Prognosis and Adjuvant Treatment

The single most important prognostic factor in penile cancer is the presence of nodal involvement. The extent of nodal involvement also has a predictive value for cancer-specific outcome. As mentioned previously, patients with one or two inguinal lymph node metastases have a 5-year survival rate of approximately 80%. 1 -7 Several studies have indicated that the number of inguinal nodes involved, extran-odal extension and pelvic nodal involvement are unfavorable parameters for disease-specific survival (Table 9.3).1-7 Hence, the indication for adjuvant treatment is based upon the presence of these adverse prognostic indicators. At the authors' institution, no adjuvant treatment is indicated when histopathological analysis of the removed inguinal dissected specimen shows one intranodal metastasis as cure alone by surgery can be obtained in these patients. Adjuvant ipsilateral radiotherapy to the inguinal lymphatic region is given when histopathological analysis shows two or more inguinal nodes involved or extranodal extension. The rationale for this arises from studies in head and neck squamous cell carcinomas showing an improvement in regional control following adjuvant radiotherapy.76 Adjuvant radiotherapy to the pelvic region is administered additionally when pelvic nodes are involved. Prophylactic radiation to the groins in all patients with penile cancer is not advised for the following reasons. Firstly, some patients with nonpalpable nodes will not benefit because they have no occult metastasis as is the case for elective lymph-adenectomy. Secondly, all patients will be exposed to the complications of radiation

Fig. 9.15 (a) Skin closure with the VAC system. A sponge is introduced into the wound. (b) After introduction of the sponge, the wound is covered with a plastic adhesive layer. (c) A small hole is made in the plastic sheath to accommodate a suction device for low pressure suction a

Fig. 9.15 (a) Skin closure with the VAC system. A sponge is introduced into the wound. (b) After introduction of the sponge, the wound is covered with a plastic adhesive layer. (c) A small hole is made in the plastic sheath to accommodate a suction device for low pressure suction

Penile Cancer

therapy, e.g. short-term complications like epidermolysis, and long-term effects such as lymphedema and fibrosis. Finally, the follow-up is more complicated because of the fibrotic changes, making physical examination less reliable. Although, Ravi et al. have indicated that patients with large (>4 cm) and/or fixed regional nodes may benefit from preoperative radiotherapy, the above-mentioned disadvantages outweigh the preoperative use. There are no studies available that have

Table 9.3 Cancer-specific survival by pathological nodal factors after inguinal lymphadenectomy

5-year

Number of

cancer-specific

patients

survival

Factors

with factor

estimates (%)

Pathological node-negative nodes

1032

95

1407

96

Pathological node-positive

1182

53

1117

35

1026

51

15677

61

No of positive nodes

1

51

82

1-3

582

81

696

76

£2

11177

74

>3

4177

33

>3

102

50

4-5

256

8

>5

86

0

Unilateral

432

86

746

63

9377

69

Bilateral

241

12

252

60

286

21

6377

49

Extranodal extension

221

5

172

0

546

9

7977

42

Pelvic nodal involvement

221

0

302

0

216

0

1378

30

3477

21

investigated the efficacy of radiotherapy versus standard lymphadenectomy in terms of local control, (cancer-specific) outcome, or complications.

Despite adjuvant radiotherapy, a previous study at the authors' institution of 102 patients with metastatic penile carcinoma treated between 1956 and 2001 has shown that extranodal extension and pelvic nodal involvement are independent predictors for survival.4 These results have recently been confirmed in an updated series which has included 156 patients with metastatic penile cancer treated between 1988 and 2008.77 These data suggest that more effective treatment is needed in this subgroup of patients with high-risk metastatic penile cancer. Whether induction chemotherapy before surgery is of any benefit in this high-risk subgroup warrants further clinical studies.

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