Penile cancer: Clinical Practice Guidelines in Oncology

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.

Neoadjuvant toripalimab plus nimotuzumab combined with taxol-based chemotherapy in locally advanced penile squamous cell carcinoma

The conventional neoadjuvant chemotherapy regimen for locally advanced penile squamous cell carcinoma (La-PSCC) has shown moderate response rates and survival benefits. This single-arm, phase II trial (NCT04475016) evaluated a neoadjuvant regimen of four cycles of toripalimab (anti-PD-1 antibody), nimotuzumab (anti-EGFR antibody), and taxol-based chemotherapy (TNT), followed by consolidative surgery. The primary endpoint was the pathological complete response (pCR) rate. Among 29 enrolled patients, 24 (82.8%) underwent consolidative surgery, with 14 (48.3%, 95% confidence interval [CI], 29.4-67.5%) achieving pCR. The objective response rate (ORR) was 82.8% (95% CI, 64.2-94.2). Median follow-up was 39.97 months, with two-year overall survival (OS) and progression-free survival (PFS) rates of 72.4% and 65.5%. Grade 3-4 treatment-related adverse events (TRAEs) occurred in 12 (41.4%) patients, with no treatment-related deaths. Biomarker analysis identified PD-L1 expression, TP53 mutation status, and CD8+ T cell density as potential predictive markers. Therefore, neoadjuvant TNT shows promising anti-tumor activity and acceptable toxicity.

Smoking and presence of human papillomavirus correlates with lymphocyte density in the stroma of penile squamous cell carcinoma

Background

Penile squamous cell carcinoma (PSCC) is the most common malignancy of the penis. Considering the increase in incidence of PSCC in many countries, there is a need for better and effective therapies for these patients. The tumor microenvironment may offer insights into a better understanding of the tumor, which may inform on predictive and prognostic targets. In this study, we investigated immune cell infiltration into the stroma of PSCC, and how it may be affected by multiple factors including smoking, HIV infection, and/or HPV infection.

Methods

We carried out a prospective analytical cross-sectional study at the University Teaching Hospital in Lusaka, Zambia. Consenting patients with confirmed PSCC, attending the Urology Clinic and scheduled for partial or total penectomy were enrolled into the study. HIV testing by serology, HPV detection and genotyping on fresh tumors by real time PCR, hematoxylin and eosin (H&E) staining and immunohistochemistry staining for CD3+ and CD8+ cells on formalin-fixed paraffin-embedded tissue, and flow cytometry for immunophenotyping circulating immune cells were done.

Results

We enrolled 33 participants into the study. The participants had a mean age of 56 years, the majority (84.8%) were HIV positive, high-risk HPV was detected in 63.6% of the tumors, and 57.6% were positive for both HIV and high-risk HPV. HPV-positive PSCC tumors had a significantly lower proportion of infiltrating lymphocytes in the stroma on H&E staining than HPV-negative tumors [18% vs 53%; p=0.025]. Smokers had a significantly lower number of infiltrating CD8+ cells in the stroma than non-smokers [68 vs 99; p=0.035]. No difference in the density of stromal lymphocytes between HPV/HIV co-infected and non-co-infected individuals was observed. There was a statistically significant positive correlation in number of CD3+ (⍴=0.38; p=0.027) and CD8+ (⍴=0.40; p=0.02) cells in the stroma and intra-tumor. Factors including histological stage, tumor grade, HPV status, and HIV status seem to influence the correlation in number of stroma and intra-tumoral immune cells.

Conclusion

Smoking and presence of hrHPV is associated with a lower density of infiltrating lymphocytes in the stroma of PSCC. There is a positive correlation in the number of CD3+ and CD8+ cells between the stroma and intra-tumoral compartment of PSCC.

Immunotherapy in the Management of Penile Cancer-A Systematic Review

Penile cancer, though a rare malignancy, presents a significant challenge in the domain of male genitourinary oncology, particularly due to its limited treatment options and due to the profound physical and psychological impact on patients [...].

Organ-sparing partial glansectomy: an alternative surgical management for invasive penile carcinoma-case report

Background

Penile cancer is a rare malignancy treated via various surgical techniques guided by disease stage and grade with current guidelines suggesting partial or total penectomy for those with pT2 or greater. We report a case of a patient with pT2 squamous cell carcinoma (SCC) of the penis who underwent circumcision with left partial-glansectomy and en bloc resection of preputial mass with good oncological control while providing good urinary and sexual function.

Case Description

An 82-year-old male presented to the clinic due to a mass that doubled in size in an 8-month timeframe. Treatment options were discussed with the patient including the risks and benefits of each electing wide-excision in glans-sparing fashion, possible partial penectomy. Given the possibility of low-grade verrucous carcinoma upon intraoperative exploration, ultimately, circumcision with left partial-glansectomy and en bloc resection of preputial mass was performed guided with intraoperative negative frozen sections. Patient's surgery and post-operative course were uncomplicated, followed with serial exams, and cross-sectional images showing no recurrence or metastasis.

Conclusions

Careful case selection with close postoperative follow-up monitoring for local recurrences, such as in this case, can allow patients to elect for organ-sparing partial glansectomy-when complete resection is feasible-as an acceptable option for oncological control in patients with pT2 penile cancer while providing good urinary and sexual function.

Proposal of a Subclassification of pN3 in Squamous Cell Carcinoma of the Penis

OBJECTIVE

To evaluate the differential prognosis of PLNM as compared to ENE and postulate a sub-classification of the pN3 stage of carcinoma penis.

METHODS

A retrospective analysis of prospectively maintained data of all the patients of penile squamous cell carcinoma operated at our institute between Jan 2016 and May 2023 was conducted. LASSO Cox regression was used to select variables affecting OS. Cox multivariate analysis was performed to derive significant factors which were permuted to form probable sub-classifications. The best sub-classification was selected based on Akaike Information Criteria (AIC) and Kaplan Meier analysis.

RESULTS

Seventy three patients were included in the study. ENE (HR: 2.6, p = 0.038) and PLNM (HR: 3.3, p = 0.004) were significantly associated with OS on Cox multivariate analysis using LASSO based variable selection. Four probable sub-classifications were created of which pN3a (only ENE) and pN3b (only PLNM and ENE+PLNM) showed least AIC (235.065). The mean OS was 36.6 and 17.2 months respectively for pN3a and pN3b subgroups.

CONCLUSIONS

ENE had a better OS as compared to PLNM and ENE+PLNM in our study. A sub-classification of pN3 stage of TNM classification is proposed. Multi-institutional prospective studies with large number of patients and longer follow-up should validate our findings.

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.

Management of Bulky Inguinal and Pelvic Lymph Nodes

Penile cancer with bulky inguinal metastasis has a high probability of harboring pathologically involved lymph nodes best managed in a multidisciplinary care setting. Appropriate staging with cross-sectional imaging and fine-needle aspirate cytology of suspicious nodes guide decision-making for the use of platinum-based neoadjuvant chemotherapy followed by inguinal lymph node dissection. Surgical resection plays an important diagnostic, therapeutic, and guiding role in disease management. Patients with adverse pathologic features, especially those with extranodal disease extension, may derive additional benefit from adjuvant radiotherapy.

Complications and adverse events in lymphadenectomy of the inguinal area: worldwide expert consensus

BACKGROUND

Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group.

METHODS

A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α.

RESULTS

Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer.

CONCLUSION

The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.

Neoadjuvant platinum-based chemotherapy and lymphadenectomy for penile cancer: an international, multi-institutional, real-world study

INTRODUCTION

This study investigated the efficacy and safety of neoadjuvant chemotherapy for locally advance penile squamous cell carcinoma for which current evidence is lacking.

METHODS

Included patients had locally advanced penile squamous cell carcinoma with clinical lymph node metastasis treated with at least 1 dose of neoadjuvant chemotherapy prior to planned consolidative lymphadenectomy. Objective response rates were assessed using Response Evaluation Criteria in Solid Tumors v1.1. The primary and secondary outcomes were overall survival and progression-free survival, estimated by the Kaplan-Meier method. Treatment-related adverse events were graded per the Common Terminology Criteria for Adverse Events v5.0.

