Non-palpable Inguinal Nodes Research Articles

The surgical technique and protocol for dynamic sentinel node biopsy for penile cancer at a Southeast Asian regional hospital.

Lymph node status is a key prognostic factor in penile cancer. The European Association of Urology (EAU) recommends intermediate-risk (pT1a, Grade 2) or high-risk (pT1b or greater) penile cancer patients with clinically non-palpable inguinal lymph node (cN0) to undergo either an invasive bilateral modified inguinal lymph node dissection (ILND) or dynamic sentinel node biopsy (DSNB). DSNB has been reported to have acceptable false negative rates, and lower rates of long-term morbidity compared to ILND. We developed a protocol for DSNB at a regional hospital in Singapore that was adopted from St James's University Hospital, Leeds Teaching Hospitals Trust. Four patients with cN0 penile cancer underwent DSNB between November 2021 and October 2022 according to this protocol. Our surgical technique and protocol are described. The patients' oncological characteristics and their outcomes were evaluated. In this small case series, there was no complication attributable to the performance of DSNB, and there was no groin that was documented to be false negative over a median follow up of 15.5 months (range, 12 to 22 months). Using our protocol, 5 of 8 groins (62.5%) were able to avoid ILND in the cN0 setting. We recommend the adoption of DSNB for the surgical staging of inguinal lymph nodes for patients with intermediate to high-risk penile cancer and non-palpable inguinal nodes due to its significantly lower risks of long-term morbidity compared to ILND. Appropriate specialist training and a multi-disciplinary team is vital to ensure the success of the procedure.

High-diagnostic accuracy of inguinal ultrasonography and fine needle aspiration followed by dynamic sentinel lymph node biopsy in men with non-palpable and palpable inguinal lymph nodes.

6 Background: Penile cancer undergoes a stepwise dissemination and metastasises first to the inguinal lymph nodes (ILN). Because men can be cured in this early stage of metastatic disease, early detection and treatment is important. Methods: We performed a retrospective analysis of men with ≥T1G2 penile cancer and negative inguinal US guided FNA undergoing DSNB. Men with suspicious US but negative FNA underwent US guided ILN excision. Men with ≥T1G2 local recurrence during follow-up and non-squamous cell histologies were excluded. Descriptive analysis was performed, and sensitivity and negative predictive values (NPV) were calculated. Results: The final cohort consisted of 403 men with a median age of 65 years (IQR 55-73) and body mass index (BMI) of 28.6 kg/m² (IQR 25-33) for this analysis. This gave 728 groins with negative FNA undergoing DSNB +/- US guided lymph node excision. At least one sentinel node (SN) was visualised in 93% during the 1st and in 7% during the 2nd lymphoscintigraphy. Median SNs visualised preoperatively was 1 and a median of 2 nodes were resected. ILN metastases were detected in 9% groins with non-palpable and in 17% with palpable lymph nodes. Stratified by non-palpable and palpable ILN, non-local recurrence despite pathologically negative DSNBs was observed in 0.5% and 0%. Limited to men with at least 24 months follow-up, non-local recurrence after negative DSNBs was observed in 0.4% and 0%. The sensitivity of DSNB was 96% and NPV was 100%. The main limitation of this analysis is its retrospective nature and inherit biases. Conclusions: Our results suggest that in a high volume centre pre-operative ultrasound +/- FNA and DSNB can be used to accurately stage men with non-palpable and palpable ILN in men with ≥T1G2 penile cancer. Further, FNA in advance of surgery provides logistical and surgical advantages. In those patients with palpable disease but negative FNA, we advocate ultrasound guided excision in case of enlarged or suspicious ILN during DSNB.[Table: see text]

Ultrasound-Guided Hook-Wire Localization for Surgical Excision of Non-Palpable Superficial Inguinal Lymph Nodes in Dogs: A Pilot Study.

