Lymph node metastases and prognosis in penile cancer

Predictors of Inguinal Lymph Node Metastasis in Penile Squamous Cell Carcinoma: Insights from a Single-Center Retrospective Study

Background: Squamous cell carcinoma (SCC) of the penis accounts for approximately 95% of penile cancers and is associated with substantial morbidity and mortality. SCC typically develops in uncircumcised men, most commonly affecting the foreskin or glans. While slow-growing, early detection is crucial to improve survival outcomes. Risk factors include advanced age, lack of circumcision, poor hygiene, HPV infection (types 16 and 18), chronic inflammation, and smoking. Methods: We conducted a retrospective, single-center study at IRCCS Hospital "G. Pascale" of Naples, Italy, involving 59 patients treated between January 2015 and January 2023. The inclusion criteria were surgically treated primary tumors, confirmed SCC pathology, and pathologically verified inguinal lymph node metastasis (ILNM). We analyzed clinical variables including lymph node involvement, lymphovascular invasion (LVI), spongiosum corpus involvement (SCI), HPV infection, and tumor differentiation. Univariate and multivariate logistic regression analyses were performed to determine independent predictors of ILNM. Results: The mean age of patients was 66.67 ± 13.97 years. ILNM was confirmed in 24 patients (40.6%), while 35 (59.3%) had no lymph node involvement. Univariate analysis identified lymph node involvement at diagnosis (p = 0.005), LVI (p = 0.003), and SCI (p = 0.003) as significant predictors of ILNM. These factors were confirmed in the multivariate analysis, with lymph node involvement (p = 0.004), LVI (p = 0.025), and SCI (p = 0.028) as independent predictors. Conclusions: Lymph node status, LVI, and SCI are significant predictors of ILNM in penile SCC. Identifying these factors can aid in risk stratification, optimizing surgical decisions, and potentially reducing unnecessary morbidity. Further large-scale studies are recommended to validate these findings and refine prognostic models.

Molecular Pathology and Biomarkers of Penile Squamous Cell Carcinoma: Implications for Classification and Management

This review explores the current understanding and management of penile squamous cell carcinoma, emphasizing recent advances in molecular pathology and treatment strategies. The article discusses the importance of human papillomavirus status in tumor classification and prognosis, highlighting the 2022 WHO classification. The article underscores the need for a multidisciplinary approach to penile cancer management and identifies areas for future research, including refining molecular classification systems and developing predictive biomarkers. It concludes by emphasizing the rapid evolution of penile cancer management and the potential for more personalized treatment strategies.

Factor associated with postoperative complications of inguinal lymph node dissection for penile cancer Test

Background

Inguinal lymph node dissection (ILND) is the standard of care for palpable, biopsy-proven lymph node metastases or high-risk groups for nonpalpable lymph nodes in the treatment of penile cancer. ILND is associated with a significant incidence of complications and adverse events, specifically wound complications. Few studies have identified risk factors related to postoperative ILND complications.

Objective

The objective of this study was to assess the prevalence of 30-day postoperative complications and to identify risk factors associated with postoperative complications of ILND for penile cancer.

Materials and Methods

This was a retrospective review of medical records for all patients who had ILND for penile cancer between January 2012 and December 2022. According to the modified Clavien-Dindo classification, the 30-day postoperative complications were collected. Using an ordinal univariate logistic regression model and multivariate analysis, potential risk variables for complications were determined.

Results

A total of 60 patients were performed ILND. Sixty percent of the patients had a postoperative complication including wound infection 50%, wound dehiscence 36.7%, skin necrosis 26.6%, lymphocele 33.3%, leg edema 46.7%, and scrotal edema 16.7%. Higher grade of modified Clavien-Dindo classification was associated with body mass index (BMI) (odds ratio [OR] = 1.15; P = 0.03), diabetes mellitus (OR = 3.13; P = 0.04), American Society of Anesthesiologist classification ≥3 (OR = 1.14; P = 0.03), radical ILND (OR = 1.57; P = 0.01), and bilateral ILND (OR = 1.60; P = 0.02). In multivariate analysis, a higher grade of modified Clavien-Dindo classification was correlated with BMI (OR = 1.48; P = 0.01) and bilateral ILND (OR = 4.56; P = 0.01).

