Reply to Kamran Zargar-Shoshtari, Pranav Sharma and Philippe E. Spiess’ Letter to the Editor re: Oliver W. Hakenberg, Eva M. Compérat, Suks Minhas, Andrea Necchi, Chris Protzel, Nick Watkin. EAU Guidelines on Penile Cancer: 2014 Update. Eur Urol 2015;67:142–50

Abstract

The authors of this letter question the rationale for the recommendation in the recent update of the European Association of Urology Guidelines on Penile Cancer [1] to perform ipsilateral pelvic lymphadenectomy in patients with two (or more) metastatic inguinal lymph nodes and criticize that this recommendation will result in a ‘‘high proportion of negative pelvic lymphadenectomies’’. In support of their opinion, the authors cite several papers analyzing retrospective series on lymph node disease in penile cancer. The most recent paper by Lughezzani et al [2] analyses predictive risk factors for pelvic nodalmetastases. However, detailed scrutiny of their data shows that patients with pelvic nodal metastases had amedian of two inguinal nodes involved. The rate of positive pelvic nodes was 15.2% in patients with less than two inguinal nodes involved (ie, one positive node) and 18.6% in those with less than three inguinal nodes involved (ie, two positive nodes). The 5-yr cancer-specific survival rate for pelvic node-positive patients in that series was 33.2% compared to 71.0% in pelvic node-negative patients. The study by Lont et al [3] presents large patient numbers but a mixture of primary inguinal nodal disease and inguinal nodal recurrence after surveillance. Furthermore, almost half of their patients with pelvic nodal disease also received adjuvant radiotherapy. Their data are therefore somewhat difficult to extrapolate; what they actually describe is that the risk of having pelvic nodal disease is higher with three affected inguinal nodes compared to having only two affected inguinal nodes, and for only this difference they calculated an odds ratio of 12.1. Liu et al [4] reported a rate of 6.5% positive pelvic nodes in patients with ‘‘two or less’’ inguinal nodes involved, that is, a proportion of patients had only one inguinal node involved, and consequently the rate of pelvic nodal involvement with two inguinal nodes involved will have been higher.