Radical Inguinal Lymph Node Dissection Research Articles

Factor associated with postoperative complications of inguinal lymph node dissection for penile cancer Test

Background: Inguinal lymph node dissection (ILND) is the standard of care for palpable, biopsy-proven lymph node metastases or high-risk groups for nonpalpable lymph nodes in the treatment of penile cancer. ILND is associated with a significant incidence of complications and adverse events, specifically wound complications. Few studies have identified risk factors related to postoperative ILND complications. Objective: The objective of this study was to assess the prevalence of 30-day postoperative complications and to identify risk factors associated with postoperative complications of ILND for penile cancer. Materials and Methods: This was a retrospective review of medical records for all patients who had ILND for penile cancer between January 2012 and December 2022. According to the modified Clavien–Dindo classification, the 30-day postoperative complications were collected. Using an ordinal univariate logistic regression model and multivariate analysis, potential risk variables for complications were determined. Results: A total of 60 patients were performed ILND. Sixty percent of the patients had a postoperative complication including wound infection 50%, wound dehiscence 36.7%, skin necrosis 26.6%, lymphocele 33.3%, leg edema 46.7%, and scrotal edema 16.7%. Higher grade of modified Clavien–Dindo classification was associated with body mass index (BMI) (odds ratio [OR] = 1.15; P = 0.03), diabetes mellitus (OR = 3.13; P = 0.04), American Society of Anesthesiologist classification ≥3 (OR = 1.14; P = 0.03), radical ILND (OR = 1.57; P = 0.01), and bilateral ILND (OR = 1.60; P = 0.02). In multivariate analysis, a higher grade of modified Clavien–Dindo classification was correlated with BMI (OR = 1.48; P = 0.01) and bilateral ILND (OR = 4.56; P = 0.01). Conclusion: ILND is associated with high rates of complication. The severity of the modified Clavien–Dindo classification was associated with BMI and bilateral ILND.

Regional lymph node mapping in patients with penile cancer undergoing radical inguinal lymph node dissection - a retrospective cohort study.

Radical inguinal lymph node dissection (rILND) is the most available treatment to cure penile cancer (PC) with limited inguinal-confined disease. However, guidelines regarding acceptable boundaries of rILND are controversial, and consensus is lacking. The authors aimed to standardize the surgical boundaries of rILND with definite pathological evidence and explore the distribution pattern of inguinal lymph nodes (ILNs) in PC. A total of 414 PC patients from two centers who underwent rILND were enrolled. The ILN distribution was divided into seven zones anatomically for pathological examination. Student's t test and Kaplan-Meier survival analysis were used. ILNs displayed a funnel-shaped distribution with high density in superior regions. ILNs and metastatic nodes are present anywhere within the radical boundaries. Positive ILNs were mainly concentrated in zone I (51.7%) and zone II (41.3%), but there were 8.7% and 12.3% in inferior zones V and VI, respectively, and 7.1% in the deep ILNs. More importantly, a single positive ILN and first-station positive zone was detected in all seven regions. Single positive ILNs were located in zones I through VI in 40.4%, 23.6%, 6.7%, 18.0%, 4.5%, and 1.1%, respectively, and 5.6% presented deep ILN metastasis directly. The authors established a detailed ILN distribution map and displayed lymphatic drainage patterns with definite pathological evidence using a large cohort of PC patients. Single positive ILNs and first-station metastatic zones were observed in any region, even directly with deep ILN metastasis. Only rILND can ensure tumor-free resection without the omission of positive nodes.

Interrogating the Impassable: A Case Series and Literature Review of Unilateral SPECT-CT Groin Visualization in Men With Penile Cancer.