RESULTS

A total of 209 patients received neoadjuvant chemotherapy for locally advanced and clinically node-positive penile squamous cell carcinoma. The study population consisted of 7% of patients with stage II disease, 48% with stage III, and 45% with stage IV. Grade 2 treatment-related adverse events occurred in 35 (17%) patients, and no treatment-related mortality was observed. Of the patients, 201 (97%) completed planned consolidative lymphadenectomy. During follow-up, 106 (52.7%) patients expired, with a median overall survival of 37.0 months (95% confidence interval [CI] = 23.8 to 50.1 months) and median progression-free survival of 26.0 months (95% CI = 11.7 to 40.2 months). Objective response rate was 57.2%, with 87 (43.2%) having partial response and 28 (13.9%) having a complete response. Patients with objective response to neoadjuvant chemotherapy had a longer median overall survival (73.0 vs 17.0 months, P < .01) compared with those who did not. The lymph node pathologic complete response rate was 24.8% in the cohort.

CONCLUSION

Neoadjuvant chemotherapy with lymphadenectomy for locally advanced penile squamous cell carcinoma is well tolerated and active to reduce the disease burden and improve long-term survival outcomes.

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.

A comprehensive review of current knowledge on penile squamous cell carcinoma

Neoplasm of the penis is relatively rare in most regions representing 0-2% of cancers worldwide. While the penis can be affected by sarcomas, basal cell carcinomas or even melanoma, Penile Squamous Cell Carcinoma (PSCC) represents approximately 95% of all penile neoplasms. Despite its rarity and most common presentation at later decades of life most individuals diagnosed with PSCC are faced with significant decrease in quality of life. The prevalence and incidence vary among different regions and populations, but a common trend is for diagnosis to occur late (stage 4). Underdeveloped countries are traditionally reported to have higher incidence rates; however, rates may vary significantly between urban and rural areas even in developed countries. Age adjusted rates are on the rise in some countries that used to have incidence rates of 1:100 000 or less. The list of associated risk factors is long and includes among others, lack of neonatal circumcision, poor genital hygiene, socioeconomic status, history of human papillomavirus (HPV) infection and penile intraepithelial neoplasia (PeIN). Many risk factors are widely debated among experts however HPV and PeIN are indisputable risk factors, and both also form part of the classification system for PSCC. Both conditions may have occurred in the past or be present at the time of diagnosis and identifying them plays a major role in management strategies. For such a rare condition PSCC can present in many different forms clinically making diagnosis no easy feat. Diagnosis of PSCC is done through clinical examination, including lymph node palpation, followed by a biopsy, which is essential for the classification. Lymph node involvement is a common finding at first presentation and investigation of spread to deep nodes is important and can be done with the aid of PET-CT. Treatment options for PSCC include surgery, chemotherapy, and radiation therapy. Surgical removal of the tumor is considered the most effective however can lead to severe decrease of quality of life. Chemotherapy is used in the case of fixed or bulky lymph nodes, where surgery is not indicated, and for distant metastasis. Radiation therapy is particularly effective in the case of HPV-positive PSCC.

Development and validation of HPV-associated and HPV-independent penile squamous cell carcinoma prognostic nomogram

OBJECTIVE

The aim of this study was to introduce HPV-associated and HPV-independent histologic classifications to analyze prognostic factors and develop a prognostic nomogram for patients with penile squamous cell carcinoma (PSCC).

METHODS

Data of 1502 PSCC patients between 2010 and 2020 were accessed from the SEER database, and the patients were randomly divided into a training set and a validation set. Independent risk factors for PSCC patients prognosis were analyzed by using univariate and multivariate COX proportional hazards regression, and was used for the construction of the nomogram, and the predictive performance of the model was evaluated by C-index, calibration curve and ROC curve. Kaplan-Meier analysis was applied to explore the impact of HPV-related factors on patient survival, while propensity score matching (PSM) and inverse probability treatment weighting (IPTW) techniques were used to balance other confounding factors like individual clinical and pathological factors, and to evaluate the differences in overall survival (OS) and cause-specific survival (CSS) between subgroups.

RESULT

The results indicated that histologic type, Grade classification, T/M stage, surgical methods and chemotherapy were independent risk factors affecting OS and CSS in PSCC patients. In addition, age and marital status were significantly associated with OS, while lymph node metastasis was an independent prognostic factor for CSS, the validation results of the model showed that the nomogram had a superior predictive performance compared with the American Joint Committee on Cancer staging system. In addition, subgroup analyses prior to and after IPTW and PSM adjustments showed that HPV-associated group had better OS and CSS than HPV-independent group.

CONCLUSION

Our study developed and validated a nomogram using a novel histologic classification and achieved satisfactory results, which can better help clinicians to predict the prognosis of penile squamous cell carcinoma patients.

Robotic or open superficial inguinal lymph node dissection as staging procedures for clinically node negative high risk penile cancer

OBJECTIVE

To evaluate perioperative and oncologic outcomes of a cohort of clinically node negative high-risk penile cancer patients undergoing robotic assisted inguinal lymph node dissection (RAIL) compared to patients undergoing open superficial inguinal lymph node dissection (OSILND).

PATIENTS AND METHODS

We retrospectively reviewed the clinical characteristics and outcomes of clinically node negative high-risk penile cancer patients undergoing RAIL at MDACC from 2013-2019. We sought to compare this to a contemporary open cohort of clinically node negative patients treated from 1999 to 2019 at MDACC and Moffit Cancer Center (MCC) with an OSILND. Descriptive statistics were used to characterize the study cohorts. Comparison analysis between operative variables was performed using Fisher's exact test and Wilcoxon's rank-sum test. The Kaplan-Meier method was used to estimate survival endpoints.

RESULTS

There were 24 patients in the RAIL cohort, and 35 in the OSILND cohort. Among the surgical variables, operative time (348.5 minutes vs. 239.0 minutes, P < 0.01) and the duration of operative drain (37 vs. 22 days P = 0.017) were both significantly longer in the RAIL cohort. Complication incidences were similar for both cohorts (34.3% for OSILND vs. 33.3% for RAIL), with wound complications making up 33% of all complications for RAIL and 31% of complications for OSILND. No inguinal recurrences were noted in either cohort. The median follow-up was 40 months for RAIL and 33 months for OSILND.

CONCLUSIONS

We observed similar complication rates and surgical variable outcomes in our analysis apart from operative time and operative drain duration. Oncological outcomes were similar between the two cohorts. RAIL was a reliable staging and potentially therapeutic procedure among clinically node negative patients with penile squamous cell carcinoma with comparable outcomes to an OSILND cohort.

Improving Quality of Life and Psychosocial Health for Penile Cancer Survivors: A Narrative Review

Treatment of penile cancer (PC) focuses on organ preservation, employing various surgical and non-surgical approaches. These interventions may lead to disfigurement, impacting patients' functional outcomes and psychosocial well-being. We reviewed studies related to penile health and PC up to February 2024, limited to studies published in English. Studies employing health-related quality of life (HRQoL) assessments have identified a detrimental association between aggressive treatment and overall health status, physical functioning, and relationships. In contrast, organ-sparing demonstrates improved measures related to HRQoL and sexual function. Assessment through validated questionnaires reveals diverse voiding outcomes, and varying impacts on QoL and sexual activity, emphasizing the necessity for multidisciplinary personalized care. Studies highlight substantial variations in sexual function, with patients reporting adaptations, reduced satisfaction, and concerns about body image and sexual well-being. Furthermore, unmet needs include challenges in patient-clinician communication, obtaining information, and accessing psychosocial support. Patient experiences underscore the importance of timely diagnosis, treatment access, and addressing psychological consequences. Organ-sparing approaches have higher QoL preservation and sexual function. Individualized support, including sexual therapy, support groups, and family counseling, is essential for post-treatment rehabilitation. Timely diagnosis and comprehensive care are paramount in addressing the multifaceted impact of PC on patients and families.

