Treatment Options and Outcomes for Men with Penile Intraepithelial Neoplasia: A Systematic Review

Retrospective clinical and molecular characterisation of patients with penile intraepithelial neoplasia

OBJECTIVES

To provide the first comprehensive molecular characterisation of penile intraepithelial neoplasia (PeIN) and to define the molecular alterations and clinical parameters associated with recurrence in order to enhance our ability to manage this disease.

PATIENTS AND METHODS

We conducted a retrospective audit of records and an analysis of archived formalin-fixed paraffin-embedded (FFPE) tissue from a single-centre population-based consecutive sample, to characterise the genetic landscape of 28 PeIN patients through DNA copy number analysis, RNA expression analysis, and gene set enrichment analysis (GSEA). The primary and secondary study outcomes were alterations in the genetic landscape of recurring vs non-recurring PeIN and clinical risk factors for recurrence.

RESULTS

In patients with PeIN recurrence, we identified seven significantly overexpressed genes (e.g., MYC, SCN8A and PSTK). Importantly, in the DNA analysis, the MYC locus was amplified (8q24.12-8q24.22 gain), the RNA analysis showed overexpression of MYC, and the MYC pathways (GSEA) were enriched compared to patients without PeIN recurrence. Limitations of the study include treatment heterogeneity and FFPE specimens challenging for RNA quality.

CONCLUSION

We identified seven overexpressed genes in patients with PeIN recurrence. Some of these transcripts were previously reported to be involved in invasive penile cancer. These findings provide molecular evidence, that PeIN is a precursor lesion with a correlation to invasive penile cancer, and could potentially lead to new topical treatment strategies for PeIN and low-risk penile cancer.

Risk of invasive penile cancer after treatment of penile intraepithelial neoplasia

OBJECTIVES

To examine the risk of progression and time to progression from penile intraepithelial neoplasia (PeIN) to invasive penile cancer in patients treated for PeIN with either surgery, laser ablation or topical treatment, and to examine recurrence risk after treatment of PeIN.

PATIENTS AND METHODS

Data on patients diagnosed with PeIN (n = 1122) between 2000 and 2020 were extracted from the Swedish National Penile Cancer Registry (NPECR). Progression was defined as a second registration of invasive penile cancer in this registry. Additionally, patient charts from the three largest cities in Sweden (Stockholm, Gothenburg and Malmö) were analysed with regard to both progression of PeIN to invasive cancer and recurrence risk after treatment.

RESULTS

The NPECR included 1122 patients with PeIN, of whom 23 were re-registered as having invasive penile cancer. In the 927 PeIN patients for whom data on treatment were available, re-registration of invasive cancer was seen in 13 patients after surgery, six after laser ablation, and one after topical treatment. The progression-free probabilities at 24 months in these treatment groups were 99.3% (95% confidence interval [CI] 0.987; 0.999), 100% (95% CI 1.000; 1.000) and 98.8% (95% CI 0.965; 1.000), respectively (log-rank test P = 0.192). In the Stockholm, Gothenburg and Malmö cohort, 253 patients with PeIN were followed and 14 developed invasive penile cancer. Of the 247 PeIN cases with data on treatment, four progressed after surgery, eight after laser ablation, and one after topical treatment. The progression-free probabilities at 24 months in these treatment groups were 98.2% (95% CI 0.956; 1.000), 86.2% (95% CI 0.744; 0.997) and 100% (95% CI 1.000; 1.000), respectively (log-rank test P < 0.001).

CONCLUSION

We found that PeIN has a low risk of progressing into invasive penile cancer regardless of treatment modality. However, laser ablation therapy is not recommended due to a higher risk of progression after such treatment compared to surgical and topical treatment. We recommend individualised follow-up protocols of PeIN based on treatment and lesion location.