Penile squamous cell carcinoma (SCC) is a rare malignancy, which is known to invade local inguinal lymph nodes prior to progressing to the pelvis. Dynamic sentinel lymph node biopsy (DSLNB) is a standard for the minimally invasive assessment of lymphadenopathy in patients with subclinical groin metastasis. Hybrid 99mTc Single-Photon Emission Computed Tomography (SPECT-CT) has been shown to increase the accuracy of identifying first draining “sentinel” nodes (SN). Unilateral inguinal visualization on SPECT-CT is a rare presentation, which may increase the likelihood of a false negative SN biopsy. Retrospective analysis from three-penile cancer uro-oncologists in Melbourne, Australia identified 78 groins undergoing DSLNB for intermediate/high risk primary disease. Unilateral SPECT-CT results were observed in four patients suggesting a functional pattern of lymph diversion. Analysis confirmed malignancy (n = 2), sarcoidosis (n = 1), and evidence of local inflammation in SPECT-CT negative groins. Findings re-iterate the role of SPECT-CT a pre-operative adjunct. Experienced multimodal groin assessment using palpation, SPECT-CT, lymphoscintigraphy, and blue dye tracking remains paramount. Unilateral SN on pre-operative SPECT-CT in men with intermediate/high-risk penile SCC should elicit a higher degree of clinical suspicion. We recommend a low threshold for recommending radical inguinal lymph node dissection (ILND) for groins refractory to minimally invasive assessment.

V11-06 DYNAMIC SENTINEL LYMPH NODE BIOPSY FOR PENILE CANCER: ACCURACY IS IN THE TECHNIQUE

You have accessJournal of UrologyCME1 May 2022V11-06 DYNAMIC SENTINEL LYMPH NODE BIOPSY FOR PENILE CANCER: ACCURACY IS IN THE TECHNIQUE Jonathan O'Brien, Jiasian Teh, Kenneth Chen, Brian Kelly, Justin Chee, and Nathan Lawrentschuk Jonathan O'BrienJonathan O'Brien More articles by this author , Jiasian TehJiasian Teh More articles by this author , Kenneth ChenKenneth Chen More articles by this author , Brian KellyBrian Kelly More articles by this author , Justin CheeJustin Chee More articles by this author , and Nathan LawrentschukNathan Lawrentschuk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002632.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile squamous cell carcinoma (SCC) is a rare disease where long-term survival depends on lymph node metastases. Minimally invasive surgical techniques have improved morbidity and oncological outcomes for men with intermediate or high-risk primary tumours. EAU and NCCN guidelines recognize dynamic sentinel lymph node biopsy (DSLNB) as a standard for assessing inguinal lymphadenopathy in this patient cohort. DSLNB accuracy has been linked with technique and surgical experience, yet no videos exist which establish an operative standard. This video demonstrates an operative technique for DSLNB and analyses oncological outcomes with 2.5 years of follow up. METHODS: A retrospective analysis was performed on patients undergoing DSLNB for inguinal lymph node staging of histologically proven penile SCC. Data was included from 2 experienced uro-oncologists with subspecialty training in penile cancer working in Victoria, Australia between January 2015 and July 2021. Variables collected included patient demographics, tumour histology, DSLNB pathology, progression to radical inguinal lymph node dissection (ILND) and recurrence patterns. Data is used to calculate DSLNB sensitivity and incidence groin sparing rate. RESULTS: DSLNB was performed on 127 groins (64 patients) during the study period. Within the cohort, 44% (n=28) of patients had a pre-operative lymphoscintigraphy with single-photon emission computed tomography (SPECT/CT). A narrated video highlights the surgical technique for DSLNB. Analysis of primary tumour intervention demonstrates that 82.8% (n=53) of men underwent penile sparing surgery. Tumor histology in 88% of patients (n=56) demonstrated pT1-pT2 disease. Overall n=19 groins undergoing DSLNB positive for malignancy and n=108 were negative. 36 groins progressed to ILND during a mean follow up of 29 months. Only 2 groins that previously had a negative DSLNB were positive on ILND, representing a false negative rate of 1.9%. Overall sensitivity was 90.5% and 71.7% of groins undergoing DSLNB proceeded for surveillance instead of prophylactic radical ILND. CONCLUSIONS: DSLNB is a safe and accurate method for assessing inguinal lymphadenopathy in men with intermediate to high risk penile SCC and impalpable groins. This video study establishes an operative standard for DSLNB with oncological outcomes that are consistent with international expectations. Standardized use of DSLNB by an experienced team will reduce morbidity while maintaining oncological safety. Source of Funding: Self funded © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e923 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan O'Brien More articles by this author Jiasian Teh More articles by this author Kenneth Chen More articles by this author Brian Kelly More articles by this author Justin Chee More articles by this author Nathan Lawrentschuk More articles by this author Expand All Advertisement PDF DownloadLoading ...