Conclusion

ILND is associated with high rates of complication. The severity of the modified Clavien-Dindo classification was associated with BMI and bilateral ILND.

MicroRNAs in Genitourinary Malignancies: An Exciting Frontier of Cancer Diagnostics and Therapeutics

Genitourinary (GU) malignancies, including prostate, urothelial, kidney, testicular, penile, and adrenocortical cancers, comprise a significant burden of cancers worldwide. While many practice-changing advances have been made in the management of GU malignancies in the last decade, there is still significant room for improvement. MicroRNAs (miRNAs) are noncoding RNAs that regulate post-transcription gene expression and which have been implicated in multiple mechanisms of carcinogenesis. Therefore, they have the potential to revolutionize personalized cancer therapy, with several ongoing preclinical and clinical studies underway to investigate their efficacy. In this review, we describe the current landscape of miRNAs as diagnostics, therapeutics, and biomarkers of response for GU malignancies, reflecting a novel frontier in cancer treatment.

Preoperative Albumin-to-Alkaline Phosphatase Ratio as an Independent Predictor of Lymph Node Involvement in Penile Cancer

Background and Objectives: To investigate the role of preoperative albumin-to-alkaline phosphatase ratio (AAPR) in predicting pathologic node-positive (pN+) disease in penile cancer (PC) patients undergoing inguinal lymph node dissection (ILND). Materials and Methods: Clinical data of patients with squamous cell carcinoma (SCC) PC + ILND at a single high-volume institution between 2016 and 2021 were collected and retrospectively analyzed. An AAPR was obtained from preoperative blood analyses performed within 30 days from their scheduled surgery. A ROC curve analysis was used to assess AAPR cutoff, in addition to the Youden Index. Logistic regression analysis was utilized for an odds ratio (OR), 95% confidence interval (CI) calculations, and an estimate of pN+ disease. A p value < 0.05 was considered to be as statistically significant. Results: Overall, 42 PC patients were included in the study, with a mean age of 63.6 ± 12.9 years. The AAPR cut-off point value was determined to be 0.53. The ROC curve analysis reported an AUC of 0.698. On multivariable logistic regression analysis lymphovascular invasion (OR = 5.38; 95% CI: 1.47-9.93, p = 0.022), clinical node-positive disease (OR = 13.68; 95% CI: 4.37-43.90, p < 0.009), and albumin-to-alkaline phosphatase ratio ≤ 0.53 (OR = 3.61; 95% CI: 1.23-12.71, p = 0.032) were predictors of pN+ involvement. Conclusions: Preoperative AAPR may be a potentially valuable prognostic marker of pN+ disease in patients who underwent surgery for PC.

Regional differences in penile cancer patient characteristics and treatment rates across the United States

INTRODUCTION

We tested for regional-specific differences in patient, tumor and treatment characteristics as well as cancer-specific mortality (CSM) of squamous cell carcinoma of the penis (SCCP) patients, across the Surveillance, Epidemiology, and End Results (SEER) registries.

METHODS

The SEER database (2000-2018) was used to tabulate patient (age at diagnosis, race/ethnicity), tumor (stage, grade, N-stage) and treatment characteristics (proportions of primary tumor surgery, local lymph node surgery, systemic therapy), according to 12 SEER registries. Multinomial regression models, as well as multivariable Cox regression models tested for CSM differences, adjusting for patient, tumor and treatment characteristics.