Simple SummaryThe evaluation of regional/sentinel lymph nodes (LN) plays an important prognostic role and assists the clinical decision making in canine cancer patients; thus, surgeons are frequently asked to perform regional/sentinel lymphadenectomies together with management of the primary tumor sites, even when these are non-palpable and/or normal size LN. Several techniques have been described to localized regional/sentinel LN in a pre-surgical setting. The wire-guided localization is commonly used to localize non-palpable breast masses in women, with the aim to reduce surgical dissection and excision of unnecessary tissue and to reduce surgical time. This study describes the use of an ultrasound-guided hook-wire localization method to facilitate intraoperative localization of non-palpable superficial inguinal LN. The results of the present study suggest that this method is safe and effective and may allow a high rate of successful superficial inguinal LN excisions in dogs.The evaluation of loco-regional lymph nodes (LN) plays an important prognostic role and assists the clinical decision making in canine cancer patients. Excision of non-palpable LN can be challenging. The aim of the study was to evaluate surgical time, successful excision rate and surgical complications associated with the use of an ultrasound-guided hook-wire (UGHW) LN localization method for non-palpable superficial inguinal LN (SILN) in dogs. Dogs that presented for excision of non-palpable SILN, performed with the aid of an UGHW placement, were enrolled. Information including signalment, SILN width, UGHW placement and surgical procedure time, hook-wire position, successful excision and intra- and post-operative complications were reviewed. Seventeen dogs were enrolled. Median LN width was 3 mm (range 2–11). Median time of preoperative UGHW placement and surgical LN excision was 8 min and 15 min, respectively. Successful SILN excision was achieved in all cases. Two minor intra-operative (hook migration and wire fragmentation) and one minor post-operative complications (seroma) were observed. No major intraoperative or post-operative complications occurred. The UGHW LN localization method is safe and effective and may allow a high rate of successful SILN excisions in dogs. This method has the potential to facilitate LN excision for other superficial LN locations.

Utility of Minimally Invasive Technology for Inguinal Lymph Node Dissection in Penile Cancer.

Our aim is to review the benefits as well as techniques, surgical outcomes, and complications of minimally invasive inguinal lymph node dissection (ILND) for penile cancer. The PubMed, Wiley Online Library, and Science Direct databases were reviewed in March 2020 for relevant studies limited to those published in English and within 2000–2020. Thirty-one articles describing minimally invasive ILND were identified for review. ILND has an important role in both staging and treatment of penile cancer. Minimally invasive technologies have been utilized to perform ILND in penile cancer patients with non-palpable inguinal lymph nodes and intermediate to high-risk primary tumors or patients with unilateral palpable non-fixed inguinal lymph nodes measuring less than 4 cm, including videoscopic endoscopic inguinal lymphadenectomy (VEIL) and robotic videoscopic endoscopic inguinal lymphadenectomy (RVEIL). Current data suggest that VEIL and RVEIL are feasible and safe with minimal intra-operative complications. Perhaps the strongest appeal for the use of minimally-invasive approaches is their faster post-operative recovery and less post-operative complications. As a result, patients can tolerate this procedure better and surgeons can offer surgery to patients who otherwise would not be a candidate or personally willing to undergo surgery. When compared to open technique, VEIL and RVEIL have similar dissected nodal count, a surrogate metric for oncological adequacy, and a none-inferior inguinal recurrence rate. Larger randomized studies are encouraged to investigate long-term outcome and survival rates using these minimally-invasive techniques for ILND.

Prognostic value of systemic inflammatory factors NLR, LMR, PLR and LDH in penile cancer

BackgroundPenile squamous cell carcinoma (PSCC) represents an important public health problem for developing countries. The major prognostic factors in PSCC are pathological subtype, perineural invasion, lymphovascular invasion, depth of invasion and grade, which are hard to obtain precisely before the operation. Besides, micro-metastases will be detected in about 30% of intermediate-risk patients with clinically non-palpable inguinal lymph nodes after inguinal lymph node dissection (ILND). It means approximately 70% of patients are unable to benefit from ILND who might suffered from the complications of surgery. We hope some biomarkers could be found which are able to predict the outcome before surgery and reflect the inguinal lymph nodes metastasis.MethodsA total of 349 consecutive patients of penile cancer in Yunnan cancer hospital in China between October 2002 and December2017. Two hundred twenty-five was succeed to follow-up. The association between NLR, LMR, PLR, LDH and Overall survival (OS), progression free survival (PFS), inguinal lymph node (N stage) was analyzed with K-M analysis, univariable, multivariable logistic regression and Kendall’s tau-b correlation coefficient.ResultsMultivariable analysis reveal that only PLR was significant independent factor which is associated with inferior OS and PFS; Age and LDH was associated with inferior OS; Lymph node and metastatic status remained significant for OS and PFS as NCCN and EAU Guidelines indicated; the tumor type, initial treatment and NLR LMR were not significant in predicting both OS and PFS. NLR, LMR and PLR were corresponded to N stage, while LDH was not associated with the N stage based on logistic regression model analysis. NLR, LMR and PLR were found weakly related to N stage through an application of Kendall’s tau-b correlation coefficient.ConclusionsPLR was significant independent factors for OS and PFS, Age and LDH was significant independent factors for OS. NLR, LMR, PLR was corresponded to N stage.

Diagnostic precision of sentinel lymph node biopsy in penile cancer.

