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Penile Cancer
to infection of the primary tumour. Traditionally, the advice has been complication rate.
30
The combined sensitivity of this procedure
to give antibiotic treatment for six weeks to treat the inflammation. was 93% with specificity of 100%. Complications occurred in fewer
However, in order not to further delay diagnosis, ultrasound imaging than 5% of explored groins, and almost all were transient and could
with fine-needle aspiration of suspicious-looking nodes is strongly be managed conservatively. In addition, no learning curve could be
advised in these cases.
18
If cytological analysis is tumour-positive, demonstrated in the initial 30 procedures in the series at St
ipsilateral inguinal lymphadenectomy is the treatment of choice. George’s Hospital.
Given the possibility of a false-negative result, it is recommended to
repeat the ultrasound with fine-needle aspiration cytology and Recently, MRI with lymphotropic nanoparticles (coated ultra-small
thereafter to perform an excision biopsy when clinical suspicion particles of iron oxide and ferrumoxtran-10) has shown promising
remains with tumour-negative cytological results. results in identifying occult metastasis in penile,
31
bladder
32,33
and
prostate cancer.
4
This imaging modality is not universally available, and
Conventional computed tomography (CT) scans or MRI are not longer follow-up with larger series is needed.
18
F-fluorodeoxyglucose
reliable enough to predict the status of the inguinal nodes either in positron emission tomography (PET)/CT scans are commercially
N0 or N+ patients. These imaging techniques have a spatial available. PET/CT has shown its feasibility as a staging procedure in
resolution of at least 2mm. In addition, the focus is on morphological penile carcinoma.
35
However, its use in identifying inguinal metastasis
characteristics such as size and shape of the node, which can be in N0 groins seems to be limited.
36
In a recent prospective study
falsely enlarged due to infection and does not provide concerning 42 N0 groins, one out of five occult metastases was
histopathological evidence. Therefore, these imaging techniques are depicted by PET/CT.
36
Although the number of tumour-positive groins
not recommended to stage the groin in penile cancer patients. was low, it seems unlikely that the sensitivity will improve with a larger
sample size in such a way to safely omit surgical staging. The spatial
Several histopathological factors of the primary tumour of the penis resolution of current (dual-modality) imaging procedures is too limited
have predictive value for the presence of lymph node metastases, to detect microscopic nodal involvement (≤2mm). Therefore, for a
such as tumour stage,
12,19
tumour grade,
12,20,21
presence of reliable assessment of the N0 groin, invasive staging procedures are
lymphangioinvasion,
22,23
peri-neural invasion
20,21
and infiltration still indicated at the moment.
depth.
20
The 2004 European Association of Urology guidelines have
Recently, the value of PET/CT scans was evaluated in identifying
pelvic nodal involvement and in staging for distant metastasis in
N+ penile carcinoma patients.
37
These patients in particular might
Partial or total amputation for penile
benefit from pre-operative PET/CT scanning, as they have more
locoregionally advanced disease that potentially exceeds the spatial
cancer has stood the test of time with
resolution. A sensitivity of 91% and specificity of 100% was found for
excellent local control, but is associated
detecting pelvic nodal involvement. The reported sensitivity and
specificity of conventional CT imaging in this respect is 37.5 and
with severe psychological morbidity and
100%,
38
respectively. In addition, distant metastases were identified
sexual dysfunction.
with great accuracy. Therefore, PET/CT may have value in staging
these N+ patients and stratifying those for primary surgical or
multimodality treatment. The utility of PET/CT in monitoring
included tumour stage, grade and absence or presence of (neoadjuvant) chemotherapy has to be determined in the near future.
lymphangioinvasion in a risk-adapted approach for the However, based on the results of various other malignancies, PET/CT
management of the inguinal regions.
24
However, these factors have is expected to be superior compared with conventional imaging
low interobserver agreement,
25
and consequently are not reliable methods in response evaluation.
39,40
enough in clinical practice.
26
Another approach has been the
introduction of a nomogram predictive of pathological inguinal Treatment
node involvement.
27
Unfortunately, this nomogram also suffers from Partial or total amputation for penile cancer has stood the test of
shortcomings, of which the most important is a lack of external time with excellent local control, but is associated with severe
validation. In clinical practice the value of the nomogram is psychological morbidity and sexual dysfunction.
41
To overcome
doubtful, as it remains at the discretion of the doctor in these problems, penile-conserving surgical techniques have gained
collaboration with the patient to determine at which cut-off point to popularity. Formerly, a 2cm tumour-free margin was considered
embark on a lymphadenectomy. mandatory for penile surgical treatment, making penis-sparing
impossible in some patients. However, recent studies have shown
Since 1994, dynamic sentinel node biopsy has been used at our that smaller margins can also be regarded as oncologically safe.
42,43
institution. After pre-operative planar lymphoscintigraphy and using Local recurrences confined to the penis can be managed with
an intra-operative gamma-ray detection probe and blue dye, only salvage surgery and have no impact on survival, provided that they
the lymph nodes on a direct lymphatic drainage pathway are are treated as soon as possible.
44
Multiple penile-conserving
removed.
28
This minimally invasive procedure has matured into a techniques are used worldwide, e.g. carbon dioxide,
45
neodymium-
reliable staging method with low morbidity.
13,29
Recently, in a large doped:yttrium–aluminium–garnet lasers,
46
circumcision, glans
prospective series of 323 patients in two tertiary referral hospitals resurfacing,
47
Mohs’ microsurgery,
48
local excision,
49,50
glansectomy
(The Netherlands Cancer Institute in Amsterdam and St George’s with or without skin grafting
51
or a combination of these methods.
Hospital in London) that use essentially the same protocol, dynamic The type of penile-conserving surgical technique is dependent on
sentinel node biopsy has shown to be a reliable method with a low T-stage at presentation.
32 EUROPEAN UROLOGICAL REVIEW