The role of inguinal lymph node dissection in men with urethral squamous cell carcinoma

Introduction

Urethral squamous cell cancer is a rare disease with limited clinical recommendations regarding management of the inguinal lymph nodes. Despite the similarities to penile cancer in terms of squamous cell carcinoma (SCC) histology and lymphatic drainage, there is not enough evidence to recommend for or against a prophylactic inguinal lymph node dissection (ILND) in patients with clinically negative groins and a primary tumor stage of T1b or higher. The objective of the study was to identify the rate of prophylactic inguinal lymph node dissection, node positive rate, and overall survival in patients with clinical T1 to T4 stage. The patients were separated into clinical N stage and the rates of node positivity were compared. We hypothesize that the node positivity rate would be similar to that observed in penile cancer of similar clinical T and N stage and provide evidence for prophylactic inguinal lymph node dissection in urethral squamous cancer. We also sought to determine the value of ILND in clinically node positive (cN+) and clinically node negative (cN?) patients.

Surgical outcome after the clearance of abdominal metastatic lymph nodes in 138 patients with thoracic esophageal carcinoma

BACKGROUND: Although abdominal lymph node metastasis in patients with thoracic esophageal squamous cell carcinoma (SCC) has been reported to be a risk factor to reduce long-term survival, only a few studies have so far evaluated the clinicopathologic factors among this group of patients. The purpose of this study was to evaluate the patients' surgical outcome after the clearance of metastatic abdominal nodes. PATIENTS AND METHODS: From 1980 to 2002, 550 consecutive patients with thoracic esophageal SCC underwent surgery with an abdominal lymph node dissection. A total of 138 patients with abdominal lymph node metastases were curatively resected. Those patients, including 62 from 1980 to 1989 and 76 from 1990 to 2002, were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the impact of clinicopathologic factors on the survival of these patients. RESULTS: The overall 5-year survival rate of the 138 patients with abdominal lymph node metastases was 23%. A univariate analysis revealed that the following groups showed a greater than 30% overall 5-year survival rate: patients with T1 or T2 tumors, patients without thoracic node metastases, and those with poorly differentiated type tumors. Good prognostic factors based on a multivariate analysis were the most recent time period of surgery and 4 or fewer positive nodes. CONCLUSION: Among the patients with abdominal lymph node metastases, those with T1 or T2 tumors, patients without thoracic node metastases, and patients with 4 or fewer positive nodes showed an acceptable overall survival after a curative resection.     

Predictive pathological factors of lymph nodes involvement in the squamous cell carcinoma of the penis

Objectives:To evaluate the predictive role ofprimary tumor histopathological features inpredicting inguinal lymph nodes involvement inpatients with penile squamous cell carcinoma.Material and methods:We retrospectivelyanalysed pathological records from 30consecutive patients who underwent penectomyfor invasive squamous cell carcinoma of thepenis. All histological specimens were reviewedby the same pathologist. We considered thefollowing histological parameters: histologicalgrading, growth pattern, deph invasion, tumourthickness, nuclear grading, poorlydifferentiated cancer rate, vascular andlymphatic embolization, eosinophilic andmononuclear infiltration and pathologicalstage.Results:Lymph nodes involvement occurred in 5patients who underwent `early' lymphadenectomyand in other 4 ones during oncologicalsurveillance. Lymph nodes metastasis resultedsignificantly correlated with histologicalgrading (p = 0.005), lymphatic (p = 0.005) andvenous (p = 0.02) embolization, corporacavernosa (p = 0.03) and urethra (p = 0.03)infiltration. Histological grading andlymphatic embolization were independentpredictive variables of lymph nodes involvement(p = 0.02).Conclusions:The histological grading andlymphatic embolization have to be considered asimportant parameters to select patients withpenile squamous cell carcinoma to undergo an`early' lymphadenectomy.     

