Are all palpable lymph nodes positive in penile cancer?retrospective study

Abstract

Background: Though rare in western countries the incidence of penile cancer in India is much higher and can represent 10-20% of malignant diseases in men ranging from 0.7-3 per 100,000. Important risk factors include phimosis, chronic inflammatory conditions, treatment with sporalene and ultraviolet A photo chemotherapy, smoking, sexual history and HPV DNA. Smegma as a carcinogen has been clearly excluded. In our country where incidence of inguinal nodes are high due to bare foot walking and infection, there must be balance between loosing patients from lack of follow-up and presenting later with inoperable inguinal nodes and the morbidity of a groin dissection.

Methods: This is 5 year retrospective study of carcinoma penis from a single institute (2007-2012). 50 cases have been included in this study. 20 of the 50 cases had clinically significant nodes of which only 14 cases were fine needle aspiration cytology positive nodes and they had been addressed with an inguinal block dissection in the same sitting with the primary. In first 6 months 8 cases had positive nodes on follow-up and between 6 months to 2 years 10 patients developed node recurrence and underwent block dissection.

Results: Median follow-up was 21.8 months. Among these 6 patients lost to follow up. All the follow up patients who underwent surgery on later date had one or more of these factors: High primary tumour grade, > pT2 status, lymphovascular invasion, pelvic lymph node involvement, extra nodal extension. Pelvic lymph node dissection was done in 4 patients. Adjuvant radiotherapy was given in 12 patients (37%) and chemotherapy in 4 patients (12%). Overall 5-year cancer specific survival was 61%. Men with extra nodal extension and pelvic lymph node involvement had significantly decreased 5-year cancer specific survival compared with men without it (42% vs. 80%). Complications of inguinal block dissections were flap necrosis, wound infection, seroma formation, lymphedema and deep vein thrombosis. Recognised adverse prognostic factors for survival in carcinoma penis were pathological T stage (>T2), differentiation grade (high grade > low grade), positive margin status, extra nodal extension, 4 or more unilateral metastatic inguinal nodes, bilateral versus unilateral metastatic involvement and pelvic lymph node involvement.

Conclusions: In Indian population, cases with carcinoma penis are generally of higher T status on presentation. Lymph nodes were palpable in majority of cases but most were not pathologically positive. Prophylactic block dissections are not practical as it carries its own morbidity and complications. High incidence of pathologically positive nodes were seen in patients with high grade, T status and lymphovascular invasion.