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

Impact of TP53 Alterations on Clinical Outcomes in Penile Squamous Cell Carcinoma

BACKGROUND

Penile squamous cell carcinoma (PSCC) is a rare, aggressive malignancy with a high risk of mortality due to metastasis. A comprehensive understanding of its mutational landscape is critical for improving early detection and therapeutic strategies.

METHODS

We analyzed tissue samples from 28 patients with PSCC treated at the Cancer Hospital of the Chinese Academy of Medical Sciences between January 2019 and March 2023. DNA from primary tumors and/or matched inguinal lymph nodes underwent targeted sequencing. Somatic mutations were profiled to compare primary and metastatic lesions. Statistical analyses assessed associations between mutational features, clinical outcomes, and treatment responses.

RESULTS

A total of 980 mutations were identified across 354 genes. Frequently mutated genes included TP53 (67.5%), TERT (45%), CDKN2A (40%), FAT1 (37.5%), and NOTCH1 (30%). Copy number variations (CNVs) revealed amplifications in EGFR, SOX2, and MSH6 and deletions in CDKN2B and CDKN2A. A strong correlation was observed between mutational profiles of primary and metastatic lesions (r = 0.61, P < .001). Metastatic tumors exhibited higher tumor mutational burden (TMB) than primary tumors (38.9% vs. 9.5%, P = .030) and displayed a greater prevalence of mismatch repair deficiency-associated mutational signatures. Patients with higher TP53 mutation frequencies responded more favorably to immune checkpoint inhibitors (P = .024), with treatment efficacy strongly correlated (AUC = 0.938).

CONCLUSION

Key mutational alterations in PSCC, including high TMB and TP53 mutations, have significant implications for early diagnosis and personalized therapies. These findings support the potential use of specific genetic markers to guide targeted therapeutic approaches.

Metastatic cancer to the penis: a multi-institutional comprehensive analysis of 31 patients

INTRODUCTION

The metastatic spread of cancer to the penis is a very rare clinical entity generally associated with disseminated disease and poor prognosis. The aim of this paper was to show the outcomes of a series of patients treated for metastatic cancer to the penis and enhance the understanding and the management of penile metastasis in order to improve patients' care and outcomes.

METHODS

We retrospectively analyzed the medical records of 31 patients diagnosed with metastatic cancer to the penis and treated at eight Ligurian urological departments between January 2014 and January 2024. Clinical characteristics, physical examination findings, diagnostic evaluations, treatment options and follow-up data were assessed.

RESULTS

27 (87%) patients had a prior history of malignancy with a metachronous metastasis. The most common primary site of malignancy was the genitourinary tract (71.1%) followed by the gastrointestinal tract (16.1%). The time interval from the diagnosis of the primary tumour to the detection of the penile metastasis was 36.0 months. The penile metastasis generally appeared with a mass (54.8%) and pain (29%), more rarely with priapism (6.5%), oedema (6.5%) and hematuria/urinary disorders (3.2%). The metastatic lesion required a total penectomy in 17 (54.8%) patients and a partial penectomy in 8 patients (25.8%). At a follow-up of 15.9 (1-75) months, 4 (18.2%) patients were still alive with disease.

CONCLUSIONS

Our data confirmed penile metastasis as a rare entity usually associated with clinical symptoms involving the penis in the context of a known primary malignancy, mainly from the neighboring pelvic organs, with a poor prognosis. The majority of our patients required a total penectomy with a negative impact on their quality of life. These aspects highlighted the importance of a penile examination and an early diagnosis of a penile metastasis during the follow-up schedule of many patients with a history of previous oncologic disease.

Evaluating the role of adjuvant therapy in improving outcomes for patients with lymph node-positive penile cancer following surgical management

Penile squamous cell carcinoma (PeCa) is a rare malignancy with poor outcomes in pN+ cases. Prognosis is particularly poor in patients with extranodal extension (ENE) or pelvic lymph node (PLN) involvement. Despite advancements in surgical techniques, the role of adjuvant therapy (AT)-including radiotherapy (ART), chemotherapy (ACT), and chemoradiotherapy (ACRT)-following radical lymphadenectomy (LAD) remains undefined, and optimal strategies are yet to be established. This review evaluates the impact of AT on survival and recurrence in pN+ PeCa, assesses associated toxicities, and explores personalized treatment approaches. A systematic search of PubMed, Web of Science, Cochrane Library, and Scopus identified studies published between January 2000 and December 2024. Eligible studies focused on AT after LAD, including radiotherapy, chemotherapy, targeted therapies, or combination regimens. ART improves locoregional control in patients with ≥ 2 positive inguinal lymph nodes, particularly in HPV+ tumors. ACT with TIP or TPF regimens enhances disease-free and overall survival in high-risk pN+ patients, including those with PLN involvement. ACRT provides modest benefits in ENE cases but is associated with significant toxicity. Emerging biomarkers, such as HPV status and p53 mutations, show potential for predicting treatment response, while novel agents and immunotherapies represent promising investigational areas. AT improves outcomes in pN+ PeCa but requires individualized strategies based on risk factors and molecular profiles. Prospective, collaborative studies are essential to refine AT protocols, reduce toxicities, and integrate immunotherapies, targeted agents, and biomarkers into treatment algorithms. Multidisciplinary management and centralized care are critical for optimizing outcomes in this malignancy.

Current Role of Robotic Inguinal Lymphadenectomy in Penile Cancer

Lymph node (LN) metastases are the most significant prognostic factor in penile cancer (PeC), so timely detection and adequate treatment of LN metastases is crucial. While open inguinal LN dissection (ILND) remains the standard for most cases, its morbidity has spurred interest in robot-assisted videoendoscopic ILND (RA-VEIL). We summarize current international guidelines and evidence on the current role of RA-VEIL in LN management for PeC. RA-VEIL is feasible and has been associated with fewer wound complications and an equivalent nodal yield in comparison to open ILND. However, lymphatic complications appear to remain the same. Therefore, for nodal staging in patients with cN0 PeC, sentinel node biopsy is preferred over RA-VEIL. In node-positive patients, more studies, especially prospective studies, are needed to confirm the long-term oncological safety of RA-VEIL before it can be incorporated in guidelines as a recommended treatment option. PATIENT SUMMARY: For patients with penile cancer, spread to the lymph nodes is a crucial factor in determining probable survival. We summarize the current role of a robot-assisted telescopic technique under video guidance for lymph node management. This technique is feasible and may lead to fewer wound infections, but lymphatic complications seem to be the same as with open surgery. More studies are needed to confirm the long-term cancer control outcomes of this technique.

Biomarkers of response to antibody-drug conjugates (TROP2 and nectin-4) and the immune microenvironment (NKG7, PD-L1, and B7-H3) in penile squamous cell carcinoma

OBJECTIVES

We aimed to assess the expression of biomarkers of response to antibody-drug conjugates (TROP2 and nectin-4) and immune microenvironment (NKG7, PD-L1, and B7-H3) in penile squamous cell carcinoma (pSCC).

METHODS

Our archive was queried for patients who had a penectomy for pSCC between 2000 and 2022. Primary tumors were immunostained for B7-H3 and NKG7, while metastatic specimens were immunostained for TROP2 and nectin-4. Expression of PD-L1, TROP2, and nectin-4 in primary tumors was previously characterized. H-scores (0-300) were used to quantify expression. Associations between biomarkers, tumor-infiltrating lymphocytes (TILs), and clinicopathologic and outcome parameters were evaluated.

RESULTS

For both TROP2 and nectin-4, H-scores within the lymph node metastases were higher compared to those within the primary tumors (mean, 264.5 vs 244.8, P = .0003; mean, 170.6 vs 146.7, P = .05, respectively; 33 paired specimens). For B7-H3 (n = 107), 32.7% of the primary tumors had an H-score of more than 0. In 34.8% of the cases, NKG7 expression was observed in 25% to 50% of the TILs. A significant association was noted between TIL density, B7-H3, NKG7, and PD-L1 expression.

CONCLUSIONS

Therapeutic strategies targeting TROP2 and nectin-4 hold promise for patients with advanced pSCC. The potential of PD-L1, B7-H3, and NKG7 for predicting response to immunomodulatory treatment warrants further research.

Dynamic sentinel node biopsy in penile cancer: 25 years of experience at a tertiary oncological center

INTRODUCTION

Penile cancer lymph node (LN) metastases are critical prognostic factors. The European Association of Urology (EAU) guidelines recommend dynamic sentinel node biopsy (DSNB) as a less invasive alternative for cN0 patients with intermediate- to high-risk tumors. Due to the rarity of penile cancer, lymph node staging tends to be underutilized, and few centers have a significant number of patients to develop the DSNB technique and observe its evolution over time. Previously, our series reported a sensitivity of 66%, and our aim is to contribute to the available evidence, based on 25 years of real-world experience.

