AUA 2022: Concomitant vs Staged Lymphadenectomy in Clinically Node-Positive Penile Squamous Cell Carcinoma: Recurrence Patterns and Survival Outcomes

( In a podium presentation at the 2022 American Urologic Association Annual Meeting held in New Orleans and virtually, Dr. Huelster discussed the role of concomitant, as compared to staged, inguinal lymph node dissection (ILND) among patients with clinically node positive disease. Multiple guidelines recommend resection of clinically positive inguinal lymph nodes in patients with penile cancer. Prior work has shown that ILND within 3 months of surgery for the primary penile cancer is associated with improved recurrence-free (RFS) and cancer-specific survival (CSS). However, whether concurrent ILND is associated with further improvement in outcomes for patients with clinically node-positive penile squamous cell carcinoma (cN+ pSCC) remains unknown.

To address this gap, the authors examined an international, multicenter cohort of 966 patients with penile cancer from 1964 to 2019 from the USA, Europe, Brazil, and China. The authors identified patients who were treated after the year 2000, had clinical evidence of nodal involvement, and who had both penile surgery and ILND performed. This study cohort was then stratified according to timing of the ILND with concomitant surgery defined where ILND and primary tumor surgery occurred on the same date or staged surgery when ILND was performed after penile surgery. 

The primary outcome was pSCC recurrence, with secondary outcomes of cancer specific and overall survival. Kaplan Meier survival estimates were compared with Mantel Cox log-rank tests. Multivariable Cox proportional hazard regression modeling determined associations with RFS, CSS, and overall survival (OS).

The authors identified 247 men who received contemporary treatment for clinically node positive penile cancer of whom 25 (9.2%) underwent ILND prior to management of the primary tumor, 96 (34.4%) underwent concomitant ILND, and 157 (56.3%) had staged ILND performed after penile surgery. Those patients undergoing staged surgery had surgery at a median of 4.6 months following primary penile surgery.

Recurrences were identified in 108 (42.7%) of all patients. The crude recurrence rate was higher among men undergoing staged ILND compared to those with concomitant LND (48.4% vs 34.4%, p = 0.03). Notably, in terms of the distribution of recurrent disease, distant metastases were more common (38.3%) than inguinal (30.5%), penile (7.0%), or pelvic (6.3%) recurrence with no significant differences between concomitant and staged LND groups. Notably, despite differences in the proportions of patients with recurrent disease, there were no significant differences in RFS (p=0.97), CSS (p=0.41), or OS (p=0.41) between management strategies. 

Further, on multivariable survival analysis adjusting for smoking, performance status, and pT stage, there were no survival differences between management strategies (p = 0.70, 0.60, and 0.70). 

However, the authors identified that younger age (p = 0.08 and 0.05), radical penectomy (p=0.002 and 0.03) were correlated with longer RFS and OS in men with cN+ pSCC undergoing penile tumor surgery and LND.

Thus, the authors conclude that inguinal lymph node dissection performed concurrently with penile surgery for clinically node-positive pSCC is associated with a lower recurrence rate but did not affect RFS, CSS, or OS compared to staged ILND.

Presented by: Heather Huelster, MD, H Lee Moffitt Cancer Center & Research Institute