Identifying an optimal lymph node yield for penile squamous cell carcinoma: prognostic impact of surgical dissection.

OBJECTIVE: To evaluate the prognostic impact of lymph node yield (LNY) on survival outcomes for penile squamous cell carcinoma (SCC). PATIENTS AND METHODS: In all, 532 patients who underwent inguinal LN dissection (ILND) across tertiary referral centres from Europe, China, Brazil and North America were retrospectively evaluated. From this cohort, 198 patients received pelvic LND (PLND).We identified threshold values for ILND and PLND using receiver operating characteristic curves. We tested prognostic value of LNY for recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) using the Kaplan-Meir method and Cox proportional hazard regression models. RESULTS: The median (interquartile [IQR]) age was 59 (49-68) years and the median (IQR) follow-up after ILND was 28 (12-68.2) months. Overall, 85% of the patients had bilateral dissections. The median (IQR) number of inguinal LNs removed was 15 (10-22). Of those receiving PLND, The median (IQR) number of LNs was 13 (8-19). A LNY of ≥15 was used for dichotomisation of ILND patients, and a LNY of ≥9 was used in the PLND cohort. Patients with a LNY ≥15 had significantly better 5-year OS vs patients with a LNY <15 (70.1% vs 58.7%). On multivariable analyses, a LNY ≥15 was a predictor of OS (hazard ratio [HR] 0.68, P = 0.029). For cN0 patients, a LNY ≥15 was an independent predictor of RFS (HR 0.52, P = 0.043) and OS (HR 0.53, P = 0.021). In the PLND cohort, a LNY ≥9 was a predictor of RFS (HR 0.53, P = 0.032). CONCLUSIONS: Using one of the largest LND datasets to date, we found LNY to be a significant predictor of outcomes after lymphatic staging for penile SCC. Prospective validation is warranted.

Individualized renal mass biopsy strategy for Chinese patients with different subtypes and necrosis area.

OBJECTIVE: To evaluate the best individualized renal biopsy strategies for Chinese patients with suspected kidney cancer. MATERIALS AND METHODS: From June 2009 to Oct 2010, 100 core biopsy and fine needle aspirations(FNA) have been performed to patients (average age: 62.0 ± 14.2 years) with an indeterminate solid renal mass by computed tomography (CT) scan imaging in-bench. The average tumor size was 4.4 ± 3.5 cm. The core biopsy was performed through a 18 Gauge needle. Frozen sections were obtained intraoperatively in 20 cases. The results were given as malignant, benign, suspect, or nonsignificant. A classification of subtypes of renal cancer might be added by the cytologist. The relationship between enhancing level in CT scan and number of positive biopsy cores rate in renal cancer patients was also analyzed. According to tumor size, two groups were constituted (<4 cm and ≥4 cm). Preoperative subtype and grade were compared with postoperative specimen results. RESULTS: Among these cellular fine needle aspirations, the specificity for malignancy or benignity was 93%. The proportion of nonsignificant samples was the same in tumors <4 cm (38.4%) as in tumors >4 cm (28.8%) (P = 1.000, Fisher's exact test). Central and peripheral renal tumor biopsies were defined by the 2 pathologists as adequate to obtain a diagnosis in 70%-79% and 79%-84% of the cases respectively. The adequacy of central biopsies increases with decreasing tumor size. Cohen's κ coefficient (CKC) for the concordance on biopsy adequacy was 0.87 (very good) for central biopsies and 0.9 (very good) for peripheral biopsies. All adequate renal tumor biopsies allowed the diagnosis of histologic subtype (HS) for both pathologists. CKC for the concordance on the diagnosis of HS was 0.91 (very good). The concordance between HS on renal tumor biopsy and surgical specimen was perfect in all cases. CONCLUSION: According to CT scan information, FNA and core biopsy give useful message accuracy rate. Fine-needle aspiration is complementary to core biopsy, which remains the gold standard of percutaneous sampling. Core renal biopsy can accurately define RCC histologic subtype. However, it does not seem to be able to detect high grade tumors. Tumor size does not seem to influence these results.

Frozen section-guided wide local excision in the treatment of penoscrotal extramammary Paget's disease.

OBJECTIVE: To analyse the clinicopathological characteristics of penoscrotal extramammary Paget's disease (EMPD) and to discuss the outcomes after frozen section-guided wide local excision. PATIENTS AND METHODS: From 1990 to 2005, at our institution, 38 patients with penoscrotal EMPD received wide local excision with intraoperative frozen-section analysis. Their medical records were reviewed for patient demographics, lesion characteristics, surgical margin status, and clinical outcome. RESULTS: No patients had EMPD secondary to a non-cutaneous malignancy; 23 patients had intraepithelial EMPD, 12 had invasive EMPD and three had EMPD with underlying adnexal adenocarcinoma. The median (range) largest diameter of the lesion was 6 (1-20) cm. Of 38 patients, 12 (32%) had positive frozen-section results and had extended surgical excision until a negative margin was obtained. Additional margin examination of the gross specimen and final examination of the frozen sections showed that five patients had false-negative results. There was a microscopic positive margin in 15 of 38 (40%) patients when a conventional 2 cm clinical tumour-free border was maintained. Skin erythematous patches were significantly correlated with the spread of disease (P = 0.03). After a median (range) follow-up of 33.5 (3-140) months, six of 38 (16%) patients had recurrent disease, of whom only two had recurrent skin lesions, while four had systemic progression. CONCLUSION: Frozen section-guided wide local excision gave an acceptable recurrence rate in the treatment of penoscrotal EMPD. Primary EMPD with dermal invasion should be actively monitored for possible aggressive behaviour.

The prognostic significance of p53, Ki-67, epithelial cadherin and matrix metalloproteinase-9 in penile squamous cell carcinoma treated with surgery.

OBJECTIVE: To evaluate the prognostic significance of p53, Ki-67, epithelial cadherin (E-cadherin) and matrix metalloproteinase-9 in primary penile cancer, as the presence of lymph node metastasis and long-term survival are hard to define in penile squamous cell carcinoma. PATIENTS AND METHODS: Paraffin-embedded primary tumour samples were obtained from 73 Chinese patients who had penile amputation and regional lymphadenectomy. The expression of molecular markers was determined by immunohistochemistry. Logistic regression was used to identify factors associated with lymph node metastasis, and a Cox proportional-hazards model was used to measure cancer-specific survival (CSS). RESULTS: Thirty (41%) patients presented with nodal disease and the 3-year CSS rate for all patients was 72%. Lymph node metastasis was significantly correlated with tumour stage, histological grade, lymphatic and vascular embolization, and the expression of p53, Ki-67 and E-cadherin. By multivariate analysis, tumour embolization and the expression of p53 were independent predictors of metastasis. Survival analysis showed that the expression of p53 was an independent prognostic factor for CSS. In stage T1 tumours, high expression of p53 was significantly associated with metastasis and poor survival. CONCLUSION: Lymphatic and vascular embolization, and p53 immunoreactivity, are helpful in establishing the probability of lymph node metastasis. The expression of p53 is an independent predictor of CSS in Chinese patients with penile cancer. In stage T1 tumours, p53 staining is an important variable determining the prognosis and treatment outcome.