Management of Groin in Cancer of the Penis

1. Management of Groin in Cancer of the Penis Hemant B. Tongaonkar Professor & Head Urologic Oncology Services Tata Memorial Hospital, Mumbai

2. Penile Cancer Presence and extent of inguinal nodal metastases most important prognostic factor for survival

3. 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

4. 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

5. 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

6. 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

7. Inguinopelvic LymphadenectomyGood Prognostic Factors • Minimal nodal disease (2 or less nodes) • Unilateral involvement • No extranodal extension • Absence of pelvic node metastases

8. 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

9. Penile CancerManagement of No groin • Early prophylactic lymphadenectomy Versus • Surveillance (delayed lymphadenectomy)

10. 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, scarpa’s fascia & saphenous veins • Myocutaneous flap coverage

11. Early vs Delayed LymphadenectomyEarly 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

12. Early vs Delayed LymphadenectomyNo 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?

13. 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?

14. 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

15. 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

16. 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

17. 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

18. 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)

19. 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

20. Penile CancerPredictors of lymph node metastases • Tumour histology • Corporal invasion • Urethral involvement • Tumour grade • Lymphatic & vascular invasion • DNA ploidy

21. Penile CancerLN mets in stage T1 G1-2 cancers

22. Penile CancerCorporal Invasion vs. LN Mets

23. Penile CancerRisk Grouping for Inguinal Nodal Metastases Low risk • Tis / Ta • T1 Grade I-II • No vascular invasion <10% LN mets Surveillance High risk • T2-T3 • Grade III • Vascular invasion • Non-compliance >50% LN mets Early lymphadenectomy

24. 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

25. 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

26. 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

27. Resectable Inguinal Lymphadenopathy • Complete inguinopelvic lymphadenectomy • Therapeutic value justifies morbidity • Goals: • To eradicate all cancer • To cover the vasculature • To ensure rapid wound healing

28. 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 >12 mo

29. 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

30. 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

31. 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

32. Penile CancerPelvic LN Mets vs. Survival

33. 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)

34. Inguinopelvic LymphadenectomyIndications for adjuvant therapy • >2 metastatic inguinal nodes • Extranodal extension of disease • Pelvic lymph node metastases

35. Penile CancerManagement of fixed nodes • Neoadjuvant chemo + surgery in responders • Palliative chemotherapy • Chemotherapy + radiation therapy

36. Complications of lymphadenectomy • Persistent lymphorrhoea • Wound breakdown, necrosis, infection • Lymphocyst • Femoral blowout • Lymphangitis • Lymphoedema of lower extremity

37. Cancer PenisMeasures to reduce morbidity of GND • Choice of incision • Downscaling of template • Saphenous vein sparing • Reconstructive techniques • Lymphovenous shunts

38. Tensor fascia lata myocutaneous flap

39. 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

40. 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