Introduction:Sentinel lymph node biopsy (SLNB) was designed as a minimally invasive method for evaluation of nodal involvement in patients with penile cancer and nonpalpable lymph nodes. Nevertheless, SLNB is not used in a regular basis due to the lack of studies that adequately characterize the performance of this procedure. The purpose of this study was to evaluate the diagnostic performance of SLNB in patients with infiltrative penile carcinoma without palpable inguinal lymph nodes in a Colombian population.Materials and Methods:This is a retrospective observational study of 89 patients diagnosed with infiltrative penile squamous cell carcinoma with nonpalpable inguinal lymph nodes. These patients underwent partial or complete penectomy, along with SLNB, between 2008 and 2017. Those individuals with a positive SLNB underwent inguinal lymphadenectomy, while those with a negative SLNB were followed on a quarterly basis with a physical examination and imaging to assess relapse. Statistical analysis was done using the STATA 14 software. A contingency table was made to calculate sensitivity, specificity, positive predictive value, negative predictive value, and exactitude, each one with its own confidence interval (CI) of 95%.Results:There was an average follow-up of 31.4 months, and all 89 patients were evaluated; most primary tumors were T2 (55%), followed by T1 (37%), all of which were subclassified as T1b and T3 (8%). Tumours were most frequently located in the glans (43%). All patients were classified as cN0 and underwent SLNB. Sixty-one patients (69%) tested negative in the SLNB, four of whom (6%) presented with lymph node relapse. On the other hand, 28 patients (31%) tested positive in the SLNB and consequently underwent inguinal lymphadenectomy, seven of whom had negative lymph nodeinvolvement (25% false positives). According to the results, the sensitivity was 84% (95% CI, 65.3–93.6) and the specificity was 89% (95% CI, 79.4–94.7), with a false-negative rate of 6.5%.Conclusions:The SLNB using radiotracer can be a useful method for lymph node staging in patients with penile cancer and nonpalpable lymph nodes when performed in experienced centers.

Pattern and clinical management of penile cancer in Rwanda

IntroductionPenile cancer is rare in developed countries but has a high prevalence in some developing countries. Surgery includes inguinal lymphadenectomy, which remains the mainstay treatment of the disease. ObjectiveThis study reports on the epidemiological profile of penile cancer and clinical management options in Rwanda. Patients and methodsFrom January 2015 to June 2016, a multicenter cross-sectional, prospective cohort study was conducted involving all male patients presenting with penile cancer after two national radio campaigns and a Ministry of Health instruction to all district hospitals. All patients with positive biopsy were included. Surgical treatment aligned with published guidelines. Clinical characteristics, surgery, pathology, and early follow-up data were collected. ResultsOver 18 consecutive months, 30 male patients were enrolled. The mean age was 60years [range 33–83]. All patients were uncircumcised before symptom onset; 50% had phimosis and 20% were HIV-positive. The estimated prevalence of penile cancer in Rwanda was 0.37 per 100,000 men. At presentation, 96.7% of patients had a T2-4 disease and 43.3% were with clinically non-palpable inguinal lymph nodes (cNO). After penectomy, bilateral inguinal lymphadenectomy was performed in 10 (33.3%) patients (modified and radical in 16 and 4 limbs, respectively). Complications included surgical site infection (10%), lymphocele (10%), urethral meatus stenosis (6.7%), skin necrosis (3.3%) and two (6.7%) patients with metastatic disease died in hospital. ConclusionPenile cancer is a rare but significant disease in Rwanda. Patients present with advanced disease. After treatment of the primary tumor, modified inguinal lymphadenectomy appears to be a safe method of cure and staging for patients with clinically impalpable inguinal lymph nodes. Our early results provide a compelling insight into this rare but serious disease.

Evaluation of the diagnostic value of preoperative sentinel lymph node (SLN) imaging in penile carcinoma patients without palpable inguinal lymph nodes via single photon emission computed tomography/computed tomography (SPECT/CT) as compared to planar scintigraphy

