Natural history, management, and surveillance of recurrent squamous cell penile carcinoma:

Surveillance strategies in the management of penile cancer

Penile cancer is a rare disease and can be associated with a high risk of recurrence in regional lymph nodes and distant sites. Surveillance strategies geared towards early detection and treatment are recommended given the significant morbidity and mortality associated with recurrences. Although physical examination is the single most important surveillance strategy, imaging is an important adjunct in high-risk disease and certain clinical scenarios.

Intraarterial chemotherapy with gemcitabine and cisplatin in locally advanced or recurrent penile squamous cell carcinoma

The prognosis of locally advanced or recurrent squamous cell carcinoma (SCC) of the penis after conventional treatment is dismal. This study aimed to evaluate the therapeutic effects of intraarterial chemotherapy with gemcitabine and cisplatin on locally advanced or recurrent SCC of the penis. Between April 1999 and May 2011, we treated 5 patients with locally advanced penile SCC and 7 patients with recurrent disease with intraarterial chemotherapy. The response rate and toxicity data were analyzed, and survival rates were calculated. After 2 to 6 cycles of intraarterial chemotherapy with gemcitabine and cisplatin, 1 patients with locoregionally advanced disease achieved a complete response, and 4 achieved partial response. Of the 7 patients with recurrent disease, 2 achieved complete response, 3 achieved partial response, 3 had stable disease, and 1 developed progressive disease. An objective tumor response was therefore achieved in 10 of the 12 patients. The median overall survival for the patients was 24 months (range, 10-50 months). Three out of 10 patients who responded were long-term survivors after intraarterial chemotherapy. Intraarterial chemotherapy with gemcitabine and cisplatin may be effective and potentially curative in locoregionally advanced or recurrent penile SCC. The contribution of this therapy in the primary management of advanced or recurrent penile SCC should be prospectively investigated.

Prognostic factors and biomarkers of penile carcinoma

Penile squamous cell carcinoma (SCC) is a rare malignancy with highest incidence in underdeveloped and developing countries. Oncogenic human papilloma virus (HPV) DNA, mainly types 16 and 18, are found in ∼ 100% of patients with uterine cervix carcinoma. The incidence of this virus in SCC and its variations range from 30.5 to 80%. Despite controversies, contrary to the cervical carcinoma, in the carcinogenesis and disease progression of SCC, HPV-dependent and HPV-independent tumors need to be considered. Lymphadenectomies continue to be the gold standard treatment of lymph node metastases. Undesirable accuracy on staging system methods and high rates of lymphadenectomy complications are the principal objections to these surgical procedures; therefore, the main issue in patients with SCC is to know who should or should not undergo lymphadenectomy. The search for primary tumor anatomopathological and biomarker risk factors for lymph node metastases, such as has occurred in other tumors, may be an important tool to select lymphadenectomies candidates better. Histological subtypes, tumor grade, growth pattern, tumor thickness, lymphatic embolization by neoplasic cells and depth of infiltration have been reported as important prognostic factors for lymph node metastases. In our series, lymphatic vascular permeation, palpable lymph node after primary tumor control (cN stage), pattern of invasion, p53 and PCNA immunoreactivity are independent lymph node metastases risk factors in the multivariate model. It is strongly recommended that patients be concentrated in specialized centers or cancer hospitals and multi-centric prospective studies carried out on tumor markers in this rare disease, in order to stage better lymph node disease and avoid unnecessary surgeries with high morbidity rates.

Penile cancer

OBJECTIVES

To review the risk factors, prevention, treatment, and management of the patient with penile cancer.

DATA SOURCES

Publications; clinical experience.

CONCLUSION

Penile cancer is a rare malignancy in the United States, but is more common in developing countries. The disease is so uncommon in the United States that there are oncology nurses who have never cared for a patient with this diagnosis.

IMPLICATIONS FOR NURSING PRACTICE

With significant psychosocial implications for the patient with penile cancer and partner, it is important that the nurse have an understanding of the diagnosis, treatment, and care of these patients.

Comparison of morphologic features and outcome of resected recurrent and nonrecurrent squamous cell carcinoma of the penis: a study of 81 cases

