NEW ORLEANS, LA USA (UroToday.com) - In the penile cancer session at the Society of Urologic Oncology meeting at the AUA, Viraj Master discussed management of inguinal lymph nodes in patients with high-risk penile tumors and no palpable and/or non-bulky adenopathy. Dr. Master began by showing the stark contrast in outcomes of patients with penile cancer based on node count. Patients with node-negative disease have 1.9% 2-year CSM, those with 1 or 2 positive nodes have 19% 2-year CSM, those with 3+ nodes and/or extranodal extension have 43.3% CSM, and patients with pelvic nodes have 68.6% CSM.
After reviewing the new NCCN guidelines that were previously presented in the penile cancer session, Dr. Master presented the risk factors included in “high-risk” disease: these include > pT1 G3/4 or pT2/ any grade; vascular invasion; or poorly differentiated tumors. The problem with these criteria is that there is significant interobserver variability in grading penile cancer specimens (Virchows Arch 2014).
Further supporting aggressive ILND in patients with non-palpable disease, Kirrander and colleagues showed that 25% of groins with impalpable nodes have micro-metastases (BJUI 2013). Moreover, delayed lymphadenoctomy for cN0 inguinal nodes is not as effective as up-front ILND, with a 3-year DSS of 35% vs 84% (J Urol 2005).
Next, Dr. Master discussed techniques for oncologically sound ILND. He compared outcomes of VEIL vs traditional open surgery, and showed oncologic equivalence when comparing node counts vs those performed for melanoma. Sentinel lymph node biopsy is commonly performed in Europe, and may be the result of regionalization of care, as it is rarely used in the United States. Per the new NCCN guidelines, this should be limited to centers of expertise (20 procedures/year), and should not be done with palpable nodes.
Johnson and colleagues (Cancer 2010) attempted to identify how many patients are getting ILNDs for penile cancer. In their study, they found that 26.5% of patients had sampling of at least one node (4% with 1 LN, 4.5% with 2-7 LN, and 18% with > 8 LN). Using the NCDB, Dr. Haseebuddin and associates from Fox Chase Cancer Center found that 35% of pT2 patients underwent ILND. Finally, Dr. Master reviewed the indications of radiation therapy: it is not recommended as prophylaxis in patients with cN0 disease as it fails to prevent future metastases, is associated with complications, and makes follow-up examination difficult due to fibrotic changes that are induced.
Dr. Master concluded that if it is difficult to get high fidelity pathologic information (grade), and imaging has poor sensitivity, and if the outcome is poor when we wait for palpable disease to appear, then it is better to err on the side of performing ILND.
Presented by Viraj A. Master, MD, PhD at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
Emory Healthcare, Atlanta, GA USA
Reported by Nikhil Waingankar, medical writer for UroToday.com