BackgroundSentinel lymph node (SLN) biopsy represents a well-established diagnostic tool for the assessment of lymphatic metastasis. Correct pre- and intraoperative visualization of SLN is of the utmost importance to ensure the safety and feasibility of the procedure. Aim of this study was to evaluate the diagnostic value of preoperative SLN imaging via single photon emission computed tomography/computed tomography (SPECT/CT) and planar scintigraphy in patients with penile carcinoma with nonpalpable inguinal lymph nodes. Materials and methodsAfter peritumoral intradermal tracer injection (150MBq/4.05mCi Tc-99m nanocolloid), we acquired planar scintigraphies including indirect body contouring using a twin head gamma camera. Subsequently we acquired SPECT/CT images of the abdomen via a hybrid system. Prospective evaluation of 52 groins in 26 examined patients was done for all image files obtained with both techniques by 2 trained experts in consensual assessment. ResultsA total of 71 SLNs in 37 groins were identified by means of planar scintigraphy. In these images, no radiolabeled lymph nodes were visualized in 15 out of 52 groins (28.8%). The SPECT/CT images showed a total of 82 SLNs in 42 groins. In 19.2% (10 of the 52 groins), there was no visualization of lymph nodes in SPECT/CT. 8 SLNs in 7 groins that were visualized in the planar technique were found to be false positive by SPECT/CT. In total, 19 SLNs in 16 groins that were overlooked by planar imaging could only be detected by SPECT/CT. In contrast to planar scintigraphy, SPECT/CT imaging enabled clear and precise anatomical localization of SLNs in all 42 groins where radiolabeled SLNs were visible. Even under consideration of all lymphatic drainage regions, statistical evaluation showed a significantly higher number of detected SLNs with SPECT/CT in comparison to the planar technique (P = 0.0022). ConclusionIn these patients SPECT/CT is capable of visualizing SLNs that cannot be detected with planar imaging. The SPECT/CT technique reduces the number of false positive findings from planar SLN imaging and is able to show anatomic SLN localization more precisely. If possible, preoperative SLN imaging should be performed by means of the SPECT/CT technique in patients with this tumor entity.

Technical considerations to minimize complications of inguinal lymph node dissection.

Penile cancer is a rare malignancy with a high propensity for regional dissemination. Current guidelines recommend inguinal lymphadenectomy in patients with penile cancer for palpable inguinal lymph nodes or in certain cases of nonpalpable inguinal lymph nodes. For many years, this procedure was performed with a traditional open approach and carried significant morbidity due to severe lymphedema, flap necrosis, wound infections, and seroma formation. The evolution of inguinal lymphadenectomy surgery for patients with penile cancer to a more minimally invasive approach has greatly reduced the morbidity of the procedure. Complications of inguinal lymphadenectomy can be minimized with modifications in surgical approach with the use of endoscopic, robotic, and various reconstructive methods. This review focuses on various intraoperative techniques to reduce morbidity in inguinal lymphadenectomies for penile cancer.

Contemporary management of patients with penile cancer and lymph node metastasis.

Penile cancer is a rare disease that causes considerable physical and psychological patient morbidity, especially at advanced stages. Patients with low-stage nodal metastasis can achieve durable survival with surgery alone, but those with extensive locoregional metastasis have overall low survival. Contemporary management strategies for lymph node involvement in penile cancer aim to minimize the morbidity associated with traditional radical inguinal lymphadenectomy through appropriate risk stratification while optimizing oncological outcomes. Modified (or superficial) inguinal lymph node dissection and dynamic sentinel lymph node biopsy are diagnostic modalities that have been recommended in patients with high-risk primary penile tumours and nonpalpable inguinal lymph nodes. In addition, advances in minimally invasive and robot-assisted lymphadenectomy techniques are being investigated in patients with penile cancer and might further decrease lymphadenectomy-related adverse effects. The management of patients with advanced disease has evolved to include multimodal treatment with systemic chemotherapy before surgical intervention and can include adjuvant chemotherapy after pelvic lymphadenectomy. The role of radiotherapy in the neoadjuvant or adjuvant setting remains largely unclear, owing to a lack of high-level evidence of possible benefits. New targeted therapies have shown efficacy in squamous cell carcinomas of other sites and might also prove effective in patients with penile cancer.

MP18-10 COMPARISON OF PLANAR SCINTIGRAPHY AND SINGLE-PHOTON EMISSION COMPUTED TOMOGRAPHY /COMPUTED TOMOGRAPHY (SPECT/CT) IN PREOPERATIVE IMAGING OF SENTINEL LYMPH NODES IN PENILE CANCER PATIENTS