阴茎癌腹腔镜下和开放式腹股沟淋巴结清扫术的对比研究

目的 比较阴茎癌腹腔镜下与开放式双侧腹股沟淋巴结清扫术的临床效果. 方法 回顾性分析2007年6月至2011年6月收治的23例阴茎癌患者的临床资料,年龄40～75岁,平均57岁.病程7d～9年,平均18.6个月.术前临床分期T1期10例,T2期7例,T3期6例.10例腹股沟淋巴结肿大,其中3例有2枚肿大淋巴结.根据腹股沟淋巴结清扫方式将患者分为腹腔镜手术(laparoscopic surgery,LS)组10例和开放式手术(open surgery,OS)组13例,两组患者的年龄、病程、肿瘤分期和淋巴结肿大情况等比较差异均无统计学意义(P＞0.05).比较两组患者的手术时间、术中出血量、术后引流管留置时间、平均住院时间、切除淋巴结数量及并发症等情况. 结果 LS组手术时间(103.6±15.2)min、术中出血量(56.5±6.8)ml、术后引流管留置时间(5.8±0.8)d、住院时间(8.5±1.1)d,OS组手术时间(156.8±18.3) min、术中出血量(88.5±9.5)ml、术后引流管留置时间(12.5±1.3)d、住院时间(15.7±1.9)d,两组比较差异均有统计学意义(P＜0.05).LS组切除淋巴结数量为(9.5±1.3)枚、OS组为(10.3±1.5)枚;LS组病理阳性淋巴结数量为5处6枚,OS组为5处7枚,两组比较差异均无统计学意义(P＞0.05).两组均无输血病例,无败血症等严重并发症发生,无死亡病例.随访12～48个月,OS组出现肺转移1例,其余患者无原位复发及转移. 结论 与开放手术比较,阴茎癌腹腔镜下双侧腹股沟淋巴结清扫术具有术中出血量少、术后恢复快、住院时间短、并发症少等优点,是一项安全有效的手术.     

Nomogram predictive of pathological inguinal lymph node involvement in patients with squamous cell carcinoma of the penis

PURPOSE: In penile cancer the therapeutic benefits of early inguinal lymphadenectomy must be counterbalanced by the high rates of morbidity, postoperative complications and mortality. A relevant aim is optimizing the selection of the patients who could really have the highest survival advantage from inguinal lymphadenectomy, limiting the cases in which this surgery might be considered over treatment with a risk of severe complications. We generated a nomogram estimating the risk of pathological inguinal lymph node involvement according to clinical lymph node stage and pathological findings of the primary tumor. MATERIALS AND METHODS: We retrospectively collected the clinical and pathological data of 175 patients who had undergone surgical therapy for squamous cell carcinoma of the penis from 1980 to 2002 at 11 urological centers in northeastern Italy. A logistic regression model was used to construct the nomogram. RESULTS: The presence of palpable groin lymph nodes and the histological findings of vascular and/or lymphatic embolization were important predictors of metastatic inguinal lymph node involvement. The nomogram predicting the risk of metastatic lymph node involvement showed a good concordance index (0.876) and good calibration. CONCLUSIONS: The clinical stage of groin lymph nodes and pathological findings of penectomy specimens allowed us to generate a nomogram to predict the probability of metastatic lymph node involvement in patients with squamous cell carcinoma of the penis. The statistical model showed an excellent ability to identify the patients with lymph node metastases and good calibration.     

Modified radical inguinal lymphadenectomy for carcinoma of the penis: technique and results

PURPOSE: Modified radical inguinal lymphadenectomy for carcinoma of the penis is presented that satisfies the requirement for complete groin dissection, while significantly decreasing postoperative complications. MATERIALS AND METHODS: Eight patients with squamous cell carcinoma and 2 with leiomyosarcoma of the penis underwent bilateral modified inguinal lymphadenectomy, including removal of the superficial and deep inguinal lymph nodes. To avoid damage to the vessels of the groin region that run parallel to the inguinal ligament and lie in the fat of the superficial layer of the superficial fascia dissection is done beneath this layer. The proper cleavage plane is just above the membranous layer of the superficial fascia, beneath which the superficial inguinal lymph nodes are located. The saphenous vein is preserved and the sartorius muscle is left in situ, so as not to disturb collateral lymphatic drainage. RESULTS: At a followup of 6 to 104 months no skin necrosis, infection or deep venous thrombosis occurred. In 2 patients early moderate lymphedema of the lower extremities resolved with time, 2 had scrotal edema and 3 had a transient lymphocele. CONCLUSIONS: As described, modified radical inguinal lymphadenectomy decreases the morbidity associated with groin dissection, while removing superficial and deep inguinal lymph nodes.     

