Surgical treatment of advanced penile cancer

The role of surgery for loco-regional and advanced urological cancers

PURPOSE OF REVIEW

There is a general misconception that surgery is the antithesis of palliation. However, symptom mitigation, the basic tenet of palliative interventions, can be achieved by invasive procedures. Surgical care, thus, plays an important role in palliative oncology, alongside radiation and systemic therapy. There is global movement to improve palliation in oncology, and thus it is timely to evaluate the role of surgical interventions can play in this setting.

RECENT FINDINGS

Many of the surgical interventions done with palliative intent were first established as curative options. Most studies looked at interventions for local control of primary tumour including extirpative surgeries, while some studies studied pain relief for bone metastases. Results show that patients have an acceptable survival outcome and complication rate comparable to those done in the curative setting. However, not all studies report functional outcomes and symptom-relief consistently, highlighting an unmet need.

SUMMARY

More studies are needed to further define the role of surgery in palliative care. Randomized controlled trials studying surgical intervention in the palliative setting will be challenging because of lack of equipoise, inherent bias in patient and disease characteristics in those who undergo surgery. Nonetheless, studies should endeavour to study symptom-free survival and PROMs as meaningful endpoints of interventions performed in a palliative setting rather than solely focus on hard oncological endpoints of survival.

The role of primary inguinal surgical debulking for locally advanced penile cancer followed by reconstruction with myocutaneous flap

PURPOSE

To evaluate surgical complications and oncological outcomes of patients submitted to primary radical inguinal surgical debulking (PRISD) and myocutaneous pediculate flap reconstruction (MPFR) for locally advanced penile cancer (PC).

MATERIALS AND METHODS

Forty-two patients with ulcerated and/or fixed bulky inguinal masses underwent unilateral or bilateral PRISD with MPFR. Tensor fascia lata flap (TFL) was the standard of care for all patients. Additional use of the gracilis flap (GF) was carried out when necessary. Contra-lateral radical inguinal lymphadenectomy (RIL) was conduced when PRISD was performed unilaterally. Surgical complications were analyzed and stratified into minor and major according to the Bevan-Thomas classification. Adjunctive treatments were assessed and oncological outcomes analyzed.

RESULTS

Of the 42 patients evaluated, 10 (23.8%) underwent bilateral PRISD and 32 (76.2%) unilateral PRISD with contra-lateral RIL, totaling 84 lymphadenectomies. A total of 62 MPFRs were performed, 52 with TFL and 10 with GF. A total of 53 complications were identified, 49 related to PRISD with MPFR and 4 to RIL. Adjuvant chemotherapy was carried out in 16 patients. Median follow-up was 10.8 months with a median overall survival (OS) of 14.0 months against 6.0 months (p=0.006) for patients submitted to PRISD with adjuvant chemotherapy in relation to surgery alone.

CONCLUSIONS

PRISD alone for advanced loco-regional PC is unlikely to promote long-term survival, although it can lead to temporary local control of the disease. Despite the feasibility of the procedure, it is related to high incidence of complications. Surgical treatment with adjuvant chemotherapy is associated with improved OS.

Prognostic Factors for Penile Cancer and Survival in Response to Multimodality Therapy

Purpose

To report treatment outcomes of penile cancer in a single institution in Thailand and to identify prognostic factors for survival, highlighting the crucial role of multi-modality treatment (MMT).

Patients and Methods

Squamous cell carcinoma of penis patients who were treated at Srinagarind hospital between 2007–2015 were retrospectively analyzed. Clinical and pathological data were retrospectively reviewed. Overall survival (OS) was calculated using the Kaplan-Meier method and data were compared using the Log rank test. Cox regression analysis of factors affecting survival was conducted.

Results

A total of 70 patients were identified with a median follow-up of 69.4 months. Twenty-eight patients (40%) presented with early-stage (stage I or II), whereas 42 patients (60%) were stage III or IV disease. The median OS was 29.3 months (Interquartile range 10.5 months - not reached) for the entire cohort. Nodal involvement was the only factor identified from the multivariate model with the adjusted HR or 5.74 (95% CI 2.52–13.04). For patients with stage IIIB/IV, multi-modality treatment (MMT) resulted in longer survival when compared with surgery alone (HR 0.37; 95% CI 0.16–0.90).

Conclusion

Patients with penile cancer in Thailand presented with younger age and more locally advanced stage. Nodal involvement is the single poor prognostic factor for OS and MMT was associated with longer survival in stage IIIB/IV disease.