You have accessJournal of UrologyImaging/Radiology: Uroradiology III1 Apr 2017MP18-10 COMPARISON OF PLANAR SCINTIGRAPHY AND SINGLE-PHOTON EMISSION COMPUTED TOMOGRAPHY /COMPUTED TOMOGRAPHY (SPECT/CT) IN PREOPERATIVE IMAGING OF SENTINEL LYMPH NODES IN PENILE CANCER PATIENTS Carsten Maik Naumann, Moritz Franz Hamann, Christian Colberg, Klaus-Peter Jünemann, Daniar Osmonov, and Ulf Lützen Carsten Maik NaumannCarsten Maik Naumann More articles by this author , Moritz Franz HamannMoritz Franz Hamann More articles by this author , Christian ColbergChristian Colberg More articles by this author , Klaus-Peter JünemannKlaus-Peter Jünemann More articles by this author , Daniar OsmonovDaniar Osmonov More articles by this author , and Ulf LützenUlf Lützen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.620AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The aim of this study was to evaluate the diagnostic value of SPECT/CT and planar lymphoscintigraphy in preoperative imaging of sentinel lymph nodes in penile cancer patients with non-palpable inguinal lymph nodes. METHODS Radio-labelling of sentinel nodes was performed by intradermal and peritumoral injection of 150MBq Tc-99 m-labelled nanocolloids according to the two day protocol. Image acquisition of planar scintigraphies was carried out by a twin head gamma camera (Siemens, ECAM and Symbia S) and indirect body contouring. Additionally, we subsequently performed SPECT/CT of the abdomen und inguinal regions using a twin-head hybrid camera system (Siemens Symbia T and Symbia Intevo). Imaging data of both modalities were prospectively evaluated by two experienced physicians in consensus reading in 52 groins of 26 patients with this tumor entity. RESULTS A total of 71 SLNs in 37 groins were identified by planar scintigraphy. Non-visualization was observed in 15 (28.8%) inguinal basins using planar scans. 82 SLNs in 42 groins were detected by SPECT/CT (non-visualization in 10 (19.2%) groins). SPECT/CT revealed 8 inguinal hotspots as shown by planar imaging in 7 groins as false positive. 19 inguinal SLNs in 16 groins were missed on planar imaging and could be detected by SPECT/CT only. In contrast to 2D planar scintigraphy, SPECT/CT allowed to determine the precise anatomical localization of the SLNs in all 42 groins. CONCLUSIONS SPECT/CT is capable of detecting SLNs missed by planar imaging, it reduces the number of false positive findings and shows the morphological location of SLNs more accurately. If available, SPECT/CT should be used for preoperative SLN imaging in penile cancer patients with non-palpable inguinal lymph node status. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e223-e224 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Carsten Maik Naumann More articles by this author Moritz Franz Hamann More articles by this author Christian Colberg More articles by this author Klaus-Peter Jünemann More articles by this author Daniar Osmonov More articles by this author Ulf Lützen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Value and efficiency of sentinel lymph node diagnostics in patients with penile carcinoma with palpable inguinal lymph nodes as a new multimodal, minimally invasive approach

The international guidelines recommend sentinel lymph node biopsy (SLNB) for lymph node staging in penile cancer with non-palpable inguinal lymph nodes (LN) but it is not recommended with palpable inguinal LN. The aim of this study was to evaluate the reliability and morbidity of SLNB in combination with an ultrasound-guided resection of suspect inguinal LNs as a new multimodal, minimally invasive staging approach in these patients. We performed SLNB in 26 penile cancer patients with 42 palpable inguinal LNs. Prior to the combined staging procedures the patients underwent an ultrasound examination of the groins as well as planar lymphatic drainage scintigraphy and SPECT/CT scans. During the surgical procedure, the radioactive-labelled sentinel lymph nodes and, in addition, sonographically suspect LNs, were resected under ultrasound guidance. Follow-up screening was done by ultrasound examination of the groins according to the guidelines of the European Association of Urology. Nineteen groins of 42 preoperatively palpable inguinal findings were histologically tumor-positive. SLNB alone showed lymphogenic metastases in 14 groins. Sonography revealed five further metastatic groins, which would not have been detected during SLNB due to a tumor-related blockage of lymphatic drainage or a so-called re-routing of the tracer. During follow-up, none of the 28 groins with tumor-negative LN status showed any LN recurrence in this combined investigation technique. The median follow-up period was 46 (24 to 92) months. Morbidity of this procedure was low at 4.76% in relation to the number of groins resp. 7.69% in relation to the number of patients. The results show that this combined procedure is a reliable multimodal diagnostic approach for treatment of penile cancer patients with palpable inguinal LNs. It is associated with low morbidity rates. SLNB alone would lead to a significantly higher false-negative rate in these patients. The encouraging results of this work can extend the range of indications for nuclear medicine in the form of SLNB using radioactive tracers in this patient group.

10-Year experience regarding the reliability and morbidity of radio guided lymph node biopsy in penile cancer patients and the associated radiation exposure of medical staff in this procedure.

