Management of Penile Cancer

March 2018

NYU Case of the MoNth Management of Penile Cancer NYU Case of the Month, March 2018 Marc A. Bjurlin, DO, MSc, FACOS, Danil V. Makarov, MD, MHS Department of Urology, NYU Langone Hospital—Brooklyn, Brooklyn, NY [Rev Urol. 2018;20(1):46–48 doi: 10.3909/riu2001NYUCOM] ® © 2018 MedReviews, LLC A n 86-year-old man presented with a lesion on his foreskin that had been present for about a year. He had first noticed it as a scratch after intercourse that did not spontaneously resolve. The lesion had progressively grown and was now draining. On physical examination, the patient’s abdomen was soft, non-tender, and non-distended. He had no palpable inguinal lymphadenopathy. On retraction of the foreskin, a thick, hard, disk-shaped lesion was visible on the inside right of the foreskin. The lesion was white and rough. It appeared freely mobile with respect to the corpora. In addition, very recently, the patient had developed a thickening around the base of the penis. Relevant Prior History and Evaluation Management The patient underwent excisional circumcision of the mass on the foreskin and excision of the mass at the base of the penis. Pathology demonstrated poorly differentiated invasive squamous cell carcinoma of the foreskin and metastatic squamous cell carcinoma in the fibroadipose tissue of the base of the penis. A few weeks following the initial circumcision and biopsy, the patient developed an ulcerating lesion in his right groin. A computed tomography (CT) scan demonstrated a mass in the right inguinal region measuring 5.0 cm 3 3.7 cm (Figure 1), with fat stranding surrounding the mass and ulceration of the overlying skin along the inferior margin of the mass. A right suprapubic lymph node, measuring 1.4 cm, was noted (Figure 2). The patient was a never smoker. He had a history of benign prostatic hyperplasia, diabetes mellitus, hypertension, and coronary artery disease and prior myocardial infarction. He had undergone coronary angioplasty and placement of a biventricular cardiac pacemaker. He denied significant voiding symptoms on finasteride and tamsulosin. Cr: 1.3 mg/dL WBC: 7.3 3 109/L Hb: 12.4 g/dL Figure 1. Computed tomography scan of right groin mass. 46 • Vol. 20 No. 1 • 2018 • Reviews in Urology 4170018_11_RiU2001NYU_V1_rev01.indd 46 4/27/18 10:31 AM Management of Penile Cancer Figure 2. Computed tomography scan of enlarged inguinal lymph node. A total penectomy with creation of a perineal urethrostomy and robot-assisted right pelvic lymph node dissection with the da Vinci Xi surgical robot was performed. A three-arm robotic approach (1 camera port, 2 robotic arm ports) was used in a “V” configuration along with an assistant port that allowed access to the femoral triangle (Figure 3). Indocyanine green (ICG) 2 mg/kg was administered subcutaneously at the base of the penis and a near-infrared scope was used to identify the lymphatic chains within the groin draining the penis (Figure 4). The final borders of dissection were the inguinal ligament superiorly, the sartorius laterally, the adductor longus medially, and the intersection of the sartorius and the adductor longus distally, replicating the open approach. Figure 4. Robotic groin dissection seen under near-infrared fluorescence imaging (left panel) and white light highlighting lymphatic drainage (right panel). All nodal tissue overlying the femoral vein was harvested. A 4-cm lymph node was identified at the level of the inguinal ligament eroding through the skin. This node was dissected circumferentially and excised with the overlying skin. Pathology revealed multiple foci of metastatic squamous cell carcinoma throughout the penis, with all margins free of tumor. The right groin mass was metastatic squamous cell carcinoma with negative margins and two associated lymph nodes free of tumor. The rest of the right groin dissection revealed metastatic squamous cell carcinoma involving two of seven lymph nodes. Figure 3. Three-arm robotic