Followup

The type and frequency of follow-up varies with the stage and grade of disease at initial presentation, but most patients with penile cancer will require surveillance, primarily to detect local recurrence and nodal disease which have the potential for cure, as opposed to metastatic disease which has an almost universally poor

Table 4.1 Follow-up intervals for pelvic nodes in the most recent (2009) EAU guidelines

Follow-up interval -

Follow-up interval -

Maximum length

Groin findings

years 1 and 2

years 3,4, and 5

of follow-up

Clinically negative, "wait

3 months

6 months

5 years

and see"

Negative groin nodes at dissection

6 months

1 year

5 years

Positive groin nodes at

3 months

6 months

5 years

dissection

outcome.112 The rate of such local recurrence and nodal metastasis varies greatly with disease grade, but is around 30% for patients with T1G2 tumors.113

Current EAU guidelines from 2009 recommend primarily clinical follow-up after partial penectomy, but intensive imaging follow-up for nodal recurrence, according to the schedule in Table 4.1. The previous guidelines, published in 2004, recommended CT follow-up, together with chest radiographs, for lymph node-positive patients,110 but the most recent guidelines modify the schedule and replace CT with ultrasound +/- fine needle aspiration, both for node positive and node-negative patients.1 Bone scans and abdominal CT are reserved for symptomatic patients. This reliance on ultrasound +/- FNA depends on radiological and cytological expertise, and is also inadequate for the early detection of pelvic nodal disease, as all but the most superficial pelvic nodes are difficult to see on ultrasound unless clearly enlarged. It may be, therefore, that in some patients CT is more practical than ultrasound, or that a combination of the two techniques most suitable.

For a clinically suspected local recurrence, a follow-up MRI may be used to stage the disease and plan surgery, although the presence of fibrosis may complicate assessment. There is some evidence for pelvic cancers that on dynamically enhanced scans fibrosis enhances later than tumor,114 but little evidence that the resolution of gradient echo sequences used is sufficient to detect small foci of recurrence in the penis.7

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