RESULTS

In 5395 SCCP patients, registry-specific patient counts ranged from 2060 (38 %) to 64 (1 %). Differences across registries existed for race/ethnicity, stage, grade and N-stage. Additionally, in stage I-II SCCP patients, proportions of local tumor destruction (LTD) ranged from 19 % to 39 % and from 33 % to 61 % for partial penectomy. In stage III-IV SCCP patients, proportions of partial penectomy ranged from 40 % to 59 % and from 17 % to 50 % for radical penectomy. Local lymph node surgery ranged from 8 % to 24 % and proportions of systemic therapy ranged from 3 % to 14 %. Significant inter-registry differences remained, after adjustment for treatment proportions. Unadjusted five-year CSM ranged from 19 % to 32 %. In multivariable analyses, one registry exhibited significantly higher CSM (SEER registry 10, Hazard Ratio [HR] 1.48), relative to the largest reference registry (SEER registry 1, n = 2060).

CONCLUSION

Important regional differences including patient, tumor and treatment characteristics exist for SCCP patients across SEER registries. After multivariable adjustment, no differences in CSM were recorded, with the exception of one registry.

Prognostic Markers and Trials in Penile Cancer

New tumor biomarkers open the potential for designing personalized therapy for penile squamous cell carcinoma. Despite the initial promising results of some biomarkers, controversy remains due to contradictory studies. Further robust research work is required before incorporating biomarkers in the personalized management of penile cancer. This narrative review aims to highlight some of the most commonly and recently investigated biomarkers of penile cancer and to summarize the ongoing registered clinical trials for the management of penile cancer patients.

Recent developments in the diagnosis and management of N1 penile cancer

PURPOSE OF REVIEW

This article presents a critical review of the current literature to provide a brief update on the contemporary advances in diagnosing and managing N1 penile cancer.

RECENT FINDINGS

Penile squamous cell carcinoma (pSCC) has evolved from being an orphan field for cancer innovation. Advances in the understanding tumour biology have enabled sophisticated diagnostics and predictive modelling to better characterize inguinal disease. Minimally invasive inguinal lymph node dissection is emerging as a technique that reduces morbidity while maintaining oncological safety. Furthermore, robust clinical trials are underway ,which will provide level one evidence to guide treatment decisions. Exciting advances in the field of immune-oncology offer promise as adjuvant therapies. International collaboration and centralisation of care will be essential to driving translational research and equitable evidence-based care.

SUMMARY

Improving outcomes for men with pSCC remains a global challenge. Radical inguinal lymph node dissection remains the gold standard for diagnosing and curing N1 disease. Although many promising developments are on the horizon, high-level evidence is required to guide therapy.

A single-center comparison of our initial experiences in treating penile and urethral cancer with video-endoscopic inguinal lymphadenectomy (VEIL) and later experiences in melanoma cases

Background

Video-endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive approach that is increasingly indicated in oncological settings, with mounting evidence for its long-term oncological safety.

Objectives

To present our single-center experience of treating penile and urethral cancer with VEIL, as well as its more recent application in melanoma patients.

Methods

We prospectively recorded our experiences with VEIL from September 2010 to July 2018, registering the patient primary indication, surgical details, complications, and follow-up.

Results

Twenty-nine patients were operated in one (24) or both (5) groins; 18 had penile cancer, 1 had urethral cancer, and 10 had melanoma. A mean 8.62 ± 4.45 lymph nodes were removed using VEIL and of these, an average of 1.00 ± 2.87 were metastatic; 16 patients developed lymphocele and 10 presented some degree of lymphedema; there were no skin or other major complications. The median follow-up was 19.35 months; there were 3 penile cancer patient recurrences in the VEIL-operated side. None of the melanoma patients presented a lymphatic inguinal recurrence.

Conclusions

VEIL is a minimally invasive technique which appears to be oncologically safe showing fewer complications than open surgery. However, complications such as lymphorrhea, lymphocele, or lymphedema were not diminished by using VEIL.