MATERIALS AND METHODS

Retrospective single-center study involving 95 groins of 51 patients with intermediate or high-risk penile squamous carcinoma, who underwent DSNB between November 1999 and July 2024. Clinical data, including histology, surgical treatment, and complications, were analyzed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Complications were registered using the Clavien-Dindo system.

RESULTS

The median age of patients was 60 (range 30-84) years. 10/51 patients (21%) had metastatic sentinel node. DSNB successfully identified sentinel nodes in 95.7% for right and 89.5% for left groins. The false-negative rate was 8.1%, with a sensitivity of 77%, specificity of 100%, PPV of 100%, and NPV of 92%. 18% (9/51) of patients suffered complications being most of them minor (6/9), 3 patients experimented major complications.

DISCUSSION AND CONCLUSION

The updated DSNB outcomes show improved diagnostic accuracy compared to previous reports, reflecting enhanced techniques and learning curves. The study highlights the accuracy and the low morbidity of DSNB.

Emerging Advances in the Molecular Landscape of Penile Cancer and Their Implications for Precision Medicine

OPINION STATEMENT

Penile cancer is a rare but aggressive malignancy, characterized by early lymphatic spread which is the most critical prognostic factor. Treatment options for patients with locally advanced and metastatic disease are limited, primarily relying on cisplatin-based chemotherapy, which is characterized by high toxicity and early resistance. In recent years, there has been a growing interest on translational research exploring the tumor microenvironment, enabling the identification of novel potential therapeutic targets. Emerging preclinical evidence supports the use of immune checkpoint inhibitors, antibody-drug conjugates and novel exploratory therapies targeting myeloid-derived suppressor cells and tumor associated macrophages, as well as their combinations. However, robust phase III trials investigating such therapies are currently lacking. A deeper understanding of the penile cancer immune landscape and the role of specific mutations in carcinogenesis, might lead to the development of novel combination strategies to overcome cisplatin resistance and disease progression, and to a better selection of patients for inclusion in future clinical trials.

Neutrophil-to-lymphocyte ratio predicts a poor prognosis for penile cancer with an immunosuppressive tumor microenvironment

Background

Chronic inflammation related to poor genital hygiene is a well-recognized pathogenic trigger for penile cancer (PC). The neutrophil-to-lymphocyte ratio (NLR) is a simple, reproducible systemic inflammatory marker and has been reported to indicate unfavorable outcomes. However, previous studies were limited by small sample sizes, confounding prognostic factors and a lack of high-quality evidence demonstrating the significance of the NLR in PC.

Methods

A large multicenter cohort of 582 PC patients who underwent radical inguinal lymphadenectomy with definitive pN stage information was assessed. Univariate and multivariate Cox regression analyses were performed to investigate the prognostic value of inflammation-related markers. Propensity score matching (PSM) was used to minimize confounding prognostic clinicopathological features. Immunofluorescence was used to assess the immunosuppressive tumor microenvironment (TME).

Results

A high preoperative NLR (≥ 3.0) was associated with advanced pT, pN, and pathological grade and lymphovascular invasion in PC patients. After PSM to eliminate interference from clinical factors, pN and the NLR were found to be independent prognostic indicators (both p<0.001). PC patients with high NLRs had shorter progression-free survival (PFS) and poorer cisplatin-based chemotherapy and PD-1 immunotherapy response. We also found that the NLR is associated with proinflammatory cytokine secretion and increased N2 tumor-associated neutrophils (TANs) infiltration and CD8+ T-cell exhaustion in TME. N2 TANs induced neutrophil extracellular trap formation might contribute to tumor progression and resistance in high-NLR PC patients.

Conclusions

The NLR is an effective, simple and independent prognostic indicator for PC. A high NLR is associated with an immunosuppressive TME and poor outcomes.

Prospective validation of clino-radio-pathological risk scoring system (CRiSS) for prediction of inguinal lymph-nodes metastasis in squamous cell carcinoma of penis

OBJECTIVE

To prospectively validate the diagnostic performance of Clino-radio-pathological Risk Scoring System (CRiSS) for prediction of inguinal lymph-node metastasis (ILNM) in squamous cell carcinoma of penis.

MATERIALS AND METHODS

A prospective observational study of all patients with SCC penis was conducted between January 1, 2021, and December 31, 2023, at our institute. Data regarding all CRiSS parameters and MRI features of >8mm size and presence of necrosis or irregular outline were recorded, and patients were assigned CRiSS scores and groups. All included patients were subjected to primary surgery (partial/total penectomy) along with bilateral radical inguinal lymph-node dissection. Multivariate logistic regression analysis was performed with both USG and MRI. Sensitivity and specificity were calculated for CRiSS scores and groups.

RESULTS

A total of 86 patients were enrolled during the study period. Size of lymph-node greater than 8mm (HR: 4.502) and irregular outline or presence of necrosis (HR: 4.002) in MRI were significantly associated with ILNM along with all other CRiSS variables in multivariate analysis. CRiSS groups had a sensitivity of 100% and a specificity of 85.71%. CRiSS could diagnose ILNM with a sensitivity of 100% in both palpable and non-palpable groins.

CONCLUSIONS

CRiSS can identify patients in whom ILND can be avoided with a zero false negative rate, irrespective of clinical lymph-node status. CRiSS can identify the patients who are candidates for ILND even after a negative FNAC and biopsy of palpable lymph-nodes. It can identify patients for concomitant penectomy and ILND. MRI is a suitable replacement for ultrasonography if not standard of care (CRiSS-M).

Retifanlimab in Advanced Penile Squamous Cell Carcinoma: The Phase 2 ORPHEUS Study

BACKGROUND AND OBJECTIVE

Patients with advanced penile squamous cell carcinoma (PSCC) have poor outcomes and very limited therapeutic options are available. Most PSCC cases have high PD-L1 expression, which is associated with worse prognosis. Immunotherapy targeting PD-L1 could benefit patients with PSCC. Our aim was to evaluate the efficacy and safety of the anti-PD-1 antibody retifanlimab in patients with advanced/metastatic PSCC.

METHODS

ORPHEUS was a single-arm, multicenter, phase 2 trial in 18 patients with advanced/metastatic PSCC, previously untreated with anti-PD-1/anti-PD-L1 agents. Patients received retifanlimab 500 mg intravenously every 4 wk for up to 2 yr. The primary endpoint was the objective response rate (ORR) according to Response Evaluation Criteria in Solid Tumors v1.1. Secondary endpoints included the clinical benefit rate (CBR), disease control rate, duration of response (DoR), time to response, progression-free survival (PFS), overall survival (OS), maximum tumor shrinkage, and safety. The Wilson method was used for the primary endpoint, and the Clopper-Pearson and Kaplan-Meier methods for secondary endpoints.

KEY FINDINGS AND LIMITATIONS

Median follow-up was 7.2 mo. The ORR was 16.7% (95% confidence interval [CI] 5.8-39.2); three patients had a partial response. Median DoR was 3.3 mo (range 1.8-8.5). The CBR was 22.2% (95% CI 6.4-47.6%). Median PFS was 2.0 mo (95% CI 1.6-3.3) and median OS was 7.2 mo (95% CI 3.0-9.8). One patient (5.6%) experienced grade 3 treatment-related adverse events (AEs). There were no grade >= 4 treatment-related AEs. The small sample size is the main limitation.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Single-agent retifanlimab exhibited signals of clinical activity in advanced/metastatic PSCC, with no new safety signals. Further investigation of retifanlimab in this setting is warranted.

PATIENT SUMMARY

Advanced penile cancer of the squamous cell type is a rare tumor with poor prognosis. The aggressiveness of this cancer is usually associated with high levels of a protein called PD-L1. We investigated whether retifanlimab, an immunotherapy drug against PD-1, has activity against this type of penile cancer. Tumor regression or stabilization occurred in one-third of the patients and the side effects were manageable.

Empowering people affected by penile cancer: towards a model for supportive self-management

Improvements in the quality of penile cancer management are difficult due to the rarity of the condition and a limited evidence base for treatment decisions. Penile cancer and some of its highly morbid treatments can cause profound psychosexual and physical effects that negatively impact quality of life. Multidisciplinary interventions are required to equip patients with the support necessary to manage their emotional, physical, work, and lifestyle challenges to optimize health, well-being, and recovery. This paper outlines a model of supported self-management, which is a novel model of care for people with penile cancer to mitigate disease and treatment morbidity.

