Clinical Stage of Primary Tumor

The latest version of the TNM staging system is more easily applicable in defining the pathological extension of the malignancy rather than elucidating the clinical stage of the tumor.7 In fact, the 1978 TNM version may be more adequate to define the clinical stage of the disease. According to this older classification, penile cancer might be classified into exophytic lesions <2 cm (T1); superficial lesions of 2-5 cm or with minimal depth invasion (T2); lesions >5 cm or with deep invasion (T3); neoplasms infiltrating adjacent structures (T4).26 Even though the major series have reported that the percentage of lymph node metastases increased with the local clinical stage, only Ficarra et al. have demonstrated that this clinical parameter was related to the risk of groin lymph node involvement in univariate analysis. Specifically, they found a percentage of inguinal metastases of 25% in cT1, 34% in cT2, and 66% in cT3-4. However, multivariate analysis has shown that this parameter had no independent prognostic role, because the only clinical prognostic factor able to independently predict inguinal metastases was the finding of palpable or fixed inguinal lymph nodes.3 More recently others have reported lymph node metastasis rates of 34-42% in cT2 and 48-52% in cT3-4.2122

In terms of 5-year survival, the seminal study reporting statistically significant differences between the different clinical stages of the primary tumor was published in 1994 by Horenblas et al. These authors demonstrated a 5-year survival of 94% in cT1, 59% in cT2, and 52% in cT3-4 cancers.27 Generally, there is an increase in the proportion of lymph node involvement in patients with higher clinical stage, especially comparing cT1 and cT2-T3 cancers.

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