Invasive Lymph Node Staging Research Articles

Follow Up Care After Penile Sparing Surgery for Penile Cancer: Current Perspectives.

Penile cancer (PeCa) is a rare urologic tumor worldwide. In 2024, 2100 new cases and 500 deaths are estimated in the United States. Radical surgery via total penectomy has historically been the cornerstone of treatment, since it provides excellent long-term oncological control. The rationale of surgery for penile cancer was to achieve a 2 cm macroscopic surgical margin that is historically advocated to reduce recurrences. Over time, numerous studies have demonstrated that resection margin status does not affect patients' survival. Different penile-sparing techniques are currently recommended in the European Association of Urology-American Society of Clinical Oncology (EAU-ASCO) guidelines for the treatment of localized primary PeCa. Centralization of care could yield multiple benefits, including improved disease awareness, higher rates of penile-sparing surgery, enhanced detection rates, increased utilization of less invasive lymph node staging techniques, enhanced quality of specialized histopathological examinations, and the establishment of specialized multidisciplinary teams. Compared to more aggressive treatments, the higher recurrence rates after penile-sparing surgery do not hamper neither the metastasis-free survival nor the overall survival. Repeated penile-sparing surgery could be considered for selected cases. The psychological impact of penile cancer is not negligible since the perceived loss of masculinity might adversely affect mental health and overall well-being. Quality of life may be compromised by sexual and urinary dysfunction which may be the result either of the loss of penile tissue or the psychological status of the patient. It is of utmost importance to offer rehabilitative treatment as sexual therapy, physical therapy, occupational therapy, family and peer counseling.

When to Consider Invasive Lymph Node Staging in Non–Small-Cell Lung Cancer? A Novel Scoring System Utilising Metabolic Parameters in 18F-FDG PET/CT

ObjectiveThe maximum standardised uptake value (SUVmax) is a widely utilised metric in positron emission tomography/computed tomography for clinically staging non–small-cell lung cancer (NSCLC), yet the reliability of SUVmax remains controversial. We herein aimed to assess the effectiveness of semi-quantitative parameters, encompassing size, SUVmax, metabolic tumour volume (MTV), total lesion glycolysis (TLG) and heterogeneity factor (HF), in evaluating both primary tumours and lymph nodes (LNs) on positron emission tomography/computed tomography. A novel scoring system was devised to appraise the role of semi-quantitative parameters and visually evaluate LNs for nodal staging. Materials and MethodsPatients with pathological NSCLC, diagnosed between 2014 and 2019 and clinically staged I-III, were enrolled in the study. Patient demographics, including age, sex, tumour location, diameter, tumour-node-metastasis stage, as well as SUVmax, MTV, TLG and HF parameters of primary tumours and LNs, were documented. ResultsThe analysis comprised 319 patients and 963 LNs. Patients had a mean age of 61.62 years, with 91.5% being male. Adenocarcinoma exhibited a histological association with LN metastasis (P=0.043). The study findings revealed that tumour size, SUVmax, MTV, TLG and HF did not significantly affect the detection of LN metastasis. Conversely, non-squamous cell carcinoma, LNs exhibiting higher FDG levels than the liver, LN size, SUVmax, MTV and TLG were identified as risk factors (P<0.0001). The identified cut-off values were 1.05cm for LN size, 4.055 for SUVmax, 1.805cm3 for MTV and 5.485 for TLG. The scoring system incorporated these parameters, and visual assessment indicated that a score of ≥3 increased the risk of metastasis by 14.33 times. ConclusionWe devised a novel scoring system and demonstrated that LNs with a score of ≥3 in patients with NSCLC have a high likelihood of metastasis. This innovative scoring system can serve as a valuable tool to mitigate excessive and extreme measures in the assessment of invasive pathological staging.