BackgroundThe guidelines of the European Association of Urologists (EAU), of the German Society of Nuclear Medicine (DGN), and the European Society for Medical Oncology (ESMO) recommend sentinel lymph node biopsy (SLNB) for lymph node staging in penile cancer with non-palpable inguinal lymph nodes as one diagnostic method. Despite this, the method is neither widely nor regularly applied in Germany – the same applies to many other countries, which may be due to insecurity in dealing with open radioactive tracers. This study aims to assess the reliability and morbidity of this method, as well as the associated radioactive burden for clinical staff.MethodsBetween 2006 and 2016, 34 patients with an invasive penile carcinoma and inconspicuous inguinal lymph node status underwent SLNB in 57 groins after application of a radiotracer (Tc-99 m nanocolloid). We collected the results prospectively. The reliability of the method was assessed by determining the false-negative rate. In addition, we evaluated complication rates and determined the radioactive burden for the clinical staff both pre- and intraoperatively.ResultsSLNB was performed in 34 patients with penile cancer with non-palpable inguinal lymph nodes in 57 groins. In two patients inguinal lymph node metastases were detected by means of SLNB. In one patient recurrent inguinal lymph node disease was found after negative SLNB in both groins. Thus, the false negative rate was 3.13 % per patient (1/32 patients) and 3.51 % per groin (2/57 groins). The morbidity rate was 2.94 % per patient (1/34 patients) and 1.75 % per groin (1/57 groins). Radiation exposure for the clinical staff during this procedure was low at a maximum of ca. four μSV per intervention.ConclusionsSLNB is a reliable method with low morbidity that is associated with a low radiation burden for clinical staff. Due to the enhanced methodological and logistic demands, this intervention should be performed in specialized centres and in an interdisciplinary approach.

Value and Efficacy of Sentinel Lymph Node Diagnostics in Patients With Penile Carcinoma With Nonpalpable Inguinal Lymph Nodes: Five-Year Follow-up.

Sentinel lymph node biopsy (SLNB) has been described as a minimally invasive method for lymph node staging in patients with a penile carcinoma and nonpalpable inguinal nodes in national and international guidelines of involved professional societies. However, this method is rarely used. The aim of this study was to validate reliability and morbidity of this method and to discuss radiation exposure of persons involved. Twenty-eight patients with histologically negative sentinel lymph nodes in 47 groins with nonpalpable inguinal lymph nodes were included in this study (17 T1(a/b)-, 8 T2- and 3 T3-stages). We recorded prospectively all cases of lymph node recurrence and complications in patients with initially nonpalpable inguinal lymph nodes and histologically negative sentinel lymph nodes. False-negative findings and morbidity were calculated as qualitative criteria. Inguinal regions with palpable lymph nodes and/or evidence of metastases were not considered in accordance with the guidelines. During a median follow-up of 68 (4-131) months, we observed one case of bilateral lymph node recurrence and one case of prolonged inguinal lymphorrhea, which could be managed conservatively. Per inguinal region, false-negative rate was 4.25%, and morbidity rate was 2.12%; seen per patient, the rates were both 3.57%. Sentinel lymph node biopsy under use of radioactive tracers is a reliable method of lymph node staging in patients with penile carcinoma and nonpalpable inguinal lymph nodes. The methodical complexity is justified by high reliability and low radiation exposure for both patient and medical staff and low morbidity rates.

Dynamic Sentinel Lymph Node Biopsy in Patients with Invasive Squamous Cell Carcinoma of the Penis: A Prospective Study of the Long-Term Outcome of 500 Inguinal Basins Assessed at a Single Institution

BackgroundDynamic sentinel node biopsy (DSNB) in combination with ultrasound scan (USS) has been the technique of choice at our centre since 2004 for the assessment of nonpalpable inguinal lymph nodes (cN0) in patients with squamous cell carcinoma of the penis (SCCp). Sensitivity and false-negative rates may vary depending on whether results are reported per patient or per node basin, and with or without USS. ObjectiveTo determine the long-term outcome of patients undergoing DSNB and USS-guided fine-needle aspiration cytology (FNAC) in our cohort of newly diagnosed cN0 SCCp patients, as well as to analyse any variation in sensitivity of the procedure. Design, setting, and participantsA series of consecutive patients with newly diagnosed SCCp, over a 6-yr period (2004–2010), were analysed prospectively with a minimum follow-up period of 21 mo. All patients had definitive histology of ≥T1G2 and nonpalpable nodes in one or both inguinal basins. Patients with persistent or untreated local disease were excluded from the study. InterventionAll eligible patients had DSNB and USS with or without FNAC of cN0 groins. Outcome measurements and statistical analysisThe primary end point was no nodal disease recurrence on follow-up. The secondary end point was complications after DSNB. Sensitivity of the procedure was calculated per node basin, per patient, with DSNB alone, and with USS with DSNB combined. Results and limitationsFive hundred inguinal basins in 264 patients underwent USS with or without FNAC and DSNB. Seventy-three positive inguinal basins (14.6%) in 59 patients (22.3%) were identified. Four inguinal basins in four patients were confirmed false negative at 5, 8, 12, and 18 mo. Two inguinal basins had positive USS and FNAC and negative DSNB results. Sensitivity of DSNB with USS, with and without FNAC, per inguinal basin was 95% and per patient was 94%. Sensitivity of DSNB alone per inguinal basin and per patient was 92% and 91%, respectively. The DSNB morbidity rate was 7.6%. ConclusionsDSNB in combination with USS has excellent performance characteristics to stage patients with cN0 SCCp, with a 5% false-negative rate per node basin and a 6% false-negative rate per patient.

