Total resection of glans penis surface by CO2 laser microsurgery

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.

Laser ablation as monotherapy for penile squamous cell carcinoma: A multi-center cohort analysis

INTRODUCTION

Although the trend towards penile sparing therapy is increasing for penile squamous cell carcinoma, outcomes for laser ablation therapy have not been widely reported. We assessed the clinical outcomes of penile cancer patients treated with only laser ablation.

MATERIALS AND METHODS

A retrospective review was performed on 161 patients across 5 multi-center tertiary referral centers from 1985 to 2015. All patients underwent penile sparing surgery with only laser ablation for squamous cell carcinoma of the penis. Laser ablation was performed with neodymium-doped yttrium aluminum garnet or carbon dioxide. Overall and recurrence-free survival was calculated using the Kaplan-Meier method and compared with the log rank test.

RESULTS

A total of 161 patients underwent laser ablation for penile cancer. The median age was 62 (IQR: 52-71) years and median follow-up was 57.7 (IQR: 28-90) months. The majority of patients were pTa/Tis (59, 37%) or pT1a (62, 39%). Only 19 (12%) had a poorly differentiated grade. The 5-year recurrence-free survival was 46%. When stratified by stage, the 5-year local recurrence-free survival was pTa/Tis: 50%; pT1a: 41%; pT1b: 38%; and pT2: 52%. The inguinal/pelvic nodal recurrence was pTa/Tis: 2%; pT1a: 5%; pT1b: 18%; and pT2: 22%. There were no differences among stages with respect to recurrence-free survival (P = 0.98) or overall survival (P = 0.20).

CONCLUSION

Laser ablation therapy is safe for appropriately selected patients with penile squamous cell carcinoma. Due to the increased risk of nodal recurrence, laser ablation coupled with diagnostic nodal staging is indicated for patients with pT1b or higher.

Advances in penile cancer management

PURPOSE OF REVIEW

Penile cancer is a rare disease that may cause devastating physical and psychological effects on patients due to the disease itself and/or the associated treatments. As with many other cancer types, significant efforts have been made in penile cancer to minimize invasiveness and morbidity of therapeutic approaches, while aiming to conserve organ function and optimize disease control. This updated review focuses on penile cancer management data published in the last few years.

RECENT FINDINGS

Several aspects of penile cancer management are discussed in this review. Wider knowledge about the disease's natural history has provided the basis for new TNM staging and follow-up schedule proposals. Modern imaging techniques and gene profiling assays have been applied. A new guideline addressing various aspects of penile cancer was recently published, and more extensive experience has been gained with sentinel lymph node biopsy and radiotherapy. Quality of life and psychosexual impact of the disease are also being addressed.

SUMMARY

New diagnostic and therapeutic techniques, as well as attempts to better identify patients who may benefit from less invasive treatments have been studied, but more experience in the field is clearly needed. For this purpose, collaborative multicenter studies are strongly encouraged.

Organ-preserving neodymium-yttrium-aluminium-garnet laser therapy for penile carcinoma: a long-term follow-up

OBJECTIVE

To retrospectively analyse the long-term follow-up of 54 patients treated with organ-preserving laser therapy for penile carcinoma, as such therapy provides excellent cosmetic and functional results, but recurrence rates are high, which might impair the oncological outcome and worsen tumour-related survival.

PATIENTS AND METHODS

Between 1979 and 2008, 54 patients with penile carcinoma were treated with the neodymium-doped yttrium-aluminium-garnet (Nd:YAG) laser at our institution; 11 were classified as having carcinoma in situ (Tis), 39 as T1 and four as T2.

RESULTS

There was local recurrence in 16 patients (42%); the mean (range) time to local recurrence was 53 (9-132) months. In half the patients the time to local recurrence was >53 months, with the latest recurrence at 132 months after initial therapy of primary tumour. There was no statistically significant difference in recurrence rates with Tis or invasive penile carcinoma. In lymph-node-negative patients at initial presentation, there were no newly developed positive lymph nodes during the follow-up.

CONCLUSIONS

Organ-preserving laser therapy showed a relatively high recurrence rate in patients with a long-term follow up, but the oncological outcome and survival were not compromised by local recurrence. Therefore, laser therapy appears to be appropriate for treating premalignant lesions and early stages of penile carcinoma. Patients should be informed about the potential for late recurrence.

Peniscopically controlled CO2 laser excision for conservative treatment of in situ and T1 penile carcinoma: report on 224 patients

OBJECTIVE

To evaluate the outcome of peniscopically controlled laser excision of early-stage penile carcinoma.

METHODS

Patients treated from 1982 to 2006 were investigated. The primary treatment was excisional surgery alone for in situ or initially invasive flat tumors, and reductive chemotherapy followed by surgery for the exophytic lesions. All excisional procedures were conducted by CO(2) laser under peniscopic control.

RESULTS

Of a total of 224 patients, 111 underwent partial excision of the glans and/or coronal sulcus surface, and 113 total surface excision. Forty patients underwent reductive chemotherapy. Complete excision was obtained in 221 cases (98.7%) at lateral margins and in 217 cases (96.9%) at deep margin. Postoperative complications were negligible. Overall, the 10-yr recurrence rate was 17.5% (95% confidence interval, 16.4-18.6%), and apparently was not affected by the in situ or invasive nature of the lesion. Amputation was required in nine patients, for a 10-yr amputation rate of 5.5% (range, 5.2-5.7%). In the remaining cases, organ form and curvature were preserved, with satisfactory cosmetic and functional results.