43 Evaluation of invasive nodal staging practice in lung cancer

43 Evaluation of invasive nodal staging practice in lung cancer

Invasive Nodal Staging via Endobronchial Ultrasound and Outcome in Patients Treated with Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer – Results from a Single Institution Study

IntroductionStereotactic body radiation therapy (SBRT) is an effective treatment for medically inoperable early-stage non-small cell lung cancer (NSCLC). The prognostic value of invasive nodal staging (INS) for patients undergoing SRBT has not been studied extensively. Herein, we report the impact of INS in addition to 18F-FDG-PET on treatment outcome for patients with NSCLC undergoing SBRT. Materials and MethodsPatients with stage I/ II NSCLC who underwent SBRT were included with IRB approval. Clinical, dosimetric, and radiological data were obtained. Overall survival (OS), regional recurrence free survival (RRFS), local recurrence free survival (LRFS), and distant recurrence free survival (DRFS) were analyzed using Kaplan Meyer method. Univariable analysis (UVA) and multivariable analysis (MVA) were performed to assess the relationship between the variables and the outcomes. ResultsA total of 376 patients were included in the analysis. Median follow up was 43 months (IQ 32.6-45.8). Median OS, LRFS, RRFS, DRFS were 40, 32, 32, 33 months, respectively. The 5-year local, regional, and distant failure rates were 13.4%, 23.5% and 25.3%, respectively. The 1-year, 3-year and 5-year OS were 83.8%, 55.6%, and 36.3%, respectively. On MVA, INS was not a predictor of either improved overall or any recurrence free survival endpoints while larger tumor size, age, and adjusted Charleston co-morbidity index (aCCI) were significant for inferior LRFS, RRFS, and DRFS. ConclusionInvasive nodal staging did not improve overall or recurrence free survival among patients with early-stage NSCLC treated with SBRT whereas older age, aCCI, and larger tumor size were significant predictors of LRFS, RRFS, and DRFS.

Additional Value of FDG-PET/MRI Complementary to Sentinel Lymphonodectomy for Minimal Invasive Lymph Node Staging in Patients with Endometrial Cancer: A Prospective Study.

Lymph node metastases (LNM) are rare in early-stage endometrial cancer, but a diagnostic systematic lymphadenectomy (LNE) is often performed to achieve reliable N-staging. Therefore, this prospective study aimed to evaluate the benefit of [18F]-Fluorodeoxyglucose (FDG) PET/MRI complementary to SPECT/CT guided sentinel lymphonodectomy (SLNE) for a less invasive N-staging Methods: 79 patients underwent a whole-body FDG-PET/MRI, SLN mapping with 99mTc-Nanocolloid SPECT/CT and indocyanine green (ICG) fluoroscopy followed by LNE which served as ground truth. FDG-PET/MRI was highly specific in N-staging (97.2%) but revealed limited sensitivity (66.7%) due to missed micrometastases. In contrast, bilateral SLN mapping failed more often in patients with macrometastases. The combination of SLN mapping and FDG-PET/MRI increased the sensitivity from 66.7% to 77.8%. Additional SLN labeling with dye (ICG) revealed a complete SLN mapping in 80% (8/10) of patients with failed or incomplete SLN detection in SPECT/CT, reducing the need for diagnostic systematic LNE up to 87%. FDG-PET/MRI detected para-aortic LNM in three out of four cases and a liver metastasis. The combination of FDG-PET/MRI and SLNE can reduce the need for diagnostic systematic LNE by up to 87%. PET/MRI complements the SLN technique particularly in the detection of para-aortic LNM and occasional distant metastases.

Vulvar Carcinoma: Standard of Care and Perspectives.

Treatment of vulvar carcinoma (VC) is challenging. The objectives of this review were to describe for clinicians the epidemiologic and clinical aspects of VC, the standard of care in terms of primary local treatment and systemic therapies, and the recent innovations and perspectives emerging from translational research in immuno-oncology. We conducted a comprehensive review outlying the clinical aspects and biologic background of vulvar cancer, highlighting modern treatment strategies on the basis of a personalized approach. Epidemiologic data showed a recent rise in incidence of VC, attributed to human papillomavirus. Surgery is the mainstay of primary treatment, but multimodal approaches are frequently required in the presence of adverse prognosis histopathologic factors. Chemoradiation is indicated when organ-sparing surgery is not feasible. However, inability to achieve high locoregional control rates in advanced cases and the morbidity associated with local treatments are still key issues. Recent clinical data showed the benefit of individualized strategies combining organ-sparing surgical strategies, less invasive lymph node staging procedures, and refinement in radiotherapy modalities. Among the most important research area, there is a sound rationale for testing modern systemic approaches such as immune checkpoint inhibitors in selected patients with recurrent and/or metastatic tumors. Although no specific data exist for VC, the role of supportive care and post-treatment rehabilitation strategies is also crucial. There are still insufficient studies dedicated to patients with VC. Public health programs for prevention, screening, and early diagnosis are required, and clinical research should be strengthened to provide high-quality clinical evidence and improve patients' oncologic and functional outcomes.

