Penis and scrotum - Staging of penile carcinoma

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Penis and scrotum

Staging of penile carcinoma

Editors: Antonio Cubilla, M.D., and Alcides Chaux , M.D. (see Authors page)

Revised: 6 January 2010, last major update January 2010

Notes

● Excludes melanomas (staged with skin tumors), sarcomas (staged with soft tissue tumors)

● Staging is based on AJCC 7th edition (Edge: AJCC Cancer Staging Manual 2009)

Jackson classification

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● Used prior to AJCC’s TNM system (Br J Surg 1966;53:33)

● Does not use characteristics of the primary lesion such as size and confinement to the epidermis (superficial or invasive)

● Does not use histologic features

● Stage I (A): Tumor is confined to glans, prepuce or both

● Stage II (B): Tumor extends onto shaft of penis; no nodal or distant metastases

● Stage III (C): Tumor has inguinal nodal metastases that are operable

● Stage IV (D): Tumor involves adjacent structures and is associated with inoperable inguinal metastasis or distant metastasis

TNM staging

Changes in AJCC 7th from AJCC 6th edition

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● T1 has been subdivided into T1a and T1b based on the presence or absence of lymphovascular invasion or poorly differentiated cancers

● T3 is limited to urethral invasion, and prostatic invasion is now considered T4

● Nodal staging is divided into clinical and pathologic categories

● The distinction between superficial and deep inguinal lymph nodes has been eliminated

● Stage II now includes T1b N0M0, as well as T2-3 N0M0

Primary Tumor (T)

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● TX: Primary tumor cannot be assessed

● T0: No evidence of primary tumor

● Tis: Carcinoma in situ

● Ta: Noninvasive verrucous carcinoma (broad pushing invasion is permitted, destruction invasion is not)

● T1a: Tumor invades subepithelial connective tissue without lymphovascular invasion and is not poorly differentiated

● T1b: Tumor invades subepithelial connective tissue and either has lymphovascular invasion or is poorly differentiated

● T2: Tumor invades corpus spongiosum or corpus cavernosum

● T3: Tumor invades urethra

● T4: Tumor invades other adjacent structures

Note: accurate clinical staging is often difficult, because the T and N categories are defined by structures that are not easily identified using physical examination or imaging (World J Urol 2009;27:151)

References: Mod Pathol 2001;14:963

Regional Lymph Nodes (N)

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Clinical stage, based on palpation and imaging

● 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: Palpable fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or bilateral

Pathologic stage, based on biopsy or surgical excision:

● pNX: Regional lymph nodes cannot be assessed

● pN0: No regional lymph node metastases

● pN1: Metastasis in a single superficial, inguinal lymph node

● pN2: Metastasis in multiple or bilateral superficial inguinal lymph nodes

● pN3: Metastasis in deep inguinal or pelvic lymph node(s), unilateral or bilateral

Distant Metastasis (M)

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● M0: No distant metastasis

● M1: Distant metastasis, or lymph node metastasis outside the true pelvis

Stage

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● 0: Tis or Ta N0 M0

● I: T1a N0 M0

● II: T1b-T3 N0 M0

● IIIa: T1-3 N1 M0

● IIIb: T1-3 N2 M0

● IV: T4 or N3 or M1

Notes:

● There is less interobserver variability in tumor staging than grading (BJU Int 2009;103:1660)

● MRI-PIPE may be more accurate than clinical staging (Radiol Med 2008;113:517)

Micro images

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Depth of invasion is measured from the deepest

malignant cells to the highest overlying dermal papilla

Lymphatic drainage of the penis involving 3 sequential

groups of lymph nodes

Limits of dissection of modified inguinal lymphadenectomy (dashed line) with classical groin dissection (dotted line). Black: superficial inguinal nodes. White: deep inguinal nodes. Gray: external iliac nodes. From Catalona WJ. Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results. J Urol. 1988;140:306-310

Staging diagram – BC Cancer Agency

End of Penis and scrotum > Staging of penile carcinoma

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