Carcinoma Penis Manifesting as Upfront Supraclavicular Lymph Node Metastases Detected by 18F-Fluorodeoxyglucose Positron Emission Tomography Scan: Report of an Extremely Rare and Aggressive Case

Carcinoma penis is a rare malignancy accounting 0.5 to 1% cases in the developed countries with a slightly higher incidence in the developing nations. Slow locoregional progression is characteristic of penile carcinoma and distant metastases are very uncommon. We hereby report a case of highly aggressive squamous cell penile carcinoma in a 46-year-old male with fulminant upfront distant dissemination to left supraclavicular lymph nodes without involving the inguinal and pelvic nodes detected by whole-body ¹⁸ F-fluorodeoxyglucose positron emission tomography scan. The scan also detected lytic destructive lesion involving the pelvic and adjacent bones with infiltration of skeletal muscles. He was treated with palliative radiotherapy to the weight-bearing sites followed by systemic chemotherapy. A thorough review of literature reveals that our case may be one of the rarest cases ever reported in world literature where an asymptomatic penile carcinoma presents with upfront supraclavicular lymph node metastasis bypassing the inguinal, pelvic, and retroperitoneal lymph node chains.

Development and Verification of Prognostic Nomogram for Penile Cancer Based on the SEER Database

Aim

We aimed to establish a prognostic nomogram for penile cancer (PC) patients based on the Surveillance, Epidemiology, and End Results Program (SEER) database.

Methods

Data from 1643 patients between 2010 and 2015 were downloaded and extracted from the SEER database. They were randomly divided into the development group (70%) and the verification group (30%), and then, univariate and multivariate Cox proportional hazards regression, respectively, was used to explore the possible risk factors of PC. The factors significantly related to overall survival (OS) and cancer-specific survival (CSS) were used to establish the nomogram, which was assessed via the concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve. An internal validation was conducted to test the accuracy and effectiveness of the nomogram. Kaplan–Meier calculation was used to predict the further OS and CSS status of these patients.

Results

On multivariate Cox proportional hazards regression, the independent prognostic risk factors associated with OS were age, race, marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type, with a moderate C-index of 0.737 (95% confidence interval (CI): 0.713–0.760) and 0.766 (95% CI: 0.731–0.801) in the development and verification groups, respectively. The areas under the ROC (AUC) of 3- and 5-year OS were 0.749 and 0.770, respectively. While marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type were significantly linked to PC patients' CSS, which have better C-index of 0.802 (95% confidence interval (CI): 0.771–0.833) and 0.82 (95% CI: 0.775–0.865) in the development and verification groups, and the AUC of 3- and 5-year CSS were 0.766 and 0.787. Both of the survival calibration curves of 3- and 5-year OS and CSS brought out a high consistency.

Conclusion

Our study produced a satisfactory nomogram revealing the survival of PC patients, which could be helpful for clinicians to assess the situation of PC patients and to implement further treatment.

Analysis of the related risk factors of inguinal lymph node metastasis in patients with penile cancer: A cross-sectional study

Purpose:

To determine independent predictors of inguinal lymph node (ILN) metastasis in patients with penile cancer.

Patients and methods:

We retrospectively analyzed all patients with penile cancer who underwent surgery at our medical center in the last ten years (n=157). Using univariate and multivariate logistic-regression models, we assessed associations with age, medical-history, phimosis, onset-time, number and maximum diameter of involved ILNs measured by imaging, pathological T stage, degree of tumor differentiation and/or cornification, lymphatic vascular infiltration (LVI), nerve infiltration, and ILN metastases. Interaction and stratified analyses were used to assess age, phimosis, onset time, number of ILNs, cornification, and nerve infiltration.

Results:

A total of 110 patients were included in the study. Multiple logistic regression analysis showed that the following factors were significantly correlated with ILN metastasis: maximum diameter of enlarged ILNs, T stage, pathological differentiation, and LVI. Among patients with a maximum ILN diameter ≥1.5cm, 50% had lymph node metastasis whereas 30.6% patients with a maximum ILN diameter <1.5cm showed LNM. Among 44 patients with stage Ta/T1, 10 showed ILN metastases, while 47.0% patients with stage T2 showed ILN metastases. Among 40 patients with highly differentiated penile-cancer, eight showed ILN metastasis, while 47.1% patients with low-to-middle differentiation showed ILN metastases. The rate of LNM was 33.3% in the LVI-free group and 64.3% in the LVI group.