Deep learning to predict breast cancer sentinel lymph node status on INSEMA histological images

BackgroundSentinel lymph node (SLN) status is a clinically important prognostic biomarker in breast cancer and is used to guide therapy, especially for hormone receptor-positive, HER2-negative cases. However, invasive lymph node staging is increasingly omitted before therapy, and studies such as the randomised Intergroup Sentinel Mamma (INSEMA) trial address the potential for further de-escalation of axillary surgery. Therefore, it would be helpful to accurately predict the pretherapeutic sentinel status using medical images. MethodsUsing a ResNet 50 architecture pretrained on ImageNet and a previously successful strategy, we trained deep learning (DL)-based image analysis algorithms to predict sentinel status on hematoxylin/eosin-stained images of predominantly luminal, primary breast tumours from the INSEMA trial and three additional, independent cohorts (The Cancer Genome Atlas (TCGA) and cohorts from the University hospitals of Mannheim and Regensburg), and compared their performance with that of a logistic regression using clinical data only. Performance on an INSEMA hold-out set was investigated in a blinded manner. ResultsNone of the generated image analysis algorithms yielded significantly better than random areas under the receiver operating characteristic curves on the test sets, including the hold-out test set from INSEMA. In contrast, the logistic regression fitted on the Mannheim cohort retained a better than random performance on INSEMA and Regensburg. Including the image analysis model output in the logistic regression did not improve performance further on INSEMA. ConclusionsEmploying DL-based image analysis on histological slides, we could not predict SLN status for unseen cases in the INSEMA trial and other predominantly luminal cohorts.

Accuracy of dynamic sentinel lymph node biopsy for inguinal lymph node staging in cN0 penile cancer

BackgroundPenile cancer is characterized by an early lymphatic dissemination. In intermediate and high-risk primary tumors without palpable inguinal lymph nodes, there is a 6–30% risk of micro-metastatic disease. Invasive lymph node staging in these patients is performed using dynamic sentinel lymph node biopsy (DSNB). In this study, the role of DSNB in cN0 penile cancer was studied, evaluating features of sentinel lymph node (SN) visualization and outcome parameters. Patients with penile cancer without inguinal lymph node metastases who were referred for DSNB at our center between January 2015 and May 2021 and had a follow-up period of at least 18 months, were retrospectively included. After injection of 85 ± 20 MBq [99mTc]Tc-nanocolloid peritumorally, dynamic, static planar and SPECT/CT imaging was performed. Primary endpoints were sensitivity of the diagnostic procedure, disease-free survival and DSNB-related adverse events. Secondary endpoints were SN detection rate, number of SNs and the number of counts of the most active SN.ResultsSeventy-seven penile DSNB procedures in 75 patients (67 ± 11 years) were included. The detection rate of DSNB was 91% and 96% per procedure and groin, respectively. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were 79%, 100%, 97% and 100%, respectively. More SNs were seen on SPECT/CT than on static planar imaging (1.33 vs. 1.17, p = 0.001). The mean counts per SN on static planar imaging was lower compared to SPECT/CT (1343 vs. 5008; p < 0.0001). There was a positive correlation between the total counts of the SN on the static planar image and the SPECT/CT (r = 0.79, p < 0.0001). Only one out of seventy-five patients (1%) experienced DSNB-related adverse events. After 18 months, 58 patients remained disease free (77%), 13 developed local recurrence (17%), and 4 developed lymphatic or distant metastases (5%).ConclusionDNSB is a safe diagnostic procedure with a good detection rate and in particular high negative predictive value. It can therefore prevent overtreatment of patients with negative inguinal groins on clinical examination and DSNB examination. Finally, DSNB enables an early detection of occult metastases which would not be visualized with standardized imaging modalities.