Primary squamous cell carcinoma of breast with ipsilateral axillary lymph node metastasis: An unusual case

Introduction

Pure squamous cell carcinoma of the breast [SCCB] is rare.

Presentation of Case

We report a case of primary squamous cell carcinoma of breast with ipsilateral axillary lymph node metastasis in a 58year old woman.

Discussion

It is a breast carcinoma entirely composed of metaplastic squamous cells that may be keratinized, non-keratinized or spindled. The pure squamous cell carcinoma usually present with central cystic cavity, which we found in our case, also supported by immunohistochemical evidence.

Conclusion

Although a rare breast cancer subtype, SCCB is of considerable interest due to its pathological heterogeneity and differences in clinical behavior and less reported occurrence of nodal metastasis.     

Renal adenocarcinoma presenting as a groin swelling: a case report

Renal cell carcinoma (RCC) is known to have myriad presentations due to the extremely vascular nature of the organ. RCC are known to metastasize extensively to various organs of the body. We report a case of a 70-years-old male who presented with multiple inguinal lymph node enlargements which on excision biopsy showed metastatic adenocarcinomatous deposit. Search for the primary revealed a RCC arising from the left kidney. Inguinal lymph nodal metastasis, an uncommon site of distant metastasis in renal neoplasm, as a fi rst clinical sign leading to the diagnosis is not yet reported in literature.     

Nomogram predictive of cancer specific survival in patients undergoing partial or total amputation for squamous cell carcinoma of the penis

PURPOSE: We created the first nomograms to predict cancer specific survival probabilities of patients with squamous cell carcinoma of the penis, clustering prognostic information from the most commonly used clinical and pathological variables. MATERIALS AND METHODS: We retrospectively collected clinical and pathological data from 175 patients who had undergone surgery for squamous cell carcinoma of the penis from 1980 to 2002 at 11 urological centers in northeastern Italy. A logistic regression model was used to construct the nomogram. RESULTS: At a median followup of 24 months, 101 patients (57.7%) were alive and disease-free while 74 (42.3%) died of penile cancer. According to multivariate analyses, 2 models predictive of cancer specific survival probability were generated. The first model was based on the pathological findings of the primary tumor after penectomy and on the clinical stage of groin lymph nodes, while the second model included the pathological data of the primary tumor and groin lymph nodes. The concordance index was 0.728 for the first model and 0.747 for the second. Calibration appeared to be good in both models. CONCLUSIONS: In this article we propose 2 models to predict the 5-year cancer specific survival probabilities of patients with squamous cell carcinoma of the penis. Both models showed good discriminating power and calibration in predicting patient 5-year cancer specific survival. These nomograms could improve the quality of prognostic data provided to patients and support physicians in planning treatment.     

Lymph-node metastases in intermediate-risk squamous cell carcinoma of the penis

OBJECTIVE

To evaluate the metastatic risk of pT1 G2 squamous cell carcinoma (SCC) of the penis.

PATIENTS AND METHODS

We retrospectively reviewed 20 patients with pT1 G2 penile SCC and determined their groin status at first presentation, their nodal status after inguinal lymph node dissection and their follow‐up for at least 18 months.

RESULTS

Four of the 20 patients had a clinically positive groin; three of these were found to have lymph node metastases. Among the 16 patients with a clinically negative groin, one of five who had surgical lymph node staging had lymph node metastases. During surveillance six of 11 patients developed lymph node metastases. There was lymphovascular invasion in three of 10 patients with lymph node metastases.

CONCLUSIONS

As the metastatic risk of pT1 G2 penile SCC was 50% in this series of patients, and 44% in those with an initially negative groin, surgical staging of inguinal lymph nodes is recommended in patients with pT1 G2 penile SCC.     

