CUE case

History
• 56 year old smoker
• Ulcerative growth over tip of penis for 6
months
• No prior circumcision
• No hematuria, LUTS, unprotected sexual
exposure, prior therapy
 Examination
• ECOG: 0
• General and systemic examination: Normal
• Abdominal examination: Normal
• No palpable inguinal lymphadenopathy
• External genitalia
– 4x3 cm, Ulceroproliferative lesion replacing the distal
penis (glans and prepuce)
– Extends proximally up to coronal sulcus
– Induration extending 2 cm proximal to the corona
Local Examination
Local Examination
 Labs
• Hemoglobin 13.5 g/dl
• Total WBC count 11700/cmm
(N 53, L37, M0, E4)
• Platelet count 128000/cmm
• Serum Creatinine 0.95 mg%
• Serum Calcium 9.4 mg%
• LFT Normal
CXR
 Wedge biopsy
• HPE
– Moderately differentiated squamous cell
carcinoma
• No vascular or perineural invasion
 Partial amputation of penis
• Histopathology :
– pT1, G2
– No LVI
 Learning points
• Lymph nodal anatomy
• Evaluation
• Management
– Primary tumor
– Lymph nodes
• Risk groups for nodal metastasis
• Management of node negative groin
Inguinal lymph nodal anatomy
 Evaluation
• Clinical examination is reliable for staging
primary tumour and detection of lymph nodes
• MRI with artificial erection- when findings are
equivocal
• No role for imaging in clinically negative groin
• CT- Obese or prior inguinal surgery to assess
nodes
 Management of primary tumour
• Surgical amputation- gold standard
– Local recurrence – 0-8%
• 2 cm margin – no longer necessary
– 3 mm- G1
– 5mm- G2
– 8 mm – G3

Agrawal A et al BJU Int. 2000

Hoffman MA et al. Cancer.1999
 Management of primary tumour
• Conservative strategies
– Low grade and stage (Tis, T1, G1 and G2)
– Higher local recurrence
• Preserve glans (sensation) or shaft length
when glans preservation is not possible
• Options : WLE, Mohs surgery, Glans
resurfacing, laser ablation, Radiation

NCCN Guidelines, 2.2017

 Risk groups for nodal metastasis
 Low risk group <10%– • Current risk groups
Carcinoma in situ (Tis), based on AJCC
verrucous carcinoma (Ta),
classification
Stage T1 G1
 Intermediate risk group • T1a – this includes the
~10-25% – Stage T1G2 previous T1G2
 High risk group >40%- • T1b
presence of venous,
perineural or lymphatic
invasion and Stage T1 Grade
3 onwards

Solsona et al. EAU guidelines. Eur Urol 2004

 Clinically negative groin
• T1a
– Surveillance
– DSNB - for T1G2 (intermediate risk) if positive 
mILND

EUA and NCCN guidelines 2017

Accuracy of Lymph node staging
modalities
 Clinically negative groin
• T1b
 FNAC (High false negative) Not included in
current
 Sentinel LNB recommendations

 Dynamic SNB
 12-15% false negative rate
 ~90% sensitivity
 Reduces the need for formal IND in > 70 %, in addition
to decreasing the morbidity to < 10 %
 Modified inguinal LN dissection (mILND)
 Dynamic sentinel node biopsy
• Introduced in 1994
 Recent systematic review
and meta analysis on SLNB

• The pooled sensitivity - 88 % (95 % CI 84-90 %)

• The pooled NPV - 99 % (98-99 %)

International Urology and Nephrology

December 2016, Volume 48, Issue 12, pp 2001–2013
Radiocolloid-based dynamic sentinel lymph node biopsy in penile cancer with
clinically negative inguinal lymph node: an updated systematic review and meta-analysis
Zi-jun Zou et al
 Follow up- Surveillance of node
negative disease
Year Low risk ( T1a) High risk (T1b)

1-2 3 months 2 months

3 4 months 3 months

4 6 months 6 months

5+ Annually Annually
Thank you