Conclusion:

Our single-center results suggested that maximum ILN diameter, pathological T stage, pathological differentiation, and LVI were independent risk factors for ILN metastases.

Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL) and Video-Endoscopic Inguinal Lymphadenectomy (VEIL) versus Open Inguinal Lymph-Node Dissection (OILND) in carcinoma of penis: Comparison of perioperative outcomes, complications and oncological outcomes. A systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis evaluating the peri-operative outcomes, complications, and oncological outcomes of Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL)/Video-Endoscopic Inguinal Lymphadenectomy (VEIL) with Open Inguinal Lymph-Node Dissection (OILND) for management of inguinal lymph-nodes in carcinoma of the penis.

METHODS

A comprehensive literature search was performed in January 2021 using the PubMed, Embase, and Cochrane databases. Data from human studies comparing RAVEIL/VEIL vs. OILND in carcinoma of penis published in English was extracted and analyzed by two independent authors.

RESULTS

Two Randomised Controlled Trials and 6 cohort studies were included in the meta-analysis. RAVEIL/VEIL group exhibited increased operative time (Mean Difference [MD] = 15.28 [14.19; 16.38], P < 0.001), shorter hospital stay (MD = -1.06 [-1.14; -0.98], P < 0.001), and decreased duration of drainage (MD = -2.82 [-3.21; -2.43], P < 0.001), wound infection (Odds Ratio [OR] = 0.15 [0.08; 0.27], P < 0.001), skin necrosis (OR = 0.12 [0.05; 0.28], P < 0.001), lymphedema (OR = 0.41 [0.24; 0.72], P = 0.002), and major complications (OR = 0.11 [0.05; 0.24], P < 0.001) as compared to OILND group. Recurrence rate and number of deaths were comparable in both the groups. RAVEIL/VEIL groups showed slightly larger lymph-node yield (MD = 0.44 [0.18; 0.70], P < 0.001) as compared to OILND group.

CONCLUSION

RAVEIL/VEIL has lesser skin complications, lymphedema, and better lymph-node yield as compared to OILND. It is comparable in terms of lymphocele and recurrence. It has lesser hospital stay and duration of drainage but owing to heterogeneity, the results should be interpreted with caution. Further studies are required to determine long-term oncological outcomes like overall survival and disease-specific survival.

Carcinoma penis manifesting as upfront supraclavicular lymph node metastases detected by 18F-fluorodeoxyglucose positron emission tomography scan: Report of an extremely rare and aggressive case

Carcinoma penis is a rare malignancy accounting 0.5%-1% of cases in the developed countries with a slightly higher incidence in the developing nations. Slow locoregional progression is characteristic of penile carcinoma (PC) and distant metastases are very uncommon. We hereby report a case of highly aggressive squamous cell PC in a 46-year-old male with fulminant upfront distant dissemination to left supraclavicular lymph nodes (LNs) without involving the inguinal and pelvic nodes detected by whole-body ¹⁸F-fluorodeoxyglucose positron-emission tomography scan. The scan also detected lytic destructive lesion involving the pelvic and adjacent bones with infiltration of skeletal muscles. He was treated with palliative radiotherapy to the wight-bearing sites followed by systemic chemotherapy. A thorough review of literature reveals that our case may be one of the rarest cases ever reported in world literature where an asymptomatic PC presents with upfront supraclavicular LN metastasis bypassing the inguinal, pelvic, and retroperitoneal LN chains.

Log ODDS (LODDS) of positive lymph nodes as a predictor of overall survival in squamous cell carcinoma of the penis

OBJECTIVE

To evaluate the role of logarithmic ODDS (LODDS) in the number of positive lymph nodes and the number of negative lymph nodes as a prognostic metric in the squamous cell carcinoma (SCC) penis.