Inguinal lymph node presenting as the delayed site of metastasis in early stage endometrial carcinoma: Case report

IntroductionInguinal lymph nodes are the frequent sites of metastasis for malignant lymphoma, squamous cell carcinoma of anal canal, vulva and penis, malignant melanoma and squamous cell carcinoma of skin over lower extremities or trunk. Anatomically, endometrial carcinoma is less likely to spread to the superficial or deep inguinal lymph nodes, thus metastatic involvement of these lymph nodes can easily be overlooked.Case presentationHere-in we report a case of a 65-year old Saudi morbid obese female, who presented with left inguinal lymphadenopathy as initial delayed site of metastasis almost 19 months after the initial treatment for FIGO IA endometrial carcinoma. Patient underwent left inguinal lymph node dissection. Histopathology confirmed metastatic endometrial adenocarcinoma, positive for cytokeratin (CK-7), estrogen receptor (ER) and progesterone receptors (PR), negative for CK-20 and CDX2. Following the post-surgery recovery, she was given extended field radiation therapy to para-aortic, pelvis and bilateral inguinal lymph nodes with concurrent cisplatin chemotherapy followed by high dose rate brachytherapy.ConclusionInguinal lymph nodes as delayed site of metastasis in early endometrial carcinoma is extremely rare entity. Incorporation of FDG-PET during the preoperative screening of inguinal nodes may be helpful. The impact of lymph node dissection and adjuvant radiation therapy on survival needs to be established.     

阴茎癌51例诊治体会

目的探讨阴茎癌有效合理的诊断及治疗方法。方法回顾性分析51例阴茎癌患者的临床资料,其中鳞状细胞癌44例,鳞状上皮乳头状瘤恶变7例。均行手术治疗,其中行单纯肿瘤切除＋包皮环切术2例,阴茎部分切除术36例,阴茎全切＋尿道会阴部造口术13例,行双侧腹股沟淋巴结清扫术11例。结果41例获得随访,行阴茎部分切除术者2年和5年生存率分别为83．3％和76．7％,行阴茎全切除术者2年和5年生存率分别为72．7％和63．6％。结论阴茎癌早期诊断并予以手术为主的治疗对于改善患者预后十分重要,证实有淋巴结转移者应积极行髂腹股沟淋巴结清扫术。     

阴茎癌腹股沟淋巴结转移行术前新辅助化疗的临床疗效分析

目的探讨阴茎癌腹股沟淋巴结转移行术前新辅助化疗的临床疗效。方法回顾性分析2001年至2008年收治的13例接受术前新辅助化疗及手术治疗的阴茎癌腹股沟淋巴结转移病例的临床及随访资料,并进行生存分析。结果阴茎癌淋巴结转移13例,均行以顺铂、博来霉素、甲氨蝶呤为主要方案的术前新辅助化疗,其后11例行阴茎部分切除术+单侧或双侧腹股沟淋巴结清扫术,2例行局部放射治疗。从阴茎癌腹股沟淋巴结转移治疗后开始计算生存率,1例失随访。1、2、5年生存率分别为75.0%(9/12)、66.7%(8/12)和41.7%(5/12)。结论对阴茎癌腹股沟淋巴结转移患者采用新辅助化疗结合手术治疗是一种有效的治疗手段。     

Prognostic evaluation for squamous cell carcinomas of the lower thoracic esophagus treated with three-field lymph node dissection