Identification and analysis of microplastics in human penile cancer tissues

BACKGROUND

Widespread pollution from microplastics (MPs) has been identified as a significant contributor to adverse health effects in humans. This research aimed to investigate the presence of MPs in human penile cancer.

METHODS

The Laser Infrared Imaging Spectrometer (LDIR) was employed to detect and analyze MPs in the cancerous tissue (CT) and adjacent normal tissue (ANT) of 17 patients diagnosed with penile cancer. Subsequently, the abundance, sizes and types of MPs in CT were compared to those in the corresponding ANT.

RESULTS

Nine types of MPs were identified in 85.3 % of the samples analyzed, with an average abundance of 6.42 particles per gram. The most prevalent types of MPs were polyethylene (PE), polypropylene (PP), and polyvinyl chloride (PVC), primarily falling within the 20-50 μm size range. MPs exhibited higher abundance and diversity in CT compared to ANT, with comparable size distributions evident in both of two areas.

CONCLUSION

Our study firstly confirm the presence of MPs in tissue samples from patients with penile cancer. Additionally, the abundance and variety of MPs in cancerous tissue are significantly higher than in adjacent normal tissue, although they had similar size distributions.

Prognostic effects of different nephroureterectomy techniques for upper urinary tract urothelial carcinoma: a network meta-analysis

BACKGROUND

Upper urinary tract urothelial carcinoma (UTUC) is an aggressive malignant tumor, with surgical intervention as the primary treatment. This study evaluates the prognostic effects of laparoscopic radical nephroureterectomy (LNU), open radical nephroureterectomy (ONU), robot-assisted laparoscopic radical nephroureterectomy (Robotic LNU), and hand-assisted laparoscopic radical nephroureterectomy (Hand LNU) in the treatment of UTUC through a network meta-analysis.

METHODS

A systematic search of the PubMed, EMBASE, Cochrane, and Web of Science databases was conducted for randomized controlled trials meeting the criteria from database inception until April 2024. Bayesian network meta-analysis was performed to compare the effects of each surgical method on overall survival (OS), cancer-specific survival (CSS), and overall recurrence rate (ORE).

RESULTS

Seventeen randomized controlled trials were included in this network meta-analysis. The results indicated that LNU significantly improved CSS compared to ONU [HR = 0.81, 95%CI= (0.7, 0.93)], while there were no significant differences between Hand LNU and Robotic LNU compared to ONU. Among minimally invasive surgeries, Hand LNU significantly shortened CSS compared to LNU [HR = 1.49, 95%CI=(1.1, 2.03)]. Regarding ORE, no significant differences were found between LNU, Hand LNU, and Robotic LNU compared to ONU, although LNU had a higher recurrence rate than Robotic LNU [HR = 1.705, 95%CI=(1.007, 3.001)]. For OS, both LNU [HR = 0.84, 95%CI=(0.75, 0.94)] and Robotic LNU [HR = 0.81, 95%CI=(0.68, 0.96)] were significantly better than ONU, whereas Hand LNU significantly shortened OS compared to LNU and Robotic LNU. There were no significant differences in progression-free survival (PFS) between LNU and ONU. The cumulative efficacy ranking indicated that Robotic LNU ranked highest for ORE and OS, while LNU ranked first for CSS.

CONCLUSION

Robotic LNU demonstrates advantages in prolonging OS and reducing recurrence rates, while LNU excels in improving CSS. Although Hand LNU shows suboptimal effects in some comparisons, it remains valuable, and surgical choices should be based on individualized needs.

A review of the carcinogenic potential of human papillomavirus (HPV) in urological cancers

Direct skin-to-skin contact during intimate sexual contact with a human papillomavirus (HPV)-positive individual is often the cause of HPV infection. In addition, many studies have been written up to date that look at the role of HPV in the growth of other types of tumors. Not all urological cancers are associated with HPV. However, penile cancer (PC) is often caused by HPV, especially high-risk types. HPV-16 has been the most frequent (68.3%), followed by HPV-6 (8.1%) and HPV-18 (6.9%). An increased risk of getting certain types of urinary cancers like prostate, bladder, testicular, and kidney has also been linked to these infections. Additionally, HPV may play a part in continuous inflammation and cancer progression in different organs and tissues. So, making HPV vaccine programs available to more people of the male sex around the world could significantly lower the number of urinary cancers caused by HPV. The critical effects of HPV on different types of urologic cancers (UCs), such as testicular, prostate, penile, and kidney cancer, and the importance of HPV vaccination have been seen in this study.

Treatment strategies in human papillomavirus-related advanced penile cancer

Penile cancer is a rare neoplasm with heterogeneous prevalence influenced by risk factors such as smoking, poor hygiene and human papillomavirus (HPV) infection. Southern Africa, South America and Southeast Asia have the highest incidence of this disease. Penile squamous cell carcinomas (PSCCs) account for the majority of instances of penile cancer, with HPV-related carcinogenesis implicated in up to half of them. Increases in PSCC incidence in industrialized nations parallel the rising high-risk HPV infection rates, particularly HPV-16. Early-stage, localized PSCC is often manageable, but treatment options in advanced disease remain limited, with poor survival outcomes. Emerging evidence suggests that HPV-positive PSCC might exhibit unique therapeutic responses, including increased sensitivity to radiotherapy and chemotherapy, as has been observed in HPV-driven head and neck squamous cell carcinoma. Results of studies in HPV-positive PSCC demonstrate improved responses to chemoradiotherapy and immunotherapy, underscoring the potential for tailored treatments and de-escalation. Additionally, incorporating immunotherapy with radiotherapy in HPV-driven PSCC might provide greater oncological benefits than standard chemotherapy. These observations suggest that treatment strategies for HPV-positive PSCC might benefit from de-escalated chemoradiotherapy regimens or immunotherapy incorporation, potentially optimizing efficacy while minimizing toxic effects. Furthermore, biomarkers such as tumour mutational burden, programmed cell death ligand 1 expression, and genetic alterations could be crucial for predicting treatment response. Comprehensive biomarker assessment and accurate HPV status determination are essential for developing patient-tailored therapeutic strategies. These data provide evidence of the potential benefits of individualized approaches based on tumour biology and biomarker profiles.

Early and Late Complications Associated with Penile Cancer Surgery and the Impact of Human Papillomavirus Status: Findings from a Retrospective Norwegian Cohort Study

Background and objective

Penile cancer (PeCa) and penile intraepithelial neoplasia (PeIN) are rare diseases, and the burden of complications associated with surgery remains under-reported. The objective was to evaluate the early (≤30 d) and late (>30 d) complications and the impact of human papillomavirus (HPV) status.

Methods

A retrospective analysis was conducted of a cohort consisting of 201 consecutive and treatment-naïve patients with PeCa/PeIN undergoing surgery (penile sparing, and partial and total amputation) between January 1, 2000 and December 31, 2023 at a tertiary centre as part of a centralised regional service.

Key findings and limitations

The median follow-up time was 39 (interquartile range 21, 76) mo. The early and late patient complication rates were 45% and 38%, respectively. Of the patients, 18.5% experienced two or more early complications. A majority (80%) of early complications were minor (Clavien-Dindo ≤2). There was a 1% admission rate to the intensive care unit, but no deaths were recorded within 30 d. Body mass index (BMI)was a significant predictor of early complications (p = 0.01). Late complications included chronic wound irritation (10%) and urethral stricture (11%). The latter was highest among those who had undergone partial amputation. One in four patients underwent reoperation due to recurrence during follow-up. HPV status had no association with the rate of either early or late complications.

Conclusions and clinical implications

PeCa surgery is associated with a relatively high complication burden, in both the early and the late postoperative period. Lymph node surgery further adds to the morbidity profile. BMI was a significant predictor of having an early complication, while HPV status did not affect the rate of early or late complications.

Patient summary

Penile cancer surgery is associated with a high rate of complications in early as well as late postoperative period. However, most of these complications are not severe. Body mass index was a significant predictor of an early complication, but human papillomavirus status was not associated with the risk of complications.

Complex Decision Making for Individual Patients With Penile Cancer: Benchmarking Divergent Practices in European High-Volume Reference Centers: Results From eUROGEN Survey

BACKGROUND AND OBJECTIVES

Penile cancer (PeCa) remains a challenge due to its rarity and the lack of prospective studies, leading to treatment challenges and controversies. Guidelines offer recommendations, but discrepancies with clinical practice persist. This study analyzed treatment practices among specialists managing high-risk PeCa in European reference centers.

