Management of Groin in Cancer of the Penis Hemant B. Tongaonkar

Management of Groin in
Cancer of the Penis
Hemant B. Tongaonkar
Professor & Head
Urologic Oncology Services
Tata Memorial Hospital, Mumbai
Penile Cancer
Presence and extent of inguinal nodal
metastases
most important prognostic factor for
survival
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
Penile cancer
Problems 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
Penile Cancer
Assessment of groin
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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
Penile Cancer: Management of
Groin Nodes
Crucial questions
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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
Inguinopelvic Lymphadenectomy
Good Prognostic Factors
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Minimal nodal disease (2 or less nodes)
Unilateral involvement
No extranodal extension
Absence of pelvic node metastases
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
Penile Cancer
Management of No groin
• Early prophylactic lymphadenectomy
Versus
• Surveillance (delayed lymphadenectomy)
Penile Cancer
Early 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, scarpa’s fascia
& saphenous veins
– Myocutaneous flap coverage
Early vs Delayed Lymphadenectomy
Early better
• Baker 1976 (n=37): 59% vs 61%
• McDougal 1986 (n=23): 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
Early vs Delayed Lymphadenectomy
No difference
• Ravi 1993: (n=371): 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?
N0 Groin: Treatment Options
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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?
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
Sentinel Node Biopsy
• Based on penile lymphangiographic
studies of Cabanas (1977)
• Accuracy questioned: False –ve 10=50%
(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
Intraoperative Lymphatic Mapping
• Potential for precise localization of sentinel
node
• Intradermal inj of vital blue dye or Tclabeled 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
Superficial Inguinal LND
• Removal of nodes superficial to fascia lata
• If nodes +ve on FS: Complete inguinopelvic 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
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)
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
Penile Cancer
Predictors of lymph node metastases
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Tumour histology
Corporal invasion
Urethral involvement
Tumour grade
Lymphatic & vascular invasion
DNA ploidy
Penile Cancer
LN 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%)
Penile Cancer
Corporal Invasion vs. LN Mets
Author
McDougal
Fraley
Theodorescu
Villavicencio
Lopes
Heyns
Solsona
Total
N
23
29
18
37
44
32
42
225
+ve nodes
11 (48%)
26 (90%)
12 (67%)
14 (38%)
28 (64%)
15 (47%)
27 (64%)
133 (59%)
Penile Cancer
Risk Grouping for Inguinal Nodal Metastases
Low risk
High risk
• Tis / Ta
• T1 Grade I-II
• No vascular invasion
• T2-T3
• Grade III
• Vascular invasion
• Non-compliance
<10% LN mets
Surveillance
>50% LN mets
Early lymphadenectomy
Penile Cancer: N0 High Risk Group
Goals 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
Management: High risk patients
Bilateral N0 groin
Bilateral superficial or modified inguinal LND
Node -ve
Unilat +ve
Conclude
Unilat inguinopelvic LND
Bilat +ve
Bilat inguinopelvic LND
Cancer Penis
Management 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
Resectable Inguinal Lymphadenopathy
• Complete inguinopelvic lymphadenectomy
• Therapeutic value justifies morbidity
• Goals:
– To eradicate all cancer
– To cover the vasculature
– To ensure rapid wound healing
Lymphadenectomy
Unilateral 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 >12 mo
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%
>3 +ve
57%
• Although overall survival 10%, occasional
long-term survivals reported
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
Inguinopelvic Lymphadenectomy
Pathologic criteria for long-term survival
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Minimal nodal metastases (upto 2)
Unilateral involvement
No extranodal extension
Absence of pelvic node metastases
80% five year survival
Penile Cancer
Pelvic LN Mets vs. Survival
Author
Dekernion
Horenblas
Srinivas
Pow-Sang
Kamat
Ravi
Total
Pts with +ve LN
2
2
11
3
6
30
54
5 yr survival
1 (50%)
0
0
2 (66%)
2 (33%)
0
5 (10%)
Cancer Penis
Substratification 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)
Inguinopelvic Lymphadenectomy
Indications for adjuvant therapy
• >2 metastatic inguinal nodes
• Extranodal extension of disease
• Pelvic lymph node metastases
Penile Cancer
Management of fixed nodes
• Neoadjuvant chemo + surgery in
responders
• Palliative chemotherapy
• Chemotherapy + radiation therapy
Complications of lymphadenectomy
• Persistent lymphorrhoea
• Wound breakdown, necrosis,
infection
• Lymphocyst
• Femoral blowout
• Lymphangitis
• Lymphoedema of lower extremity
Cancer Penis
Measures to reduce morbidity of GND
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Choice of incision
Downscaling of template
Saphenous vein sparing
Reconstructive techniques
Lymphovenous shunts
Tensor fascia lata myocutaneous flap
Measures to reduce morbidity of GND
TMH 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
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