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Indian Journal of Cancer, Vol. 46, No. 3, July-September, 2009, pp. 182-183 Guest Editorial Delayed lymphadenectomy in patients with carcinoma of penis Hegarty PK Anderson Cancer Center, Houston, Texas Code Number: cs09040 PMID: 19574667 The authors are to be congratulated for tackling this controversy on the timing of lymph node dissection. [1] Although retrospective, this article clearly demonstrates that delayed lymphadenectomy is not a safe oncological practice. The high rate of complications associated with inguinal lymph node surgery as well as poor correlation between the pathological features of the primary tumor and potential lymph node metastases has allowed evolution of the delayed approach. Nonetheless, patients with micrometastatic disease benefit from surgery, even as a monotherapy. Furthermore, those with gross nodal involvement need resection to prevent regional progression, and may still benefit from multimodal therapy. The European Association of Urology (EAU) has published guidelines that address this issue. [2] We have shown that men with palpable nodes on presentation, without use of antibiotics, have a 72% risk of lymph node disease. [3] The difficulty lies with those that have impalpable lymph nodes. Despite risk stratification, only 18% of those with impalpable nodes, who were recommended by EAU guidelines to undergo lymphadenectomy, actually had micrometastatic disease. Although these 18% benefited from surgery, the remaining 82% had unnecessary surgery. Nonetheless, in those whose primary cancer did not warrant prophylactic lymphadenectomy, no patient developed regional or metastatic disease. Clearly we need better patient selection. Sentinel lymph node biopsy is one option with far lower morbidity than inguinal lymphadenectomy. The false negative rate has been reduced to only 5%, with modifications of the technique, as demonstrated by Horenblas′s and Watkin′s groups in Europe. [4] This is an attractive approach, although it needs considerable expertise and expense. It is debatable, what false negative rate is acceptable, but when counseled, many patients seem content to accept this risk. The incision for inguinal lymphadenectomy causes much of the morbidity. Minimally invasive techniques using laparoscopic instruments have been described recently. [5],[6] These preliminary reports are exciting, but as with all minimally invasive approaches, they need careful study, with strict benchmarks compared to the existing techniques. In particular, the new technique must remove the template described by Catalona. [7] Furthermore, the long-term oncological outcome must be confirmed prior to recommending dissemination. Fortunately cancer-specific survival curves flatten out within three years for penile cancer, [3] which ought to facilitate any future study of these innovations. Offering patients lymphadenectomy simultaneously with surgery for the primary lesion requires an accurate grading of the lesion preoperatively, and may need an intraoperative frozen section to stage the lesion as T2 or higher, if the cancer is grade 1, for patients to comply with the EAU guidelines. In addition, bilateral lymphadenectomy may affect the healing of the primary lesion due to lymphoedema or infection. This is particularly important in cases where reconstructive techniques such as glansectomy and split skin grafting are performed. Despite techniques that preserve shaft length and function, [8] chronic scrotal edema may lead to the patient requiring a delayed perineal urethrostomy. Further oncological strategies include the use of neoadjuvant chemotherapy for lymph node positive disease followed by consolidative lymphadenectomy. Patients with palpable nodes on presentation undergo fine needle aspiration and cytology to establish the diagnosis of nodal metastasis prior to neoadjuvant chemotherapy. The ifosfamide, paclitaxel, and cisplatin regime is well tolerated and achieved N0 in three of ten patients, as confirmed by consolidative surgery. [9] These promising results are being followed currently by a phase II trial. [10] The rarity of penile cancer in Europe and the US has hindered much of the clinical research. The recent evolution of cancer centers and referral networks has facilitated the pooling of expertise and experience that is finally leading to meaningful advances in the management of this condition. The population of India and its relatively higher incidence of penile cancer represents a resource that ought to be leveraged to accrue maximal clinical benefit for patients in the future. References
Copyright 2009 - Indian Journal of Cancer |
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