Distant Recurrence

The majority of distant recurrences are incurable because they are often accompanied by advanced disease. It seems reasonable to focus follow-up in patients with penile carcinoma on the locoregional situation with additional imaging when indicated. It is important to emphasize that the risk of lymphatic dissemination beyond the groin is correlated with the extent of nodal involvement. 1 9-23 In general, 20-30% of patients with positive inguinal nodes have positive pelvic nodes.19-23 The likelihood of pelvic nodal involvement is related to the number of positive nodes in the inguinal specimen and/or presence of extranodal extension.22,23 Such features and also pelvic lymphade-nopathy are consequently predictors of further metastatic spread, i.e. distant metastasis. Hence, patients without or only minimal metastatic disease (e.g. one intranodal metastasis) are at low risk for development of distant recurrence. If patients have recurrences beyond the groins they are candidates for palliative treatment only or for inclusion in clinical trials as the disease-specific survival is poor.

The group of patients at high risk for pelvic metastasis could potentially benefit from preoperative imaging techniques. Unfortunately, the use of CT imaging is limited. Recently, Zhu et al. showed that CT imaging detected pelvic lymphade-nopathy with a 37.5% sensitivity and 100% specificity.24 These figures are in accordance with data from CT imaging in detecting lymph node metastasis in prostate cancer.25 In recent years, fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography with CT (PET/CT) for staging lymph nodes have shown its superiority compared with CT imaging or PET alone.26,27 For example, in 260 patients with solid tumors, the nodal status identified by PET/CT was significantly more accurate compared to CT alone (92% vs. 76%).27 In patients with clinically node-positive penile carcinoma PET/CT imaging has also shown potential in depicting pelvic lymphadenopathy with a sensitivity of 91% (95% confidence interval [CI]: 58-100) and specificity of 100% (95% CI: 80-100).28 An extra advantage of screening patients at risk for pelvic nodal involvement with whole-body PET/CT imaging is identification of distant metastasis. Although in the previous study, no direct comparison was made with CT alone, no differences are to be expected in favor of contrast-enhanced CT imaging in depicting pelvic metastasis.26,27 Considering the poor survival in patients with pelvic metastasis, patients with preoperative evidence of pelvic lymphadenopathy are in need for more treatment than surgery alone. Neoadjuvant chemotherapy has successfully been used in small series,29,30 and is probably required to improve survival.

Table 14.2 Recommendations for follow-up

Interval of follow-up

Years 1 and 2

Examinations

Maximum length of follow-up

Recommendations for follow-up of primary tumor

Penile-preserving treatment 3 months

Amputation 6 months

Recommendations for follow-up of the inguinal lymph nodes

Wait and see 3 months pNO 6 months pN 3 months

6 months

1 years

6 months 1 year 6 months

Regular self-examination 5 years Regular self-examination 5 years

Regular self-examination 5 years

Ultrasound with FNAC

Regular self-examination 5 years

Ultrasound with FNAC

Regular self-examination 5 years

Ultrasound with FNAC

Adapted from Leijte et al.1

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