Unmasking the Metabolite Signature of Bladder Cancer: A Systematic Review

Bladder cancer (BCa) research relying on Omics approaches has increased over the last few decades, improving the understanding of BCa pathology and contributing to a better molecular classification of BCa subtypes. To gain further insight into the molecular profile underlying the development of BCa, a systematic literature search was performed in PubMed until November 2023, following the PRISMA guidelines. This search enabled the identification of 25 experimental studies using mass spectrometry or nuclear magnetic resonance-based approaches to characterize the metabolite signature associated with BCa. A total of 1562 metabolites were identified to be altered by BCa in different types of samples. Urine samples displayed a higher likelihood of containing metabolites that are also present in bladder tumor tissue and cell line cultures. The data from these comparisons suggest that increased concentrations of L-isoleucine, L-carnitine, oleamide, palmitamide, arachidonic acid and glycoursodeoxycholic acid and decreased content of deoxycytidine, 5-aminolevulinic acid and pantothenic acid should be considered components of a BCa metabolome signature. Overall, molecular profiling of biological samples by metabolomics is a promising approach to identifying potential biomarkers for early diagnosis of different BCa subtypes. However, future studies are needed to understand its biological significance in the context of BCa and to validate its clinical application.

Characterization of T cell receptor repertoire in penile cancer

Tumor-infiltrating lymphocytes (TILs) play a key role in regulating the host immune response and shaping tumor microenvironment. It has been previously shown that T cell infiltration in penile tumors was associated with clinical outcomes. However, few studies have reported the T cell receptor (TCR) repertoire in patients with penile cancer. In the present study, we evaluated the TCR repertoires in tumor and adjacent normal tissues from 22 patients with penile squamous cell carcinoma (PSCC). Analysis of the T cell receptor beta-variable (TRBV) and joining (TRBJ) genes usage and analysis of complementarity determining region 3 (CDR3) length distribution did not show significant differences between tumor and matched normal tissues. Moreover, analysis of the median Jaccard index indicated a limited overlap of TCR repertoire between these groups. Compared with normal tissues, a significantly lower diversity and higher clonality of TCR repertoire was observed in tumor samples, which was associated with clinical characteristics. Further analysis of transcriptional profiles demonstrated that tumor samples with high clonality showed increased expression of genes associated with CD8 + T cells. In addition, we analyzed the TCR repertoire of CD4 + T cells and CD8 + T cells isolated from tumor tissues. We identified that expanded clonotypes were predominantly in the CD8 + T cell compartment, which presented with an exhausted phenotype. Overall, we comprehensively compared TCR repertoire between penile tumor and normal tissues and demonstrated the presence of distinct T cell immune microenvironments in patients with PSCC.

The evolution of PET imaging in renal, bladder, upper urinary tract urothelial, testicular and penile carcinoma - Today's impact, tomorrow's potential

INTRODUCTION

The advancement of hybrid PET/CT or PET/MRI imaging for non-prostate genitourinary cancers has not experienced the rapid progress of prostate cancer. Nevertheless, these neoplasms are aggressive and reliable imaging plays a pivotal role in enhancing patients' quality of life and prognosis.

AREAS COVERED

the main evidence regarding [18F]FDG and non-[18F]FDG PET/CT or PET/MRI in non-prostate uro-oncological malignancies are summarized and discussed. Moreover, potential future directions concerning PET imaging in these neoplasms are debated, with the aim to stimulate future research projects covering these fields.

EXPERT OPINION

In Renal Cell Carcinoma (RCC), [18F]FDG PET/CT demonstrates varying efficacy in staging, restaging, and prognostic stratification, but PSMA PET/CT is emerging as a potential game-changer, particularly in advanced, high-grade aggressive clear cell RCC. [18F]FDG PET/CT may see an increased use in N and M-staging of bladder cancer, as well as for detecting recurrence and response to neoadjuvant chemotherapy. Preliminary data regarding [68Ga]-FAPI also looks promising in this context. [18F]FDG PET/MRI could be useful for the T-staging of bladder cancer, while upper tract urothelial carcinoma still lacks of molecular imaging literature reports. In testicular and penile cancer [18F]FDG PET/CT has demonstrated its usefulness in several clinical settings, although experiences with non-[18F]FDG radiotracers are lacking.

SPP1 is associated with adverse prognosis and predicts immunotherapy efficacy in penile cancer

BACKGROUND

The effect of SPP1 in squamous cell carcinoma of the penis (PSCC) remained unknown. We attempted to clarify the function of the SPP1 gene in PSCC.

METHOD

Eight paired penile cancer specimens (including penile cancer tissue, paracancerous tissue, and positive lymph node tissue) subjected to whole transcriptome sequencing were analysed to identify differentially expressed genes. We used immunohistochemistry to detect the expression of SPP1 protein and immune cell related proteins in penile cancer tissue. Then, we performed weighted gene coexpression network analysis (WGCNA) to identify the genes related to SPP1 in penile cancer tissue and positive lymph node tissue. Based on the GSE57955 dataset, the CIBERSORT and ssGSEA algorithms were carried out to investigate the immune environment of PSCC. GSVA analysis was conducted to identify the signaling pathways related to SPP1 subgroups. Enzyme-linked immunosorbent assay (ELISA) method was adopted to detect SPP1 level in the serum of 60 patients with penile cancer.

RESULTS

Differential analysis indicated that SPP1 was the most differentially upregulated gene in both penile cancer tissues and positive lymph node tissues. Survival analysis suggested that the prognosis of the low-SPP1 group was significantly poorer than that of the high-SPP1 group. Subsequently, immune-related bioinformatics showed that SPP1 was significantly associated with B cells, CD8 + T cells, CD4 + T cells, macrophages, helper T cells, neutrophils and dendritic cells. The immunohistochemical results showed that the high-SPP1 group was characterized by relatively high expression of CD16 and relatively low expression of CD4. GSVA analysis indicated that high-SPP1 group was significantly associated with immune-related pathways such as PD-L1 expression and the PD-1 checkpoint pathway in cancer and the TNF signaling pathway. ELISA demonstrated that the serum level of SPP1 in patients with positive lymph node metastasis of penile cancer was significantly higher than that in patients with negative lymph node metastasis of penile cancer.

CONCLUSION

Our study shows that the SPP1 gene might be an effective biomarker for predicting the prognosis and the efficacy of immunotherapy in PSCC patients.

Safety and efficacy of immune checkpoint inhibitors in advanced penile cancer: report from the Global Society of Rare Genitourinary Tumors

BACKGROUND

Treatment options for penile squamous cell carcinoma are limited. We sought to investigate clinical outcomes and safety profiles of patients with penile squamous cell carcinoma receiving immune checkpoint inhibitors.

METHODS

This retrospective study included patients with locally advanced or metastatic penile squamous cell carcinoma receiving immune checkpoint inhibitors between 2015 and 2022 across 24 centers in the United States, Europe, and Asia. Overall survival and progression-free survival were estimated using the Kaplan-Meier method. Objective response rates were determined per Response Evaluation Criteria in Solid Tumours 1.1 criteria. Treatment-related adverse events were graded per the Common Terminology Criteria for Adverse Events, version 5.0. Two-sided statistical tests were used for comparisons.

RESULTS

Among 92 patients, 8 (8.7%) were Asian, 6 (6.5%) were Black, and 24 (29%) were Hispanic and/or Latinx. Median (interquartile range) age was 62 (53-70) years. In all, 83 (90%) had metastatic penile squamous cell carcinoma, and 74 (80%) had received at least second-line treatment. Most patients received pembrolizumab monotherapy (n = 26 [28%]), combination nivolumab-ipilimumab with or without multitargeted tyrosine kinase inhibitors (n = 23 [25%]), or nivolumab (n = 16 [17%]) or cemiplimab (n = 15 [16%]) monotherapies. Median overall and progression-free survival were 9.8 months (95% confidence interval = 7.7 to 12.8 months) and 3.2 months (95% confidence interval = 2.5 to 4.2 months), respectively. The objective response rate was 13% (n = 11/85) in the overall cohort and 35% (n = 7/20) in patients with lymph node-only metastases. Visceral metastases, Eastern Cooperative Oncology Group (ECOG) performance status of 1 or higher, and a higher neutrophil/lymphocyte ratio were associated with worse overall survival. Treatment-related adverse events occurred in 27 (29%) patients, and 9.8% (n = 9) of the events were grade 3 or higher.

