EAU & ASCO: Penile Cancer 2023: Difference between revisions

Line 438:

** '''Additional staging is warranted'''

** initial LN staging is focused on identifying (micro)metastatic disease in the inguinal LNs as early as possible

* Non-surgical staging

** Imaging

===== Staging =====

*** Not reliable to evaluate clinically node-negative patients

**** Conventional imaging modalities such as US, computed tomography (CT) or MRI cannot detect micrometastases

====== Non-surgical staging ======

****18F-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG-PET) does not detect LN metastases < 10 mm

* Imaging

****These imaging modalities can be of value to detect enlarged/abnormal nodes in patients when physical examination is challenging (e.g., due to obesity).

** Not reliable to evaluate clinically node-negative patients

* Surgical staging

*** Conventional imaging modalities such as US, computed tomography (CT) or MRI cannot detect micrometastases

** Invasive/surgical staging remains indispensable to identify micro-metastasis before nodal metastases become palpable/visible.

***18F-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG-PET) does not detect LN metastases < 10 mm

** '''Indications'''

***These imaging modalities can be of value to detect enlarged/abnormal nodes in patients when physical examination is challenging (e.g., due to obesity).

*** '''Recommended'''

**** '''High-risk tumors: T1b or higher'''

====== Surgical staging ======

*** Optional for intermediate-risk (pT1a G2)

* Invasive/surgical staging remains indispensable to identify micro-metastasis before nodal metastases become palpable/visible.

**** Surveillance is an alternative to surgical staging in patients willing to comply with strict follow-up

* '''Indications'''

** '''Options'''

** '''Recommended'''

*** '''Dynamic sentinel node biopsy (DSNB) (preferred)'''

*** '''High-risk tumors: T1b or higher'''

**** Developed to avoid resecting unnecessary LNs and thereby minimizing the morbidity of surgical staging

** Optional for intermediate-risk (pT1a G2)

**** A sentinel node (SN) is defined as the first LN on a direct drainage pathway from the primary tumour.

*** Surveillance is an alternative to surgical staging in patients willing to comply with strict follow-up

***** Based on this concept, it is assumed that if the SN is negative, this indicates the absence of lymphatic tumour spread in the corresponding inguinal basin. In case histopathology identifies SN (micro)metastasis, ipsilateral completion ILND is indicated

* '''Options'''

**** High diagnostic accuracy and low complication rates, especially when performed in experienced centres (sensitivity 92–96%, false negative rates 4–8%, complication rate 6–14%)

** '''Dynamic sentinel node biopsy (DSNB) (preferred)'''

**** '''Technique'''

*** Developed to avoid resecting unnecessary LNs and thereby minimizing the morbidity of surgical staging

***** '''Inguinal US is obtained prior to DSNB'''

*** A sentinel node (SN) is defined as the first LN on a direct drainage pathway from the primary tumour.

****** If sonographically suspicious nodes are detected, fine needle aspiration cytology (FNAC) can easily be performed in the same session to confirm the diagnosis of inguinal LN metastasis

**** Based on this concept, it is assumed that if the SN is negative, this indicates the absence of lymphatic tumour spread in the corresponding inguinal basin. In case histopathology identifies SN (micro)metastasis, ipsilateral completion ILND is indicated

******* if US + FNAC is positive, it can reduce the need for DSNB and allow for additional staging and therapeutic LN dissection at an earlier stage

*** High diagnostic accuracy and low complication rates, especially when performed in experienced centres (sensitivity 92–96%, false negative rates 4–8%, complication rate 6–14%)

****If DSNB is not available, and referral to a centre with experience with DSNB is not feasible, or if the patient does not want to run the risk of a false-negative procedure, ILND (modified/superficial/video-endoscopic) can be considered after informing the patient of the inherent risk of higher morbidity associated with these procedures.