approach (1 camera port, 2 robotic arm ports) in a “V” configuration along with an assistant port that allowed access to the femoral triangle. Since N3 disease was discovered with the robotic groin dissection, the patient was offered pelvic lymph node dissection, consistent with NCCN guidelines. However, given his comorbidities, the patient, in consultation with his family, elected surveillance. Discussion The management of poorly differentiated penile cancer involves control of the primary lesion, often with a partial or a radical penectomy, followed by management of the lymph nodes. Inguinal lymphadenectomy, although effective for disease control, is a notoriously morbid surgery. Inguinal node dissection is associated with infections, skin flap complications, and lower extremity lymphedema. These complications contribute to extended length of hospitalization, reduced quality of life, and delayed return to normal activities.1-6 In an effort to minimize these complications and their sequelae, NYU Langone Health Department of Urology surgeons have turned to minimally invasive techniques with excellent early results. In a recent article, Bjurlin and coauthors7 describe the novel technique used to treat the patient Vol. 20 No. 1 • 2018 • Reviews in Urology • 47 4170018_11_RiU2001NYU_V1_rev01.indd 47 4/24/18 2:06 PM Management of Penile Cancer continued described in this case presentation: robotic inguinal lymphadenectomy with near-infrared fluorescence imaging with ICG to facilitate lymph node identification during robotic groin dissection. The NYU Langone series consisted of 10 groin surgeries performed on five patients over the last several years. The surgeons were able to harvest 5 to 13 lymph nodes (mean, 8 nodes) from each side. The mean operation time was 207 minutes, with a range of 164 to 258 minutes. Blood loss was minimal: a mean of 38 mL, with a range of 25 mL to 50 mL. The mean length of stay in the hospital was 1.8 days, ranging from discharge day of surgery to 4 days. Surgeons identified the lymphatic drainage pattern from the superficial groin nodes to the deep groin nodes to the pelvic nodes underneath the inguinal ligament in all patients. With a mean follow- up of 10 months, there have been no postoperative infections, lymphatic leaks, wound breakdowns, or necroses. This is a stark departure from wound complication rates of 70% to 80% reported in the literature. The NYU Langone technique of robotic inguinal lymphadenectomy with fluorescence lymphangiography allows for identification and excision of both superficial and deep groin nodes with a significant reduction in morbidity compared with the open approach. References 1. 2. 3. 4. 5. 6. 7. Chang SB, Askew RL, Xing Y, et al. Prospective assessment of postoperative complications and associated costs following inguinal lymph node dissection (ILND) in melanoma patients. Ann Surg Oncol. 2010;17:2764-2772. Beitsch P, Balch C. Operative morbidity and risk factor assessment in melanoma patients undergoing inguinal lymph node dissection. Am J Surg. 1992;164:462-465; discussion 465-466. Bland KI, Klamer TW, Polk HC Jr, Knutson CO. Isolated regional lymph node dissection: morbidity, mortality and economic considerations. Ann Surg. 1981;193:372-376. Hudson CN, Shulver H, Lowe DC. The surgery of ‘inguinofemoral’ lymph nodes: is it adequate or excessive? Int J Gynecol Cancer. 2004;14:841-845. de Vries M, Vonkeman WG, van Ginkel RJ, Hoekstra HJ. Morbidity after inguinal sentinel lymph node biopsy and completion lymph node dissection in patients with cutaneous melanoma. Eur J Surg Oncol. 2006;32:785-789. Tonouchi H, Ohmori Y, Kobayashi M, et al. Operative morbidity associated with groin dissections. Surg Today. 2004;34:413-418. Bjurlin MA, Zhao LC, Kenigsberg AP, et al. Novel use of fluorescence lymphangiography during robotic groin dissection for penile cancer. Urology. 2017;107:267. 48 • Vol. 20 No. 1 • 2018 • Reviews in Urology 4170018_11_RiU2001NYU_V1_rev01.indd 48 4/24/18 2:06 PM