Elsevier

Urology

Volume 96, October 2016, Pages 29-34
Urology

Penile Cancer
Predictors of Nodal Upstaging in Clinical Node Negative Patients With Penile Carcinoma: A National Cancer Database Analysis

https://doi.org/10.1016/j.urology.2016.06.033Get rights and content

Objective

To examine the risk factors associated with upstaging at inguinal lymph node dissection (ILND) in men with penile cancer and clinically negative lymph nodes (cN0) using a large US cancer database.

Methods

The National Cancer Data Base was queried from 1998 to 2012 to identify men with penile cancer who underwent ILND and had complete clinical or pathologic node status available. Lymphovascular invasion (LVI) was available after 2010. Multivariate logistic regression evaluated factors (cT stage, grade, LVI) associated with pathologic nodal upstaging in those with cN0 disease. Correlations between clinical and pathologic node status were also calculated with weighted kappa statistics.

Results

Complete clinical and pathologic LN status was available for 875 patients. Of these, 461 (53%) were cN0. Upstaging occurred in 111 (24%). When stratified by low, intermediate, and high-risk groups, the proportion with pathologically positive LNs was 16%, 20%, and 27%, respectively (P = .12). On multivariate analysis, limited to men with LVI data available (N = 206), LVI (odds ratio 3.10, 95% confidence interval 1.39-6.92), but not increasing stage (univariate only) or grade (univariate only), was significantly associated with upstaging at ILND.

Conclusion

In this analysis, of 461 patients with node-negative penile cancer undergoing ILND, upstaging was observed in 24%. LVI was the strongest independent predictor of occult lymph node disease. These findings corroborate the presence of LVI as the significant risk factor for occult micrometastases and suggest a possible improvement in existing risk stratification groupings, with the presence of LVI, regardless of stage or grade, to be considered high-risk disease.

Section snippets

Data Source

The NCDB was utilized and includes patient demographic and socioeconomic variables as well as hospital site-specific factors and referral patterns for oncology. Cancer-specific variables include tumor characteristics, grade, stage, treatment, and vital status at time of last follow-up.19, 20 All staging refers to the AJCC Cancer Staging Handbook, Seventh Edition.21

Study Population

We queried the NCDB from 1998 to 2012 to identify men with penile cancer who underwent ILND and had complete clinical and pathologic

Baseline Demographics

A total of 875 patients who underwent ILND had complete clinical and pathologic LN status available and were included in the analysis (Table 1). The mean and median ages of the population were 61 (standard deviation: 13) and 62 (interquartile range: 52-71), respectively, and were healthy (Charlson-Deyo score of 0) and of white race (85%). The majority of patients who underwent ILND presented with clinical T2 (cT2) disease (42%, N = 347), cN0 (53%, N = 461), and well to moderately differentiated

Discussion

LN status remains the most important prognostic indicator for long-term survival in men with penile carcinoma.13 Predicting LN involvement in patients with nonpalpable LNs (approximately 20%-25% overall4, 5, 6) is important to avoid the potential morbidity of ILND in those at low risk while not omitting surgery in those who will benefit. In our large US cohort, we found that 24% of patients with cN0 disease were upstaged and demonstrate the importance of LVI as the strongest predictor of LN

Conclusion

In this analysis of 461 patients with node-negative penile cancer undergoing ILND, upstaging was observed in 24%. LVI was the strongest independent predictor of occult LN disease. These findings corroborate the presence of LVI as the significant risk factor for occult micrometastases and suggest a possible improvement in existing risk stratification groupings with the presence of LVI, regardless of stage or grade, to be considered high-risk disease.

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    • Cited by (0)

    Financial Disclosure: The authors declare that they have no relevant financial interests.

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