An Approach to Staging the Disease EAU Guidelines

The most recent EAU guidelines give an approach for staging the disease, and to summarize them1 we might divide up the staging according to the TNM classification.

T: local staging. Ultrasound and MRI are 'optional'. MRI is likely slightly more accurate for larger tumors with deep invasion; in smaller tumors ultrasound may be of higher resolution, though if the tumor is small and superficial imaging may not add usefully to clinical and operative findings. Some authors now advocate MRI for all suspected penile cancers,7 though this is not part of the guidelines.

N: nodal staging. The appropriate investigations depend on clinical and pathological findings. For high-risk (pT2 or G3) disease, there is a strong case for bilateral lymphadenectomy regardless of clinical findings (although some centers still perform sentinel node biopsy100) .

For low and intermediate-risk disease with impalpable nodes, ultrasound +/- fine needle aspiration can be performed first; if positive, the need for inguinal lymphadenec-tomy is clear. If negative, then in low-grade tumors surveillance is reasonable. For inter-mediate-(pT1 G2), defined in the 2004 guidelines110) risk tumors, sentinel node biopsy, if available, may be used, and some would advocate its use in some cases of low-risk disease with significant potential for metastasis (particularly pT1 G167), or according to nomograms of risk including depth and perineural invasion. 1 11 However, the learning curve is steep and this necessitates the centralization of surgery for penile cancer. One other possible application of sentinel node biopsy is in the contralateral groin, with impalpable nodes, when tumor has already been found on the opposite side.

For palpable nodes, sentinel node biopsy is not reliable, and an attempt at diagnosis should be made by FNA, core or excision, ideally when a possible inflammatory swelling has been allowed to subside, with the option of repeating the FNA/core biopsy in negative cases. PET and lymphotropic nanoparticles are described as 'under investigation'.

M: CT of the pelvis +/- abdomen is recommended in all cases of node-positive disease, with bone scan in symptomatic patients.

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