Inguinal Lymph node dissection (ILND) is an important component in the management of penile cancer for accurate staging and prognostication.(1) This article summarizes the current status of ILND in cancer penis, focusing on recent advances and guidelines.
Rationale for LND: The most important prognostic factor in penile cancer is lymph node status.(1) The occult metastasis occurs in 25-30% of patients even in clinically node-negative (cN0) cases, which significantly impacts survival. In intermediate- and high-risk patients.(2) The elective ILND offers better survival outcomes than delayed dissection.(1,2)
Risk stratification and LND indications: Risk-adapted strategy is indicated with observation for low-risk patients, sentinel node biopsy for intermediate-risk patients, and LND for high-risk cases as shown in table 1 and figure 2.
Role of Sentinel Lymph Node Biopsy (SLNB): SLNB offers a minimally invasive alternative to ILND for cN0 patients and also limits morbidity while maintaining accuracy in identifying nodal involvement. However, it requires expertise and is not universally available.(3)
Extent of LND: In penile cancer, superficial inguinal LND is often performed initially, and deep inguinal or pelvic LND is considered if superficial nodes are positive.(2,4) Bilateral LND is typically recommended when unilateral lymph nodes are involved, as there’s a risk of contralateral metastasis.(2,4)
Minimizing Morbidity: Standard ILND offers superior oncological clearance, with no groin recurrences, but at the cost of higher wound-related complications in comparison to modified ILND.(4) Video Endoscopic Inguinal Lymphadenectomy (VEIL) and Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL) have emerged as alternatives to open ILND, offering reduced morbidity (e.g., lower rates of wound infection, lymphedema, and skin necrosis) while maintaining equivalent oncological outcomes.(4,5)
Challenges:
Surgeon Expertise: Better results are reported from specialized and high volume centers with expertise in penile cancer treatment.(5,6)
Patient Selection: The challenge lies in determining which cN0 patients should undergo ILND, as the procedure is associated with significant morbidity but is beneficial for long-term survival.(6)
Conclusion: ILND remains a cornerstone in the appropriate management of penile cancer. The careful selection of patient and adequate expertise are key factors in optimizing outcomes. SLNB and minimally invasive procedures aims to provide equivalent oncological control while minimizing morbidity.
Table 1: Risk stratification and indications of LND
Risk group | Tumor characteristics | LND approach |
Low-risk | Tis, Ta, T1a, low grade | Active surveillance or SLNB if follow-up is difficult |
Intermediate-risk | T1b, higher grade | SLNB or early ILND |
High-risk | T2 or higher, node positive | Immediate bilateral ILND with pelvic LND if inguinal nodes are positive or Neoadjuvant chemotherapy in patients with bulky nodal disease |
Figure 2: Management algorithm
Authored by Dr Mahendra Singh, AIIMS, Jodhpur