Solsona et al and European Association of Urology EAU Risk Groups

The risk of regional lymph node involvement can be estimated in a more accurate fashion combining the information provided by the pathological stage and the his-tological grading of the primary tumor (Table 10.2).

In 1992 Solsona et al. proposed a stratification of penile cancer patients into 3 groups, each with a different risk for inguinal node involvement, combining the pathological stage and histological grade of the primary tumor. Patients with pT1/grade 1 disease were classified as low risk of node involvement; those with pT1/grade 2-3 and pT2/grade 1 as intermediate risk; those with pT2/grade 2-3 or >pT3 as high risk. The percentage of node metastases in the 3 groups was 0%, 36.4%, and 80%, respectively.40 This classification was validated in 2001 by the same group in a prospective series of 37 patients where the percentage of inguinal metastases was 0% in low-risk, 33% in intermediate-risk, and 83% in high-risk groups.41

The ability of the Solsona et al. classification to stratify patients with penile cancer according to the different risk of inguinal lymph node metastases was recently confirmed in an Italian multicentre study analyzing 175 patients observed between 1980 and 2002. In this study, lymph node metastases were observed in 4% of low-risk, 29.1% in intermediate-risk, and 53.5% in high-risk patients (p < 0.001).17

The expert panel drafting the EAU guidelines proposed a similar but slightly different classification to that by Solsona et al. in 1992. Specifically, patients were classified as low risk in cases of pTis, pTaG1-2, pT1G1 disease; as intermediate risk in case of pT1G2 tumors; as high risk in case of >pT2 or G3 cancer.42 The risk of inguinal metastases according to the EAU classification was 4% in low-risk, 34.8% in intermediate-risk, 45.8% in high-risk patients.17

Nevertheless, a recently published study by Novara et al. showed that both the Solsona et al. and the EAU risk groups have a low prognostic accuracy. In this study the receiver operating characteristic (ROC) curves showed values of 0.697 (95% CI 0.618-0.777) for the Solsona et al. classification and 0.632 (95% CI 0.548-0.715) for the EAU one.43

Ornellas et al. recently proposed a new classification of penile cancer patients into 3 different risk groups according to primary tumor pathological stage and his-tological grade. Patients were defined as low risk in cases of T1G1-2 tumor; as intermediate risk in T2G1-2 or T3G1-2 disease; as high risk in case of T1-3G3 or T4G1-3 cancer. The authors observed a significant difference in terms of 10-year cancer-specific survival between low and intermediate-risk patients (p=0.01) and between intermediate- and high-risk patients (p < 0.001).31

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