METHODS

Data were retrospectively collected from 96 cases of SCC penis that underwent bilateral groin dissection between 2010 and 2015 at our institute. Lymph node density (LND) and LODDS were calculated for all the patients and classified according to American Joint Committee on Cancer (AJCC) pN staging. Thresholds for LND (24% and 46%) and LODDS (-0.75 and 0) were established. Multivariate analysis of various cofactors was done with overall survival (OS) as a dependent factor. Three classification systems were compared using receiver operative characteristic (ROC) curve analysis.

RESULTS

Univariate analysis showed that AJCC pN, LND, and LODDS were all significantly correlated with OS. However, only LODDS (HR, 11.185; p = .023) remained an independent prognostic factor through multivariate analysis. LODDS (log-likelihood = 3832 vs. 3798; p < .001) had better prognostic performance than pN and better discriminatory ability than LND (AIC = 3902 vs. 3928). LODDS had better power of discrimination than LND and pN. LODDS could predict survival in lymph node yield (LNY) < 15 (p < .001).

CONCLUSION

LODDS is an independent predictor of OS in the SCC penis and has superior prognostic significance than the AJCC pN and LND classification systems.

Lessons learned from histological step-sectioning of sentinel lymph nodes in penile cancer

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.

Current controversies and developments on the role of lymphadenectomy for penile cancer

Penile squamous cell carcinoma is a rare cancer in men. The main prognosticators of survival for penile cancer patients remain the presence and the extent of lymph node metastasis. While radical inguinal lymphadenectomy has been the cornerstone of regional lymph node management for many years, it is still associated with significant morbidity and psychological distress. Recent developments in penile squamous cell carcinoma management have been met with some controversy in the urologic oncology community. Herein, we review the current controversies and developments on the role of inguinal lymphadenectomy for penile cancer.

Delay to Inguinal Lymph Node Dissection Greater than 3 Months Predicts Poorer Recurrence-Free Survival for Patients with Penile Cancer

PURPOSE

To our knowledge it is unknown whether concomitant inguinal lymph node dissection at the time of penectomy improves outcomes in patients with penile cancer. We analyzed predictors of regional recurrence as well as disease specific survival based on time of inguinal lymph node dissection. We also determined an optimal time to perform inguinal lymph node dissection.

MATERIALS AND METHODS

We reviewed the records of 84 consecutive patients with available nodal pathology findings. Recurrence-free and disease specific survival was estimated using the Kaplan-Meier method. Optimal time to inguinal lymph node dissection was assessed by ROC curves and used for dichotomization. Cox proportional HRs were used to identify predictors of regional recurrence after inguinal lymph node dissection.

RESULTS

A total of 47 (56%) and 37 patients (44%) presented with cN0 and cN+ disease, respectively, during a median followup of 21 months. A cutoff point of 3 months to perform inguinal lymph node dissection was used to dichotomize the cohort into early vs delayed groups. Early dissection in 51 men demonstrated 5-year recurrence-free survival of 77% vs 37.8% in 33 who underwent delayed dissection. Positive node disease (HR 23.2, 95% CI 2.98-181.2) and early inguinal lymph node dissection (HR 0.48, 95% CI 0.21-0.98) were predictors of regional recurrence. Five-year disease specific survival was 64.1% and 39.5% in the early and late dissection groups, respectively.

CONCLUSIONS

Three months appears to be an optimal window for performing inguinal lymph node dissection. While prospective trials are needed to define the role of upfront groin dissection, our results may help delineate patterns of referral and timing of inguinal lymph node dissection in patients with penile cancer.

Surgical treatment of advanced penile cancer

Purpose

To evaluate the therapeutic effect of surgery in patients with advanced penile cancer, who have a dismal prognosis.

Patients and methods

Between September 2007 and July 2015, we treated 12 patients with surgical therapy.

Results

The median follow-up period for all the patients was 16 months (range 4–60 months). The outcome and concomitant symptoms were analyzed, and the survival rates were calculated. Three of the patients are currently alive. The median overall survival of the patients was 9 months (range 4–13 months).