The Pedicled Flap of Adductor Longus, a New Technique for Inguinal Reconstruction.

Introduction: Reconstruction surgeries of the inguinal area pose a challenge for oncological and orthopedic surgeons, especially after radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both. Although numerous surgical procedures have been reported, there is no report about a pedicle adductor longus flap method. The aim of this work is to show our experience about inguinal reconstruction with pedicled adductor longus flap and associated outcomes.Patients and Methods: A retrospective study of 16 patients with localized inguinal region interventions and reconstructed by adductor longus flap from March 2016 to July 2020. Patients' average age was 60.0 years (range = 38–79 years) and had postoperative follow-up of 10 months (ranging 2–19 months). All patients had unilateral inguinal region involvement—seven cases on the left and nine cases on the right. The patients' clinical course, operative course, and postoperative follow-up data were evaluated.Results: All 16 patients recovered well post-operatively and did not require any re-intervention. Four patients experienced negligible discomfort around the groin area. Five patients experienced a minor strength deficit in thigh adduction compared with that of preoperative strength in the same or contralateral leg. The aforementioned complications resolved during the postoperative course and had no functional impact on their activity of daily living. All adductor longus flaps survived, completely filled the inguinal dead space, and wounds healed uneventfully within 3 weeks except for three patients who suffered delayed wound healing for more than 4 weeks. Other common complications such as infection, seroma, or wound dehiscence were not encountered in this series.Conclusion: The adductor longus flap is a reliable alternative method for inguinal region reconstruction following radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both.

Definition and severity grading of postoperative lymphatic leakage following inguinal lymph node dissection

PurposeLymphatic complications occur frequently after radical inguinal lymph node dissection (RILND). The incidence of lymphatic leakage varies considerably among different studies due to the lack of a consistent definition. The aim of the present study is to propose a standardized definition and grading of different types of lymphatic leakage after groin dissection.MethodsA bicentric retrospective analysis of 82 patients who had undergone RILND was conducted. A classification of postoperative lymphatic leakage was developed on the basis of the daily drainage output, any necessary postoperative interventions and reoperations, and any delay in adjuvant treatment.ResultsIn the majority of cases, RILND was performed in patients with inguinal metastases of malignant melanoma (n = 71). Reinterventions were necessary in 15% of the patients and reoperations in 32%. A new classification of postoperative lymphatic leakage was developed. According to this definition, grade A lymphatic leakage (continued secretion of lymphatic fluid from the surgical drains without further complications) occurred in 13% of the patients, grade B lymphatic leakage (persistent drainage for more than 10 postoperative days or the occurrence of a seroma after the initial removal of the drain that requires an intervention) in 28%, and grade C lymphatic leakage (causing a reoperation or a subsequent conflict with medical measures) in 33%. The drainage volume on the second postoperative day was a suitable predictor for a complicated lymphatic leakage (grades B and C) with a cutoff of 110 ml.ConclusionThe proposed definition is clinically relevant, is easy to employ, and may serve as the definition of a standardized endpoint for the assessment of lymphatic morbidity after RILND in future studies.