*** '''Technique'''

*** Inguinal lymph node dissection (ILND)

**** '''Inguinal US is obtained prior to DSNB'''

**** Radical inguinal lymph node dissection (ILND) is the most accurate surgical staging method, but is associated with the highest complication rates

***** If sonographically suspicious nodes are detected, fine needle aspiration cytology (FNAC) can easily be performed in the same session to confirm the diagnosis of inguinal LN metastasis

**** Modified ILND lowers morbidity while maintaining sufficient sensitivity

****** if US + FNAC is positive, it can reduce the need for DSNB and allow for additional staging and therapeutic LN dissection at an earlier stage

***** Modifications in modified ILND

***If DSNB is not available, and referral to a centre with experience with DSNB is not feasible, or if the patient does not want to run the risk of a false-negative procedure, ILND (modified/superficial/video-endoscopic) can be considered after informing the patient of the inherent risk of higher morbidity associated with these procedures.

****** Shorter skin incision

** Inguinal lymph node dissection (ILND)

****** No dissection lateral to the femoral artery

*** Radical inguinal lymph node dissection (ILND) is the most accurate surgical staging method, but is associated with the highest complication rates

****** No dissection caudal to the fossa ovalis

*** Modified ILND lowers morbidity while maintaining sufficient sensitivity

****** Preservation of the saphenous vein

**** Modifications in modified ILND

****Video-endoscopic/robot-assisted radical LND has been introduced more recently

***** Shorter skin incision

*****Similar lymph node yield compared to open

***** No dissection lateral to the femoral artery

*****Reduces wound-related complications compared to open ILND, but no significant reduction in lymphatic complications

***** No dissection caudal to the fossa ovalis

******Main predictor of lymphatic complications is the number of lymph nodes removed

***** Preservation of the saphenous vein

***Video-endoscopic/robot-assisted radical LND has been introduced more recently

****Similar lymph node yield compared to open

****Reduces wound-related complications compared to open ILND, but no significant reduction in lymphatic complications

*****Main predictor of lymphatic complications is the number of lymph nodes removed

==== Clinically node-positive patients (cN+) ====

@@ Line 438: / Line 438: @@
 ** '''Additional staging is warranted'''
 ** initial LN staging is focused on identifying (micro)metastatic disease in the inguinal LNs as early as possible
-* Non-surgical staging
-** Imaging
+===== Staging =====
-*** Not reliable to evaluate clinically node-negative patients
-**** Conventional imaging modalities such as US, computed tomography (CT) or MRI cannot detect micrometastases
+====== Non-surgical staging ======
-****18F-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG-PET) does not detect LN metastases < 10 mm
+* Imaging
-****These imaging modalities can be of value to detect enlarged/abnormal nodes in patients when physical examination is challenging (e.g., due to obesity).
+** Not reliable to evaluate clinically node-negative patients
-* Surgical staging
+*** Conventional imaging modalities such as US, computed tomography (CT) or MRI cannot detect micrometastases
-** Invasive/surgical staging remains indispensable to identify micro-metastasis before nodal metastases become palpable/visible.
+***18F-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG-PET) does not detect LN metastases < 10 mm
-** '''Indications'''
+***These imaging modalities can be of value to detect enlarged/abnormal nodes in patients when physical examination is challenging (e.g., due to obesity).
-*** '''Recommended'''
-**** '''High-risk tumors: T1b or higher'''
+====== Surgical staging ======
-*** Optional for intermediate-risk (pT1a G2)
+* Invasive/surgical staging remains indispensable to identify micro-metastasis before nodal metastases become palpable/visible.
-**** Surveillance is an alternative to surgical staging in patients willing to comply with strict follow-up
+* '''Indications'''
-** '''Options'''
+** '''Recommended'''
-*** '''Dynamic sentinel node biopsy (DSNB) (preferred)'''
+*** '''High-risk tumors: T1b or higher'''
-**** Developed to avoid resecting unnecessary LNs and thereby minimizing the morbidity of surgical staging
+** Optional for intermediate-risk (pT1a G2)