CONCLUSIONS

Immune checkpoint inhibitors are active in a subset of patients with penile squamous cell carcinoma. Future translational studies are warranted to identify patients more likely to derive clinical benefit from immune checkpoint inhibitors.

Genomic Profiles and Clinical Outcomes of Penile Squamous Cell Carcinoma With Elevated Tumor Mutational Burden

Importance

Tumor mutational burden (TMB) is a putative biomarker of efficacy for immune checkpoint inhibitor (ICI) therapies of solid tumors, but not specifically for penile squamous cell carcinoma (PSCC).

Objective

To characterize biomarker features and ICI therapy outcomes associated with high TMB in PSCC in the routine clinical practice setting.

Design, Setting, and Participants

In this cohort study, 397 PSCC cases were analyzed to identify genomic alterations in more than 300 cancer-associated genes and genomic signatures, including TMB, using a hybrid capture-based comprehensive genomic profiling assay. Tumor mutational burden was categorized as low (<10 mutations per megabase [mut/Mb]), high (10-19 mut/Mb), or very high (≥20 mut/Mb). Germline status of genetic alterations was predicted using a validated somatic-germline computational method. Clinical outcomes of patients with metastatic PSCC receiving first-line ICI were abstracted using the deidentified nationwide Clinico-Genomic Database (CGDB) from January 1, 2011, through December 31, 2022.

Exposure

Comprehensive genomic profiling was performed using FoundationOne and FoundationOne CDx assays from Foundation Medicine Inc.

Main outcomes and measures

The spectrum of genetic alterations by TMB level in PSCC, the percentage of germline genetic alterations, and the outcome (overall survival with routine clinical treatment) by TMB of chemotherapy-naive patients with PSCC who received ICI treatment up front were assessed in this descriptive study.

Results

Among 397 patients (median [IQR] age, 65 [54-73] years; 266 [67.0%] of European, 83 [20.9%] of admixed American, and 34 [8.5%] of African or other genomic ancestry), the median (IQR) age (eg, 65 [53-73] years for low TMB vs 68 [61-78] years for TMB ≥10 mut/Mb) and genomic ancestry distribution (eg, European 228 of 339 [67.3%] for low TMB vs 38 of 58 [65.5%] for TMB ≥10 mut/Mb) were similar between TMB subgroups. There were 339 PSCC cases (85.4%) with low TMB, 40 cases (10.1%) with high TMB, and 18 cases (4.5%) with very high TMB. Comparisons of TMB of 10 mut/Mb or higher vs low TMB showed an enrichment of genetic alterations in PIK3CA (48.3% vs 18.3%; P < .001) and KMT2D (29.3% vs 7.7%; P < .001) and less frequent genetic alterations in CDKN2A (25.9% vs 45.7%; P = .05). Most genetic alterations did not co-occur. Human papillomavirus identification was more frequent as TMB increased: 28.3% for low TMB, 50.0% for high, and 72.2% for very high. In total, 95 of 1377 genetic alterations (6.9%) were germline. Of 10 patients identified from the CGDB receiving frontline ICIs, median (IQR) follow-up was 9.9 months. Four patients had overall survival with clinical treatment of more than 12 months, including 2 of 3 patients with TMB of 10 mut/Mb or higher.

Conclusions and Relevance

In this cohort study of advanced metastatic PSCC based on TMB levels, significant differences were observed for biomarkers in nearly 15% of patients with a TMB of 10 mut/Mb or higher. Germline testing and ICI-based therapy should be integrated into the management of selected PSCC cases.

The Utility of Salvage Radiotherapy for an Inoperable Inguinal Recurrence of Squamous Cell Carcinoma of the Penis

Penile cancer is a rare genitourinary malignancy for which limited treatment options exist beyond primary surgical resection. Metastatic lymphadenopathy represents a particularly poor prognosis with a lack of literature to suggest the effectiveness of radiation or systemic therapies. Our case documents an inguinal recurrence of penile squamous cell carcinoma not amenable to surgical intervention demonstrating complete response to salvage radiotherapy in the palliative setting. These observations propose the need for further research around the utility of radiotherapy in the management of metastatic penile malignancies.

Lymph node metastasis in cancer progression: molecular mechanisms, clinical significance and therapeutic interventions

Lymph nodes (LNs) are important hubs for metastatic cell arrest and growth, immune modulation, and secondary dissemination to distant sites through a series of mechanisms, and it has been proved that lymph node metastasis (LNM) is an essential prognostic indicator in many different types of cancer. Therefore, it is important for oncologists to understand the mechanisms of tumor cells to metastasize to LNs, as well as how LNM affects the prognosis and therapy of patients with cancer in order to provide patients with accurate disease assessment and effective treatment strategies. In recent years, with the updates in both basic and clinical studies on LNM and the application of advanced medical technologies, much progress has been made in the understanding of the mechanisms of LNM and the strategies for diagnosis and treatment of LNM. In this review, current knowledge of the anatomical and physiological characteristics of LNs, as well as the molecular mechanisms of LNM, are described. The clinical significance of LNM in different anatomical sites is summarized, including the roles of LNM playing in staging, prognostic prediction, and treatment selection for patients with various types of cancers. And the novel exploration and academic disputes of strategies for recognition, diagnosis, and therapeutic interventions of metastatic LNs are also discussed.

[Systemic treatment of penile cancer: New concepts? New achievements?]

Systemic chemotherapy has been in use for metastatic penile carcinoma for years, but its success is limited. Its significance is largely associated with its role in multimodal treatment for lymphatic metastasis in the context of radical lymph node surgery. In cases of limited lymph node involvement, the combination of surgical treatment plus cisplatin- and taxane-based triple combinations may be curative. Advances in the understanding of molecular changes in penile cancer and the search for potential therapy targets have led to numerous studies. Although there is evidence of efficacy of immunotherapeutics, no significant therapeutic improvements have been seen in the clinical routine.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Immune cell infiltration, tumour budding, and the p53 expression pattern are important predictors in penile squamous cell carcinoma: a retrospective study of 152 cases

Penile squamous cell carcinoma (pSCC) is a rare malignancy with a slowly increasing incidence and variable prognosis. Regional lymph node involvement signifies poor prognosis but represents a late sign, and more prognostic markers for effective patient risk stratification are urgently needed. In this retrospective study, 152 tumour samples with formalin-fixed, paraffin-embedded tissue were analysed for traditional pathological variables, tumour budding, p53, p16, and mismatch repair proteins (MMR) immunohistochemistry. The density of tumour lymphocytic infiltrate was also determined, using subjective evaluation by two pathologists (brisk/non-brisk/absent) and also using the immunoscore method, which categorised the cohort into five immunoscore groups according to the number of CD3+ and CD8+ T-cells in both the tumour centre and tumour invasion front. Only one case (0.6%) was MMR-deficient. Tumour budding count ≥5 tumour buds/20× power field and non-brisk/absent lymphocytic infiltrate were significant negative predictors of both the overall survival (OS) and cancer-specific survival (CSS), whereas a low immunoscore was a significant marker of shorter OS but not CSS. Advanced pT stage (3+4) was a significant marker of shorter CSS but not OS. In the multivariate analysis, high-grade budding was a significant parameter if adjusted for the patient's age and associated variables, except for the pN stage. The lymphocytic infiltrate retained its prognostic significance if adjusted for age and associated variables. The negative prognostic significance of the previously described parameters (lymphatic, venous, and perineural invasion, regional lymph node metastasis, and p53 mutated profile) were confirmed in our study. Grade, histological subtype, and HPV status (as determined by p16 immunohistochemistry) showed, surprisingly, little or no prognostic significance.

Assessment and Reporting of Perioperative Adverse Events and Complications in Patients Undergoing Inguinal Lymphadenectomy for Melanoma, Vulvar Cancer, and Penile Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Inguinal lymph node dissection (ILND) plays a crucial role in the oncological management of patients with melanoma, penile, and vulvar cancer. This study aims to systematically evaluate perioperative adverse events (AEs) in patients undergoing ILND and its reporting.

METHODS

A systematic review was conducted according to PRISMA. PubMed, MEDLINE, Scopus, and Embase were queried to identify studies discussing perioperative AEs in patients with melanoma, penile, and vulvar cancer following ILND.

