissection for curative intent (no pelvic adenopathy) (2):</span>''' | |||
*# '''<span style="color:#ff0000">≥2 positive inguinal lymph nodes</span>''' | *# '''<span style="color:#ff0000">≥2 positive inguinal lymph nodes</span>''' | ||
*# '''<span style="color:#ff0000">Extra-nodal extension is present</span>''' | *# '''<span style="color:#ff0000">Extra-nodal extension is present</span>''' | ||