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JU INSIGHT: Concomitant vs Staged Inguinal Lymphadenectomy in Node Positive Penile Squamous Cell Carcinoma
By: Heather L. Huelster, MD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Andrew Chang, MD, PhD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Kyle M. Rose, MD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Marco Bandini, MD, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy; Maarten Albersen, MD, PhD, University Hospitals Leuven, Belgium; Eduard Roussel, MD, University Hospitals Leuven, Belgium; Juan Chipollini, MD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Yao Zhu, MD, PhD, Fudan University Shanghai Cancer Center, China; Ding-Wei Ye, MD, Fudan University Shanghai Cancer Center, China; Antonio A. Ornellas, MD, PhD, Hospital Mário Kröeff and Brazilian Cancer Institute, Rio de Janeiro; Mario Catanzaro, MD, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; Laura Marandino, MD, IRCCS San Raffaele Hospital, Milan, Italy; Filippo Pederzoli, MD, PhD, Weill Cornell Medicine, New York, New York; Oliver W. Hakenberg, MD, University Hospital Rostock, Germany; Axel Heidenreich, MD, Universitätsklinikum Köln, Germany; Friederike Haidl, MD, Universitätsklinikum Köln, Germany; Nick Watkin, FRCS, MChir, St George’s University Hospitals, NHS Foundation Trust, London, United Kingdom; Michael Ager, MBBS, MRCS, St George’s University Hospitals, NHS Foundation Trust, London, United Kingdom; Mohamed E. Ahmed, MD, Mayo Clinic, Rochester, Minnesota; Jeffrey R. Karnes, MD, Mayo Clinic, Rochester, Minnesota; Alberto Briganti, MD, PhD, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy; Youngchul Kim, PhD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Francesco Montorsi, MD, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy; Andrea Necchi, MD, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy; Philippe E. Spiess, MD, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida | Posted on: 17 Mar 2023
Huelster HL, Chang A, Rose KM, et al. Concomitant vs staged therapeutic inguinal lymphadenectomy in clinically node positive penile squamous cell carcinoma: does it make a difference?. J Urol. 2023;209(3):557-564.
Study Need and Importance
While men with penile squamous cell carcinoma (pSCC) and palpable inguinal lymph nodes are at an over 60% risk of metastases in the groin, controversy regarding the indication, extent, and timing of inguinal lymph node dissection (ILND) remains. Variable ILND timing is largely driven by surgeon experience, clinical presentation, and practical considerations such as access to and timing of referral to tertiary centers and recommendation of neoadjuvant chemotherapy.
What We Found
We present the first examination of oncologic outcomes in men with palpable inguinal adenopathy and no distant metastatic disease undergoing concomitant vs staged ILND with management of the primary tumor. We did not see evidence that lymphadenectomy performed in a staged manner after excision of the penile tumor was associated with adverse survival outcomes on unadjusted or adjusted analysis (see Figure).
Limitations
Although these data represent the largest collection of their kind in a diverse global cohort of pSCC patients, they remain limited by their retrospective and nonrandomized nature, heterogeneity of management and posttreatment surveillance, and risk of immortal time bias inherent to defining pSCC recurrence after completion of ILND in survival comparisons. However, careful cohort selection, multivariable modeling, and sensitivity analysis adjusting for variability in practice patterns between global treatment centers lend credence to the overarching conclusions in the penile cancer setting where prospective data are limited.
Interpretation for Patient Care
This multinational study of men with penile cancer and clinically positive inguinal lymph nodes suggests that there are no differences in recurrence-free, cancer-specific, or overall survival when performing ILND and penile tumor excision concomitantly compared to in a staged manner. We conclude that surgeons may base the decision to perform ILND concomitantly compared to staging within 3 months of resection of the penile tumor on patient-specific factors such as clinical presentation, compliance, comorbidity optimization, timing of referral to an experienced center, and completion of neoadjuvant chemotherapy.
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