RESULTS

Our search generated 3.469 publications, with 296 studies meeting the inclusion criteria. Details of 14.421 patients were analyzed. Of these studies, 58 (19.5%) described intraoperative AEs (iAEs) as an outcome of interest. Overall, 68 (2.9%) patients reported at least one iAE. Postoperative AEs were reported in 278 studies, combining data on 10.898 patients. Overall, 5.748 (52.7%) patients documented ≥1 postoperative AEs. The most reported ILND-related AEs were lymphatic AEs, with a total of 4.055 (38.8%) events. The pooled meta-analysis confirmed that high BMI (RR 1.09; p = 0.006), ≥1 comorbidities (RR 1.79; p = 0.01), and diabetes (RR 1.81; p =  < 0.00001) are independent predictors for any AEs after ILND. When assessing the quality of the AEs reporting, we found 25% of studies reported at least 50% of the required criteria.

CONCLUSION

ILND performed in melanoma, penile, and vulvar cancer patients is a morbid procedure. The quality of the AEs reporting is suboptimal. A more standardized AEs reporting system is needed to produce comparable data across studies for furthering the development of strategies to decrease AEs.

Inguinal lymph node dissection in the era of minimally invasive surgical technology

BACKGROUND

Inguinal lymph node dissection (ILND) is an essential step in both treatment and staging of several malignancies including penile and vulvar cancers. Various open, video endoscopic, and robotic-assisted techniques have been utilized so far. In this review, we aim to describe available minimally invasive surgical approaches for ILND, and review their outcomes and complications.

METHODS

The PubMed, Wiley Online Library, and Science Direct databases were reviewed in February 2020 to find relevant studies published in English within 2000-2020.

FINDINGS

There are different minimally invasive platforms available to accomplish dissection of inguinal nodes without jeopardizing oncological results while minimizing postoperative complications. Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy are safe and achieve the same nodal yield, a surrogate metric for oncological adequacy. When compared to open technique, Video Endoscopic Inguinal Lymphadenectomy and Robotic Video Endoscopic Inguinal Lymphadenectomy may offer faster postoperative recovery and fewer postoperative complications including wound dehiscence, necrosis, and infection. The relatively high rate and severity of postoperative complications hinders utilization of recommended ILND for oncologic indications. Minimally invasive approaches, using laparoscopic or robotic-assisted platforms, show some promise in reducing the morbidity of this procedure while achieving adequate short and intermediate term oncological outcomes.

High cardiovascular disease mortality after penile squamous cell carcinomas diagnosis: Results from the United States SEER population, 2005-2016

Background

Cancer survivorship care is an emerging and necessary component of oncology management. To explore cardiovascular disease (CVD)-specific mortality and prognostic factors among patients with penile squamous cell carcinomas (PSCC). These results aid clinicians in furtherly understand this disease's prognosis.

Method

We analyzed Surveillance, Epidemiology and End Results Program data for 2668 PSCC cases diagnosed between 2005 to 2016. We calculated standardized mortality ratios (SMRs) of CVD and all-cause mortality, comparing PSCC patients with general population men. A cumulative mortality curve and competitive risk regression model were utilized to evaluate the prognostic factors of CVD-specific death.

Results

Death distribution is as follows: PSCC (42.4%), other causes (21.3%) CVD (19%), and other cancers (17.3%). PSCC patients are more like to die from CVD (SMR=3.2, 95%CI: 3.1-3.3) and all-cause death compared with the general population. Meanwhile, patients undergoing surgery show a relatively higher CVD-specific mortality than the general population (SMR=2.7, 95%CI: 2.4-3.2). In the competitive risk model, higher CVD mortality is associated with age, region, year of diagnosis, stage, and marital status (all P<0.05). Patients with the localized stage show a higher risk of CVD-specific death than those with regional or distant stage.

Conclusion

Our study mainly reveals that cardiovascular disease was the important cause of death and higher CVD-specific mortality among PSCC patients. Several associated factors related to CVD-specific death are also identified. In the future, more work in educating health care professionals on the components of survivorship care is needed to meet the long-term and late effects cancer patients experience.

Updates in the use of radiotherapy in the management of primary and locally-advanced penile cancer

Objective

Penile cancer is a rare malignancy in most developed countries, but may represent a significant oncologic challenge in certain African, Asian, and South American regions. Various treatment approaches have been described in penile cancer, including radiotherapy. This review aimed to provide a synopsis of radiotherapy use in penile cancer management and the associated toxicities. In addition, we aimed to discuss palliative radiation for metastases to the penis and provide a brief overview of how tumor biology may assist with treatment decision-making.

Methods

Peer-reviewed manuscripts related to the treatment of penile cancer with radiotherapy were evaluated by a PubMed search (1960–2021) in order to assess its role in the definitive and adjuvant settings. Selected manuscripts were also evaluated for descriptions of radiation-related toxicity.

Results

Though surgical resection of the primary is an excellent option for tumor control, select patients may be treated with organ-sparing radiotherapy by either external beam radiation or brachytherapy. Data from randomized controlled trials comparing radiotherapy and surgery are lacking, and thus management is frequently determined by institutional practice patterns and available expertise. Similarly, this lack of clinical trial data leads to divergence in opinion regarding lymph node management. This is further complicated in that many cited studies evaluating lymph node radiotherapy used non-modern radiotherapy delivery techniques. Groin toxicity from either surgery or radiotherapy remains a challenging problem and further risk assessment is needed to guide intensification with multi-modal therapy. Intrinsic differences in tumor biology, based on human papillomavirus infection, may help aid future prognostic and predictive models in patient risk stratification or treatment approach.

Conclusion

Penile cancer is a rare disease with limited clinical trial data driving the majority of treatment decisions. As a result, the goal of management is to effectively treat the disease while balancing the importance of quality of life through integrated multidisciplinary discussions. More international collaborations and interrogations of penile cancer biology are needed to better understand this disease and improve patient outcomes.

Trends in Incidence, Mortality, and Survival of Penile Cancer in the United States: A Population-Based Study

Purpose

The aim of this study is to investigate the trends in incidence and mortality, and explore any change in survival of penile cancer in the United States.

Methods

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database (2000-2018) utilizing the SEER Stat software. The joinpoint regression was used to analyze the secular trend of incidence and incidence-based mortality (IBM) stratified by age, race, and summary stage. The 5-year relative survival rate was also calculated.

Result

The age-adjusted rates of penile cancer patients were 0.38 (0.37-0.39) and 0.21 (0.2-0.21) for overall incidence and IBM, respectively. The 5-year relative survival rates were 67.7%, 66.99%, and 65.67% for the calendar periods of 2000-2004, 2005-2009, and 2010-2014, respectively. No significant changes in incidence by era were observed from 2000 to 2018 [annual percentage change (APC) = 0.5%, p = 0.064]. The IBM rate of penile cancer showed an initial significant increase from 2000 to 2002 (APC = 78.6%, 95% CI, -1.7-224.6) followed by a deceleration rate of 4.6% (95% CI, 3.9-5.3) during 2002 to 2018. No significant improvement in 5-year relative survival was observed. The trends by age, race, and summary stage in incidence and IBM were significantly different.

Conclusion

This study, using population-level data from the SEER database, showed an increasing trend in IBM and no significant improvement in the 5-year relative survival rate. Meanwhile, the incidence of penile cancer exhibited a relatively stable trend during the study period. These results might be due to the lack of significant progress in the treatment and management of penile cancer patients in the United States in recent decades. More efforts, like increasing awareness among the general population and doctors, and centralized management, might be needed in the future to improve the survival of this rare disease.

