Local staging with multiparametric MRI in daily clinical practice: diagnostic accuracy and evaluation of a radiologic learning curve.

PURPOSE: To estimate the diagnostic accuracy of multiparametric MRI (mpMRI) for the detection of locally advanced prostate cancer (T-stage 3-4) prior to radical prostatectomy, in a multicenter cohort representing daily clinical practice. In addition, the radiologic learning curve for the detection of locally advanced disease is evaluated. METHODS: Preoperative mpMRI findings of 430 patients (2012-2016) were compared to pathology results following radical prostatectomy. The diagnostic accuracy (sensitivity, specificity, PPV, and NPV) for the detection of locally advanced disease was calculated and compared for all years separately, to evaluate the presence of a radiological learning curve. RESULTS: Of all 137 patients with locally advanced disease, 62 patients were preoperatively detected with mpMRI [sensitivity 45.3% (95% CI 36.9-53.6%), specificity 75.8% (CI 70.9-80.7%), PPV 46.6% (CI 38.1-55.1%), and NPV 74.7% (CI 69.8-79.7%)]. The diagnostic accuracy did not improve significantly over time (sensitivity p = 0.12; specificity p = 0.57). CONCLUSIONS: In daily clinical practice, the diagnostic accuracy of mpMRI for the detection of locally advanced prostate cancer remains limited. It, therefore, seems questionable whether mpMRI is adequate to guide preoperative decision-making. No significant radiologic learning curve for the detection of locally advance disease was observed.

Penis conserving treatment for T1 and T2 penile carcinoma: clinical implications of a local recurrence.

PURPOSE: We evaluated our experience with primary tumor treatment for T1 and T2 penile squamous cell carcinoma and discussed the clinical implications of a local recurrence. MATERIALS AND METHODS: The primary tumor treatment and clinical course of 257 patients with T1 or T2 penile carcinoma were evaluated. Primary tumor treatment consisted of penis preservation in 157 and (partial) amputation in 100 patients. Median followup was 106 months (range 16 to 541). RESULTS: The 5-year local recurrence-free estimate after penis preservation was similar for T1 and T2 tumors (log rank test p = 0.1) and overall 63% (CI: 54%-72%) compared to 88% (CI: 81%-95%) for partial amputation (log rank test p = 0.0003). In case of a local recurrence after penis preserving treatment, local control could be achieved in 94% (51 of 54) of cases. Of patients with T1 tumors treated with penis preservation, regional recurrence developed in 33% (7 of 21) of patients with local recurrence compared to only 6% (3 of 47) of patients without local recurrences (Fisher's exact test p = 0.005). Of the patients with T2 tumors treated with penis preservation, regional recurrence developed in 27% (9 of 33) of patients with local recurrence compared to 27% (12 of 45) of patients without local recurrence (chi-square test p = 0.96). Of 10 patients with a local recurrence after partial amputation of the penis, 9 died of disease. CONCLUSIONS: The incidence of local recurrence increases with penis preservation but can be treated accurately in most cases. Local recurrences can signify lymphatic regional spread. A local recurrence after penile amputation carries a poor prognosis.

[The aortocaval fistula, a rare complication of an aneurysm of the abdominal aorta]. / De aortocavale fistel, een zeldzame complicatie van een aneurysma van de abdominale aorta.

Four patients, 3 men aged 73, 60 and 81 years with hemodynamic instability and 1 man aged 80 with abdominal symptoms and breathlessness appeared to have an arteriovenous fistula secondary to spontaneous rupture of an atherosclerotic aneurysm: between the aorta and the V. cava inferior or between the A. and the left V. iliaca communis. One patient died, one patient had postoperative decompensatio cordis, one suffered a deep vein thrombosis and the 4th recovered without symptoms. The presence of an aortocaval fistula has to be considered in patients with a symptomatic abdominal aneurysm with a harsh bruit heard over the abdomen, signs of high venous pressure and peripheral hypoperfusion. When no rupture of the aneurysm is found at laparotomy in symptomatic patients, the presence of a fistula is rare, but has to be considered. Furthermore, a fistula can be the underlying cause of therapy-resistant heart failure or acute renal dysfunction. Pre-operative identification can lead to decrease of morbidity and mortality of the phenomenon.

Morbidity of dynamic sentinel node biopsy in penile carcinoma.