Anatomical Characterization of the Inguinal Lymph Nodes Using Micro‐Computed Tomography to Inform Radical Inguinal Lymph Node Dissections for Metastatic Penile Cancer

Background, Rationale & AimIn men with penile cancer, a radical inguinal lymph node dissection (rILND) is integral to prevent metastasis and improve disease specific survival. Unfortunately, lymphocele and lymphedema are severe post‐surgical complications that are common to this procedure. The development of a modified inguinal lymph node dissection, that greatly reduced the amount of lymphatic resection, was effective at reducing the incidence of lymphedema and lymphocele; however, it was not suited for patients with advanced‐stage disease as it risked an incomplete cancer resection. As such, there exists a clinical need for a novel surgical template ‐ informed by the lymphatic anatomy ‐ to reduce these post‐surgical complications while ensuring a thorough cancer resection. However, the lymphatic anatomy of the inguinal region is not well characterized in the literature, with no definitive location or number of lymph nodes reported. Therefore, this study aims to elucidate the lymphatic anatomy within the current surgical borders of a rILND using human cadavers.MethodologyTo visualize the position of the lymph nodes, tissue packets excised from the inguinal region were imaged using micro‐computed tomography (μCT; 154 μm Locus Ultra CT scanner). To characterize the distribution of lymph nodes within each tissue packet, lymph nodes were segmented by grayscale values in 3D using a modified seed‐growing algorithm (Region Growing v1.5; Kellner, 2011) in MATLAB. To compare anatomy between tissue packets, the segmented lymph nodes were aligned (registered) with one another by translating, scaling, rotating, and mirroring (if necessary) such that they were all superimposed in a common coordinate system. This was achieved using a specimen‐specific transformation matrix that was obtained from a generalized Procrustes analysis performed using the positions of four landmarks from each specimen; the anterior superior iliac spine, pubic tubercle, sapheno‐femoral junction, and sartorius as it crosses the femoral artery. These landmarks were chosen due to their consistency between individuals as well as their use as surgical landmarks.ResultsPreliminary findings from five samples (n=3 cadavers) show a median of 6 lymph nodes (range = 3–7); their anatomical distribution is illustrated in Figure 1. In addition to obtaining more specimens, ongoing work focuses on segmentation of structures in this region, such as saphenous vein and the sartorius muscle, to provide spatial context to the identified lymph node distribution.Significance & ImplicationsThis study provides the first standardized comparison of lymph node anatomy in the inguinal region, and utilizes a novel imaging methodology validated by our lab to study the anatomy of lymphatic tissue in 3D and in situ. In doing so, the anatomy elucidated in this study will help inform refinement to the borders of the radical surgical template, to limit unnecessary resection in an attempt to reduce the incidence of post‐surgical lymphedema and/or lymphocele.The standardized lymph node data after having the generalized Procrustes analysis applied. The dotted lines represent the rILND surgical borders.Figure 1

Surgical technique of video-endoscopic radical inguinal lymph node dissection

Surgical technique of video-endoscopic radical inguinal lymph node dissection

Management of the penile squamous cell carcinoma patient after node positive radical inguinal lymph node dissection: current evidence and future prospects.

The level of evidence for current (adjuvant) treatment strategies after node positive inguinal lymphadenectomy is relatively low because of a paucity of prospective studies and controversy exist between the two major guidelines. The present review aims to provide a review of current literature on the available treatment options of patients after a tumor positive inguinal lymph node dissection. Patients without inguinal extranodal extension or less than two tumor positive inguinal nodes are at low risk of ipsilateral pelvic nodal disease. Patients with pN1 disease are unlikely to benefit from adjuvant treatment, whereas patients with pN2 disease might benefit from adjuvant radiotherapy. For patients with high risk of pelvic nodal disease, prophylactic pelvic lymph node dissection (PLND) is advised by current guidelines. The InPACT study investigates whether adjuvant chemoradiotherapy could be used instead of prophylactic PLND. Subgroup analyses of retrospective cohorts suggest that patients with pN3 disease based on tumor positive pelvic nodes may benefit from adjuvant radiotherapy or chemotherapy. Given the weak level of evidence and substantial toxicity associated with current regimens, adjuvant chemotherapy cannot be generally recommended. Despite current treatment strategies, patients with pN2-pN3 disease still have a poor prognosis. Prospective international multicenter studies are necessary to identify the best treatment options for patients with advanced node positive penile squamous cell carcinoma.