METHODS

A cross-sectional survey included 39 PeCa specialists from 13 European countries representing high-volume centers. Descriptive analysis assessed (neo)adjuvant therapy preferences, systemic regimen choices, immunotherapy use, and next-generation sequencing (NGS) integration.

KEY FINDINGS AND LIMITATIONS

Variations in managing high-risk PeCa, especially in (neo)adjuvant therapy utilization, were noted among participants. The differences highlight the influence of professional backgrounds and variations in treatment approaches between participants. Systemic regimen preferences and immunotherapy utilization also varied. Limited NGS integration indicated gaps in precision medicine adoption. Limitations included sample size, self-reported data, and cross-sectional design.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This study offered insights into PeCa management by specialists in high-volume European reference centers, stressing the need for evidence-based recommendations, guideline adherence, and collaboration to enhance PeCa care.

PATIENT SUMMARY

Managing PeCa is complex due to its rarity and treatment controversies. This study examined practices among specialists in European reference centers, revealing treatment variations. The findings emphasize the importance of evidence-based care and collaboration in optimizing PeCa management.

Canadian Association of Radiologists Cancer Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Cancer Expert Panel is made up of physicians from the disciplines of radiology, medical oncology, surgical oncology, radiation oncology, family medicine/general practitioner oncology, a patient advisor, and an epidemiologist/guideline methodologist. The Expert Panel developed a list of 29 clinical/diagnostic scenarios, of which 16 pointed to other CAR guidelines. A rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of the remaining 13 scenarios. Recommendations from 21 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop the recommendation for these scenarios. During recommendation formulation, one additional scenario was mapped to an existing CAR guideline scenario, leaving 12 scenarios with new recommendations. The guideline focuses on cancer diagnosis and does not cover cancer staging, follow-up, and surveillance. This guideline presents the methods of development and the referral recommendations for suspected pancreatic cancer, suspected liver cancer, incidental liver mass, incidental colon mass or suspected colon cancer, suspected anal cancer, suspected penile cancer, suspected cervical cancer, suspected endometrial/uterine cancer, suspected vulvar cancer, suspected vaginal cancer, suspected haematologic malignancies, and suspected skin cancer. The guideline also points to other CAR guidelines for suspected neck, thyroid, brain, lung, intracardiac/pericardial, esophageal/gastric, renal, adrenal, bladder, testicular, prostate and ovarian cancers, suspected soft tissue mass or tumour, suspected bone tumour, suspected bone tumour --myeloma, suspected spine tumours, and incidental lung cancer.

Tumor-infiltrating plasma cells are a prognostic factor in penile squamous cell carcinoma

Penile cancer (PeCa) is a rare disease with poor prognosis in the metastatic stage. Neither effective adjuvant nor palliative therapeutic options are available. Research efforts in this field have so far failed to establish robust predictors of survival. To identify prognostic targets in PeCa, the current project focused on characterizing the tumor microenvironment (TME). A study cohort of 93 men with PeCa was used for the construction of a tissue microarray and immunohistochemical staining for CD3, CD4, CD8, CD20, CD56, CD138, FoxP3, and PD-L1. The quantity and spatial distribution of tumor-infiltrating immune cells were analyzed using digital image analysis. PD-L1 staining of tumor and immune cells was manually scored (combined positivity score (CPS)). T cells, T helper cells, cytotoxic T cells (CTLs), and regulatory T cells were detected in > 90% of PeCa and B cells in 88%, plasma cells in 85%, and NK cells in 23%. Approximately 50% of the PeCa samples were PD-L1 positive. In the univariate survival analysis, high PD-L1 CPS, plasma cells, CTLs, and B cells were significantly associated with favorable overall survival (OS), and the latter two with adverse recurrence-free survival. In multivariate analysis, plasma cells remained a significant factor for favorable OS (p = 0.04). In this study, the immune cells in the TME, especially plasma cells, were favorably associated with patient survival compared to other established prognostic factors in PeCa. Contemporarily, plasma cells have been discussed in the light of contributing to responses to modern immunotherapies. The results of this study support this notion.

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.

Penile intraepithelial neoplasia incidence, clinical classification, microenvironment and implications for imiquimod treatment

OBJECTIVES

To provide an outline of the existing data on penile intraepithelial neoplasia (PeIN), as well as a narrative review on imiquimod (IQ; a toll-like receptor 7 agonist) treatment and immune microenvironment markers that may predict response to treatment.

METHODS

A narrative review of the literature from 2000 to the present was conducted on PubMed, and we describe the most relevant data and cross references.

RESULTS

The incidence of PeIN is increasing. Local therapy with IQ may offer an easy applicable treatment with complete response rates of up to 63% but can be associated with considerable side-effects. There is no conclusive data on the optimal treatment schedule for PeIN, but evaluation of treatment results for other human papillomavirus-related pre-malignancies suggest three times a week for a duration up to 16 weeks. There are no published studies concerning the PeIN immune microenvironment. However, findings from the few studies on penile cancer and pre-cancerous vulvar and cervical lesions imply that specific immune cell subpopulations can serve as future predictors for successful immunomodulation treatments such as IQ.

CONCLUSIONS

Overall, limited data are available on IQ treatment for PeIN and no published data exists on the PeIN immune microenvironment. Further translational studies are warranted to gain more understanding on the pathophysiology of PeIN and potential predictors of progression and of response to topical treatments.

Diagnostic trajectories of patients with rare cancer in the Netherlands: results from a nationwide cross-sectional survey

Diagnosing rare cancers is challenging and often leads to prolonged diagnostic trajectories. This study investigated the diagnostic trajectory of patients with rare cancers in The Netherlands. Data from 1541 patients were recruited via patient advocacy in a national online survey on their diagnostic trajectory, such as first general practitioner (GP) consultation to hospital referral and number of hospital visits before final diagnosis. Differences between solid vs. non-solid tumours and EURACAN domains were explored. Diagnostic timelines varied from less than 3 months to over 12 months. Most patients (76.0%) first consulted their GP before going to a hospital. 76.3% of all patients were referred to a hospital within less than 3 months. 32.1% reported receiving an incorrect diagnosis, and 44.6% of them underwent treatment or medication for the (perceived) incorrect diagnosis. Patients with solid vs. non-solid rare cancers trajectories differed significantly for treatment hospital, route to diagnosis, correctness of initial diagnosis, and number of hospital visits before correct diagnosis (all p < 0.001). Patients with neuroendocrine (NET; 21.7%) and endocrine tumours (17.5%) experienced longer GP-to-hospital visit waiting times. Patients with non-solid cancers often received a correct diagnosis after one hospital visit (75%) when compared with patients with solid cancer (2+ = 57.7%). Those with rare skin cancer and non-cutaneous melanoma, head and neck, and thoracic cancer visited multiple hospitals before an accurate diagnosis (56.7%, 53.8%, and 50.0%). Patients with rare cancers face significant challenges with diagnostic delays and inaccuracies. Researching symptom signatures and investing in regional clinical networks might improve diagnostic timelines.

French AFU Cancer Committee Guidelines-Update 2024-2026: Penile cancer

OBJECTIVE

Update of the recommendations for the management of penile lesions.

MATERIALS AND METHODS

Comprehensive PubMed review from 2022 of the literature on the diagnosis, treatment and follow-up of penile tumours. The level of evidence of the studies was assessed.

RESULTS

A total of 95% of infiltrating penile cancers are squamous cell carcinomas, one-third of which are related to human papillomavirus (HPV) infection. Clinical examination can reveal the size of the lesion, its location, its proximity to the urethral meatus and its infiltration depth. Urinary and sexual function should be assessed. Magnetic resonance imaging (MRI) is the gold standard for local assessment. Penile tumours are classified as low-risk (≤pT1a and well-differentiated G1), intermediate-risk (pT1a G2) or high-risk (≥pT1b, G3, or sarcomatoid contingent). Lymph node assessment in penile cancer is fundamental. The sentinel node technique is recommended for the evaluation of cN0 patients with tumours of intermediate risk or higher. 18FDG PET is recommended for cN+ patients. Surgery is the standard treatment locally and depends on the size, location and grade of the tumour. Topical treatment or brachytherapy may be indicated in some cases. Radical inguinal curettage (RIC) is recommended for stages cN1/cN2. Neoadjuvant chemotherapy is recommended for patients with cN3-stage lesions, combined with RIC in responders. Metastatic forms may be treated with palliative chemotherapy and immunotherapy as part of a clinical trial.

CONCLUSION

The treatment of penile cancer is essentially surgery, with or without chemotherapy in the case of lymph node involvement. The main prognostic factor is lymph node involvement, which justifies early diagnostic and therapeutic management of the inguinal areas.