MP33-11 P16 STATUS IS AN INDEPENDENT PREDICTOR OF OVERALL SURVIVAL IN METASTATIC PENILE CANCER IN A LARGE CONTEMPORARY COHORT

You have accessJournal of UrologyCME1 Apr 2023MP33-11 P16 STATUS IS AN INDEPENDENT PREDICTOR OF OVERALL SURVIVAL IN METASTATIC PENILE CANCER IN A LARGE CONTEMPORARY COHORT James Churchill, Ashwin Sachdeva, Craig Jones, Allaudin Issa, Christian Fankhauser, Andrew Hudson, Anna Tran, Pedro Oliveira, Helen Johnson, Maurice Lau, Arie Parnham, and Vijay Sangar James ChurchillJames Churchill More articles by this author , Ashwin SachdevaAshwin Sachdeva More articles by this author , Craig JonesCraig Jones More articles by this author , Allaudin IssaAllaudin Issa More articles by this author , Christian FankhauserChristian Fankhauser More articles by this author , Andrew HudsonAndrew Hudson More articles by this author , Anna TranAnna Tran More articles by this author , Pedro OliveiraPedro Oliveira More articles by this author , Helen JohnsonHelen Johnson More articles by this author , Maurice LauMaurice Lau More articles by this author , Arie ParnhamArie Parnham More articles by this author , and Vijay SangarVijay Sangar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003266.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile squamous cell carcinoma (PSCC) is rare and there is a need to refine selection of patients for optimal management. Human papilloma virus infection is a known PSCC risk factor, measured by the histopathological presence of the p16 protein. This study has examined effect of p16 status on overall survival (OS) of PSCC patients managed at a tertiary referral centre. METHODS: We analysed retrospective data from a prospectively maintained database for patients with PSCC treated between 2003 and 2022. We excluded patients without reported p16 status. TNM stage was defined by histopathology (AJCC v8) except where fixed inguinal nodes (cN3), pelvic lymphadenopathy (cN3) or distant metastatic disease (M1) were present without histopathological confirmation. The primary outcome was OS (time from definitive primary surgery to death, censored for last follow-up). Multivariate Cox regression analysis for age, p16 status, TNM-stage and grade was performed. Audit approval was obtained. RESULTS: We identified 470 eligible patients. Median follow-up was 28 months (range 0-265). 118 patients (25%) did not undergo invasive lymph node staging (pNX). For the whole cohort, p16+ patients demonstrated 10% greater 5-year OS compared to p16- (71% versus 61%; Figure 1). After multivariate analysis (Table 1), there remained a significant difference in OS with 40% reduction in the risk of death for p16+ patients compared to p16-. On exploratory analysis by stage, only the N1 group retained this difference, suggesting that this is the group where p16 status may be of most clinical impact. CONCLUSIONS: Our data demonstrate that p16+ predicts for improved OS compared to p16- status in PSCC patients. After adjusting for age, stage and grade, this difference was retained in patients with N1 disease, suggesting that p16 status could be further explored as a predictive biomarker in this group. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e454 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Churchill More articles by this author Ashwin Sachdeva More articles by this author Craig Jones More articles by this author Allaudin Issa More articles by this author Christian Fankhauser More articles by this author Andrew Hudson More articles by this author Anna Tran More articles by this author Pedro Oliveira More articles by this author Helen Johnson More articles by this author Maurice Lau More articles by this author Arie Parnham More articles by this author Vijay Sangar More articles by this author Expand All Advertisement PDF downloadLoading ...