Video-endoscopic radical inguinal lymph node dissection for a patient with vulvar cancer

Vulvar carcinoma is an uncommon cancer whose treatment and follow-up centers mainly on surgical management. In the case here described, we introduce an approach for inguinal lymph node dissection through video-endoscopy which is different to that of traditional open surgery. We believe our approach reduces surgical trauma, and its implementation could be valuable in improving patient outcomes.

MP73-15 THE SYSTEMIC INFLAMMATORY MARKERS IN PERIPHERAL BLOOD BEFORE SURGICAL TREATMENT IN PENILE SQUAMOUS CELL CARCINOMA ARE PREDICTORS OF SURVIVAL

INTRODUCTION AND OBJECTIVES:Penile cancer is an aggressive and uncommon disease. Greater than 95% are caused by squamous cell carcinomas (SCC).There is growing evidence to support the association of systemic inflammation in cancer development and progression. We aimed to evaluate whether systemic inflammatory markers in peripheral blood before penectomy and before radical inguinal lymph node dissection (ILND) may be prognostic marker.METHODS:We retrospectively reviewed data from 230 patients with penile cancer followed between 2009 and 2018 in a single center, to identify 126 patients who were submitted to total or partial penectomy and 79 patients who were submitted to ILND for non-metastatic PSCC. We evaluated neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR) and platelet to lymphocyte ratio (PLR) obtained preoperatively. The cut-off point of NLR ≥ 3.0 was chosen following positive results found in previous studies in penile cancer and the cut-off point of LMR and PLR was chosen f...

Tissue sealants for the prevention of lymphoceles after radical inguinal lymph node dissection in patients with melanoma: A systematic review and individual patient data meta-analysis.

Postoperative lymphoceles and further wound complications occur frequently after radical inguinal lymph node dissection (ILND). In various studies, tissue sealants have shown to reduce the incidence of postoperative morbidity. A systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of tissue sealants in reducing the incidence of postoperative lymphoceles following ILND in patients with melanoma was conducted. Individual patient data was requested to pool the data for meta-analysis appropriately. Thousand seven hundred twenty-nine manuscripts were screened for eligibility. Six RCTs published between 1986 and 2012 were identified including 194 patients for ILND. Only four RCTs were included in the meta-analysis. No study properly defined the term "lymphocele." Tissue sealants failed to influence the duration of drain placement (mean difference [MD] = -3.05 days; z = 1.18; P = 0.24), total drainage volume (MD = 598.39 mL; z = 1.49; P = 0.14), the incidence of postoperative seroma, wound infection and skin necrosis. No improvement was identified with the use of tissue sealants, however, a valid comparison of the results of included trials was difficult owing to the lack of a definition of the term "lymphocele." Other surgical techniques and trials using validated endpoint definitions are required to reevaluate these findings.

Incidence and Magnitude of Complications Related to Modified Inguinal Lymph Node Dissection for Patients with Penile Squamous Cell Carcinoma

Objective: We investigated complications related to modify inguinal lymph node dissection (ILND) for penile squamous cell carcinoma (PSCC). Modified ILND was performed for poor performance status, groins with contralateral impalpable nodes in unilateral palpable nodes, and conventional indications.Methods: From April 2011 to November 2016, modified ILND was performed at the Yokohama City University Medical Center and its hospital for 16 groins of 12 patients with penile cancer. Seventeen groins of 11 patients who underwent radical ILND were compared (control group).Results: The mean age of 12 patients at surgery was 67.2 years; mean follow-up was 17.1 months. Skin edge necrosis was observed in 18.8% (3/16) in the modified ILND group. However, the percentage of skin necrosis in the radical ILND group was 94.1% (16/17), which was significantly higher than that in the modified group. The mean duration of drain placement was 6.7 ± 2.6 days, which was significantly shorter than that of the radical ILND group (p=0.005). The incidence of leg edema was 25.0%; leg edema had no influence on walking in any case. One patient died of local recurrence and two died of distant metastasis. No locoregional recurrence was reported after modified ILND. The remaining patients survived with no evidence of disease.Conclusion: Complications occurred less often for modified ILND than for radical ILND. Modified ILND might be a substitute for radical ILND in PSCC patients when dissection of impalpable intermediate-risk or high-risk nodes cannot be performed.