Penile squamous cell carcinoma (SCC) is considered a loco-regional disease with a fairly predictable pattern of progression. Widespread dissemination occurs in at least one-third of the patients. Local recurrence (defined as the presence of tumor after a primary treatment affecting any remainder tissue, including skin, erectile corpora, or urethra) present in up to 30% of the patients increases the risk of regional inguinal and pelvic lymph nodes metastases. The aim of this study was to identify adverse pathologic prognostic factors in patients with recurrent tumors. Clinicopathologic features of 81 surgically treated patients (25 with recurrent and 56 with nonrecurrent SCC) were evaluated; 56 patients (19 with recurrent and 37 with nonrecurrent tumors) additionally received groin dissections. Follow-up (2 to 372 mo, mean of 71 mo) was obtained in all patients. Comparison of recurrent tumors at the time of the primary diagnosis and of recurrence showed that histologic subtype and grade were identical in 76% of the cases and converted to a higher grade tumor in 24% of the cases, especially, in patients treated with local excisions and circumcisions. Most of the recurrences (67%) seemed at or before 12 months. Comparison of recurrent and nonrecurrent tumors showed that high grade tumors (basaloid and sarcomatoid) tended to be significantly associated with recurrent tumors, whereas low grade variants (papillary, warty and verrucous) were more frequent in the nonrecurrent group; recurrent tumors invaded into deeper anatomic levels than nonrecurrent tumors. The incidence of inguinal lymph node metastasis was higher in recurrent tumors (79% vs. 49%, P=0.0272). Cancer-specific survival was of 46% versus 76% at 3 years of follow-up in recurrent and nonrecurrent tumors, respectively. Patients with recurrent tumors had a median survival of 2.9 years; no major changes in survival were noted after 3 years of follow-up. Mortality was higher in the recurrent group (56% vs. 29%, P=0.0188); 80% of patients with high-grade tumors (basaloid, sarcomatoid, and high grade usual or hybrid verrucous SCCs) died from penile cancer. Mortality in patients with usual SCC was higher in the recurrent group, but similar in basaloid and sarcomatoid SCCs. After 3 years there was no survival difference in patients with low-grade recurrent tumors; however, in the high grade recurrent group there was a progressive and gradual decrease in survival from 2 to 10 years (median survival of 2.5 y). In summary, histologic subtypes and grades of SCCs were similar in the majority of original and recurrent carcinomas. Inguinal metastasis and mortality were higher in recurrent than in nonrecurrent carcinomas. Basaloid, sarcomatoid, and mixed usual-verrucous variants and invasion of corpora cavernosa or preputial skin were significant adverse prognostic factors of recurrent carcinomas. Local excision and partial penectomy were not adequate procedures for sarcomatoid and basaloid penile carcinomas. Carcinomas of foreskin had a better prognosis. Conversion from low to high-grade carcinoma was related to significant mortality. The identification of the adverse prognostic factors found in this study should be the base for an aggressive initial therapy to prevent recurrence in a subset of penile cancers. Re-excision of the recurrent tumor permitted the control of the disease only in one-third of the patients.

Endoscopic Lymphadenectomy for Penile Carcinoma

BACKGROUND AND PURPOSE

Groin dissection remains the gold standard for the treatment of penile carcinoma that has metastasized to the inguinal lymph nodes. However, it is associated with wound-related complications. Modified groin dissection offers a less-radical approach without compromising oncologic outcomes. We present our technique for endoscopic lymphadenectomy for penile carcinoma (ELPC).

PATIENTS AND METHODS

Eight patients with clinical stage T(2) N(0-3)M(0) penile carcinoma underwent ELPC. Preoperative Doppler ultrasound mapping of the inguinal lymph nodes and the saphenous vein was performed.

RESULTS

Fourteen lymphadenectomies, including superficial with or without deep inguinal and pelvic-node dissection, were completed in eight patients. The median operative time was 91 minutes (range 50-150 minutes), and the mean number of nodes removed was 9 (range 4-15). No perioperative complications occurred. Lymphoceles developed in three groins (23%). No wound-related complications were seen.

CONCLUSIONS

The ELPC is a safe and feasible technique that appears to diminish the wound-related complications associated with the standard open approach.

Surgical treatment of a rare case of penile squamous cell carcinoma in a 65-year-old man

Penile squamous cell carcinoma has been commonly reported in the past decades. We describe a rare case of a huge squamous cell carcinoma of the penis in a 65-year-old patient with a 4-year history of tumor growth, for which total penectomy, perineal urethrostomy and bilateral inguinal lymphadenectomy were carried out. We suggest that aggressive surgical intervention should be recommended for those with well-differentiated penile carcinoma regardless of the size of the tumor.

Cisplatin, methotrexate and bleomycin for treating advanced penile carcinoma

OBJECTIVE

To retrospectively evaluate the efficacy and toxicity of chemotherapy with cisplatinum, methotrexate and bleomycin (CMB) in the adjuvant and palliative setting, and its effect on survival in patients with locally advanced or metastatic penile carcinoma, which carries a very poor prognosis.

PATIENTS AND METHODS

Thirteen patients (mean age 54 years) with radically resected local and nodal disease (eight), metastatic disease (two) or metastatic recurrence (three) had chemotherapy with CMB between February 1996 and July 2003. In all, 45 treatment courses were given, with a mean (range) of 3.5 (2-6) courses per patient.

RESULTS

Three of the eight patients with adjuvant treatment showed no evidence of disease after a mean (range) of 54 (41-76) months, while four in this group died from disease progression after a mean of 11 (5-20) months, and one died from treatment-related toxicity. All five patients with metastatic disease died from disease progression after three had shown temporary signs of regression.

CONCLUSIONS

Chemotherapy with CMB had little effect on metastatic penile cancer and responses were transient. However, patients with minimal disease after radical local and lymphatic resection seemed to benefit from adjuvant therapy, but the toxicity was high and carried a risk of death.

