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Guidelines

Penile Cancer

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  1. Introduction
  2. Methods
  3. Epidemiology Aetiology And Pathology
  4. Staging And Classification Systems
  5. Diagnostic Evaluation And Staging
  6. Disease Management
  7. Follow Up
  8. References
  9. Conflict Of Interest
  10. Citation Information
  11. Copyright And Terms Of Use
4. Staging And Classification Systems
  • 1. Introduction
  • 2. Methods
  • 3. Epidemiology Aetiology And Pathology
  • 4. Staging And Classification Systems
  • 5. Diagnostic Evaluation And Staging
  • 6. Disease Management
  • 7. Follow Up
  • 8. References
  • 9. Conflict Of Interest
  • 10. Citation Information
  • 11. Copyright And Terms Of Use
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4. STAGING AND CLASSIFICATION SYSTEMS

4.1. TNM classification

The 8th edition of the UICC/AJCC TNM is the currently used classification system for penile cancer which was last updated in 2017 [73,83] Compared to the previous (7th) edition, some changes were introduced. The T1 category is stratified into two different risk groups depending on the absence or presence of lymphovascular invasion, perineural invasion, or poor differentiation (T1a vs. T1b, respectively, see Table 4.1) [84]. Furthermore, invasion into the urethra was previously classified as T3 disease. However, a tumour near the meatus may directly invade into the distal urethra through the corpus spongiosum, which is not associated with worse outcome. In addition, previous studies have shown that corpus spongiosum invasion is associated with a lower incidence of inguinal LN metastasis and has better survival compared to corpus cavernosum invasion. Therefore, invasion into the corpus spongiosum and corpus cavernosum is classified into T2 and T3, respectively [85,86]. Patients with T4 tumours have extension into adjacent tissues (e.g., prepubic fat, scrotum, spermatic cord, pubic bone, prostate).

The pN1 category was modified to include up to two unilateral inguinal LN metastases, while the pN2 category was modified to be three or more unilateral, or any bilateral LN metastases. This was based on data showing poor outcomes in cases involving three or more unilateral or bilateral LNs compared with those involving one or two unilateral LNs [86,87]. pN3 stage is defined as pelvic nodes (uni- or bilateral) or presence of extranodal extension (ENE) (inguinal or pelvic, regardless of the number of LN metastases) [73,83]. Further retroperitoneal LN spread cranial to the pelvic template is classified as extra-regional and therefore as distant metastases.

Table 4.1: UICC/AJCC 8th edition TNM clinical and pathological classification of penile cancer [73,83]

Clinical classification

T - Primary Tumour

TX

Primary tumour cannot be assessed

T0

No evidence of primary tumour

Tis

Carcinoma in situ (Penile Intraepithelial Neoplasia – PeIN)

Ta

Non-invasive verrucous carcinoma*

T1

Tumour invades subepithelial connective tissue


T1a

Tumour invades subepithelial connective tissue without lymphovascular invasion or perineural invasion and is not poorly differentiated


T1b

Tumour invades subepithelial connective tissue with lymphovascular invasion or perineural invasion or is poorly differentiated

T2

Tumour invades corpus spongiosum with or without invasion of the urethra

T3

Tumour invades corpus cavernosum with or without invasion of the urethra

T4

Tumour invades other adjacent structures

N - Regional Lymph Nodes

cNX

Regional lymph nodes cannot be assessed

cN0

No palpable or visibly enlarged inguinal lymph nodes

cN1

Palpable mobile unilateral inguinal lymph node

cN2

Palpable mobile multiple or bilateral inguinal lymph nodes

cN3

Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or bilateral

M - Distant Metastasis

cM0

No distant metastasis

cM1

Distant metastasis

Pathological classification

The pT categories correspond to the clinical T categories.

The pN categories are based upon biopsy or surgical excision

pN - Regional Lymph Nodes

pNX

Regional lymph nodes cannot be assessed

pN0

No regional lymph node metastasis

pN1

Metastasis in one or two inguinal lymph nodes

pN2

Metastasis in more than two unilateral inguinal nodes or bilateral inguinal lymph nodes

pN3

Metastasis in pelvic lymph node(s), unilateral or bilateral or extranodal extension of regional lymph node metastasis

pM - Distant Metastasis

pM1

Distant metastasis microscopically confirmed

G - Histopathological Grading

GX

Grade of differentiation cannot be assessed

G1

Well differentiated

G2

Moderately differentiated

G3

G4

Poorly differentiated

Undifferentiated

*Including verrucous carcinoma.

4.2. Cancer stage grouping

In the UICC TNM 8th edition, stage II was newly subdivided into Stage IIA and Stage IIB based on T categories. Stage IIA is defined as T1b–2N0M0, while Stage IIB is defined as T3N0M0 [73] (Table 4.2).

Table 4.2 UICC TNM Stage/Prognostic Groups 

Stage

T

N

M

0

Tis

N0

M0

Ta

N0

M0

I

T1a

N0

M0

IIA

T1b

N0

M0

T2

N0

M0

IIB

T3

N0

M0

IIIA

T1–3

N1

M0

IIIB

T1–3

N2

M0

IV

T4

Any N

M0

Any T

N3

M0

Any T

Any N

M1

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