MP50-04 OVERALL SURVIVAL IN PENILE CANCER: ANALYSIS OF A LARGE CONTEMPORARY COHORT TREATED AT A TERTIARY REFERRAL CENTRE

You have accessJournal of UrologyCME1 Apr 2023MP50-04 OVERALL SURVIVAL IN PENILE CANCER: ANALYSIS OF A LARGE CONTEMPORARY COHORT TREATED AT A TERTIARY REFERRAL CENTRE James Churchill, Ashwin Sachdeva, Craig Jones, Allaudin Issa, Christian Fankhauser, Andrew Hudson, Anna Tran, Pedro Oliveira, Helen Johnson, Maurice Lau, Arie Parnham, and Vijay Sangar James ChurchillJames Churchill More articles by this author , Ashwin SachdevaAshwin Sachdeva More articles by this author , Craig JonesCraig Jones More articles by this author , Allaudin IssaAllaudin Issa More articles by this author , Christian FankhauserChristian Fankhauser More articles by this author , Andrew HudsonAndrew Hudson More articles by this author , Anna TranAnna Tran More articles by this author , Pedro OliveiraPedro Oliveira More articles by this author , Helen JohnsonHelen Johnson More articles by this author , Maurice LauMaurice Lau More articles by this author , Arie ParnhamArie Parnham More articles by this author , and Vijay SangarVijay Sangar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003298.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile squamous cell carcinoma (PSCC) is rare and overall survival (OS) in metastatic disease remains poor. This study examines the OS, classified by TNM stage, in a large contemporary cohort of PSCC patients managed at a tertiary referral centre. METHODS: We analysed retrospective data from a prospectively maintained database for patients with PSCC treated between 2003 and 2022. We excluded clinically node-negative (cN0) patients who did not undergo invasive nodal staging (pNX). TNM stage was defined by histopathology (AJCC version 8) except where clinical/radiological findings of fixed inguinal nodes (cN3), pelvic lymphadenopathy (cN3) or distant metastatic disease (M1) were present. All patients were treated according to local guidelines. The primary outcome of OS (time from definitive primary surgery to death, censored for last follow-up) was analysed using the Kaplan-Meier method and log rank test. Multivariate Cox regression analysis for age, p16 status, TNM-stage and grade was performed. Audit approval was obtained from the host clinical governance committee. RESULTS: We identified 634 eligible patients. Baseline characteristics were similar in each group, with median age 64 years (range 26-94) and median follow-up 55 months (range 0-187). We describe OS (Figure 1) and risk of death by N and M stage, after multivariate analysis (Table 1). CONCLUSIONS: We demonstrate the contemporary OS outcomes of a large cohort of penile cancer patients receiving standard of care treatment at a tertiary referral centre, with significant OS differences by N and M stage. Our data confirm the poor survival outcomes of patients with N3 and M1 disease and these groups should be the target for developing novel management strategies. Conversely, patients with N1 and N2 disease have significantly longer survival, reinforcing the need for predictive biomarkers to help refine patient selection for optimal management. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e686 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Churchill More articles by this author Ashwin Sachdeva More articles by this author Craig Jones More articles by this author Allaudin Issa More articles by this author Christian Fankhauser More articles by this author Andrew Hudson More articles by this author Anna Tran More articles by this author Pedro Oliveira More articles by this author Helen Johnson More articles by this author Maurice Lau More articles by this author Arie Parnham More articles by this author Vijay Sangar More articles by this author Expand All Advertisement PDF downloadLoading ...

Radioisotope-Guided Sentinel Lymph Node Biopsy in Penile Cancer: A Long-Term Follow-Up Study.

Lymph node (LN) management is critical for survival in patients with penile cancer. However, radical inguinal lymphadenectomy carries a high risk of postoperative complications such as lymphedema, lymphocele, wound infection, and skin necrosis. The European Association of Urology guidelines therefore recommend invasive LN staging by modified inguinal lymphadenectomy or dynamic sentinel node biopsy (DSNB) in clinically node-negative patients (cN0) with intermediate- and high-risk tumors (≥ T1G2). However, the timing of DSNB (simultaneous vs. subsequent to partial or total penile resection) is controversial and the low incidence of penile cancer means that data on the long-term outcomes of DSNB are limited. The present study aimed to analyze the reliability and morbidity of DSNB in patients with penile cancer during long-term follow-up. This retrospective study included 41 patients (76 groins) who underwent radioisotope-guided DSNB simultaneously or secondarily after penile surgery from June 2004 to November 2018. In total, 193 sentinel LNs (SLNs) and 39 non-SLNs were removed. The median number of dissected LNs was 2.5 (interquartile range 2–4). Histopathological analysis showed that five of the 76 groins (6.6%) contained metastases. None of the non-SLNs were tumor-positive. In accordance with the guidelines, all inguinal regions with positive SLNs underwent secondary radical inguinal lymphadenectomy, which revealed three additional metastases in one groin. Regional LN recurrence was detected in three patients (four groins) during a median follow-up of 70 months, including two patients in whom DSNB had been performed secondarily after repetitive penile tumor resections. DSNB-related complications occurred in 15.8% of groins. Most complications were mild (Clavien–Dindo grade I; 50%) or moderate (II; 25%), and invasive intervention was only required in 3.9% of groins (IIIa: n = 1; IIIb: n = 2). In summary, this study suggests that the current radioisotope-guided DSNB procedure may reduce the complication rate of inguinal lymphadenectomy in patients with cN0 penile cancer. However, DSNB and penile surgery should be performed simultaneously to minimize the false-negative rate. Recent advances, such as new tracers and imaging techniques, may help to reduce the false-negative rate of DSNB further.