Evaluation of data quality in the Swedish National Penile Cancer Register

OBJECTIVE

The National Penile Cancer Register (NPECR) in Sweden was initiated in year 2000 and currently contains more than 3,900 men diagnosed with penile cancer. The aim of this study was to evaluate data quality in the NPECR in terms of completeness, timeliness, comparability, and validity.

MATERIAL AND METHODS

Completeness was assessed by cross-linkage to the Swedish Cancer Register. Timeliness, defined as time from date of diagnosis to date of reporting in the NPECR, was calculated. Comparability was evaluated by reviewing and comparing coding routines in the NPECR with national and international guidelines. To assess validity, medical records of 375 men with a penile cancer diagnosis in the NPECR between 2017 and 2020 were reviewed and selected variables were re-abstracted and compared with previously registered data.

RESULTS

Completeness was high (93%). Timeliness was in median 4.6 (Inter Quartile Range 2.6-8.8) months. Comparability was good with coding routines and the registration forms were in compliance with current guidelines. Overall, the validity was high. The majority of variables showed an exact agreement exceeding 90%.

CONCLUSION

Data quality in the Swedish NPECR is generally high with respect to completeness, timeliness, comparability, and validity. Hence, the NPECR represents a reliable data source for monitoring the quality of penile cancer care and research. Data quality can be further improved by revision of reporting forms and manuals, training of reporting staff, and by organizational adjustments.

Comparing the safety and effectiveness of minimally invasive surgery and open inguinal lymph node dissection in penile cancer: A systematic review and meta-analysis

OBJECTIVE

To compare the safety and effectiveness of minimally invasive surgery (MIS) with open inguinal lymph node dissection (O-ILND) in penile cancer.

METHODS

We performed a systematic reviews and cumulative meta-analyses of primary results of interest according to PRISMA criteria, and quality assessment followed AMSTAR. The system searched five databases, including Zhiwang, Embase, PubMed, Cochrane Library and Web of Science. The search period ranged was from database creation until September 2023. The statistical analysis software used Stata16.

RESULTS

A total of 16 studies, including 898 patients. Compared to O-ILND, MIS is superior in length of stay (WMD = -2.96, 95%CI [-4.38, -1.54], P < 0.05), drainage time (WMD = -3.24, 95%CI [-4.70, -1.78], P < 0.05) and estimated blood loss (WMD = -35.70, 95%CI [-46.27, -25.14], P < 0.05), while operation time, recurrence rate and 5-year overall survival rate are the same. The number of lymph nodes dissection between the two groups are not statistically significant. Subgroup analyses found that there are more lymph nodes dissection in robotic-assisted inguinal lymph nodes dissection (WMD = 0.50, 95%CI [0.20, 0.80], P < 0.05). The overall complication rate of MIS was lower (OR = 0.26, 95%CI [0.09, 0.70], P < 0.05).

CONCLUSION

Minimally invasive inguinal lymph nodes dissection appears to be a better option for penile cancer cases. But more large samples and multicenter studies are needed to further confirm.

The Prognostic Value of Human Papillomavirus Status in Penile Cancer: Outcomes From a Norwegian Cohort Study

INTRODUCTION

Penile squamous cell carcinoma (PSCC) can develop from human papillomavirus (HPV) infection. This study investigates if the prognostic value of the TNM stage groups or the components tumor stage (pT), grade of differentiation (Grade), lymphovascular invasion (LVI), and nodular stage (pN) depend on HPV status. Also, whether the value of tumor parameters (pT, Grade, and LVI) for predicting node-positive disease depends on HPV status was investigated.

PATIENTS AND METHODS

Stored tumor tissue from 226 patients treated for PSCC in Western Norway between 1973 and 2023 was investigated for HPV DNA. Histopathological variables were reevaluated according to the current TNM classification. Disease course was registered from hospital records. Inclusion of an interaction term between HPV and TNM stage groups in Cox regression enabled analysis of whether cancer-specific survival (CSS) of the stage groups depended on HPV status. This was also done separately for pT, Grade, LVI, and pN. Logistic regression with interaction terms between HPV and the tumor parameters were used to investigate if their predictive value depended on HPV status.

RESULTS

HPV DNA was detected in 43% of the tumors. Stratified by HPV status, there was no significant interaction term in the Cox regression between HPV status and TNM stage groups (P = .74). Similar results were found for pT (P = .94), Grade (P = .08), LVI (P = .91) and pN (P = .77). Moreover, there were no significant interaction terms in the logistic regression between HPV status and the tumor parameters pT, Grade, and LVI (all P > .2).

CONCLUSIONS

This study found that prognosis of the TNM stage groups and the components pT, Grade, LVI, and pN were not modified by HPV in PSCC. The value of pT, Grade, and LVI for predicting lymph node-positive disease was not affected by HPV status.

Indocyanine green and methylene blue dye guided sentinel lymph node biopsy in patients with penile cancer (PeCa): results of 50 inguinal basins assessed at a single institution in India

AIM

The primary aim of this study was to validate the reliability, sensitivity and safety profile of novel combination of ICG- methylene blue dye as an SN tracer for PeCa.

METHODS

This is a validation and non-randomised prospective observational study involving 25 patients (50 inguinal basins) who underwent SLNB where in ICG and methylene blue were used for localisation. The patients with clinically node negative groins were recruited in the study. SNs were identified intraoperatively using near infrared fluorescence imaging (NIRF Imaging system, SPY-PHI, Stryker, Sweden) and blue dye. The numbers of SNs identified by each tracer and the rates of complications and nodal recurrence during the followup.

RESULTS

Overall 137 SNs were identified intraoperatively. Among the 137 SNs excised fluorescence, blue dye and Combined (blue + green) identified 57(41.6%), 27 (19.7%), and 51 (37.2%), respectively. The average number of SLNs removed per patient was 5 (range, 1-11) with sentinel lymph nodes detection rate at 94% (47/50). Seven patients had malignancy on SLNB and underwent ipsilateral radical inguinal lymphadenectomy. One patient had false negative SN and positive node in modified inguinal lymphadenectomy specimen. No adverse events were observed in all cases.

CONCLUSION

The Novel combination of ICG fluorescence-Methylene blue dye technique is simple, reliable and safe. Moreover, it demonstrates a high SLN detection rate with a low false-negative rate, and it avoids radiation exposure.

HPV and Penile Cancer: Epidemiology, Risk Factors, and Clinical Insights

Penile cancer (PC) is a rare malignancy predominantly of squamous cell origin. Approximately 40% of penile tumors are associated with human papillomavirus (HPV) infection. Diagnosing PC remains challenging due to its rarity and variety of clinical presentations. Furthermore, the impact of HPV on the tumor immune microenvironment complicates clinical management, although recent advancements in immune checkpoint inhibitors (ICIs) have shown some efficacy in treating HPV-associated PC. Ongoing research efforts aim to develop oncologic treatments that target HPV-induced cellular modifications. Additionally, novel therapeutic vaccines and adoptive T-cell therapies targeting HPV oncoproteins represent emerging treatment modalities. Our review highlights the complex interplay between HPV and penile carcinogenesis, emphasizing its epidemiology, etiology, clinicopathological characteristics, and potential therapeutic implications.

Brachytherapy and external beam radiation in the management of primary penile cancer - Game changer for organ preservation?

OBJECTIVE

In squamous cell carcinoma of the penis (PeCa), treatment options for primary tumors vary by disease stage and may include surgery, radiation, topical chemotherapy, or laser excision. This review aims to highlight the current evidence on the value of radiotherapy as an organ-preserving strategy in primary PeCa.

MATERIAL AND METHODS

Manuscripts on primary PeCa treatment with external beam radiotherapy (EBRT) and brachytherapy were evaluated via Scopus, PubMed/MEDLINE, and Web of ScienceTM (2013-2023) to assess their efficacy and safety. Animal studies, studies with <5 patients, and case reports were excluded.

RESULTS

Radiotherapy offers the potential for organ preservation with tumor control rates comparable to radical surgery, while disease-specific survival rates up to 70 % were experienced with EBRT. Brachytherapy (BT) is the preferred method of irradiation for glans-limited tumors, whereas a higher relapse risk is expected for tumors >4 cm. BT shows 73 % amputation-free survival at 8-10 years and 81 % progression-free survival at 5-10 years. Compared with BT, total amputation significantly improves 5-year disease-free survival rate. BT offers a superior 5-year local control and penile preservation rates compared to EBRT. Common acute toxicities of brachytherapy include radiodermatitis, sterile urethritis, and urethral adhesions. The primary late adverse events of BT are soft tissue necrosis (0-31 %) and meatal stenosis (0-43 %).