-**** A sentinel node (SN) is defined as the first LN on a direct drainage pathway from the primary tumour.
+*** Surveillance is an alternative to surgical staging in patients willing to comply with strict follow-up
-***** Based on this concept, it is assumed that if the SN is negative, this indicates the absence of lymphatic tumour spread in the corresponding inguinal basin. In case histopathology identifies SN (micro)metastasis, ipsilateral completion ILND is indicated
+* '''Options'''
-**** High diagnostic accuracy and low complication rates, especially when  performed in experienced centres (sensitivity 92–96%, false negative rates 4–8%, complication rate 6–14%)
+** '''Dynamic sentinel node biopsy (DSNB) (preferred)'''
-**** '''Technique'''
+*** Developed to avoid resecting unnecessary LNs and thereby minimizing the morbidity of surgical staging
-***** '''Inguinal US is obtained prior to DSNB'''
+*** A sentinel node (SN) is defined as the first LN on a direct drainage pathway from the primary tumour.
-****** If sonographically suspicious nodes are detected, fine needle aspiration cytology (FNAC) can easily be performed in the same session to confirm the diagnosis of inguinal LN metastasis
+**** Based on this concept, it is assumed that if the SN is negative, this indicates the absence of lymphatic tumour spread in the corresponding inguinal basin. In case histopathology identifies SN (micro)metastasis, ipsilateral completion ILND is indicated
-******* if US + FNAC is positive, it can reduce the need for DSNB and allow for additional staging and therapeutic LN dissection at an earlier stage
+*** High diagnostic accuracy and low complication rates, especially when  performed in experienced centres (sensitivity 92–96%, false negative rates 4–8%, complication rate 6–14%)
-****If DSNB is not available, and referral to a centre with experience with DSNB is not feasible, or if the patient does not want to run the risk of a false-negative procedure, ILND (modified/superficial/video-endoscopic) can be considered after informing the patient of the inherent risk of higher morbidity associated with these procedures.
+*** '''Technique'''
-*** Inguinal lymph node dissection (ILND)
+**** '''Inguinal US is obtained prior to DSNB'''
-**** Radical inguinal lymph node dissection (ILND) is the most accurate surgical staging method, but is associated with the highest complication rates
+***** If sonographically suspicious nodes are detected, fine needle aspiration cytology (FNAC) can easily be performed in the same session to confirm the diagnosis of inguinal LN metastasis
-**** Modified ILND lowers morbidity while maintaining sufficient sensitivity
+****** if US + FNAC is positive, it can reduce the need for DSNB and allow for additional staging and therapeutic LN dissection at an earlier stage
-***** Modifications in modified ILND
+***If DSNB is not available, and referral to a centre with experience with DSNB is not feasible, or if the patient does not want to run the risk of a false-negative procedure, ILND (modified/superficial/video-endoscopic) can be considered after informing the patient of the inherent risk of higher morbidity associated with these procedures.
-****** Shorter skin incision
+** Inguinal lymph node dissection (ILND)
-****** No dissection lateral to the femoral artery
+*** Radical inguinal lymph node dissection (ILND) is the most accurate surgical staging method, but is associated with the highest complication rates
-****** No dissection caudal to the fossa ovalis
+*** Modified ILND lowers morbidity while maintaining sufficient sensitivity
-****** Preservation of the saphenous vein
+**** Modifications in modified ILND
-****Video-endoscopic/robot-assisted radical LND has been introduced more recently
+***** Shorter skin incision
-*****Similar lymph node yield compared to open
+***** No dissection lateral to the femoral artery
-*****Reduces wound-related complications compared to open ILND, but no significant reduction in lymphatic complications
+***** No dissection caudal to the fossa ovalis
-******Main predictor of lymphatic complications is the number of lymph nodes removed
+***** Preservation of the saphenous vein
+***Video-endoscopic/robot-assisted radical LND has been introduced more recently
+****Similar lymph node yield compared to open
+****Reduces wound-related complications compared to open ILND, but no significant reduction in lymphatic complications
+*****Main predictor of lymphatic complications is the number of lymph nodes removed
 ==== Clinically node-positive patients (cN+) ====