Immunotherapy Combined With Chemotherapy for Postoperative Recurrent Penile Squamous Cell Carcinoma: A Case Report and Literature Review

Penile squamous cell carcinoma (SCC) is a rare malignant tumor in males with a poor prognosis. Currently, the primary treatment is surgery. Recurrent cases have limited treatment options after failed radiotherapy and chemotherapy. The therapeutic effect of immunotherapy in penile SCCs has not been reported. Tislelizumab, a new PD1 inhibitor, has shown a satisfactory impact in treating head and neck SCC and lung SCC combined with chemotherapy. However, there is currently no report on its efficacy in penile SCC. Here, a 76-year-old man with multiple enlarged inguinal lymph nodes 11 months after radical surgery for penile SCC was administered immunotherapy (tislelizumab) combined with chemotherapy (albumin paclitaxel plus nedaplatin) for 2 cycles. Pelvic Magnetic resonance imaging (MRI) showed that the multiple lymph nodes in the groin area disappeared. To our knowledge, this is the first case report of immunotherapy combined with chemotherapy showing promising results in recurrent penile SCC. It provides a basis for developing a new treatment option combining immunotherapy and chemotherapy, whose efficacy needs to be further evaluated in penile SCC.

Get insight into the cause of death distribution and epidemiology of penile squamous cell carcinoma: A population-based study

Background

Penile squamous cell carcinoma (PSCC) survival had no significant improvement since 1990 in the United States. This study aims to get insight into the changing trend and distribution of death causes of PSCC. The epidemiology of PSCC is also investigated.

Methods

The Surveillance, Epidemiology, and End Results (SEER) (1992–2018) database is utilized to get patients diagnosed with penile squamous cell carcinoma. The trend of incidence, distribution of age, changing trend and distribution of death cause, and survival outcome are analyzed for all PSCC patients and each race.

Results

Three thousand four hundred and twenty‐three male patients with PSCC are enrolled in our study. The age‐adjusted incidence rate of the white has a slight increase (Annual percent change [APC] = 0.647%). American Indian/Alaska Native men have the highest average annual incidence, while Asian /Pacific Islander men have the lowest. PSCC patients aged 70–80 are the most common, and patients over 80 years have the highest 3‐year (50%) and 5‐year (63.93%) mortality rate. Non‐cancer disease, especially circulatory system disease, is the most common cause of death, whereas the proportion of patients who died of PSCC significantly increased from 21.17% (1992–2001) to 41.3% (2012–2017) in PSCC patients (p < 0.001). These results have not changed significantly when we only focus on primary PSCC without previous malignant tumors. Hispanics are shown better overall survival than non‐Hispanic White and non‐ Hispanic Black men. (p < 0.001) No statistical differences in cancer‐specific survival are observed (p = 0.15).

Conclusion

The current study provides essential initial data regarding the presentation and clinical outcomes of PSCC patients. Notably, non‐cancer disease, especially circulatory system disease, is the more common cause of death than PSCC. However, the proportion of patients who died of penile squamous cell carcinoma has a relatively significant increase in recent years. The increasing trends in the advanced stage of PSCC patients might account for this change.

Angioprevention of Urologic Cancers by Plant-Derived Foods

The number of cancer cases worldwide keeps growing unstoppably, despite the undeniable advances achieved by basic research and clinical practice. Urologic tumors, including some as prevalent as prostate, bladder or kidney tumors, are no exceptions to this rule. Moreover, the fact that many of these tumors are detected in early stages lengthens the duration of their treatment, with a significant increase in health care costs. In this scenario, prevention offers the most cost-effective long-term strategy for the global control of these diseases. Although specialized diets are not the only way to decrease the chances to develop cancer, epidemiological evidence support the role of certain plant-derived foods in the prevention of urologic cancer. In many cases, these plants are rich in antiangiogenic phytochemicals, which could be responsible for their protective or angiopreventive properties. Angiogenesis inhibition may contribute to slow down the progression of the tumor at very different stages and, for this reason, angiopreventive strategies could be implemented at different levels of chemoprevention, depending on the targeted population. In this review, epidemiological evidence supporting the role of certain plant-derived foods in urologic cancer prevention are presented, with particular emphasis on their content in bioactive phytochemicals that could be used in the angioprevention of cancer.

Minimal invasive approaches in lymph node management of carcinoma of penis: A review

INTRODUCTION

Inguinal lymph node dissection (ILND) is an integral part in the management of carcinoma penis. The concerns about the postoperative morbidity associated with open ILND led to modification in the template of dissection and adoption of minimally invasive techniques such as video endoscopic inguinal lymphadenectomy (VEIL) and robotic-assisted VEIL (R-VEIL). In this review, we aim to describe the techniques, case selection, perioperative outcomes, and oncological outcomes of VEIL and R-VEIL and to compare it with open ILND.

METHODS

Databases of PubMed, Embase, and Google Scholar were searched to identify the articles for VEIL and R-VEIL. Using PRISMA guidelines, literature search yielded 3783 articles, of which 32 full-text articles relevant to the topic were selected and reviewed, after consensus from authors.

RESULTS

After the first description of VEIL, various modifications in port placements and approaches were described. Several studies have shown, VEIL and R VEIL are safe and feasible in both node-negative and node-positive Ca penis patients. Compared to open ILND, VEIL had fewer wound infections and skin necrosis, minimal blood loss, shorter mean hospital stays, and reduced duration of drain kept. There is no difference in mean lymph node yield and recurrence rates between open ILND, VEIL, R-VEIL.

CONCLUSION

VEIL and R-VEIL are safe and have comparable oncological outcomes with open ILND.

The prognostic value of lymph node ratio in comparison to positive lymph node count in penile squamous cell carcinoma

PURPOSE

Penile cancer is a rare male neoplasm with a wide variation in its global incidence. In this study, the prognostic value of lymph node ratio (LNR) was compared to that of positive lymph node count (PLNC) in penile squamous cell carcinoma.

METHODS

A total of 249 patients with penile squamous cell carcinoma were enrolled from The Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. The X-tile program was used to calculate the optimal cut-off values of LNR and PLNC that discriminate survival. We used the χ2 or the Fisher exact probability test to assess the association between clinical-pathological characteristics and LNR or PLNC. Univariate and multivariate Cox regression analyses were performed to identify independent prognostic factors for survival. Spearman correlation analysis was used to determine the correlation between LNR and PLNC.

RESULTS

We found that patients with high LNR tended to have advanced N stage, the 7th AJCC stage, and higher pathological grade, while patients with high PLNC had advanced N stage and the 7th AJCC stage. Univariate Cox regression analysis revealed that the N stage, M stage, the 7th AJCC stage, lymph-vascular invasion, LNR, and PLNC were significantly associated with prognosis. Multivariate Cox regression analysis demonstrated that LNR rather than PLNC was an independent prognostic factor for cancer-specific survival. Subgroup analysis of node-positive patients showed that LNR was associated with CSS, while PLNC was not.

CONCLUSION

LNR was a better predictor for long-term prognosis than PLNC in patients with penile squamous cell carcinoma.

National trends and survival outcomes of penile squamous cell carcinoma based on human papillomavirus status

Background

There are no series evaluating penile squamous cell carcinoma (pSCC) based on human papillomavirus (HPV) infection. Herein, we present national registry data on clinical and survival outcomes for pSCC based on HPV status.

Methods

We performed a retrospective review of 1224 pSCC patients with known HPV staining from the National Cancer Database. Patients with cM1 disease, those who did not receive treatment, or had missing follow‐up data were excluded. Logistic regression identified factors associated with locally aggressive disease. Univariable, multivariable, and inverse probability of treatment weighting (IPTW)‐Cox proportional hazard modeling were used to assess hazard ratios (HR) associated with overall survival (OS).

Results

After exclusion criteria, we identified 825 cases of which 321 (38.9%) were HPV positive. The HPV‐positivity rate did not significantly change by year. HPV‐positive patients were younger, had lower Charlson‐Deyo performance score, and resided in areas with both lower median household income and lower school education completion. HPV‐positive tumors presented with lower American Joint Committee on Cancer clinical T‐stage (cT), poorer differentiation, lower rates of lymphovascular invasion (LVI), but more node‐positive disease (cN+). For those who underwent lymph node surgery, there were no differences in final pathologic stage, upstaging, or presence of extranodal extension. Only tumor differentiation, LVI, and performance score were independent predictors for locally aggressive disease. HPV status was not a predictor of OS (IPTW‐HR:0.89, p = 0.13).

Conclusions

In the largest series evaluating pSCC based on HPV status, HPV‐positive tumors were associated with lower cT stages, less LVI, but more cN + disease. More studies on prognostic factors are needed, and time may still be immature to use HPV information for risk stratification.