The Role of Imaging in the Surveillance of Urologic Malignancies

Urologic malignancies are common, accounting for approximately 25% of all new cancer cases in the United States. Patients with urologic malignancies require long-term surveillance to detect progression or recurrence as early as possible. The urologist is faced with the task of balancing patient safety and cost-effectiveness, while finding the most practical follow-up regimen. For each urologic malignancy, this article reviews the commonly used radiologic techniques for surveillance and offers recommended follow-up schedules.

Penile cancer

Penile cancer, while relatively rare in the western world, remains a disease with severe morbidity and mortality, not to mention significant psychological ramifications. Furthermore, the disease is observed with dramatically increased incidence in other parts of the world. A review of the literature has shown that the overwhelming majority of penile cancers are in situ or invasive squamous cell carcinomas, including a well-differentiated variant, verrucous carcinoma. Important predisposing factors are lack of circumcision, human papillomavirus infections, and penile lichen sclerosus, although other factors have occasionally been reported as well. Prevention, careful monitoring of patients at risk, and early diagnosis are essential to reduce the incidence of penile carcinoma and to provide a definitive cure. Public health measures, such as prophylactic use of circumcision, have proved successful but are controversial. Also, no standard therapeutic guidelines as to the best treatment strategy according to different stages, including efficacy of conservative nonsurgical modalities and indications for lymph nodal dissection, are available so far. It is common opinion that penile cancer is an emerging problem that deserves further investigations, and physicians, especially dermatologists, should be aware of this issue.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with penile carcinoma, its risk factors, its clinical and histologic presentation, and the treatments currently available for its management.

Prepubic Sentinel Node Location in Penile Carcinoma

An unusual sentinel node location in a patient with penile carcinoma is described. The preoperative lymphoscintigram showed a prepubic sentinel node. The node could be harvested during surgery. This case illustrates one of the advantages of lymphatic mapping in penile carcinoma: preoperative lymphoscintigraphy can identify lymph nodes outside the usual nodal basins.

What's new in the management of penile cancer?

PURPOSE OF REVIEW

Penile cancer is a rare disease. This has led to little in the way of therapeutic advances in the last two decades. Efforts have been made to minimize the use of disfiguring or morbid procedures in treating the primary tumor or managing the inguinal region. In addition, new insights have been gained into multimodal therapy for treating metastatic disease. We reviewed the literature published during the past two years to define the recent insights into the diagnosis and management of penile cancer.

RECENT FINDINGS

Surveillance, Epidemiology and End Results Program data revealed poor outcome among African-American patients compared with Caucasians with penile cancer. Risk factors, including human papilloma virus, HIV, and the practice of circumcision have been reassessed. To improve diagnosis and staging, new modifications in imaging have been developed including magnetic resonance imaging with artificial erection. In addition, the technique of dynamic sentinel node biopsy has been refined. Pathologic features of the primary tumor (i.e., stage, grade, vascular invasion) assist in identifying patients who would benefit from lymphadenectomy. Organ-sparing treatments using laser ablation and reconstructive procedures to preserve glans or phallus length have also been developed. Systemic chemotherapy regimens, including consolidative approaches with surgery or radiotherapy, are discussed for advanced penile cancer.

SUMMARY

Penile cancer remains a rare disease. Epidemiologic insights reveal provocative findings with respect to risk factors and racial differences in the outcome. Recent literature provides information that will aid urologists in (1) minimizing the need for disfiguring treatment of penile tumors in some patients and (2) reducing the number of unnecessary inguinal staging procedures in others. Novel systemic therapies that generate durable responses tested in multi-institutional treatment trials are needed.

Peniskarzinom — Nachsorge mit Konsequenz

Penile cancer is a rare tumor entity but penile carcinoma is characterized by a high recurrence rate regarding local, lymphatic, and hematogenous recurrence. The critical period for tumor recurrence is in the first 5 years. Therapeutic options for tumor recurrence can be differentiated by the type of recurrence and the preceding therapy. The prognosis of local or small lymphatic recurrence-if detected early and diligently diagnosed-can be improved significantly by radical surgery. On the other hand, systemic therapy of advanced lymphatic recurrences and hematogenous metastases will influence disease progression only marginally. Based on these considerations, the follow-up of penile cancer should be risk adapted but close as suggested by our algorithm. With a reduced, but close follow-up we can offer our patients aftercare with the consequence of improved prognosis.

Contemporary management of penile squamous cell carcinoma

Squamous cell carcinoma (SCC) is the most common tumor of the penis. The natural history and its proclivity to spread via regional lymphatics has been well defined. Laser ablation of the primary tumor has a prominent role in patients with a superficial tumor as a penis-conserving approach. Patients with deeper infiltrating tumors, should undergo (partial) penile amputation. For patients presenting with proven metastatic nodes complete (ilio-) inguinal lymphadenectomy should be performed. During the last two decades, the management of penile carcinoma patients with impalpable regional lymph nodes has improved due to better knowledge of risks for metastases, the introduction of modified lymphadenectomy, and sentinel node biopsy. Future perspectives in penile cancer comprises continuing research to reduce mutilation without jeopardizing clinical outcome.