CONCLUSION

BT is a favorable radiation modality, offering an efficient and conservative approach. HDR BT is favored for its enhanced dose distribution and radiation protection. Collaboration between radiation oncologists and urologists is essential in order to provide an optimal patient selection and manage toxicities thus optimizing patient outcomes.

[68Ga]Ga-FAPI-46 PET/CT for penile cancer - a feasibility study

PURPOSE

Penile cancer is a rare entity and has a good prognosis in localized stage. Delayed surgical treatment of lymphatic disease is associated with poor overall survival but conventional imaging cannot detect occult lymph node metastasis sufficiently. Imaging cancer related fibroblasts has shown promising results as non-invasive staging tool in various tumor entities but has not yet been evaluated in penile cancer.

METHODS

In this single-center pilot study, patients planned for surgical treatment for penile cancer underwent preoperatively [68Ga]Ga-FAPI-46 PET/CT. Post-operative histopathology was compared to [68Ga]Ga-FAPI-46 PET/CT results.

RESULTS

From January 2022 to June 2022, a total number 11 patients with histopathologically proven penile cancer underwent surgery and received [68Ga]Ga-FAPI-46 PET/CT prior therapy. 8 primary tumor sites and 4 lymph node regions were analyzed. FAPI uptake was increased on primary tumor site (SUVmax 16.2 (9.1 - 25.8)). Histopathological proven lymph node regions showed highly increased FAPI uptakes (SUVmax 17.9 (16.4 - 23.5) on [68Ga]Ga-FAPI-46 PET/CT.

CONCLUSION

In this first pilot cohort, there were no false-positive FAPI uptake which might allow the detection of occult lymph node metastasis by [68Ga]Ga-FAPI-46 PET/CT and might consequently lead to omitting lymph node regions during surgery that had no increased FAPI uptake pre-operatively.

Current Role of PET CT in Staging and Management of Penile Cancers

Penile cancer (PeCa) is a rare urological malignancy characterized by significant geographical variations in both incidence and mortality rates. Due to its rarity and the consequent lack of randomized trials, current management is based on retrospective studies and small prospective trials. In addition, both the diagnostic pathways and treatment strategies exhibit substantial heterogeneity, differing significantly between less-developed and well-developed countries. The prognosis of PeCas is determined by the presence and extent of regional lymph node (LN) involvement. Therefore, the early detection and treatment of LN metastasis is paramount to ensure better outcomes. In recent decades, overall survival of PeCas has increased, mainly due to advancements in imaging techniques and risk stratification. We aim to provide an overview of the current role of PET CT imaging in the management of patients with PeCa.

Exploring the Multifactorial Landscape of Penile Cancer: A Comprehensive Analysis of Risk Factors

Penile cancer, while rare, is a critical public health issue due to its profound impact on patients and the complexities of its management. The disease's multifactorial etiology includes risk factors such as HPV infection, poor hygiene, smoking, genetic predispositions, and socioeconomic determinants. This article provides a comprehensive review and analysis of these diverse risk factors, aiming to enhance understanding of the disease's underlying causes. By elucidating these factors, the article seeks to inform and improve prevention strategies, early detection methods, and therapeutic interventions. A nuanced grasp of the multifactorial nature of penile cancer can enable healthcare professionals to develop more effective approaches to reducing incidence rates and improving patient outcomes.

Psychosocial Impact of Penile Cancer: An Unmet Need

Penile cancer is a rare cancer, where patients not only need to deal with the anxiety around a cancer diagnosis, but also manage the consequences of treatment on their self-esteem, body image, and intimate relationships. Many find it embarrassing and difficult to talk to family and friends. Due to this, changes in urination and other physical effects of treatment, many will withdraw from social activities too. Patients need psychosocial support and more needs to be done to address this unmet need. Holistic and multidisciplinary approaches in clinic, with access to counseling, may help patients adjust to their new situation.

New Therapeutic Horizons for Advanced or Metastatic Penile Cancer

Penile cancer is a rare malignancy with a poor prognosis. Studies with single-agent immune checkpoint inhibitors (ICIs) have demonstrated efficacy, but response rates are low. Studies combining ICIs with both chemotherapy and targeted therapy are ongoing. Up to 50% of penile cancer cases are associated with human papillomavirus (HPV). HPV-targeting therapies, such as HPV-targeting vaccines and T-cell receptor therapies, are an area of active investigation. Penile cancer cells also express cell surface antigens that may be targeted by the emerging class of antibody-drug conjugates.

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?

Single-cell Atlas of Penile Cancer Reveals TP53 Mutations as a Driver of an Aggressive Phenotype, Irrespective of Human Papillomavirus Status, and Provides Clues for Treatment Personalization

BACKGROUND AND OBJECTIVE

TP53 loss-of-function (TP53LOF) mutations might be a driver of poor prognosis and chemoresistance in both human papillomavirus (HPV)-independent (HPV-) and HPV-associated (HPV+) penile squamous cell carcinoma (PSCC). Here, we aim to describe transcriptomic differences in the PSCC microenvironment stratified by TP53LOF and HPV status.

METHODS

We used single-cell RNA sequencing (scRNA-seq) and T-cell receptor sequencing to obtain a comprehensive atlas of the cellular architecture of PSCC. TP53LOF and HPV status were determined by targeted next-generation sequencing and sequencing HPV-DNA reads. Six HPV+ TP53 wild type (WT), six HPV- TP53WT, and four TP53LOF PSCC samples and six controls were included. Immunohistochemistry and hematoxylin-eosin confirmed the morphological context of the observed signatures. Prognostic differences between patient groups were validated in 541 PSCC patients using Kaplan-Meier survival estimates.

KEY FINDINGS AND LIMITATIONS

Patients with aberrant p53 staining fare much worse than patients with either HPV- or HPV+ tumors and WT p53 expression. Using scRNA-seq, we revealed 65 cell subtypes within 83 682 cells. TP53LOF tumors exhibit a partial epithelial-to-mesenchymal transition, immune-excluded, angiogenic, and morphologically invasive environment, underlying their aggressive phenotype. HPV- TP53WT tumors show stemness and immune exhaustion. HPV+ TP53WT tumors mirror normal epithelial maturation with upregulation of antibody-drug-conjugate targets and activation of innate immunity. Inherent to the scRNA-seq analysis, low sample size is a limitation and validation of signatures in large PSCC cohorts is needed.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This first scRNA-seq atlas offers unprecedented in-depth insights into PSCC biology underlying prognostic differences based on TP53 and HPV status. Our findings provide clues for testing novel biomarker-driven therapies in PSCC.

PATIENT SUMMARY

Here, we analyzed tissues of penile cancer at the level of individual cells, which helps us understand why patients who harbor a deactivating mutation in the TP53 gene do much worse than patients lacking such a mutation. Such an analysis may help us tailor future therapies based on TP53 gene mutations and human papillomavirus status of these tumors.

Setting-up a training programme for intraoperative molecular imaging and sentinel node mapping: how to teach? How to learn?

BACKGROUND

The current expansion of image-guided surgery is closely related to the role played by radio-guided surgery in supporting the sentinel node (SN) procedure during more than three decades. The so-called triple approach (lymphoscintigraphy, gamma probe detection and blue dye) was not only essential in the seminal validation of the SN procedure but also a first collective learning effort based on skill transfer and outcome-related evaluation which laid the fundaments to delineate the field of intraoperative molecular imaging (IMI) based on a similar multimodality approach and multidisciplinary practice.

METHODS

These elements are also becoming valid in the current incorporation of SPECT/CT and PET/CT to existing and new protocols of IMI procedures and SN mapping concerning other clinical applications. On the other hand, there is a growing tendency to combine novel modern technologies in an allied role with gamma guidance in the operating room following the development of hybrid tracers and multimodal detection approaches. Against this background, learning initiatives are required for professionals working in this area.

RESULTS

This objective has led to a group of European practitioners with large experience in SN mapping and IMI applications to give shape to a programme made up out of specific learning modules aimed to be used as a conductive thread in peripherical or centralised training instances concerning the topic.

CONCLUSION

The presented work, written as a tutorial review, is placed in an available prior-art context and is primarily aimed at medical and paramedical practitioners as well as at hardware and software developers.

