Low yield of pathological lymph node metastasis among patients with invasive penile squamous cell carcinoma in the context of high HIV burden: evidence from a prospective cohort study in Zambia

Introduction: Penile squamous cell carcinoma (PSCC) is common in developing countries such as those in sub-Saharan Africa (SSA) and has been attributed to a high prevalence of human papillomavirus (HPV). Additionally, since the prevalence of human immunodeficiency virus (HIV) is high in SSA, and considering that HIV causes reactive lymphadenopathy, this may potentially affect the clinical manifestation, including staging and surgical management, of inguinal lymph nodes in PSCC. Data on surgical staging via inguinal lymph node dissection (ILND) in penile cancer patients from areas of high HIV burden, such as SSA, are scanty. We evaluated the use of ILND as a staging tool to determine the status of inguinal lymph nodes in patients with invasive PSCC in the context of a high HIV burden. Methods: This was a prospective cross-sectional cohort study of participants recruited between November 2022 and January 2024 at the University Teaching Hospital in Lusaka, Zambia. Patients with surgically resectable PSCC who underwent surgery for both the primary tumor and inguinal lymph nodes simultaneously were recruited into the study. A questionnaire was administered to capture relevant clinical information. The dissected lymph nodes were pathologically analyzed for lymph node number, size, and the presence of metastasis. Results: Forty patients were enrolled in the study, with a mean age of 53 years (SD 10.28). Thirty-five patients (87.5%) were HIV seropositive, with most patients being virologically suppressed at the time of surgery. Thirty-two patients (80%) presented with clinically palpable inguinal lymph nodes (cN+). The yield of pathological lymph node metastasis (LNM) from surgical staging was 37.5% (12/32) among patients with clinically palpable (cN+) inguinal lymph nodes. Conclusion: The study demonstrates a modestly low yield of pathological inguinal lymph node metastasis in patients with clinically palpable nodes in the context of a high HIV burden. Minimally invasive biopsy techniques to assess nodal status should be explored in this setting to reduce the morbidity associated with surgical staging while accurately assessing nodal status.