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468 Indian J Urol, Jul-Sept 2010, Vol 26, Issue 3

2009;83:55-9.

5. Hahn RG. Influence of the fluid balance on the cortisol and glucose

responses to transurethral prostatic surgery. Acta Anaesthesiol Scand

1989;33:638-41.

6. Kagansky N, Levy S, Knobler H. The role of hyperglycemia in acute

stroke. Arch Neurol 2001;58:1209-12.

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Shortcomings of current TNM classification of carcinoma penisDharamveer Singh, Pawan Vasudeva, Satyanarayan Sankhwar

Department of Urology, C.S.M.M.U (Upgraded King George’s Medical College), Lucknow, Uttar Pradesh, India.

E-mail: [email protected]

Leijte JA, Gallee M, Antonini N, Horenblas S. Evaluation of current TNM classification of penile carcinoma. J Urol. 2008;180:933-8

SUMMARY

The authors in this study have assessed the prognostic valueof the currently followed TNM classification of carcinomapenis, which has remained unchanged since 1987.

From 1956 to January 2006, 513 patients with biopsy-proven penile squamous cell carcinoma for whom a follow-up of at least 3 months was available and none of themhad received neoadjuvant chemotherapy were includedin this retrospective study. All tumors were restagedaccording to the currently followed TNM classification.

Most Tis, Ta, and T1 tumors had been treated with penile-sparing methods, those with T2 tumors <2 cm generallyunderwent penis conserving surgery, while those with

larger T2 tumors had undergone partial penectomy.All T3/T4 tumors had been treated with partial/total

penectomy. For a histologically proven tumor-positivegroin, inguinal lymph node dissection had been done andif two or more positive inguinal lymph nodes were present,then ipsilateral pelvic lymph node dissection was alsodone. For extracapsular disease or tumor-positive pelvic

lymph nodes, adjuvant radiotherapy was administered.For clinically node-negative disease, nodal status was notknown for a number of patients with Tis, Ta, and T1 andeven a minority with T2G1 and T2G2 prior to 1994 as nodalsurgery had not been performed due to presumed low risk

of positive nodes, that is, policy of watchful waiting hadbeen employed. After 1994, node-negative patients withT1G3 or greater disease underwent sentinel node biopsy.

Median age at diagnosis was 65 years, median follow-up

was 58.7 months, and 5-year disease-specific survival was80.5%. Tumor grade and angioinvasion were significantpredictors of survival (P < 0.001). No significant differencein survival was found between the pTis/Ta and pT1categories (P = 0.063) as well as between the pT2 and

pT3 groups (P = 0.568), while it differed significantly

among all other pT categories. No significant difference in

survival was found between the pN1 and pN2 groups (P

= 0.176). Survival among the other pN categories differedsignificantly. The best prognostic stratification in the Ncategory was realized by involving the laterality and fixityof inguinal lymph node involvement.

COMMENTS

The TNM classification of malignant tumors is the mostwidely used tool for staging various malignancies. Since1987, the TNM classification for penile carcinoma hasremained unchanged and it has several shortcomings, sothere is need to further improve its prognostic stratificationand clinical usefulness.

Based on their analysis, the authors have proposed thefollowing changes to the current TNM classification for penile cancer in an attempt to improve stage prognosticationand facilitate clinical staging.1. The authors have proposed that current T2 stage, that

is, tumor involvement of the corpus-spongiosum and/or

cavernosal bodies, be revised and be limited to tumorswith corpus-spongiosum involvement. They propose thattumors with cavernosal involvement be staged as T3.The authors have tried to emphasize upon theimportance of corpus-cavernosum involvement in penile

cancer. That such involvement increases risk of nodalmetastasis and has a negative impact on survival hasbeen documented in earlier studies.[1–3] The biological

rationale for poorer prognosis may be that a tumor whichis able to break through the relatively thick tunica-albuginea covering the cavernous bodies is likely to bean aggressive tumor.

2. Current T3 stage, that is, tumors with urethral/prostaticinvolvement be modified as mentioned earlier. Tumorsinvolving the prostate should be downstaged to T4,

which in the current TNM comprise of tumors directly



Indian J Urol, Jul-Sept 2010, Vol 26, Issue 3 469

invading into adjacent structures. This suggestion isbased on the author’s study finding that ingrowth intothe prostate always occurred in combination withingrowth in other adjacent structures. The authorspropose that urethral involvement should not be takeninto account while staging penile carcinoma.

3. Changes in nodal classification were also suggested based

on:(a) Accurate nodal staging is dif ficult because of theinability of clinical/imaging techniques to readilydifferentiate between super ficial and deep inguinalnodes.

(b) The current nodal staging does not incorporatelymph node laterality, fixity/extracapsular nodalgrowth; however, the lymph node factors influencingsurvival adversely, for example, bilateral nodalmetastases, number of positive inguinal nodes, pelvicnodal metastasis, and extranodal extension, havebeen reported in previous studies.[4,5]

The authors have proposed N1 category as unilateralinguinal node involvement, N2 as bilateral inguinal nodeinvolvement, and N3 as pelvic lymph node involvement or a fixed inguinal node.

Although the suggestions are thought-provoking, whether these modifications can form the basis of a revised TNM

classification is something that would need more studiesfor clarification.

REFERENCES

1. Soria JC, Fizazi K, Piron D, Kramar A, Gerbaulet A, Haie-Meder C,et al. Squamous cell carcinoma of the penis: Multivariate analysis of

prognostic factors and natural history in monocentric study with a

conservative policy. Ann Oncol 1997;8:1089-98.

2. Emerson RE, Ulbright TM, Eble JN, Geary WA, Eckert GJ, Cheng L.

Predicting cancer progression in patients with penile squamous cell

carcinoma: The importance of depth of invasion and vascular invasion.

Mod Pathol 2001;14:963-8.

3. Slaton JW, Morgenstern N, Levy DA, Santos MW Jr, Tamboli P, Ro

JY, et al. Tumor stage, vascular invasion and the percentage of

poorly differentiated cancer: Independent prognosticators for

inguinal lymph node metastasis in penile squamous cancer. J Urol

2001;165:1138-42.

4. Pandey D, Mahajan V, Kannan RR. Prognostic factors in node-positive

carcinoma of the penis. J Surg Oncol 2006;93:133-8.

5. Lont AP, Kroon BK, Gallee MP, van Tinteren H, Moonen LM, Horenblas

S. Pelvic lymph node dissection for penile carcinoma: Extent of

inguinal lymph node involvement as an indicator for pelvic lymph node

involvement and survival. J Urol 2007;177:947-52.

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FORTHCOMING EVENTSFORTHCOMING EVENTS

7th Men’s Health World Congress • 3rd European Men’s Health Conference

28th – 30th October 2010 – Nice, France

More information: www.ismh.org/worldcongress

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