Penis carcinoma- surgery- iln mgt

1. MANAGEMENT OF INGUINAL
NODES IN CA PENIS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. INGUINAL NODES
 Biology of squamous penile ca-prolonged locoregional
phase before distant dissemination
 Inguinal mets more important prognostic factor than
tumour grade,macroscopic or microscopic pattern of the
primary
3
Dept of Urology, GRH and KMC, Chennai.

4. 5YR SURVIVAL RATE
•Normal inguinal examination- 73%
•Resected inguinal mets-60% (0 to 86%)
•Minimal nodal inv (less than 2)-77%
•Greater nodal inv-25%
•Pelvic nodal mets- 10 to 15%
4
Dept of Urology, GRH and KMC, Chennai.

5. LONG TERM SURVIVAL
 Minimal nodal disease (<2)
 unilateral involvement
 No extranodal extension of cancer
 Absence of pelvic nodal mets
5 yr survival rate after curative resection- 80%(long
surgical cure in face of regional nodal mets in
comparison with blader,prostate and kidney)
5
Dept of Urology, GRH and KMC, Chennai.

6.  Presence of palpable nodal mets assd with proven
nodal mets in 50%
 New nodal development during follow up- more
likely a tumour than inflammation
6
Dept of Urology, GRH and KMC, Chennai.

7. FNAC
 Can be done simultaneously or immediately after
treatment of primary tumour
 False negative rate-20% to 30%
7
Dept of Urology, GRH and KMC, Chennai.

8. IMMEDIATE vs DELAYED
SURGERY
 Earlier lymphadenectomy in selected group(with
no palpable adenopathy)
 Routine lymphadenectomy in clinical negative
nodes-false negativity in 29%
8
Dept of Urology, GRH and KMC, Chennai.

9. MORBIDITY vs BENEFIT
 Ilioingunal morbidity > pelvic or retroperitoneal
 Phlebitis,PE,wound infection,flap
necrosis,lymphedema
Care,surgical techniques,plastic surgical
consultation,preservation of dermis,scarpas
fascia and saphenous vein & modification of the
extent
9
Dept of Urology, GRH and KMC, Chennai.

10. MORBIDITY vs BENEFIT
 Ingunal lymphadenectomy in microscopinc
disease less complications than in bulky nodes
 More complications when done simultaneously
and as palliatively
10
Dept of Urology, GRH and KMC, Chennai.

11. EARLY vs DEALYED
 Adjunctive Lymphadenectomy(83%)-no nodes
 Early therapeutic lymphadenectomy-66%-nodes+
 Delayed lymphadenectomy -36%
 6 series early therapeutic> delayed therapeutic
 5 series –delayed therapeutic dissection ncan
rarely salvage pts who experience recurrence
11
Dept of Urology, GRH and KMC, Chennai.

12. IMPACT OF PRIMARY ON
NODE PREDICTION
 T1-nodal mets 4 to 14 %
 T2- 59%
Presence of vascular invasion as prognostic
indicator of inguinal lymph node mets is now
evident
presence of mutated p53 and HPV staining—
recent prognosticators
12
Dept of Urology, GRH and KMC, Chennai.

13. LOW & HIGH RISK GROUP
 Tis,Ta,T1 G1-2,no vascular invasion-LOW RISK
 T2-4,Grade 3,vascular invasion-HIGH RISK
13
Dept of Urology, GRH and KMC, Chennai.

14. EXPECTANT MANAGEMENT
 LOW RISK GP- Expectant management
 But periodical follow up needed
 Low risk-10% noadl mets
 High risk-50 to 70% of nodal mets
14
Dept of Urology, GRH and KMC, Chennai.

15. FOLLOW UP
15
Dept of Urology, GRH and KMC, Chennai.

16. RISK BASED Rx
16
Dept of Urology, GRH and KMC, Chennai.

17. MODIFIED INGUINAL
PROCEDURES
 No inguinal palpable adenopathy/adverse
prognostic factors of the primary
 FNAC,sentinal lymph node.extended lymph node
biuosy,intraoperative lymphatic
mapping,superficial dissection, and modified
complete dissection
17
Dept of Urology, GRH and KMC, Chennai.