CONCLUSIONS

Early-stage penile carcinomas can be effectively treated with the organ-sparing strategy described here. Because local recurrences occur in a minority of patients and can be safely treated, organ preservation is compatible with local disease control. Reductive systemic chemotherapy in selected exophytic cases broadens the indication for our conservative approach.

Penile carcinoma: a challenge for the developing world

Although rare in developed countries, carcinoma of the penis is an important problem in the developing world. Circumcision done in childhood offers the greatest protection against this disease. Poor penile hygiene and phimosis are strong risk factors for development of penile carcinoma. Early disease can be treated by conventional resection of the penis, or in selected patients by organ preserving techniques including Mohs micrographic surgery, and laser and radiation therapy. For more advanced primary disease, partial or total penectomy is needed. Elective or therapeutic lymph-node dissection is recommended for inguinal metastatic disease, and depending on the disease status, unilateral or bilateral inguinal or ilioinguinal lymphadenectomy might be needed. The role of chemotherapy, as adjuvant or primary treatment in metastatic disease, needs to be defined in prospective clinical trials, which can be done in developing countries.

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

For men with penile carcinoma, surveillance strategies may be tailored to the risks of local and regional recurrence, which vary according to the pathologic characteristics of the primary tumor and the modalities employed for local therapy (phallus sparing or extirpative) and regional therapy (surveillance or lymphadenectomy). Men at a higher risk for local or regional recurrence who should have more rigorous follow-up include those (1) treated with phallus-sparing strategies such as laser ablation, topical therapies, or radiotherapy; (2) patients with clinically negative inguinal lymph nodes who are managed without lymphadenectomy despite high-risk primary tumors (pT2-3, grade 3, vascular invasion); and (3) those with lymph node metastases after lymphadenectomy. Good candidates for less-stringent surveillance include patients with low-risk primary tumors (pTis, pTa, pT1, grades 1-2) and those with negative inguinal nodes after lymphadenectomy whose primary tumors were managed with partial or total penectomy.

Conservative surgical therapy for penile and urethral carcinoma

OBJECTIVES

Invasive penile and urethral tumors are traditionally treated with aggressive excision that requires involved organ and adjacent organ sacrifice. An alternative approach seeks to completely excise the tumor with adequate margins while preserving form and function of the organ. We present 6 patients who underwent such organ-sparing surgery.

METHODS

Six selected cases (4 penile and 2 urethral) are presented with operative photographs and pertinent data.

RESULTS

Three distal tumors of the penis were treated with excision limited to the glans with histopathologic findings of verrucous carcinoma, melanoma, and angiosarcoma. One patient with squamous cell carcinoma of the distal shaft refused partial penectomy and underwent a local wedge resection. A patient with locally advanced bulbourethral transitional cell carcinoma (TCC) refused cystourethrectomy and underwent an anterior urethrectomy and perineal urethrostomy. A 48-year-old woman with an adenocarcinoma contained in a very distal urethral diverticulum underwent simple diverticulectomy and excision of distal urethra. Postoperative voiding and sexual function were well preserved. Follow-up was 12 to 48 months. The patient with angiosarcoma died of lung metastases at 48 months with no local disease, and the patient with bulbourethral TCC developed pelvic disease at 12 months with no local recurrence and died of metastases at 25 months.

CONCLUSIONS

Organ-sparing surgery is appropriate in selected patients on the basis of stage and location, high risk of distant failure, and patient disposition. Close follow-up is necessary. Comanagement with reconstructive and oncologic specialists optimizes results and outcomes.

CO2 laser resection for preneoplastic and initially invasive neoplastic lesions of the penis: Indications and technique

Superficial resection of preneoplastic and initially invasive penile lesions by CO2 laser has been developed as an alternative treatment modality to traditional surgical and destructive methods. Hyperkeratosis, pigmented lesions, chronic inflammatory disease, erythroplasia of Queyrat, Bowenoid papulosis are the main diagnostic and therapeutic indications. Therapeutic resection is indicated for histologically proven penile intraepithelial neoplasia (PIN) grade II and III, and initially invasive squamous cell carcinoma. Conservative laser resection is also indicated for exophytic, superficially infiltrating T1NO squamous cell carcinoma, responsive to systemic chemotherapy. Laser excisional procedures are always performed in association with the operating microscope, under local anaesthesia, often on an outpatient basis. Based on the disease extent, partial or total glans surface resection can be performed or associated with circumcision. Surgical specimens are always adequate for histological examination as to the extent of the disease in depth and width. Uncleared margins of resection indicate the need for further treatment. Technical, anatomical, and functional results confirm the clinical effectiveness of this microsurgical approach for selected lesions.

Squamous carcinoma of the penis and previous recurrent balanitis: a case report

A 33 year old uncircumcised Caucasian male who had a 7 year history of intermittent erosive balanitis and herpes, presented with an 18 month history of progressively worsening penile ulceration not responding to the usual medication. Biopsy of the glans penis carried out in view of the long standing ulceration showed a sqamous cell carcinoma of the penis. As there was no response to radiotherapy, partial penectomy was carried out. The importance of early biopsy is emphasised when ulcerative lesions of the penis do not respond adequately to medical therapy. Different treatment modalities available are reviewed.