Conclusion

The present results suggest that surgery is a valuable treatment option for patients with advanced penile cancer. The prognosis of advanced penile cancer is closely related to lymph node and distant metastases. Flap repair can solve the problem of large area skin defect. Advanced penile cancer is difficult to treat regardless of chemotherapy or radiotherapy, and surgery cannot prolong the lives of patients. However, the dissection of lesions and repair of large area skin defects can dramatically improve the quality of life of patients, especially those with locally advanced disease without distant metastasis.

Patterns of Regional Lymphadenectomy for Clinically Node-negative Patients With Penile Carcinoma: Analysis From the National Cancer Database From 1998 to 2012

PURPOSE

Evidence supports upfront regional lymphadenectomy (rND) when primary penile tumors exhibit high-risk features and negative inguinal adenopathy (cN0). We sought to analyze trends in the utilization of early rND as well as assess factors associated with its use and survival outcomes using a nationwide cancer registry database.

PATIENT AND METHODS

The National Cancer Database was queried for patients with clinically nonmetastatic penile carcinoma and available nodal status who underwent rND from 1998 to 2012. Temporal trends in the utilization of early rND for those with cN0 disease were analyzed, and a multivariable logistic regression model was used to identify predictors for receiving rND. Survival analysis based on rND status was performed using the Kaplan-Meier method and Cox proportional hazard regression.

RESULTS

From 1919 patients with available clinicopathologic variables, performance of early rND was documented in 377 (19.6%) patients with an increase in utilization over time (P = .001). The increase was driven by academic and comprehensive cancer programs compared with community programs (P < .001). Positive predictors were treatment facility, clinical tumor stage, and grade (all P < .05). African American patients (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33-0.86; P = .01) and those aged > 75 years (OR, 0.42; 95% CI, 0.26-0.68; P < .001) were significantly less likely to receive rND. Early rND was associated with improved overall survival (hazard ratio [HR], 0.67; 95% CI, 0.52-0.87; P = .003).

CONCLUSION

There was increased use of early lymphadenectomy for patients with cN0 penile cancer driven by comprehensive and academic cancer programs. The study demonstrated demographic and socioeconomic differences that can help identify barriers to care for patients with penile cancer in the United States.

Contemporary management of patients with penile cancer and lymph node metastasis

Penile cancer is a rare disease that causes considerable physical and psychological patient morbidity, especially at advanced stages. Patients with low-stage nodal metastasis can achieve durable survival with surgery alone, but those with extensive locoregional metastasis have overall low survival. Contemporary management strategies for lymph node involvement in penile cancer aim to minimize the morbidity associated with traditional radical inguinal lymphadenectomy through appropriate risk stratification while optimizing oncological outcomes. Modified (or superficial) inguinal lymph node dissection and dynamic sentinel lymph node biopsy are diagnostic modalities that have been recommended in patients with high-risk primary penile tumours and nonpalpable inguinal lymph nodes. In addition, advances in minimally invasive and robot-assisted lymphadenectomy techniques are being investigated in patients with penile cancer and might further decrease lymphadenectomy-related adverse effects. The management of patients with advanced disease has evolved to include multimodal treatment with systemic chemotherapy before surgical intervention and can include adjuvant chemotherapy after pelvic lymphadenectomy. The role of radiotherapy in the neoadjuvant or adjuvant setting remains largely unclear, owing to a lack of high-level evidence of possible benefits. New targeted therapies have shown efficacy in squamous cell carcinomas of other sites and might also prove effective in patients with penile cancer.

Modification of N staging systems for penile cancer: a more precise prediction of prognosis

BACKGROUND

The tumour-node-metastasis (TNM) classification is the most widely used tool for penile cancer. However, the current system is based on few studies and has been unchanged since 2009. We determined whether a modified pathological N staging system that incorporates the laterality and number of lymph node metastases (LNMs) increases the accuracy of the results in predicting survival compared with the 7th edition of the pathological N staging system of the American Joint Committee on Cancer (AJCC) for penile cancer.