Pretreatment Invasive Nodal Staging in Lung Cancer: Knowledge, Attitudes, and Beliefs Among Academic and Community Physicians

Pretreatment invasive nodal staging is paramount for appropriate treatment decisions in non-small cell lung cancer. Despite guidelines recommending when to perform staging, many studies suggest that invasive nodal staging is underused. Attitudes and barriers to guideline-recommended staging are unclear. The National Lung Cancer Roundtable initiated this study to better understand the factors associated with guideline-adherent nodal staging. What are the knowledge gaps, attitudes, and beliefs of thoracic surgeons and pulmonologists about invasive nodal staging? What are the barriers to guideline-recommended staging? A web-based survey of a random sample of pulmonologists and thoracic surgeons identified as members of American College of Chest Physicians (CHEST) was conducted in 2019. Survey domains included knowledge of invasive nodal staging guidelines, attitudes and beliefs toward implementation, and perceived barriers to guideline adherence. Among 453 responding physicians, 29%were unaware that invasive nodal staging guidelines exist. Among the 320 physicians who knew guidelines exist, attitudes toward the guidelines were favorable, with 91%agreeing guidelines are generalizable and 90%agreeing that recommendations improved their staging and treatment decisions. Approximately 80%responded that guideline recommendations are based on satisfactory levels of scientific evidence, and 50%stated a lack of evidence linking adherence to guidelines to changes in management or better patient outcomes. Nearly 9 in 10 physicians reported at least one barrier to guideline adherence. The most common barriers included patient anxiety associated with treatment delays (62%), difficulty implementing guidelines into routine practice (52%), and time delays of additional testing (51%). Among physicians who responded to our survey, more than one-quarter were unaware of invasive nodal staging guidelines. Attitudes toward guideline recommendations were positive, although 20%reported insufficient evidence to support staging algorithms. Most physicians reported barriers to implementing guidelines. Multilevel interventions are likely needed to increase rates of guideline-recommended invasive nodal staging.

Penile-sparing surgery for patients with superficial or initially invasive squamous cell carcinoma of the penis: long-term oncological outcomes

PurposeTo report long-term oncological outcomes after penile-sparing surgery (PSS) for superficial (Ta-Tis) or initially invasive (T1) penile cancer patients. MethodsWe retrospectively analysed 85 patients with Ta/Tis/T1cN0cM0 penile cancer (1996-2018). All patients underwent PSS: circumcision, excision or laser ablation. First, Kaplan-Meier plots and multivariable Cox regression models tested tumor recurrence rates (any local/regional/metastatic). Second, Kaplan-Meier plots depicted progression-free survival (≥T2 or N1-3 or M1 disease). ResultsMedian (IQR) follow-up time was 64 (48–95) months. Overall, 48 (56%) patients experienced tumor recurrence. Median (IQR) time to tumor recurrence was 34 (7–52) months. Higher recurrence rates were observed for Tis (65%) and T1 (64%), compared to Ta (40%), but these differences were not significant on multivariable Cox regression analyses (HR:2.0 with 95% CI [0.9–5.1] and HR:2.2 with 95% CI [0.9–5.9], respectively). Moreover, higher recurrence rates were observed for G2-3 tumors (74%), compared to G1 (57%), but these differences were not significant on multivariable Cox regression analyses (HR:1.6; 95% CI [0.8-3.2]). During follow-up, 15 (17.5%) vs. 18 (21.2%) vs. 10 (11.5%) patients underwent 1 vs. 2 vs. ≥3 PSS. Moreover, 26 (30.6%) and 4 (4.7%) men were treated with glansectomy and partial/total penile amputation due to local progression, tumor size or patient preference. Additionally, 24 (28%) men underwent invasive nodal staging. Last, 22 (25.9%) patients experienced disease progression. Median (IQR) time to disease progression was 51 (31–82) months. ConclusionPatients treated with PSS for newly diagnosed superficial or initially invasive squamous cell carcinoma of the penis should be informed about the non-negligible risk of tumor recurrence and disease progression over time. In consequence, strict follow-up protocols are needed.