Multicenter Evaluation of Morbidity and Predictors of Response to Imiquimod Treatment for Penile Intraepithelial Neoplasia

Introduction and objective

Imiquimod (IQ) is an immunomodulator used in the management of penile intraepithelial neoplasia (PeIN) lesions. However, IQ treatment may be associated with bothersome side effects (SEs). To date, studies reporting on this morbidity and evaluating predictors of response to IQ are scarce and included small cohorts. The primary objective of our study was to assess the response to IQ treatment, associated SEs, and potential predictors of response in the largest reported cohort to date.

Methods

We conducted a collaborative retrospective study involving patients diagnosed with PeIN and treated with IQ between 2010 and 2022 in two high-volume centers in the Netherlands and Belgium. Eligible patients had a confirmed diagnosis of PeIN and a minimum of 6-mo follow-up. Response to IQ was categorized as a complete response (CR), partial response, or no response. Descriptive statistics were generated and statistical tests included the Mann-Whitney U test for age and Fisher's exact test for categorical variables.

Key findings and limitations

The study included a total of 44 patients, with a median age of 65.4 yr (interquartile range 56-72). Of these patients, 28 (64%) achieved a CR, while 14 (32%) had a partial response and two (4.5%) had no response. In the CR subgroup, the 3-yr recurrence rate was 25%. No significant correlation was found between response status and age, human papillomavirus status, history of penile cancer, or circumcision before treatment. Among the patients, 50% reported SEs, mainly local pain, irritation, and bleeding, and 12% discontinued treatment because of SEs. There was no significant correlation between CR and the incidence or type of SE.

Conclusions and clinical implications

Despite the high overall response rate to IQ, a significant number of patients experienced local recurrence within 3 yr, and approximately half of the patients reported SEs. Our results did not identify any clinical or pathological factors or local SEs predictive of the therapeutic response to IQ. Prospective studies are needed to help in predicting which patients are likely to respond to IQ so that those who will not benefit can be spared the SEs associated with this treatment.

Patient summary

Our study looked at responses to imiquimod (IQ), an immune-based treatment in cream format, for precancerous lesions on the penis, called penile intraepithelial neoplasia. More than 95% of patients had a complete or partial response to IQ, but 50% reported side effects, and 25% of the group with a complete response had recurrence within 3 years. More research is needed to help in selecting patients who will benefit the most from IQ treatment.

Benefits and challenges of Mohs micrographic surgery for human papilloma virus-associated cutaneous malignancies: a systematic review

Mohs micrographic surgery is the gold standard for treating many types of skin cancer, particularly skin cancers of high-risk areas such as the face, genitalia, and digits, due to its tissue-sparing technique and low recurrence rates. The use of Mohs micrographic surgery for human papilloma virus-associated cutaneous malignancies has yet to be explored in a systematic review. The authors sought to assess outcomes including recurrence rates of Mohs micrographic surgery for human papilloma virus-associated cutaneous malignancies. PubMed was searched for the use of Mohs micrographic surgery in types of human papilloma virus-associated cutaneous malignancies. After application of exclusion and inclusion criteria, 33 articles were included. 700 cases from 33 studies were included. Overall recurrence rate following Mohs micrographic surgery was 39/478 (8.2%) at a mean follow-up time of 51.5 months. Recurrence rate for nail unit/digit squamous cell carcinoma was 10/103 (9.7%) at mean follow-up of 47.6 months. Recurrence rate for penile squamous cell carcinoma was 15/181 (8.3%) at mean follow-up of 45.9 months. Recurrence rate for Bowen's disease in extragenital areas was 11/189 (5.9%) at mean follow-up of 59.7 months. Patients overall reported satisfactory functional and cosmetic results. Mohs micrographic surgery demonstrates low recurrence rates and excellent functional and cosmetic outcomes in the treatment of human papilloma virus-associated cutaneous malignancies.

