Extended lymphadenectomy in penile cancer

There are many controversies regarding the optimal management of the inguinal nodes in patients with penile cancer. The inflammatory response of the draining regional lymph nodes can cause enlargement without implying the presence of metastases. On the other hand, 20% of patients with clinically non-suspicious nodes contain micrometastases. We studied the dissemination risk factors of the primary lesion in penile cancer, the preferential lymphatic pathways, and the extension of lymphadenectomies, in order to understand how to better control this cancer.

In this prospective study of 50 patients (aged 21-73; median age 54) with penile carcinoma, the initial clinical and pathologic findings were compared to biopsy specimens obtained in routine, bilateral, superficial, deep and pelvic lymphadenectomies. Patients were followed from 6 months to 18 years.

We found that first, risk factors of tumor spread were primary lesions greater than 2 cm in diameter, unfavorable histology findings, and invasive lesions. Second, these risk factors were present in all patients who had node metastases. Third, clinical staging was not accurate, since there was a tendency to understage 19% of localized disease and overstage 51.5% of metastatic disease. Fourth, the sentinel nodes were the most commonly infiltrated nodes but were only present in 2 (11%) of 18 metastatic cases. Fifth, there were no cases of deep inguinal nodes without superficial infiltration. Lastly, there were no cases of pelvic node without prior contamination of inguinal nodes.

Ideal candidates for watchful waiting after primary lesion treatment are those who do not have primary lesions greater than 2 cm in diameter, unfavorable histology findings, invasive lesions, or palpable nodes. Performing limited surgery on positive nodes risks leaving some of the tumor. Superficial lymphadenectomy is the procedure of choice in cases of patients with clinical negative nodes and risk factors of tumor spread.