Impact of radiation therapy on perineal urethrostomy for penile cancer

OBJECTIVE

A lack of demonstrated clinical benefit precludes radiotherapy (RT) from being recommended for pN1/pN2 penile cancer (PeCa) lesions; but it may be recommended in case of extranodal (pN3) disease or for positive resection margins. Perineal urethrostomy (PU) is a technique of urinary diversion in patients with PeCa requiring total or subtotal penectomy as primary therapy. Prior studies suggest PU failure rates of up to 30%, without specific mention of the potential role of RT. When RT is delivered for PeCa it is usually to the pre-pubic fat, groin and lateral pelvis, and not to the region of the PU. Here we describe the role of perioperative RT in a large, multi-institutional registry of PU for PeCa.

METHODS

In our cohort, 299 patients from seven international, high-volume centers in Belgium, Brazil, China, Netherlands, United Kingdom and the United States underwent PU as urinary diversion for PeCa between 2000 and 2020. Demographic and clinicopathologic characteristics were reviewed.

RESULTS

Median patient age was 67 years and median follow-up was 19 months. Seven patients (2.3%) received pre-operative RT; six of them with chemotherapy. 37 received RT post-operatively, 21 (57%) with chemotherapy. Stenosis of the PU occurred in 35 (12%) of the total population. The majority of these patients (74%) required surgical revision at a median of 6.1 months post-operatively. RT delivery was neither significantly related to PU stenosis (p = 0.16) or to subsequent revision (p = 0.75).

CONCLUSION

Receipt of RT was not significantly associated with increased stenosis risk in PeCa patients who underwent PU.

A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of penile cancer

Squamous cell carcinoma of the penis (SCCP) is uncommon in some countries (including the U.S.), but is an important malignancy elsewhere. As a rare disease, progress has been slow compared to more common tumor types discussed in this anniversary issue and most often limited to single-center or retrospective datasets.  In this section we describe developments leading to the current standard approach with current research questions.

Recommendations and Clinical Validation of Inguinal Clinical Target Volume Delineation in Penile Cancer

PURPOSE

This study determined the patterns of distribution of inguinal nodes and the optimal margin needed around the femoral vessels to propose guidelines for inguinal clinical target volume (CTV) delineation in penile cancer.

METHODS AND MATERIALS

Patients with biopsy-proven penile squamous cell carcinoma with inguinal node metastases were identified on a computed tomography scan. Distribution of nodes and distance of nodes to the nearest femoral vessel and inferior edge of pubic symphysis (IPS) were obtained. A 3-dimensional CTV margin to cover 95% of the nodes was estimated to evolve contouring guidelines. A comprehensive contouring guide with a visual atlas for inguinal CTV delineation was created. The proposed CTV was prospectively validated in 14 consecutive patients with penile squamous cell carcinoma treated with post-operative radiation therapy to the inguino-femoral region.

RESULTS

Of the 222 inguinal lymph nodes analyzed in 33 patients, 99% were located anterior (81% antero-medial, 18% antero-lateral) to femoral vessels. A majority (95%) of the antero-laterally located nodes were superior to IPS. Margin around the femoral vessels to cover 95% of the nodes for supra-IPS region in anterior, medial, and lateral directions was 29, 23, and 21 mm, respectively, and for infra-IPS region in anterior and medial directions was 21 and 23 mm, respectively. Cranial and caudal extent of CTV delineation with respect to IPS was at 48 and 50 mm, respectively for 95% nodal coverage. On prospective validation, after a median follow-up of 24 months (range, 5-31), none of the patients developed marginal recurrences. Grade 1 and grade 2 lymphedema was seen in 6 (42.8%) and 4 (28.5%) patients, respectively.

CONCLUSIONS

This study analyzed pattern of distribution of inguinal nodes and proposes guidelines for inguinal CTV delineation in penile cancer. The proposed guidelines were validated prospectively in a small cohort of patients and found to be implementable and safe.

Development and Validation of a Nomogram for the Prediction of Inguinal Lymph Node Metastasis Extranodal Extension in Penile Cancer

Purpose

To determine whether a clinicopathologic and laboratory-based nomogram is capable of predicting the risk of lymph node extranodal extension (ENE) in patients with penile cancer.

Materials and Methods

From June 2006 to January 2021, 234 patients who underwent bilateral inguinal lymph node dissection (ILND) surgery were included in the analysis. A Lasso regression model was utilized to select the most useful predictive features from among 46 laboratory variables. Then, a logistic regression analysis was used to develop the prediction model. Calibration curves, concordance index (C-index) and Areas under the receiver-operating characteristic curves (AUCs) were performed to evaluate the performance of the nomogram. We also investigated model fit using changes in Akaike Information Criteria (AICs). Decision curve analyses (DCAs) were applied to assess the clinical usefulness of this nomograms. Its internal validation was confirmed.

Results

Among the 234 patients, 53 were confirmed to have ENE. The platelet-lymphocyte ratio (PLR) and Squamous cell carcinoma antigen (SCC-Ag) were significantly associated with ENE (P<0.05). The individualized prediction nomogram, including the PLR, SCC-Ag, lymphovascular invasion (LVI), and pathologic tumor stage(pT-stage), showed good discrimination, with a C-index of 0.817 (95% CI, 0.745 to 0.890) and good calibration. Clinical-laboratory nomogram (AIC, 180.034) become the best-fitting model. DCA findings revealed that the clinical-laboratory nomogram was more clinically useful than the pT-stage or tumor grade.

Conclusions

This study presents a clinicopathologic and laboratory-based nomogram that incorporates PLR, SCC-Ag, lymphovascular invasion (LVI), and pT-stage, which can be conveniently utilized to facilitate the individualized prediction of lymph node metastasis ENE in patients with penile cancer.

Outcomes of perineal urethrostomy for penile cancer: A 20-year international multicenter experience

PURPOSE

Perineal urethrostomy (PU) is often the definitive form of urinary diversion in patients with locally-advanced or anatomically unfavorable penile cancer (PC) requiring total penectomy. Here, we report post-operative PU-related complications and PU stenosis rates after total penectomy with PU in a large multicenter cohort of PC patients.

METHODS

We retrospectively reviewed the medical records of 299 patients who underwent PU as a means of urinary diversion for primary PC across seven international centers from 2000 to 2020. The Clavien-Dindo grading system was used to record 30-day post-operative complications. Cumulative incidence of stenosis was evaluated using the Kaplan-Meier method.

RESULTS

Median patient age was 67 years (interquartile range (IQR) 58-74), and median follow-up was 19 months (IQR 7.2-57). A total of 58 patients (19%) developed a 30-day post-operative complication, of which 45 (79%) were deemed minor (CD Grade I and II). Wound infection (11%; CD grade I-III) and dehiscence (4.0%; CD grade I-III) were the more common complications. The overall incidence of stenosis was 12% (35/299 patients), of which 26 (74%) needed surgical revision (probability of stenosis revision at one year of 9.3%, median time until the revision: 6.1 months (IQR 3.0-13)). Only two stenoses were seen after two years of follow-up.

CONCLUSION

We present the most extensive series of PU in the management of PC to date. Wound infections of the primary surgical site were the most common complication. Stenosis occurred mostly within one and a half years after treatment.

Salvage therapy for localized recurrences of penile cancer

PURPOSE OF REVIEW

To review the current literature and guidelines regarding salvage therapy for local and regional recurrence of primary penile cancer.

RECENT FINDINGS

While invasive surgical management has not significantly changed, penile sparing treatments (PSTs) may have a promising role in the management of local recurrence. Penile sparing surgeries do appear to have higher rates of recurrence. However, the overall survival rate is comparable to that of partial and total penectomies. Additionally, a combination of therapies may have a more profound effect on management of penile cancer.

SUMMARY

Clinicians must discuss the role of each type of therapy for penile cancer with their patients, and tailor their management to the extent of disease in each patient. While it is important to discuss the balance between quality of life and rates of relapse, one must also emphasize the rates of overall survival in patients with local recurrence who are treated with PSTs.