Prospective study comparing video‐endoscopic radical inguinal lymph node dissection (VEILND) with open radical ILND (OILND) for penile cancer over an 8‐year period

To compare the complications and oncological outcomes between video-endoscopic inguinal lymph node dissection (VEILND) and open ILND (OILND) in men with carcinoma of the penis. A prospectively collected institutional database was used to determine the outcomes in 42 consecutive patients undergoing ILND between 2008 and 2015 in a centre for treating penile cancer. Before 2013 all procedures were OILNDs. Since 2013 we have performed VEILND on all patients in need of ILND. The wound-related and non-wound-related complications, length of stay, and oncological safety between OILND and VEILND groups were compared. The mean duration of follow-up was 71months for OILND and 16months for the VEILND groups. In the study period 42 patients underwent 68 ILNDs (OILND 35, VEILND 33). The patients' demographics, primary stage and grade, and indications were comparable in both groups. There were no intraoperative complications in either group. The wound complication rate was significantly lower in the VEILND group at 6% compared to 68% in the OILND group. Lymphocoele rates were similar in both the groups (27% and 20%). The VEILND group had a better or the same lymph node yield, mean number of positive lymph nodes, and lymph node density confirming oncological safety. There were no groin recurrences in either group of patients. VEILND significantly reduced the mean length of stay by 4.8days (P < 0.001). VEILND is an oncologically safe procedure with considerably low morbidity and reduced length of stay, at a mean (range) follow-up of 16 (4-35) months.

Penile cancer: Perspective from a Canadian tertiary care centre.

Penile squamous cell carcinoma (SCC) is rare in North America; however, the morbidity can be devastating. This analysis represents the first reported penile cancer experience at a tertiary care centre in Canada. We carried out a retrospective review of all patients who received care at our centre for penile SCC from 2005 until the present time. Epidemiological and clinical data were collected for all patients. Survival analysis was performed using Kaplan-Meier methods with log-rank test and Cox regression for univariate and multivariate analysis, respectively. We identified 42 patients who were treated at our centre for penile SCC. Of these, 29% underwent excisional biopsy, 38% had partial penectomy, and 33% had total penectomy. Five patients with high-risk tumours underwent modified inguinal lymph node dissection (ILND), while 7 patients had radical ILND for clinically palpable disease. Overall, the median cancer specific survival (CSS) was undefined, with a 60% survival at 102 months. However CSS was significantly correlated to pT stage, pN stage, and tumour grade. The median follow-up was 25 months (interquartile range: 11-48). These findings confirm the poor CSS of patients with positive lymph nodes in penile SCC. Patients with pN0 after ILND had a durable CSS. Risk factors for penile SCC were confirmed as elevated body mass index, positive smoking history, and lack of circumcision. This first epidemiologic report on penile SCC from a Canadian tertiary care centre should be expanded to other national centres.

706 Prospective study comparing complications and short term oncological safety of videoendoscopic radical inguinal lymph node dissection (VEILND) and open radical inguinal lymphnode dissection (OILND) for penile cancer over a 5 year period in a tertiary referral centre

706 Prospective study comparing complications and short term oncological safety of videoendoscopic radical inguinal lymph node dissection (VEILND) and open radical inguinal lymphnode dissection (OILND) for penile cancer over a 5 year period in a tertiary referral centre

A case of cutaneous clear cell sarcoma determined by clinicopathological and cytogenetic analysis