Penile Intraepithelial Neoplasia in an Asian Male: A Case Report

Penile intraepithelial neoplasia is a rare presentation in Asian males. It is usually observed as small lesions in the penis. It primarily influences the penetrative sexual intercourse ability and urination. Major risk factors associated are smoking, human papillomavirus infection, phimosis, tobacco consumption, and poor hygiene practices. Prompt diagnosis and treatment can lead to good prognostic outcomes. A 70-year-old male presented with penile swelling, weight loss, and burning micturition. The lesion on initial presentation looked malignant clinically due to the abnormal size of the lesion. This was later found to be premalignant/benign on histopathology. The lesion was timely treated saving the patient from losing organ functionality and from the terrifying effects of chemotherapy.

Squamous Cell Carcinoma In Situ-The Importance of Early Diagnosis in Bowen Disease, Vulvar Intraepithelial Neoplasia, Penile Intraepithelial Neoplasia, and Erythroplasia of Queyrat

Cutaneous squamous cell carcinoma (cSCC) is the second-most-prevalent malignancy in humans. A delayed diagnosis of cSCC leads to heightened invasiveness and positive surgical margins. Bowen's disease (BD) represents an early form of cSCC and presents as a small erythematous, photo-distributed, psoriasiform plaque. Although certain dermoscopy features in BD are quite characteristic, histopathology remains the gold standard for diagnosis and provides a severity-scoring system that assists in guiding appropriate treatment strategies. The classification of precancerous lesions of the vulva and penis has undergone multifarious transformations due to variations in clinical and histopathological characteristics. Presently, erythroplasia of Queyrat is categorized as a clinical variant of penile intraepithelial neoplasia (PeIN). The diagnoses of vulvar intraepithelial neoplasia (VIN) and PeIN present significant challenges and typically necessitate one or more biopsies, potentially guided by dermoscopy. Aceto-white testing demonstrates a notably high negative predictive value for genital precancerous lesions. Histopathological examination represents the gold-standard diagnosis in VIN and PeIN, while p16 and p53 immunostainings alongside HPV testing provide crucial diagnostic clues. The histopathologic features, degree of differentiation, and associations with lichen planus, lichen sclerosus, and HPV guide the selection of conservative treatments or surgical excision.

Pathology of Squamous Cell Carcinoma of the Penis: Back to Square One

The landscape of squamous cell carcinoma of the penis (SCC-P) has undergone a significant transformation since the new World Health Organization classification of genitourinary cancers and recent European Association of Urology/American Association of Clinical Oncology guidelines. These changes emphasize the necessity to categorize SCC-P into 2 groups based on its association with human papillomavirus (HPV) infection. This shift has major implications, considering that prior knowledge was derived from a mix of both groups. Given the distinct prognosis, treatment options, and staging systems observed for HPV-associated tumors in other body areas, the question now arises: will similar patterns emerge for SCC-P?

[Organ-preserving treatment as the most important option in the treatment of primary penile cancer]

The treatment of patients with penile cancer presents a significant challenge for therapists and patients alike. In this context, the focus must not only be on surgical techniques but rather on patient education and collaborative treatment planning. Consistent information about potential organ preservation and its consequences is essential. Following clinical examination and histological confirmation of the diagnosis, an organ-preserving and stage-adapted surgical procedure should be used in almost all cases. Intraoperatively, the aim should be to achieve tumour-free surgical margins through rapid pathological examination. Psycho-oncological support should be offered to all patients. Centralisation of treatment appears highly desirable for Germany, considering the excellent outcomes observed in English and Dutch centres. Until this has been achieved, following the valuable experience of the "Second Opinion Network for Testicular Tumours", the Second Opinion platform "eKonsil Urologie" (https://www.ekonsil.org) can be used as a reference.