Technical management of inguinal lymph-nodes in penile cancer: open versus minimal invasive

Inguinal lymphadenectomy (ILND) remains the standard of care for patients with invasive squamous cell carcinoma of the penis, dictating patient prognosis, adjuvant therapies, and surveillance strategies. Importantly the performance of an ILND has been shown to improve cancer-specific outcomes, providing a modifiable factor for patients with an aggressive malignancy. Surprisingly, the procedure remains underutilized, mainly due to the high surgical morbidity associated with the procedure. The open lymphadenectomy technique has undergone several modifications over the last 30 years to minimize its associated surgical morbidity, but wound-related complications remain significant. Minimally invasive surgery (MIS) techniques have been recently introduced to help mitigate wound-related complications associated with open lymphadenectomy, with promising results. In this review, we highlight the importance of ILND, present a detail review of the surgical and oncological outcomes associated with open, laparoscopic and robotic ILND for patients with penile cancer.

A Clinical Nomogram for Predicting Lymph Node Metastasis in Penile Cancer: A SEER-Based Study

Purpose: We developed a nomogram to predict the possibility of lymph node metastasis in patients with squamous cell carcinoma of the penis.

Methods: Identifying patients with squamous cell carcinoma of the penis diagnosed between 2004 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate analyses were carried out by logistic regression to assess significant predictors associated with lymph node metastasis. A nomogram was established and validated by a calibration plot and receptor operating characteristic curve (ROC) analysis.

Results: A total of 1,016 patients with penile squamous cell carcinoma (SCCP) were enrolled in this study. One hundred and ninety-five patients (19%) had lymph node involvement (N1-3). Multivariate analysis showed that age, primary tumor site, grade, tumor size, and T stage were identified as being significantly (p < 0.05) associated with lymph node involvement. All the above factors that showed a statistically significant predictive capability were selected for building the nomogram. This model had a calibration slope of 0.9 and a c-index of 0.776, indicating the good discrimination and effectiveness of the nomogram in predicting lymph node status.

Conclusion: Although the prediction model has some limitations, the nomogram revealed the relationship between the clinicopathological characteristics of SCCP patients and the risk of lymph node metastasis. This tool will assist patients in counseling and guide treatment decisions for SCCP patients.

Management of Advanced Penile Cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer, with approximately 2000 new cases in the United States and 35,000 globally every year. Multiple risk factors are involved in PSCC, but most importantly, the high-risk human papillomavirus infection is thought to be present in approximately 50% of cases. Penile squamous cell carcinoma presents as localized or locally advanced disease. Multiple prognostic markers have been explored over the past 3 decades, but lymph node status remains the strongest predictor of clinical outcomes. Surgical decisions are based on the primary tumor pathologic findings, nodal clinical examination, and imaging results. Most patients with high-risk advanced PSCC benefit from a multimodal treatment approach combining chemotherapy with consolidation surgical treatment. The role of neoadjuvant chemotherapy with radiation therapy has not been well explored in PSCC. Prospective clinical studies, like the International Penile Advanced Cancer Trial, have been launched to provide high-level evidence for multimodal treatment. The International Penile Advanced Cancer Trial is the first randomized clinical trial among patients with PSCC and is currently accruing, with the expectation to generate results in 2023. Unfortunately, most patients with high-risk locally advanced PSCC will have relapsed or refractory cancer after cisplatin-based combination chemotherapy. These patients have dismal outcomes with salvage chemotherapy, highlighting the major unmet need to expand our knowledge of the disease's biology and develop clinical trials that use novel systemic agents. This narrative review synthesizes relevant publications retrieved from PubMed. Our aim is to discuss current approaches in the management of PSCC, summarize ongoing efforts to improve care, and identify future areas for enhancing our understanding of the disease.

Expansion of tumor-infiltrating lymphocytes (TIL) from penile cancer patients

Penile cancer is a rare but highly lethal cancer, and therapeutic options for patients presenting with lymph nodal disease are very limited. Adoptive cell therapy (ACT) using tumor-infiltrating lymphocytes (TIL) was shown to provide durable objective response in patients with metastatic melanoma and TIL have been expanded from solid tumors at rates between 70 and 90% depending on the specific diagnosis. We evaluated whether TIL could be expanded from surgical specimens of patients with penile cancer. Tumor samples from metastatic lymph nodes obtained at the time of inguinal lymph node dissection were collected, minced into fragments, placed in individual wells of a 24-well plate, and propagated in high dose IL-2 for four weeks. The phenotype of expanded TILs was assessed by flow cytometry and their anti-tumor reactivity was assessed by IFN-γ ELISA. TIL were expanded from 11 out of 12 (91.6%) samples of metastatic lymph nodes. Expanded TIL were predominantly CD3⁺ (mean 67.5%, SD 19.4%) with a mean of 46.8% CD8⁺ T cells (SD 21.1%). Five out of 11 samples (45.4%) from expanded TIL secreted IFN-γ in response to autologous tumor. TIL expansion and phenotype of expanded T cell lymphocytes were independent of previous HPV infection and treatment with neoadjuvant chemotherapy. This is the first report demonstrating successful expansion of tumor-reactive TIL from penile cancer patients, which support development of ACT strategies using TIL for the treatment of advanced and recurrent penile cancer.

Penile cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer with orphan disease designation and a prevalence of 0.1-1 per 100,000 men in high-income countries, but it constitutes up to 10% of malignancies in men in some African, Asian and South American regions. Risk factors for PSCC include the absence of childhood circumcision, phimosis, chronic inflammation, poor penile hygiene, smoking, immunosuppression and infection with human papillomavirus (HPV). Several different subtypes of HPV-related and non-HPV-related penile cancers have been described, which also have different prognostic profiles. Localized disease can be effectively managed by topical therapy, surgery or radiotherapy. As PSCC is characterized by early lymphatic spread and imaging is inadequate for the detection of micrometastatic disease, correct and upfront surgical staging of the inguinal lymph nodes is crucial in disease management. Advanced stages of disease require multimodal management. Optimal sequencing of treatments and patient selection are still being investigated. Cisplatin-based chemotherapy regimens are the mainstay of systemic therapy for advanced PSCC, but they have poor and non-durable responses and high rates of toxic effects, indicating a need for the development of more effective and less toxic therapeutic options. Localized and advanced penile cancers and their treatment have profound physical and psychosexual effects on the quality of life of patients and survivors by altering sexual and urinary function and causing lymphoedema.

Experimental Models for Studying HPV-Positive and HPV-Negative Penile Cancer: New Tools for An Old Disease

Simple Summary

Penile cancer is an uncommon and understudied malignancy that is most commonly diagnosed in developing countries. Therapeutic advances have been slow, in part due to the lack of in vitro and in vivo models for testing new drugs before performing clinical trials. Recently, this difficulty has been partly overcome and multiple new pre-clinical models were reported. These important developments will help develop new therapies for penile cancer patients. The present review summarizes and discusses the available data concerning the pre-clinical models of penile cancer and their uses. Comparisons are drawn between different models, allowing researchers to choose the most adequate setting for their experiments. The remaining gaps in this array of penile cancer models are also discussed, in particular the lack of models for studying metastatic disease and cell lines representing tumors associated with human papillomavirus.

Abstract

Penile cancer is an uncommon malignancy that occurs most frequently in developing countries. Two pathways for penile carcinogenesis are currently recognized: one driven by human papillomavirus (HPV) infection and another HPV-independent route, associated with chronic inflammation. Progress on the clinical management of this disease has been slow, partly due to the lack of preclinical models for translational research. However, exciting recent developments are changing this landscape, with new in vitro and in vivo models becoming available. These include mouse models for HPV⁺ and HPV⁻ penile cancer and multiple cell lines representing HPV⁻ lesions. The present review addresses these new advances, summarizing available models, comparing their characteristics and potential uses and discussing areas that require further improvement. Recent breakthroughs achieved using these models are also discussed, particularly those developments pertaining to HPV-driven cancer. Two key aspects that still require improvement are the establishment of cell lines that can represent HPV⁺ penile carcinomas and the development of mouse models to study metastatic disease. Overall, the growing array of in vitro and in vivo models for penile cancer provides new and useful tools for researchers in the field and is expected to accelerate pre-clinical research on this disease.