Testicular and penile cancer-survival and quality of life : New guideline and network for second opinions

Testicular cancer occupies aspecial position in several respects. Although it belongs to the group of rare tumors, which is why extensive experience in treating this tumor can not be guaranteed, interdisciplinary experts collaboration and the consequent implementation of clinical studies have resulted in standardized treatment recommendations. Because testicular cancer is one of the most curable cancers, long-term toxicity and treatment sequelae are of special importance. In the early stages, toxicity could be reduced by minimizing therapy to the extent possible, but without decreasing treatment success. Nevertheless, treatment is still controversially discussed, especially concerning treatment of stageI disease. Finally particular focus should be paid to non-germinal tumors which are even more rare, but partly also more dangerous. Therefore known facts should be made available for the broad medical community. In penile cancer, which is also avery rare tumor entity, organ-sparing surgery and consequent invasive lymph node staging are mandatory.

MA09.10 Location of Lymph Nodes Missed after Invasive Mediastinal Staging in a Well-Staged Non-Small Cell Lung Cancer Cohort

Nodal stage is prognostic and predictive of adjuvant therapy benefit in potentially curable non-small cell lung cancer (NSCLC). Using a cohort of patients who met National Comprehensive Cancer Network (NCCN) pathologic nodal staging quality (examination of ≥1 N1 and ≥3 mediastinal nodal stations) as reference, we evaluated the thoroughness of invasive nodal staging to determine the frequency of non-examination of specific hilar/mediastinal nodes and missed node metastasis. We also compared survival between NCCN-quality and non-NCCN quality-attaining resections on the basis of missed nodal metastasis on invasive staging.

Quality of care criteria in the treatment of penile cancer

Penile cancer is arare malignancy and the wide range of quality of care associated with it often results in inferior oncologic and functional treatment outcomes. Assessment of the current healthcare situation in clinical routine and identification of the relevant key features and reference values for quality of care. Search for relevant peer-reviewed articles and published congress abstracts in Medline, Embase and other databases as well as Google web search engine. Key quality features of penile cancer management include organ-sparing surgery of the primary tumor, invasive inguinal lymph node staging and systemic treatment. Adherence to treatment guidelines is currently low. Centralization of care has already led to aconsiderable improvement in the quality of care in some areas and increasing conformity with the guidelines' recommendations. Centralization of care and networks based on this can significantly improve patient outcomes. Thus, reference values for core parameters of quality cancer care can be generated and validated. Moreover, organ-sparing surgery, invasive lymph node staging and systemic therapy should be increasingly utilized. As areference value, 90% adherence to the guidelines for these three features is recommended. However, before centralization of care can be introduced, aspects relevant to practical implementation must be addressed, such as the reimbursement of travel costs for those affected, infrastructure costs and instruments to measure quality of life and patient satisfaction after centralization.

Trends in mediastinal nodal staging and its impact on unforeseen N2 and survival in lung cancer

Guidelines for invasive mediastinal nodal staging in resectable nonsmall cell lung cancer (NSCLC) have changed over the years. The aims of this study were to describe trends in invasive staging and unforeseen N2 (uN2) and to assess a potential effect on overall survival. A nationwide Dutch cohort study included all clinical stage IA-IIIB NSCLC patients primarily treated by surgical resection between 2005 and 2017 (n=22 555). We assessed trends in invasive nodal staging (mediastinoscopy 2005-2017; endosonography 2011-2017), uN2 and overall survival and compared outcomes in the entire group and in clinical nodal stage (cN)1-3 patients with or without invasive staging. An overall increase in invasive nodal staging from 26% in 2005 to 40% in 2017 was found (p<0.01). Endosonography increased from 19% in 2011 to 32% in 2017 (p<0.01), while mediastinoscopy decreased from 24% in 2011 to 21% in 2017 (p=0.08). Despite these changes, uN2 was stable over the years at 8.7%. 5-year overall survival rate was 41% for pN1 compared to 37% in single node uN2 (p=0.18) and 26% with more than one node uN2 (p<0.01). 5-year overall survival rate of patients with cN1-3 with invasive staging was 44% versus 39% in patients without invasive staging (p=0.12). A significant increase in invasive mediastinal nodal staging in patients with resectable NSCLC was found between 2011 and 2017 in the Netherlands. Increasing use of less invasive endosonography prior to (or as a substitute for) surgical staging did not lead to more cases of uN2. Performance of invasive staging indicated a possible overall survival benefit in patients with cN1-3 disease.