Objective: The efficacy of esophagectomy with three-field lymph node dissection in surgical treatment for patients with squamous cell carcinomas of the lower thoracic esophagus remains controversial. This report documents the outcomes of this surgical procedure for a large series. Methods: From February 1986 to November 1998, 437 patients with squamous cell carcinomas of the thoracic esophagus underwent transthoracic esophagectomy with three-field lymph node dissection. One hundred and sixteen of these had cancer of the lower thoracic esophagus. To avoid the influence of adjuvant therapy on survival, 20 who also received radiation and/or chemotherapy were excluded, leaving 96 patients who were retrospectively analyzed. Results: The operative morbidity, and 30-day and in-hospital mortality rates were 62, 0, and 3%, respectively. The overall 1-, 3-, and 5-year survival rates were 89, 65, and 59%, with a median survival of 76 months. In those with lymph node metastases (66% of cases), the values were 87, 56, and 48%, as compared with 94, 84, and 79%, respectively (P=0.005) for patients without lymph node metastasis. Factors significantly influencing the overall survival rates were patient age (≥65 vs. <65), clinical N status (cN1 vs. cN0), clinical M status (cM1 vs. cM0), longitudinal tumor length of resected specimen (≥5 vs. <5 cm), pathologic T status (pT3 vs. pT1, 2), pathologic N status (pN1 vs. pN0), lymphatic invasion (positive vs. negative), vascular invasion (positive vs. negative) and intramural metastasis (present vs. absent). Independent prognostic factors for survival determined by multivariate analysis were pathologic T status (P=0.02), pathologic N status (P=0.03), and presence of intramural metastasis (P=0.04). Additional pathologic M1 status, cervical or celiac lymph node metastasis, was without significant influence. Conclusions: Patients with pathologic T3 tumors with both pathologic N1 status and the presence of intramural metastasis in the lower thoracic esophagus had a poor prognosis. Cervical or celiac lymph node metastasis in patients with carcinomas of the lower thoracic esophagus should be distinguished from pathologic M1 status in the UICC-TNM staging system.     

A protocol for performing extended lymph node dissection using primary tumor pathological features for patients treated with radical nephrectomy for clear cell renal cell carcinoma

PURPOSE: We determined the primary pathological features of clear cell renal cell carcinoma that are predictive of positive regional lymph nodes at radical nephrectomy (RN) and developed a protocol for the selective use of extended lymph node dissection. MATERIALS AND METHODS: We studied 1,652 patients who underwent RN for unilateral pM0 sporadic clear cell renal cell carcinoma between 1970 and 2000. A multivariate logistic regression model was used to determine the pathological features of the primary tumor that were associated with positive regional lymph nodes at RN. RESULTS: There were 887 (54%) patients with no positive nodes (pN0), 57 (3%) with 1 positive node (pN1), 11 (1%) with 2 or more positive nodes (pN2) and 697 (42%) who did not have any lymph nodes dissected (pNx). Nuclear grade 3 or 4 (p <0.001), presence of a sarcomatoid component (p <0.001), tumor size 10 cm or greater (p = 0.005), tumor stage pT3 or pT4 (p = 0.017) and histological tumor necrosis (p = 0.051) were significantly associated with positive regional lymph nodes in a multivariate setting. These features can be used to identify candidates for extended lymph node dissection at the time of RN. For example, only 6 (0.6%) of the 1,031 patients with 0 or 1 of these features had positive lymph nodes at RN compared with 62 (10%) of the 621 patients with at least 2 of these features. CONCLUSIONS: The primary tumor pathological features of nuclear grade, sarcomatoid component, tumor size, stage and presence of tumor necrosis can be used to predict patients at the greatest risk for regional lymph node involvement at RN.     

Squamous cell carcinoma of the penis: Predicting nodal metastases by histologic grade, pattern of invasion and clinical examination

With a diagnosis of squamous cell carcinoma of the penis, there is still a significant need to define the tumor criteria that allow the disease to be stratified according to the risk of developing lymph node metastases.The histopathology of the primary tumor in 72 consecutive patients with resected squamous cell carcinoma of the penis was reviewed for this study. Tumor tissue was reviewed for (1) histologic grade, (2) invasion pattern, (3) tumor stage, (4) proportion of poorly differentiated tumor cells, (5) invasion depth, (6) proportion of tumor necrosis, (7) angioinvasion, (8) histologic classification, (9) number of lesions, (10) growth pattern, (11) number of mitoses, (12) degree of keratinization, and (13) clinical groin status.It was found that the presence of inguinal lymph node metastases correlated in descending order of frequency with grade G2/G3, clinically positive groin status, reticular invasion, stage pT2/T3, >50% poorly differentiated tumor cells, depth of invasion, and comedolike tumor necrosis. These results revealed that the risk of inguinal lymph node metastasis in penile carcinoma can be predicted on the basis of 3 major factors: histologic grade, pattern of invasion, and clinical groin status.