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Indian Journal of Cancer, Vol. 47, No. 3, July-September, 2010, pp. 352 Letter To Editor Does delay in lymphadenectomy alone influence the survival in carcinoma penis? Ramakrishnan AS, Kathiresan N Department of Surgical Oncology, Cancer Institute (WIA), Annexe Campus, No.18, Sardar Patel road, Guindy, Chennai - 600 036, India Code Number: cn10088 PMID: 20587923 DOI: 10.4103/0019-509X.64714 Sir, The article "Impact of delay in inguinal lymph node dissection in patients with carcinoma of penis" by Gulia et al.[1] raises several questions. First, the authors have not specified if the delayed dissection was done with a therapeutic or prophylactic intent. Because 17 of their patients had palpable nodes, which is associated with a high incidence of pathological node- positive disease, [2] we presume that their intent was therapeutic. If that is the case, it is only natural that a delay in therapy has led to a poor survival. Second, only 13 patients underwent pelvic nodal dissection. How many patients in each group underwent a pelvic dissection and why were the remaining 10 patients not offered a pelvic dissection? Third, it is evident that in group 1, although 9 patients had palpable nodes, only 5 had pathologically positive nodes. Could this high false-positive rate of clinically palpable nodes be attributed to an inflammatory enlargement of the nodes due to an ulcerated, infected primary tumor? The authors have not attempted cytologic confirmation of nodal disease before surgery. In a large series of nodal dissection for patients with cytologically proven or clinically highly suspicious nodal disease, Pandey et al [3] reported pathologically negative nodes in only 20% of the patients. The question, therefore, is did early lymphadenectomy result in increase in unnecessary surgeries and did the high false-positive rate influence the survival? Fourth, although it is generally believed that many patients in India never attend follow-up, our experience is different. We practice an active follow-up strategy in our institution and in our recent series of clinically node-negative penile cancers, only less than 8 out of 200 patients defaulted follow-up. [4] Finally, it has been well documented in large studies of penile cancer from India that factors, such as nodal metastasis, number of involved inguinal nodes, bilateral nodal metastasis, presence of pelvic nodal metastasis, extranodal extension, and fixed nodes independently influence survival. [3],[5] In the series of Gulia et al, [1] the percentage of patients who had pathologically positive nodes and extracapsular extension was more in group 2 than in group 1, which by itself could have resulted in a poor survival rather than just a delay in lymphadenectomy. We understand that a multivariate analysis may not have been feasible in a small series, but these factors should have been accounted for in the discussion. References
Copyright 2010 - Indian Journal of Cancer |
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