Cutaneous clear cell sarcoma (CCS) is a rare soft tissue malignancy that typically manifests in the distal extremities of young adults. Although it shows melanocytic differentiation, CCS is clearly pathologically and genetically distinct from malignant melanoma. Here, we report the case of a 43-year-old male who had an asymptomatic, deep-seated, slowly enlarging, firm mass over the right heel for 30 years that recently and rapidly progressed with tenderness. We arranged for the total excision of the tumor. Pathological and cytogenetic analysis of the biopsied specimen showed that it was a clear cell sarcoma. Computed tomography and positron emission tomography scans showed no signs of metastasis, and no other abnormal hypermetabolic lesions were detected. Wide excision with split-thickness skin graft and a sentinel lymph node biopsy were performed. Because of positive findings in the sentinel lymph nodes, the patient was transferred to the plastic surgery department for further radical popliteal and inguinal lymph node dissection. The patient has received regular outpatient follow-up care in our hospital for the past 8 months with no evidence of recurrence.

A Nomogram to Predict the Duration of Drainage in Patients With Penile Cancer Treated With Inguinal Lymph Node Dissection

We developed a nomogram to predict the duration of drainage in patients with penile cancer treated with inguinal lymph node dissection. A total of 111 groin basins in 56 patients who underwent radical inguinal lymph node dissection for penile cancer were retrospectively assessed. We retrieved the clinicopathological factors from the medical records including age, body mass index, albumin, smoking history, hypertension, diabetes, preoperative radiotherapy/chemotherapy, palpable lymph nodes, previous lymph node biopsy, total number of resected lymph nodes and ratio of positive lymph nodes. The criterion of drain removal was total drain output of 50 ml or less per day for 2 days starting from postoperative day 3. A multivariate Cox proportional hazards model was used to explore the risk factors of drainage duration and variable selection was performed according to Akaike's information criteria. A nomogram was built based on regression coefficients and internally validated with 200 bootstrap resamples. Median postoperative drainage duration was 7 days. The prediction model using pretreatment factors showed a concordance index of 0.55. With the addition of lymph node related variables a second model was constructed which produced a better concordance index (0.65) and good calibration. On multivariate analysis young age, high body mass index, total number of resected lymph nodes and ratio of positive lymph nodes were independent predictors of prolonged lymphatic drainage. On the basis of readily obtained clinicopathological variables we developed a nomogram to predict the duration of lymphatic drainage which, if externally validated, could be helpful for patient consultation, treatment decision making and clinical trial design.

Management of the Lymph Nodes in Penile Cancer

Management of the Lymph Nodes in Penile Cancer

Chemoradiation in Advanced Vulval Carcinoma

Vulval carcinoma is uncommon, affecting approximately 2 per 100,000 women annually. The treatment of choice is radical vulvectomy and inguinal lymph node dissection. Advanced vulval carcinomas involve midline structures (such as clitoris, urethra, or anus) and/or adjacent pelvic organs or bone, and adequate excision may require urinary diversion, colostomy, or pelvic exenteration. Less morbid and less mutilating therapeutic alternatives have been investigated, particularly chemoradiation, which has shown success in the management of anal carcinomas. Chemoradiation has been used, instead of primary radical surgery, to treat advanced vulval carcinomas at Groote Schuur Hospital (GSH) since 1982. This is a retrospective study of the GSH's experience of the use of chemoradiation as primary therapy for women with advanced vulval carcinoma. Data from patients' medical records were transcribed onto a standardized pro forma, computerized, and analyzed. Between 1982 and 2001, 50 women with advanced vulval carcinomas were treated with chemoradiation at GSH. Fourteen women (28%) who had a complete response to chemoradiation had significantly improved survival compared with 29 (58%) who had a partial response (P = 0.000218). Partial responders who had surgery had significantly better survival than those who did not (P = 0.0064). Other prognostic factors for survival were performance status and tumor stage. Less than a third of the women treated with primary chemoradiation had a complete response. Survival was improved in women who responded partially but had residual disease surgically excised. Performance status, age, and tumor stage were also associated with survival.