Organ-sparing treatment for T1 and T2 penile cancer: an updated literature review

PURPOSE OF REVIEW

Penile cancer (PeCa) is an orphan disease due to its rare incidence in high-income countries. Traditional surgical options for clinical T1-2 disease, including partial and total penectomy, can dramatically affect patient's quality of life and mental health status. In selected patients, organ-sparing surgery (OSS) has the potential to remove the primary tumor with comparable oncologic outcomes while maintaining penile length, sexual and urinary function. In this review, we aim to discuss the indications, advantages, and outcomes of various OSSs currently available for men diagnosed with PeCa seeking an organ-preserving option.

RECENT FINDINGS

Patient survival largely depends on spotting and treating lymph node metastasis at an early stage. The required surgical and radiotherapy skill sets cannot be expected to be available in all centers. Consequently, patients should be referred to high-volume centers to receive the best available treatments for PeCa.

SUMMARY

OSS should be used for small and localized PeCa (T1-T2) as an alternative to partial penectomy to preserve patient's quality of life while maintaining sexual and urinary function and penile aesthetics. Overall, there are different techniques that can be used with different response and recurrence rates. In case of tumor recurrence, partial penectomy or radical penectomy is feasible, without impacting overall survival.

European Association of Urology-American Society of Clinical Oncology Collaborative Guideline on Penile Cancer: 2023 Update

CONTEXT

Penile cancer is a rare disease but has a significant impact on quality of life. Its incidence is increasing, so it is important to include new and relevant evidence in clinical practice guidelines.

OBJECTIVE

To provide a collaborative guideline that offers worldwide physician and patient guidance for the management of penile cancer.

EVIDENCE ACQUISITION

Comprehensive literature searches were performed for each section topic. In addition, three systematic reviews were conducted. Levels of evidence were assessed, and a strength rating for each recommendation was assigned according to the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology.

EVIDENCE SYNTHESIS

Penile cancer is a rare disease but its global incidence is increasing. Human papillomavirus (HPV) is the main risk factor for penile cancer and pathology should include an assessment of HPV status. The main aim of primary tumour treatment is complete tumour eradication, which has to be balanced against optimal organ preservation without compromising oncological control. Early detection and treatment of lymph node (LN) metastasis is the main determinant of survival. Surgical LN staging with sentinel node biopsy is recommended for patients with a high-risk (≥pT1b) tumour with cN0 status. While (inguinal) LN dissection remains the standard for node-positive disease, multimodal treatment is needed in patients with advanced disease. Owing to a lack of controlled trials and large series, the levels of evidence and grades of recommendation are low in comparison to those for more common diseases.

CONCLUSIONS

This collaborative penile cancer guideline provides updated information on the diagnosis and treatment of penile cancer for use in clinical practice. Organ-preserving surgery should be offered for treatment of the primary tumour when feasible. Adequate and timely LN management remains a challenge, especially in advanced disease stages. Referral to centres of expertise is recommended.

PATIENT SUMMARY

Penile cancer is a rare disease that significantly impacts quality of life. While the disease can be cured in most cases without lymph node involvement, management of advanced disease remains challenging. Many unmet needs and unanswered questions remain, underlining the importance of research collaborations and centralisation of penile cancer services.

British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma in situ (Bowen disease) 2022

The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for the management of squamous cell carcinoma in situ (SCC in situ). The document aims to: offer an appraisal of all relevant literature up to 13th August 2021, focusing on any key developments; address important, practical clinical questions relating to the primary guideline objective; provide guideline recommendations and if appropriate research recommendations.

Immunotherapy for the treatment of penile intraepithelial neoplasia associated with human papilloma virus type 16 using topical imiquimod and human papilloma virus vaccination

Penile intraepithelial neoplasia (PeIN) is frequently associated with human papilloma virus (HPV). Three cases of PeIN associated with HPV-type 16 were successfully treated with topical imiquimod and concurrent HPV vaccination. Human papilloma vaccine protects against oncogenic human papilloma viruses. In New Zealand, a decline in incidence of PeIN is anticipated with the recent funding of human papilloma vaccine for boys and young men aged 9-26 years. Therefore, HPV vaccination may have a role for treatment of PeIN and prophylaxis.