PURPOSE: We report on the morbidity of dynamic sentinel lymph node biopsy (DSNB) in penile squamous cell carcinoma (SCC). MATERIALS AND METHODS: Between 1994 and 2003 DSNB was performed in 129 patients with T2 or T3 penile SCC who had 243 clinically node negative groins. Patients with groins with a tumor positive sentinel node underwent additional standard inguinal lymphadenectomy. RESULTS: A total of 285 sentinel nodes were harvested in 223 explored groins. The sentinel nodes were tumor-free in 189 groins. A total of 34 standard inguinal lymphadenectomies were performed because of a tumor positive sentinel node. There were 6 regional relapses during a median followup of 50 months (range 5 to 124) resulting in a false-negative rate of 15% (6 of 40 groins). This rate was 17% when calculated per patient (6 of 35 patients). Early and/or late complications following DSNB only occurred in 7% (14 of 189) of the groins. After DSNB followed by a standard inguinal lymphadenectomy, the rate was 68% (23 of 34). All complications of DSNB were minor and easily managed. CONCLUSIONS: Morbidity of DSNB in penile SCC is low. However, an in field recurrence after a negative DSNB is perhaps the greatest complication of the procedure.

Patients with penile carcinoma benefit from immediate resection of clinically occult lymph node metastases.

PURPOSE: In this retrospective study we compared the clinical outcome of early vs delayed excision of lymph node metastases in patients with penile squamous cell carcinoma. MATERIALS AND METHODS: A total of 40 patients with a T2-3 penile carcinoma with lymph node metastases were included in this study. All patients initially presented with bilateral impalpable lymph nodes. In 20 patients (50%) metastases were removed when they became clinically apparent during meticulous followup (median interval 6 months, range 1 to 24). There were 20 patients (50%) who underwent resection of inguinal metastases detected on dynamic sentinel node biopsy before they became palpable. The histopathological characteristics of the tumors and lymph nodes were reevaluated. RESULTS: The 2 populations were similar in terms of patient age, T-stage, pathological tumor grade, vascular invasion and infiltration depth. Disease specific 3-year survival of patients with positive lymph nodes detected during surveillance was 35% and in those who underwent early resection, 84% (log rank p = 0.0017). In multivariate analysis early resection of occult inguinal metastases detected on dynamic sentinel node biopsy was an independent prognostic factor for disease specific survival (p = 0.006). CONCLUSIONS: Early resection of lymph node metastases in patients with penile carcinoma improves survival.

Sarcomatoid squamous cell carcinoma of the penis: a clinical and pathological study of 5 cases.

PURPOSE: We analyzed clinical, morphological and immunohistochemical features in 5 cases of sarcomatoid or spindle cell squamous cell carcinoma of the penis. MATERIALS AND METHODS: The clinical and pathological files of all patients with penile carcinoma treated at our hospital between 1956 and 2002 were reviewed. Cases diagnosed as sarcomatoid squamous cell cancer were selected. RESULTS: Five of 341 patients (1.4%) had sarcomatoid penile carcinoma. Tumor stage was T2N0 in 2 patients, T2N2 in 2 and T4N3 in 1. In all patients partial or total penectomy was eventually performed. Three patients underwent bilateral inguinal lymphadenectomy. Four of 5 patients had distant metastatic disease and died within 1 year after diagnosis. One patient had exclusive hematogenous spread without lymph node involvement. Foci of distant metastatic tumor sites were the lung, skin, bone, pericardium and pleura. In 4 patients the diagnosis was based on the expression of keratin filaments in a predominantly spindle cell penile tumor or by the identification of carcinomatous and sarcomatoid areas on hematoxylin and eosin stained slides of the primary tumor. In 1 case a squamous component in a lymph node metastasis rendered the keratin negative spindle cell primary tumor sarcomatoid squamous cell carcinoma. CONCLUSIONS: Sarcomatoid squamous cell carcinoma of the penis is a subtype of squamous cell carcinoma with a poor prognosis often associated with wide hematogeneous spread. It is a rare malignancy that is often difficult to diagnose, requiring additional immunohistochemical stains.

How to avoid false-negative dynamic sentinel node procedures in penile carcinoma.