Re: Video-assisted left inguinal lymphadenectomy for penile cancer

The concept of endoscopic inguinal dissection for penile cancer was proposed by Bishoff et al. from San Antonio, Texas, USA in 2003 with the dissection of 2 cadaveric models. After some modifications, the first case in clinical scenario was successfully operated at ABC Medical School, Sao Paulo, Brazil in 2003 by Tobias-Machado et al which nominate their procedure as VEIL (video endoscopic inguinal lymphadenectomy) (1). In order to achieve the maximum benefits of the minimally invasive approach, regarding mor-bidity reduction, the ABC Medical School technique was based in 10 major steps and we would like to emphasize 3 of them: distal lymphatic tissue ligation at the femoral triangle vertex, proximal control of visualized lymphatics with clips and ligation of the proximal portion of the lymphatic tissue at the deep portion of the femoral channel (2). We are concerned about these issues because in the presented video no lymphatic clipage was documented, the tissue was sectioned using only monopolar electro-cautery. This can increase the post-operative complications related to the lymphatic tissue, thereby reducing the benefits of minimally invasive procedure. It is fundamental to stress that no energy source (electric, ultrasonic, ligasure) can adequately seal lymphatic vessels. One other interesting observation is that monopolar energy can be used but control is needed when it is utilized near the skin to prevent an isquemic event. The present video demonstrates the dissection in the correct plane (under Scarpa´s fascia) to maintain some fat under the skin. A randomized comparison with open surgery in nonpalpable inguinal nodes patients showed a reduced overall complication rate of endoscopic technique (20 X 70%) specially related to skin events (0 x 40%) (3). The same number of nodes could be obtained comparing the approaches. Five year follow-up series showed cancer specific survival of 100% for negative inguinal nodes and 80% for positive nodes suggesting that VEIL is oncological effective (4). Veil is having a growing international acceptance but experience is yet small. Actually about 20 centers around the world performed the endoscopic procedure with success and very similar re-sults. Some centers are applying endoscopic surgery for other tumors as melanoma, vulvar and anal cancers. Actual results lead us to think that this technique has the potential to reduce post-operative morbidity (2-6). Nevertheless we would like to congratulate Britto et al who demonstrated the reproducibility of the method at the Federal University of Rio Grande do Norte, it could be consider especially impor-tant because VEIL can be of great value in a region which has a high incidence of penile cancer.

517 Dynamic sentinel lymph node biopsy in patients with invasive squamous cell carcinoma of the penis: A prospective study of the outcome of 500 inguinal basins assessed in a single institution

Background: Dynamic sentinel node biopsy (DSNB) in combination with ultrasound scan (USS) has been the technique of choice at our centre since 2004 for the assessment of nonpalpable inguinal lymph nodes (cN0) in patients with squamous cell carcinoma of the penis (SCCp). Sensitivity and false-negative rates may vary depending on whether results are reported per patient or per node basin, and with or without USS. Objective: To determine the long-term outcome of patients undergoing DSNB and USSguided fine-needle aspiration cytology (FNAC) in our cohort of newly diagnosed cN0 SCCp patients, as well as to analyse any variation in sensitivity of the procedure. Design, setting, and participants: A series of consecutive patients with newly diagnosed SCCp, over a 6-yr period (2004–2010), were analysed prospectively with a minimum follow-up period of 21 mo. All patients had definitive histology of T1G2 and nonpalpable nodes in one or both inguinal basins. Patients with persistent or untreated local disease were excluded from the study. Intervention: All eligible patients had DSNB and USS with or without FNAC of cN0 groins. Outcome measurements and statistical analysis: The primary end point was no nodal disease recurrence on follow-up. The secondary end point was complications after DSNB. Sensitivity of the procedure was calculated per node basin, per patient, with DSNB alone, and with USS with DSNB combined. Results and limitations: Five hundred inguinal basins in 264 patients underwent USS with or without FNAC and DSNB. Seventy-three positive inguinal basins (14.6%) in 59 patients (22.3%) were identified. Four inguinal basins in four patients were confirmed false negative at 5, 8, 12, and 18 mo. Two inguinal basins had positive USS and FNAC and negative DSNB results. Sensitivity of DSNB with USS, with and without FNAC, per inguinal basin was 95% and per patient was 94%. Sensitivity of DSNB alone per inguinal basin and per patient was 92% and 91%, respectively. The DSNB morbidity rate was 7.6%. Conclusions: DSNB in combination with USS has excellent performance characteristics to stage patients with cN0 SCCp, with a 5% false-negative rate per node basin and a 6% false-negative rate per patient.

