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LETTER TO EDITOR
Year : 2010  |  Volume : 47  |  Issue : 3  |  Page : 352
 

Does delay in lymphadenectomy alone influence the survival in carcinoma penis?


Department of Surgical Oncology, Cancer Institute (WIA), Annexe Campus, No.18, Sardar Patel road, Guindy, Chennai - 600 036, India

Date of Web Publication28-Jun-2010

Correspondence Address:
A S Ramakrishnan
Department of Surgical Oncology, Cancer Institute (WIA), Annexe Campus, No.18, Sardar Patel road, Guindy, Chennai - 600 036
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.64714

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How to cite this article:
Ramakrishnan A S, Kathiresan N. Does delay in lymphadenectomy alone influence the survival in carcinoma penis?. Indian J Cancer 2010;47:352

How to cite this URL:
Ramakrishnan A S, Kathiresan N. Does delay in lymphadenectomy alone influence the survival in carcinoma penis?. Indian J Cancer [serial online] 2010 [cited 2019 Dec 8];47:352. Available from: http://www.indianjcancer.com/text.asp?2010/47/3/352/64714


Sir,

The article "Impact of delay in inguinal lymph node dissection in patients with carcinoma of penis" by Gulia et al.[1] raises several questions. First, the authors have not specified if the delayed dissection was done with a therapeutic or prophylactic intent. Because 17 of their patients had palpable nodes, which is associated with a high incidence of pathological node- positive disease, [2] we presume that their intent was therapeutic. If that is the case, it is only natural that a delay in therapy has led to a poor survival.

Second, only 13 patients underwent pelvic nodal dissection. How many patients in each group underwent a pelvic dissection and why were the remaining 10 patients not offered a pelvic dissection?

Third, it is evident that in group 1, although 9 patients had palpable nodes, only 5 had pathologically positive nodes. Could this high false-positive rate of clinically palpable nodes be attributed to an inflammatory enlargement of the nodes due to an ulcerated, infected primary tumor? The authors have not attempted cytologic confirmation of nodal disease before surgery. In a large series of nodal dissection for patients with cytologically proven or clinically highly suspicious nodal disease, Pandey et al [3] reported pathologically negative nodes in only 20% of the patients. The question, therefore, is did early lymphadenectomy result in increase in unnecessary surgeries and did the high false-positive rate influence the survival?

Fourth, although it is generally believed that many patients in India never attend follow-up, our experience is different. We practice an active follow-up strategy in our institution and in our recent series of clinically node-negative penile cancers, only less than 8 out of 200 patients defaulted follow-up. [4]

Finally, it has been well documented in large studies of penile cancer from India that factors, such as nodal metastasis, number of involved inguinal nodes, bilateral nodal metastasis, presence of pelvic nodal metastasis, extranodal extension, and fixed nodes independently influence survival. [3],[5] In the series of Gulia et al, [1] the percentage of patients who had pathologically positive nodes and extracapsular extension was more in group 2 than in group 1, which by itself could have resulted in a poor survival rather than just a delay in lymphadenectomy. We understand that a multivariate analysis may not have been feasible in a small series, but these factors should have been accounted for in the discussion.

 
  References Top

1.Gulia AK, Mandhani A, Muruganandham K, Kapoor R, Ansari MS, Srivastava A. Impact of delay in inguinal lymph node dissection in patients with carcinoma of penis. Indian J Cancer 2009;46:214-8.  Back to cited text no. 1  [PUBMED]  Medknow Journal  
2.Hegarty PK, Kayes O, Freeman A, Christopher N, Ralph DJ, Minhas S. A prospective study of 100 cases of penile cancer managed according to European Association of Urology guidelines. BJU Int 2006;98:526-31.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Pandey D, Mahajan V, Kannan RR. Prognostic factors in node-positive carcinoma of the penis. J Surg Oncol 2006;93:133-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Ramkumar A, Seshadri RA, Narayanaswamy K, Balasubramanian S. Risk factors for lymph node metastasis in clinically node-negative penile cancer patients. Int J Urol 2009;16:383-6.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Kamat MR, Kulkarni JN, Tongaonkar HB. Carcinoma of the penis: The Indian experience. J Surg Oncol 1993;52:50-5.  Back to cited text no. 5  [PUBMED]    



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