ObjectivesTo estimate the diagnostic accuracy of sentinel node biopsy (SNB) combined with preoperative 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) for inguinal lymph node (LN) evaluation in patients with invasive penile squamous cell carcinoma (PSCC) with no clinical evidence of inguinal metastases (cN0) at two tertiary centres with complete clinical follow-up. Patients and MethodsFrom April 2010 in Centre one and from January 2013 in Centre two, we prospectively enrolled patients diagnosed with invasive PSCC and scheduled for SNB at the only two university centres treating penile cancer in Denmark. All patients had FDG PET/CT before SNB. The sentinel LNs were preoperatively located by planar lymphoscintigraphy in 134 groins (68 patients) and by single-photon emission CT/ CT in 120 groins (61 patients). The primary endpoints were the sensitivity, specificity, and false-negative rate of SNB combined with FDG PET/CT. The secondary endpoint was SNB-related morbidity. ResultsWe examined 254 groins in 129 patients by SNB combined with FDG PET/CT. The median (interquartile range, IQR) follow-up of survivors was 23 (14-35) months. Of 201 LNnegative groins, two were false negatives, and despite radiochemotherapy treatment, both patients died from penile cancer. Four of 23 radiotracer-silent groins, had a FDG PET/CT-positive LNs and were surgically explored. In one of four of the explored groins, a positive LN was found. Combined FDG PET/CT-SNB sensitivity was 94.4% (95% confidence interval [CI] 81-99%) per groin. The falsenegative rate was 5.6% (95% CI 1-19%) per groin. In 15 patients (11.6%) there were 25 SNB-related complications of Clavien-Dindo grades I-IIIa. The only Clavien-Dindo IIIa complication was an inguinal lymphocele treated by aspiration. ConclusionIn this study, we present a favourable SNB false-negative rate of 5.6% in a national cohort of clinically LN-negative patients with invasive PSCC with a pre-SNB FDG PET/CT scan. The combination of FDG PET/CT and SNB seems to be a promising diagnostic approach. Even so, a false-negative SNB was fatal in two of two cases and we are determined to continue the development of our SNB technique. The SNBrelated morbidity was limited.

ObjectivesTo estimate the diagnostic accuracy of sentinel lymph node biopsy (SNB) in patients with penile cancer and assess SNB complications in a national multicentre setting. Patients and methodsRetrospectively data were collected from records in four university centres by one medical doctor covering all SNBs performed in Denmark between 1 January 2000 and 31 December 2010. Patients had either impalpable lymph nodes (LNs) in one or both groins, or had a palpable inguinal mass from which aspiration cytology failed to reveal malignancy. Patients were injected with nanocolloid technetium and had a scintigram recorded before the SNB. The primary endpoint was LN recurrence on follow-up. The secondary endpoint was complications after SNB. Diagnostic accuracy was computed. ResultsIn all, 409 groins in 222 patients were examined by SNB. The median (interquartile range) follow-up of patients who survived was 6.6 (5-10) years. Of 343 negative groins, eight were false negatives. The sensitivity was 89.2% (95% confidence interval 79.8-95.2%) per groin. Interestingly, four of 67 T1G1 patients had a positive SNB. In all, 28 of 222 (13%) patients had complications of Clavien-Dindo grade I-IIIa. ConclusionPenile cancer SNB with a close follow-up stages LN involvement reliably and has few complications in a national multicentre setting. Inguinal LN dissection was avoided in 76% of patients. Keywordssquamous cell carcinoma of the penis, penile cancer, sensitivity, sentinel node, lymph node staging, multicentre

Objectives To evaluate diagnostic accuracy of 18F‐fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) compared to contrast‐enhanced CT in assessment of inguinal lymph node (ILN) metastases, distant metastases and synchronous cancers in patients with penile squamous cell carcinoma (pSCC). Patients and Methods During a 4‐year period, patients with pSCC were scheduled for FDG PET/CT prior to surgical treatment at two referral centres that manage all penile cancers in Denmark. The primary endpoint was diagnostic accuracy of FDG PET/CT and of CT alone with histopathology or Response Evaluation Criteria In Solid Tumors (RECIST) as reference. Results We evaluated 171 patients for distant metastases and synchronous incident cancers and examined 286 groins in 143 patients for LN metastases by FDG PET/CT. Six groins disclosed false negatives. FDG PET/CT sensitivity was 85.4% per patient. In 135 patients (270 groins), CT images were evaluated separately and 22 groins disclosed false negatives. CT sensitivity was 47.5% per patient. FDG PET/CT detected pSCC distant metastases in seven patients. Distant metastases from other cancers were newly detected in three patients. In eight patients, an incidental synchronous cancer was detected. Seven out of the 18 distant malignancies detected depended on FDG PET information. Conclusion This study underlines the increased diagnostic accuracy of FDG PET/CT compared to CT alone in the evaluation of ILN status. In patients with palpable LNs, the advantage of FDG PET/CT over CT is less pronounced. FDG PET/CT may play a role in penile cancer evaluation.

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Objectives To assess prevalence of voiding and sexual symptoms and quality of life in penile cancer patients. Methods From 1 January 2013 to 31 December 2015, we approached three separate groups of Danish penile cancer patients and asked them to complete a face‐validated questionnaire at diagnosis (Group 1), after 1 year (Group 2) and after 2 years (Group 3). We analysed symptom prevalence and bother and quality of life items and explored differences between groups. Results In total, we analysed 157 questionnaires. The response rates at diagnosis, after 1 year and after 2 years were 29%, 46% and 30%. The pad use (p = 0.001) and occurrence of nocturia twice a night or more (p = 0.006) was significantly decreasing 2 years after treatment. There was an increasing trend in sexual thoughts and importance of sexuality from 1 to 2 years after treatment, but the proportion of patients reporting a frequency of orgasm at more than once in the past 6 months was significantly decreasing after treatment (p = 0.03). Likewise, the trend for erectile dysfunction worsened after treatment with 49% of patients reporting an erection never sufficient for intercourse at diagnosis increasing to 62% after 1 year and 69% after 2 years. We observed trends towards lower self‐esteem with increasingly mutilating treatment. Conclusion Pad use, nocturia and frequency of orgasm were significantly reduced after penile cancer treatment. We observed trends towards lower self‐esteem with increasingly mutilating treatment and increase in erectile dysfunction after treatment.

Aims Histopathological examination of sentinel lymph nodes in penile cancer has varied during the first 10 years after introduction of the dynamic sentinel node (SLN) procedure in Denmark, and guidelines have been sparse. The aim of this study was to investigate the impact of rigorous step‐sectioning of sentinel lymph nodes in penile cancer and improve guidelines. Methods and results Seventy‐two penile squamous cell carcinoma patients undergoing SLN procedure at a single institution in 2000–2010 were included. The archived lymph node tissues already subjected to a standard pathological examination were retrieved and the initially negative lymph nodes were subjected to an extended step‐sectioning procedure. The results were compared to clinical patient outcome from a national database and subsequent pathology reports. The original histopathological examination had detected 26 SLN with metastasis, 21 macro metastases and five micro metastases. The additional step‐sectioning procedure of this study generated 4606 slides; seven SLN metastases, two macro metastases and five micro metastases, were detected. One of the macro metastases originated from a patient in which a clinical relapse had occurred in the same groin. None of the other metastases detected in this study showed ipsilateral relapse during follow‐up. Conclusion The results underline the value of our current practice of step‐sectioning sentinel lymph nodes in penile cancer and the need for histopathological routines and guidelines. The Danish national guidelines on histopathological handling of sentinel lymph nodes have been adapted to detect any potential clinically relevant metastases.

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