METHODS

The clinical and histopathologic data from 111 patients with penile cancer with LNMs were analysed. Univariate and multivariate Cox proportional hazard regression analyses were used to determine the impact of the clinical and pathological factors on disease-specific survival of these patients. The predictive accuracy was further assessed using the concordance index.

RESULTS

According to the 7th edition of the pathological N classification, the 3-year disease-specific survival (DSS) rates for patients with pN1, pN2, and pN3 disease are 89.6%, 65.9%, and 33.6%, respectively (P(N1-N2)=0.030, P(N2-N3)<0.001, P<0.001). Under the modified pathological N category criteria, the 3-year DSS rates for pN1, pN2, and pN3 patients were 90.7%, 60.5%, and 31.4%, respectively (P(N1-N2)=0.005, P(N2-N3)=0.004, P<0.001). In separate multivariate Cox regression models, only modified N stages (hazard ratio: 4.877, 10.895; P=0.018, P<0.001) exhibited independent effects on the outcome. The accuracy of the modified pathological N category was significantly increased.

CONCLUSIONS

The modified pathological N staging system is a better reflection of the prognosis of patients with penile cancer. Our study should contribute to the improvement of prognostic stratification and systemic treatment to avoid overtreatment of patients.

Neoadjuvant concurrent chemoradiation for curative treatment of penile squamous cell carcinoma

Introduction. Penile cancer is a rare malignancy often treated with neoadjuvant chemotherapy followed by surgery. However, the utility of neoadjuvant chemoradiation, particularly when the tumor is resistant to chemotherapy alone, has not been established. In this study, we report a case of pT3cN3M0 penile squamous cell carcinoma with progression of nodal disease on chemotherapy, which was cured with use of neoadjuvant concurrent chemoradiation. Case Report. A 65-year-old male presented with a fixed left inguinal lymph node with associated firmness of the penile glans. Biopsies of both sites revealed evidence of squamous cell carcinoma. The patient underwent partial penectomy for the primary lesion and began neoadjuvant chemotherapy to reduce the size of the unresectable left inguinal node. However, he displayed disease progression in the left inguinal node. As such, we attempted concurrent chemoradiation therapy with regression of his nodal disease. The patient was able to undergo left inguinal node dissection and has no evidence of disease 18 months since his initial surgery. Conclusion. The use of neoadjuvant chemoradiation for bulky cN2-3 disease seems appropriate in the setting of progressive disease. Further studies are necessary to assess the utility of concurrent chemoradiation both in the neoadjuvant and salvage setting.

Validation of the prognostic value of lymph node ratio in patients with penile squamous cell carcinoma: a population-based study

PURPOSE

The aim of this study was to validate the prognostic value of lymph node ratio (LNR), the proportion of metastatic among removed lymph nodes, for patients with penile squamous cell carcinoma in a population-based database.

METHODS

A total of 210 eligible patients with node-positive disease were identified from the surveillance epidemiology end results database. Cancer-specific survival (CSS) was the clinical outcome of interest. The prognostic ability of LNR was assessed by Cox regression analyses. Logrank test was used to compare CSS between low-risk and high-risk groups stratified by cutoff points of LNR.

RESULTS

The median number of LNs removed was 16, and the median value of LNR was 0.20. First, LNR was a significant prognostic factor of CSS in univariate analysis (HR = 4.08). Second, LNR retained independent predictive ability (HR = 6.74) in the multivariate model including demographic data, disease characteristics and number-based LN variables. Addition of LNR remarkably improved the predictive accuracy and clinical usefulness of the survival model. Third, maximum stratification of CSS can be achieved at the cutoff point of 0.33.

CONCLUSION

In the population-based study, LNR outperformed number-based LN variables for predicting CSS of node-positive penile cancer. The ratio-based prognostic factor stresses the important role of adequate LND and identification of metastatic LNs in the community setting.