Diagnosis and Staging of Penile Cancer

A comprehensive literature study was conducted to evaluate the levels of evidence (LEs) in publications on the diagnosis and staging of penile cancer. Recommendations from the available evidence were formulated and discussed by the full panel of the International Consultation on Penile Cancer in November 2008. The final grades of recommendation (GRs) were assigned according to the LEs of the relevant publications. The following consensus recommendations were accepted: physical examination of the primary penile lesion is mandatory, evaluating the morphologic and physical characteristics of the lesion (GR A). Evaluation of the primary lesion with ultrasonography is of limited value for local tumor staging (GR C); however, evaluation of the primary tumor with magnetic resonance (MRI) imaging during artificial erection induced by intracavernosal injection of prostaglandin might be more useful (GR B). Histologic or cytologic diagnosis of the primary lesion is mandatory (GR A). For accurate histologic grading and staging, a resected specimen is preferable to a biopsy specimen alone (GR B). Penile cancer should be staged according to the TNM system; however, the 1987/2002 TNM staging system requires revision using data from larger patient cohorts to validate the recently proposed modifications (GR B). The histopathology report should provide information on all prognostic parameters, including the tumor size, histologic type, grade, growth pattern, depth of invasion, tumor thickness, resection margins, and lymphovascular and perineural invasion (GR B). Physical examination of the inguinal and pelvic areas to assess the lymph nodes is mandatory (GR B). Ultrasound-guided fine needle aspiration cytology is indicated for both palpable and nonpalpable inguinal nodes. If the findings confirm lymph node metastasis (LNM), complete inguinal lymph node dissection is indicated (GR B). In patients with nonpalpable inguinal nodes, if the ultrasound-guided fine needle aspiration cytology findings are negative for tumor, dynamic sentinel node biopsy can be performed if the equipment and technical expertise are available (GR C). In patients at high risk of inguinal LNM according to the available guidelines and nomograms, surgical staging can be performed by complete, bilateral inguinal lymph node dissection, which might also be curative (GR B). In patients at intermediate risk of LNM, sentinel node biopsy or modified (limited) inguinal lymph node dissection might be performed (GR B). In patients with nonpalpable inguinal nodes, imaging with computed tomography (CT) or MRI is not indicated, because they are not useful in detecting small-volume LNM. Also, it is very unlikely that large-volume LNM (detectable by CT/MRI) would be present in the pelvic nodes (GR B). In patients with confirmed inguinal LNM, CT of the pelvis is indicated to detect iliac LNMs (GR B). Abdominal CT and chest radiography are advisable if the pelvic CT findings are positive (GR B).

Management of the Lymph Nodes in Penile Cancer

Management of the Lymph Nodes in Penile Cancer

Modified Technique of Radical Inguinal Lymphadenectomy for Penile Carcinoma: Morbidity and Outcome

Classic radical inguinal lymphadenectomy is associated with significant morbidity. Modified inguinal lymphadenectomy has been used to decrease the complication rate but it may compromise the oncological effect and depends on the use of intraoperative frozen sections, which may be inaccurate. We modified the technique of radical inguinal lymphadenectomy to decrease postoperative complications without compromising oncological effectiveness. We performed 150 modified radical inguinal dissections in 75 patients with penile carcinoma from February 1999 to September 2008. Patients underwent modified radical inguinal dissection characterized by an S-shaped incision, precisely separating layers using an anatomical landmark and preserving the fascia lata. The boundaries of dissection are the same as those of radical inguinal lymphadenectomy. Survival and morbidity data were retrospectively analyzed, and survival probabilities were calculated. Followup ranged from 12 to 113 months. Overall 3-year survival was 92%, and for N0, N1, N2 and N3 disease it was 100%, 100%, 85% and 57.1%, respectively. A total of 37 complications occurred including wound infection (1.4%), skin necrosis (4.7%), lymphedema (13.9%), seroma (2.0%), lymphocele (2.0%) and deep venous thrombosis (0.7%). Morbidity related to groin dissection in patients with penile carcinoma can be decreased and oncological effectiveness can be preserved using this modified inguinal dissection technique.