Steerable DROP-IN radioguidance during minimal-invasive non-robotic cervical and endometrial sentinel lymph node surgery

PURPOSE

The recently introduced tethered DROP-IN gamma probe has revolutionized the way robotic radioguided surgery is performed, fully exploiting the nature of steerable robotic instruments. Given this success, the current first-in-human study investigates if the DROP-IN can also provide benefit in combination with steerable non-robotic instruments during conventional laparoscopic surgery, showing equivalence or even benefit over a traditional rigid gamma probe.

METHODS

The evaluation was performed in ten patients during laparoscopic cervical (n = 4) and endometrial (n = 6) cancer sentinel lymph node (SLN) procedures. Surgical guidance was provided using the hybrid, or bi-modal, SLN tracer ICG-99mTc-nanocolloid. SLN detection was compared between the traditional rigid laparoscopic gamma probe, the combination of a DROP-IN gamma probe and a steerable laparoscopic instrument (LaproFlex), and fluorescence imaging.

RESULTS

The gynecologists experienced an enlarged freedom of movement when using the DROP-IN + LaproFlex combination compared to the rigid laparoscopic probe, making it possible to better isolate the SLN signal from background signals. This did not translate into a change in the SLN find rate yet. In both cervical and endometrial cancer combined, the rigid probe and DROP-IN + LaproFlex combination provided an equivalent detection rate of 96%, while fluorescence provided 85%.

CONCLUSION

We have successfully demonstrated the in-human use of steerable DROP-IN radioguidance during laparoscopic cervical and endometrial cancer SLN procedures, expanding the utility beyond robotic procedures. Indicating an improved surgical experience, these findings encourage further investigation and consideration on a path towards routine clinical practice and improved patient outcome.

TRIAL REGISTRATION

HCB/2021/0777 and NCT04492995; https://clinicaltrials.gov/study/NCT04492995.

New EAU/ASCO guideline recommendations on sentinel node biopsy for penile cancer and remaining challenges from a nuclear medicine perspective

INTRODUCTION

The European Association of Urology (EAU) and the American Society of Clinical Oncology (ASCO) recently issued updated guidelines on penile cancer, emphasising dynamic sentinel node biopsy (DSNB) as the preferred method for surgical staging among patients with invasive penile tumours and no palpable inguinal lymphadenopathy. This paper outlines the rationale behind this new recommendation and describes remaining challenges, as well as strategies for promoting DSNB worldwide.

MAIN TEXT

DSNB offers high diagnostic accuracy with the lowest postoperative complications compared to open or minimally invasive inguinal lymph node dissection (ILND), prompting its preference in the new guidelines. Nevertheless, despite its advantages, there are challenges hampering the widespread adoption of DSNB. This includes the false-negative rate associated with DSNB and the potential negative impact on patient outcome. To address this issue, improvements should be made in several areas, including refining the timing and interpretation of the lymphoscintigraphy and the single photon emission computed tomography/computed tomography images. In addition, the quantity of tracer employed and choice of the injection site for the radiopharmaceutical should be optimised. Finally, limiting the removal of nodes without tracer activity during surgery may help minimise complication rates.

CONCLUSION

Over the years, DSNB has evolved significantly, related to the dedicated efforts and innovations in nuclear medicine and subsequent clinical studies validating its efficacy. It is now strongly recommended for surgical staging among selected penile cancer patients. To optimise DSNB further, multidisciplinary collaborative research is required to improve SN identification for better diagnostic accuracy and fewer complications.

Penile Cancers Attributed to Human Papillomavirus Are Associated with Improved Survival for Node-positive Patients. Findings from a Norwegian Cohort Study Spanning 50 Years

BACKGROUND

Human papillomavirus (HPV) infection is a risk factor for the development of penile squamous cell carcinoma (PSCC). It remains inconclusive whether HPV-related PSCC has a different prognosis from non-HPV-related PSCC.

OBJECTIVE

To investigate the relationship between HPV status and survival as well as temporal changes in the proportion of HPV-related PSCC.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort of 277 patients treated in Norway between 1973 and 2022 was investigated for HPV DNA in tumor tissue. Clinicopathological variables and disease course were registered.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Kaplan-Meier curves and Cox regression were used to investigate the determinants of cancer-specific survival (CSS). The chi-square test for trend in proportions enabled investigation of temporal changes in the HPV-related proportion of PSCC patients treated in Western Norway (n = 211).

RESULTS AND LIMITATIONS

HPV DNA was detected in tumor tissue from 131 (47%) patients. Stratified by HPV status, 5-yr CSS did not differ between groups (p = 0.37). When investigating only node-positive patients, however, presence of HPV DNA was an independent predictor of better survival in multivariable Cox regression after adjustment for age, nodal stage, and adjuvant therapy (hazard ratio 0.54, 95% confidence interval: [0.30-0.99], p = 0.04). In cases from Western Norway, an increasing proportion of HPV-related cases over time was found (p = 0.01). The main limitation is the retrospective study design.

CONCLUSIONS

HPV DNA in tumor tissue was associated with significantly better CSS for node-positive patients. The proportion of HPV DNA-positive PSCC has increased significantly in Western Norway over the past 50 yr.

PATIENT SUMMARY

We investigated the impact of human papillomavirus (HPV) on the survival of penile cancer patients treated over a 50-yr period in Norway. We found that for patients with lymph node metastasis, survival was better for HPV-related cases. We also found that the proportion of cases due to HPV has increased in Western Norway.

High-risk human papilloma virus status & outcomes for penile squamous cell carcinoma: A single institution experience

OBJECTIVES

There is a paucity of data on North American cohorts of patients with penile squamous cell carcinoma (pSCC). Herein, we aimed to assess the sensitivity of various modalities to identify human papillomavirus (HPV) status, determine the prevalence of high-risk HPV-positivity, and evaluate the prognostic impact of relevant clinicopathologic variables.

METHODS

Patients with pSCC (n = 121) consecutively treated with partial/total penectomy (2000-2022) at a single institution were included. HPV status (based on immunohistochemistry [IHC], in situ hybridization [ISH], and panviral metagenomic sequencing [PMS]), histologic features, and outcomes were reviewed. Outcome events included death due to disease and progression.

RESULTS

The majority of patients were white (105/121, 86.8%). Thirty-seven (30.6%) were high-risk HPV-positive, and morphologic evaluation had a sensitivity of 97.3% (95% confidence interval [CI], 86.2-99.5) for predicting high-risk HPV status compared to IHC/ISH/PMS. Disease progression was more common among high-risk HPV-negative compared to high-risk HPV-positive patients (HR 2.74, CI 1.12-8.23, P = 0.03). Moreover, among high-risk HPV-negative patients, those with moderate-poorly differentiated tumors had increased disease-specific mortality (32.6%, CI 17.1-48.1) compared to those with well-differentiated tumors (0%). Among high-risk HPV-positive patients, those with basaloid morphology had lower disease-specific mortality (0% vs 14.4%, CI 0.0-33.1).

CONCLUSIONS

We demonstrate high-risk HPV-positivity in approximately one-third of patients with pSCC. Morphologic evaluation alone had a high sensitivity in correctly determining HPV status. Our results suggest that high-risk HPV status and morphologic features (differentiation in high-risk HPV-negative, and basaloid subtype in high-risk HPV-positive pSCC) may have prognostic value.

Advances in molecular basis of response to immunotherapy for penile cancer: better screening of responders

Penile cancer is a rare malignant tumor of the male urinary system. The treatment benefit of standard first-line chemotherapy is not ideal for patients with locally advanced or metastatic lymph nodes. Immunotherapy has brought new treatment strategies and opportunities for patients with penile cancer. At present, clinical studies on immunotherapy for penile cancer have been reported, and the results show that it is effective but not conclusive. With the development of immunotherapy and the progress of molecular research technology, we can better screen the immunotherapy response population and explore new combination treatment regimens to evaluate the best combination regimen and obtain the optimal treatment options, which is also an important research direction for the immunotherapy of penile cancer in the future.

Altered tumor microenvironment heterogeneity of penile cancer during progression from non-lymphatic to lymphatic metastasis

BACKGROUND

Lymphatic metastasis is the major challenge in the treatment of penile cancer. The prognosis of individuals with lymphatic metastasis is extremely poor. Therefore, early identification of disease progression and lymphatic metastasis is an urgent task for researchers in penile cancer worldwide.

METHODS

In this study, using single-cell RNA sequencing, an immune landscape was established for the cancer ecosystem based on 46,861 cells from six patients with penile cancer (four with lymphatic metastasis [stage IV] and two without lymphatic metastasis [stage I]). Using bulk RNA sequencing, the discrepancy between the cancers and their respective metastatic lymph nodes was depicted based on seven patients with penile cancer.