Incidence, prevalence, and factors associated with lymphedema after treatment for cervical cancer: a systematic review

BackgroundLower limb lymphedema is a frequent and debilitating complication after cervical cancer treatment.ObjectiveTo evaluate the incidence and prevalence of lymphedema after treatment for cervical cancer and evaluate the factors associated...

Impact of invasive nodal staging on regional and distant recurrence rates after SBRT for inoperable stage I NSCLC

Purpose/ObjectivesBefore definitive stereotactic body radiation therapy (SBRT) for presumably node-negative, early-stage NSCLC, many patients are staged with PET/CT alone. In patients undergoing PET/CT prior to SBRT, the role of invasive nodal staging (INS) with endobronchial ultrasound (EBUS) or mediastinoscopy is uncertain. We sought to characterize the impact of nodal staging modality on outcomes. Materials/MethodsPatients receiving definitive SBRT for T1-2N0 NSCLC deemed node-negative by either PET/CT plus INS (EBUS or mediastinoscopy) or PET/CT alone were identified. Patients with initially equivocal or positive nodes on PET/CT were excluded from this analysis. All patients received 3–5 fraction SBRT according to institutional guidelines. Control was assessed by at least one follow-up CT in all patients. Multivariable logistic regression (MVA) was performed to identify variables independently associated with use of INS. ResultsWe identified 651 eligible patients at our institution from 2005–2016. INS was performed in 15.2% of patients (n = 99) with EBUS (n = 78) or mediastinoscopy (n = 21). Median follow-up was 19.4 months (0.2–135.1). Median survival was 28.5 months (0.6–140). Factors predictive of increased likelihood of INS after negative PET/CT on MVA were age (OR for decreasing age 1.033; 95% CI 1.058–1.010), Caucasian race (OR vs. non-white 1.852; 1.044–3.289), male sex (1.629; 1.031–2.575), central location (1.978; 1.218–3.211) and squamous histology (2.564; 1.243–5.287). Nodal and/or distant control at 2 years was similar between PET/CT alone (78%, 95% CI 74–82%) and INS + PET/CT (75%, 95% CI 65–85%) (p = 0.877) as well as on MVA. Overall survival did not differ based on staging modality. ConclusionsIn patients with early-stage NSCLC deemed node-negative by PET/CT, addition of INS did not appreciably alter patterns of failure or survival after definitive SBRT. This study does not question the established value of INS for equivocal or suspicious nodes.

Invasive Staging Procedures Do Not Prevent Nodal Metastases From Being Missed in Stage I Lung Cancer

Up to 20% of clinical stage I lung cancer patients harbor lymph node metastases that go undetected (missed) during the clinical staging evaluation. We investigated to what degree the addition of invasive nodal staging procedures to imaging, as currently practiced, prevents radiographically occult nodal metastases from being missed during the clinical staging evaluation. Treatment-naive patients, imaged by positron emission tomography and computed tomography, who underwent lobectomy for clinical stage I lung cancer from 2012 to 2017 in The Society of Thoracic Surgeons General Thoracic Surgery Database were studied. Rates of missed nodal metastases (MNM) (ie, nodal metastases in lobectomy specimens undetected during clinical staging evaluation) were determined. Risk factors were assessed with multivariable modeling. Of the 30,685 clinical stage I patients identified, 3895 (12.7%) underwent preoperative endobronchial ultrasound and 3341 (10.9%) underwent mediastinoscopy. Invasive staging was more common with tumors > 2 cm (66.4% vs 50.2%, P < .001) and squamous histology (26.9% vs 16.9%, P < .001). MNM were discovered in 14.7% of patients, including 20.1% of patients (95% confidence interval, 18.8%-21.5%) who had undergone endobronchial ultrasound and 18.2% (95% confidence interval, 16.7%-19.6%) who had undergone mediastinoscopy. Hilar nodes were most often "missed" (9.5%). Using cut-points in tumor size, histology, laterality, and age, patients could be stratified into particularly high-risk (25% MNM) and low-risk (6% MNM) cohorts. Substantial risk of occult lymph node metastases persists in patients with clinical stage I lung cancer despite negative invasive nodal staging, positron emission tomography, and computed tomography. In the absence of a thorough surgical nodal evaluation, early-stage lung cancer patients are at risk of under-treatment.