PURPOSE: Evaluation of the false-negative dynamic sentinel node procedures in penile carcinoma at our institute. MATERIALS AND METHODS: Between January 1994 and February 2003, 123 patients with penile squamous cell carcinoma underwent dynamic sentinel node biopsy. RESULTS: The sentinel node revealed metastasis in 28 (23%) of 123 patients. Regional recurrence after excision of a tumor-negative sentinel node or after nonvisualization was seen in 6 patients resulting in a false-negative rate of 18% (6 of 34). We assume that 1 false-negative case was due to tumor blockage, 3 to tumor blockage and rerouting, 1 to a pathological sampling error and 1 to a low radioactivity level in the sentinel node during surgery. CONCLUSIONS: Based on the false-negative results, important adaptations have been made in the dynamic sentinel node biopsy procedure for penile carcinoma at our institute. Pathological analysis was extended by serial sectioning and immunohistochemical staining, and preoperative ultrasonography with fine needle aspiration cytology has been added. Furthermore, exploration of groin without visualized sentinel nodes and intraoperative palpation of the wound have been introduced.

Management of clinically node negative penile carcinoma: improved survival after the introduction of dynamic sentinel node biopsy.

PURPOSE: We evaluated the clinical outcome of clinically node negative penile carcinoma managed by surveillance or further diagnosed by dynamic sentinel node biopsy with subsequent resection of lymph node metastases. MATERIALS AND METHODS: From 1956 to 1994, 85 patients with primary T2-3N0M0 penile squamous cell carcinoma were treated with initial surveillance of the regional lymph nodes. From 1994 until 2001, 68 patients underwent dynamic sentinel node biopsy. RESULTS: The 2 populations were similar in terms of patient age, clinical T stage, tumor grade, vascular invasion and infiltration depth. Disease specific 3-year survival in the surveillance and sentinel node groups was 79% and 91%, respectively (log rank test p = 0.04). CONCLUSIONS: Early detection of lymph node metastases by dynamic sentinel node biopsy and subsequent resection in clinically node negative T2-3 penile carcinoma improves survival compared with a policy of surveillance.

A comparison of physical examination and imaging in determining the extent of primary penile carcinoma.

OBJECTIVE: To determine the accuracy of physical examination and imaging in assessing the extent of the primary tumour in squamous cell carcinoma of the penis. PATIENTS AND METHODS: A physical examination, ultrasonography and magnetic resonance imaging (MRI) were used before surgery in 33 patients with penile carcinoma. The tumour size, infiltration of the penile structures and infiltration depth were assessed. The results were compared with the histopathological examination of the resected specimen. RESULTS: Tumour size was determined with the highest precision by the physical examination (residual sd of 8.1 mm); ultrasonography and MRI were less precise (residual sd 8.9 mm and 9.3 mm). In assessing infiltration depth, ultrasonography and MRI had comparable precision (residual sd 3.7 mm and 3.8 mm). The positive predictive value of corpus cavernosum infiltration was 6/6 for physical examination, 4/6 for ultrasonography and 6/8 for MRI; the sensitivity was 6/7, 4/7 and 6/6, respectively. CONCLUSION: Physical examination is a reliable method for estimating penile tumour size and predicts corpus cavernosum infiltration with a high positive predictive value. Tumours for which the infiltration of the corpora cannot be determined properly by physical palpation only should be examined by imaging.

Dynamic sentinel node biopsy for penile cancer: reliability of a staging technique.

PURPOSE: We determine the value of dynamic sentinel node biopsy for staging squamous cell carcinoma of the penis. MATERIALS AND METHODS: A total of 90 patients with clinically node negative penile cancer were prospectively entered in this study. Preoperative lymphoscintigraphy was performed after intradermal injection of 99mtechnetium nanocolloid around the primary tumor. The sentinel node was intraoperatively identified with the aid of intradermal administered patent blue dye and a gamma ray detection probe. Histopathological examination of sentinel nodes included serial sectioning and immunohistochemical staining. Regional lymph node dissection was performed only if metastasis was found in a sentinel node. Median followup was 36 months (range 5 to 95). RESULTS: Lymphoscintigraphy visualized 217 sentinel nodes in 159 inguinal regions of 88 patients. A total of 208 sentinel nodes were intraoperatively identified in 149 inguinal regions of 88 patients. Sentinel node metastasis was found in 19 inguinal regions of 18 patients. Four of 8 patients with unilateral clinical stage N1 disease had a tumor positive sentinel node on the opposite site. Regional recurrence after excision of a tumor negative sentinel node or after nonvisualization was seen in 5 patients, resulting in a false-negative rate of 22% (5 of 23). The 3-year disease specific survival was 98% and 71% for patients with a tumor negative or tumor positive sentinel node, respectively (p = 0.0018). CONCLUSIONS: Occult lymph node metastases in penile cancer can be detected with a sensitivity of about 80% by dynamic sentinel node biopsy, including preoperative lymphoscintigraphy, vital dye and a gamma ray detection probe.