RESULTS

The interaction between epithelial cells, fibroblasts, and endothelial cells, and the functional cooperation among invasion, epithelial-mesenchymal transition, and angiogenesis were found to be important landscapes in the penile cancer ecosystem, playing important roles in progression of cancer and lymph node metastasis.

CONCLUSIONS

This study is the first to investigate the altered tumor microenvironment heterogeneity of penile cancer as it evolves from non-lymphatic to lymphatic metastasis and provides insights into the mechanisms underlying malignant progression, the premetastatic niche, and lymphatic metastasis in penile cancer.

A Systematic Review on the Diagnostic Value of Fibroblast Activation Protein Inhibitor PET/CT in Genitourinary Cancers

In contemporary oncologic diagnostics, molecular imaging modalities are pivotal for precise local and metastatic staging. Recent studies identified fibroblast activation protein as a promising target for molecular imaging across various malignancies. Therefore, we aimed to systematically evaluate the current literature on the utility of fibroblast activation protein inhibitor (FAPI) PET/CT for staging patients with genitourinary malignancies. Methods: A systematic Embase and Medline search was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process, on August 1, 2023. Relevant publications reporting on the diagnostic value of FAPI PET/CT in genitourinary malignancies were identified and included. Studies were critically reviewed using a modified version of a tool for quality appraisal of case reports. Study results were summarized using a narrative approach. Results: We included 22 retrospective studies with a cumulative total of 69 patients, focusing on prostate cancer, urothelial carcinoma of the bladder and of the upper urinary tract, renal cell carcinoma, and testicular cancer. FAPI PET/CT was able to visualize both local and metastatic disease, including challenging cases such as prostate-specific membrane antigen (PSMA)-negative prostate cancer. Compared with radiolabeled 18F-FDG and PSMA PET/CT, FAPI PET/CT showed heterogeneous performance. In selected cases, FAPI PET/CT demonstrated superior tumor visualization (i.e., better tumor-to-background ratios and visualization of small tumors or metastatic deposits visible in no other way) over 18F-FDG PET/CT in detecting local or metastatic disease, whereas comparisons with PSMA PET/CT showed both superior and inferior performances. Challenges in FAPI PET/CT arise from physiologic urinary excretion of most FAPI radiotracers, hindering primary-lesion visualization in the bladder and upper urinary tract, despite generally providing high tumor-to-background ratios. Conclusion: The current findings suggest that FAPI PET/CT may hold promise as a future tool to aid clinicians in detecting genitourinary malignancies. Given the substantial heterogeneity among the included studies and the limited number of patients, caution in interpreting these findings is warranted. Subsequent prospective and comparative investigations are anticipated to delve more deeply into this innovative imaging modality and elucidate its role in clinical practice.

Corporal Skip Metastases in Penile Squamous Cell Carcinoma: An Unknown and Distinct Pattern of Spread with Poor Prognosis

BACKGROUND

Penile squamous cell carcinoma (PSCC) is characterised by stepwise lymphatic dissemination. Skip metastases (SkMs) are rare metastases in the corpus cavernosum or spongiosum without continuity to the primary tumour or its resection site.

OBJECTIVE

To assess the distinct pattern of spread in SkM+ patients and the effect of SkM on prognosis.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective analysis of patients with SkM+ PSCC at ten high-volume international referral centres between January 2006 and May 2022.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We evaluated histopathological data, primary lymph node (LN) staging, and metastatic spread. We included a cohort of patients matched for pT stage, LN status, and grade who did not have SkM (SkM-) to compare the SkM prognosis and predictive value for cancer-specific mortality (CSM).

RESULTS AND LIMITATIONS

Among the 63 SkM+ patients who met our inclusion criteria, the SkM diagnosis was synchronous in 54.0% and metastases were mostly located in the corpus cavernosum. SkM was symptomatic in 14% of cases, was detected on imaging in 32%, and was found incidentally on pathological examination in 27%. Fifty-one patients (81%) presented with positive LNs and 28 (44%) developed distant metastases. Seven patients (11%) presented with or developed distant metastasis without displaying any LN involvement. The 2-yr cancer-specific survival estimates were 36% (95% confidence interval [CI] 25-52%) for SkM+ and 66% (95% CI 55-80%) for matched SkM- patients (p < 0.001). On multivariable Cox regression analysis, SkM presence was an independent predictor for higher CSM (hazard ratio 2.05, 95% CI 1.06-4,12; p = 0.03).

CONCLUSIONS

PSCC-related SkM is associated with aggressive disease behaviour and poor survival outcomes. Palpation of the entire penile shaft is essential, and distant staging is recommended in patients suspected of having SkM owing to the tendency for distant metastatic spread.

PATIENT SUMMARY

We investigated outcomes for patients with cancer of the penis who had metastases in the tissues responsible for erection. We found that metastases in this location were associated with poor prognosis, even in the absence of more typical spread of cancer via the lymph nodes.

Robot-assisted inguinal lymphadenectomy to treat penile and vulvar cancers: a scoping review

INTRODUCTION

Inguinal lymph nodes dissection (ILND) is recommended in patients presenting with high-risk penile (PC) or vulvar cancers (VC). Though, this surgical procedure is underused because of its anticipated morbidity. Minimally invasive approaches were proposed to minimize complications associated with open surgery. In this review, we analyze current available data exploring intra and perioperative outcomes of robot-assisted ILND (RAIL).

EVIDENCE ACQUISITION

On April 9th, 2023, a literature search was conducted using the PubMed and Scopus databases. The search employed the combination of the following terms: ("robotic assisted" OR "robot-assisted" OR "robotic") AND ("inguinal lymph node dissection" OR "lymphadenectomy") AND ("penile cancer" OR "vulvar cancer"). Out of the 404 identified articles, 18 were used for the present scoping review and their results were reported according to the PRISMA statement.

EVIDENCE SYNTHESIS

Data on 171 patients, ranging in age from 32 to 85 years, were obtained. Most of them (90.6%) harbored a penile squamous cell carcinoma and presented with no palpable nodes (85%). Operation time (OT) ranged between 45 and 300 min. Estimated blood loss varied from 10 to 300 mL. One single intra-operative complication was reported and one conversion to open was recorded. The lymph nodes (LNs) count spanned from 3 to 26 per groin, with 17 studies reporting a median yield >7 nodes. Hospital stay was 1-7 days, while the duration of drainage ranged from 4 to 72 days. Post-operative complications included lymphocele (22.2%; 0-100%), lymphedema (13.4%; 0-40%), cellulitis (11.1%; 0-25%), skin necrosis (8.7%; 0-15.4%). seroma (3.5%; 0-20%) and wound breakdown/wound infection (2.9%; 0-10%). Out of the included studies, 7 provided at least a 12-month follow-up, with recurrence-free rates ranging from 50% to 100% in patients affected by penile cancer and from 92% to 100% in vulvar cancer patients.

CONCLUSIONS

The available evidence on RAIL for the treatment of PC and VC is limited. The approach appears to be safe and effective, as it provides an adequate lymph node yield while ensuring a minimally morbid postoperative course and a short hospital stay.

Trajectories of squamous cell carcinoma antigen and outcomes of patients with advanced penile cancer after chemotherapy based on paclitaxel, ifosfamid, and cisplatin regimen

INTRODUCTION

Penile cancer (PC) is a lethal malignancy with no effective prognostic biomarker. We aim to investigate associations between trajectories of squamous cell carcinoma antigen (SCC-A) and patient outcomes after chemotherapy based on paclitaxel, ifosfamid, and cisplatin (TIP) regimen.

METHODS

Consecutive AJCC staging III/IV PC patients who received TIP chemotherapy and repeated SCC-A measurements in 2014-2022 were analyzed. Latent class growth mixed (LCGM) models were employed to characterize patients' serum SCC-A trajectories. Patient survival, and clinical and pathological tumor responses were compared. Inverse probability treatment weighting was used to adjust confounding factors.

RESULTS

Eighty patients were included. LCGM models identified two distinct trajectories of SCC-A: low-stable (40%; n = 32) and high-decline (60%; n = 48). Overall survival (HR [95% CI]: 3.60 [1.23-10.53], p = 0.019), progression-free survival (HR [95% CI]: 11.33 [3.19-40.3], p < 0.001), objective response rate (37.5% vs. 62.5% p = 0.028), disease control rate (60.4% vs. 96.9% p < 0.00), and pathological complete response rate (21.2% vs. 51.9%, p = 0.014) were significantly worse in the high-decline arm.

CONCLUSION

PC patients' SCC-A change rate was associated with tumor response and patient survival after TIP chemotherapy. SCC-A might assist tumor monitoring after systemic therapies.