18. FNAC
 Pedal/penile lymphangiography
 20% false negative rate
 Kroon et al FNAC by USG guidance- 39%
sensitve to surgical staging
 Clinical neg groin- no sensitivity
 Palpable nodes if positive --ok
18
Dept of Urology, GRH and KMC, Chennai.

19. SENTINEL LYMPH NODE BIOPSY
 Cabana 1977
 Superomedial to the jn of saphenous and femoral
veins in area of superficial epigastric vein
 Postivity-complete ilioinguinal dissection
 10 & 12 % false negative rate
19
Dept of Urology, GRH and KMC, Chennai.

20. 20
Dept of Urology, GRH and KMC, Chennai.

21. PETTAWAY SENTINEL LYMPH
NODE BIOPSY
 1995
 Additional nodal dissection
 False neg rate 25%
 Anatomical variation
 No longer recommended
21
Dept of Urology, GRH and KMC, Chennai.

22. 22
Dept of Urology, GRH and KMC, Chennai.

23. INTRAOP LYMPH MAPPING
 Vital dyes or gamma emission
 False neg rate 5 to 18%
 Direct palpation of dye best
 Technical aspects,learning curve and lower no of
case limits its wide application
23
Dept of Urology, GRH and KMC, Chennai.

24. SUPERFICIAL AND MODIFIED
COMPLETE DISSECTION
 Minimal morbidity
 All surgeons can perform
 Adv over sentinel
 More information than single node
24
Dept of Urology, GRH and KMC, Chennai.

25. 25
Dept of Urology, GRH and KMC, Chennai.

26. TRADITIONAL ILIOINGUINAL
LYMPHADENECTOMY
 Resectable metastatic adenopathy
 Goals-eradicate all ca,coverage for exposed
vasculature & rapid wound healing
26
Dept of Urology, GRH and KMC, Chennai.

27. QUERIES
 Should inguinal lympnadenectomy be bilateral in
unilateral adenopathy—yes 79% bilateral drainage
 Should ing lymph be B/L in delayed U/L
presentation after treating the primary—yes in
bulky nodes (30%
 Shoulkd pelvic lymph in pts with inguinal mets-
yes
27
Dept of Urology, GRH and KMC, Chennai.

28. METASTATIC DISEASE
28
Dept of Urology, GRH and KMC, Chennai.

29. BULKY AND FIXED NODES
 Combination of surgery and chemotherapy
 Neoadjuvant CT followed by aggressive surgical
resection for pts responding
29
Dept of Urology, GRH and KMC, Chennai.

30. RADIATION THERAPY
 Uncertainity of staging and lack of histo evidence
 Inguinal area tolerate poorly
 Failure rate around 50%
 5 yr survival rate-around 25%
 Not effective as surgery-limited to palliation in
inoperable nodes
 Even radiation to primary/ingunal region only
surgery
30
Dept of Urology, GRH and KMC, Chennai.

31. CHEMOTHERAPY
 Combination therapy-cis platin,bleomycin and
methotrexate-50% response of 6 months duration
and median survival of 1 year
 Toxicity significant
 Partial response and short duration
 Neoadjuvant in mets-ok
 Locally advanced-CT plus surgery or RT-OK but
needs trials
31
Dept of Urology, GRH and KMC, Chennai.

32. 32
Dept of Urology, GRH and KMC, Chennai.

33. SUMMARY
 Protracted locoregional phase
 Ealrly detection and treatment of mets
 High risk-inguinal lymphadenectomy even when
no nodes
 High risk- direct FNAC without the antibiotic
course
 Primary and secondary not operated
simultaneously (sepsis & mortality-3.3%)
33
Dept of Urology, GRH and KMC, Chennai.

34. SUMMARY
 Ingunal mets extent determine survival]
 Palpable inguinal lymphadenopathy undergo
sutrgery
 Based on primary-risk assesed for treating non
palpable ingunal nodes
 Morbidity of lymphadenectomy decreasing in
contemporay series
 Intraop lymph mapping remains investigational
34
Dept of Urology, GRH and KMC, Chennai.