Lymphatic Drainage Patterns And Natural History Of Penile Cancer

Anatomic studies by Rouviere at the beginning of this century and subsequent studies by Daseler, as well as clinical observations, have given us insight into normal lymphatic drainage patterns of the penis [1,2]. The lymph nodes in the groin are considered to be the primary regional nodes. The pelvic (iliac) nodes are second-tier nodes.

Squamous cell carcinoma is characterized by local invasion and regional spread, with late onset of hematogenous dissemination. Lymph node metastasis is an adverse prognostic factor for survival. However, patients with minimal involvement of the nodes have an excellent prognosis after regional lymphade-nectomy. By contrast, most patients with extensive inguinal metastases or spread to the pelvic nodes die of their disease, hence, the rationale to perform a lymph node dissection at the earliest possible moment to remove metastases at a time when they are still clinically occult. By definition, occult metastases cannot be detected by simple physical examination. Analysis at our institution has shown that the negative predictive value of normal findings at physical examination (probability of absence of metastasis with negative findings at physical examination) of the inguinal region is 88%. Lymphangiography, ultrasound, computerized tomography, and magnetic resonance imaging are all incapable of improving this figure [3]. This leads us to state that no test is more reliable than physical examination in assessing clinically node-negative patients with squamous cell carcinoma of the penis and that physical examination has limitations. The limited value of clinical methods in detecting occult metastasis and the excellent survival figures of patients with minimal nodal involvement have led some investigators to recommend a lymph node dissection for all patients presenting with penile cancer. However, more than 80% of these node dissections are unnecessary because of the absence of nodal involvement in the resected specimen. Some 2040% of the patients develop short-term and/or long-term complications such as wound-healing problems and lymphedema of the limb and/or the genital area [4]. Based on studies at our and other institutions, risk profiles for nodal involvement have been established [5]. Low-risk and high-risk patients are defined according to the extent of the primary tumor and the grade of differentiation. Examining the high-risk category patients only, 40% of the elective node dissections at our institution were unnecessary because of the absence of node metastasis. The need for better detection of occult metastasis is clearly apparent.

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