A Technique to Deliver Conformal External Beam Radiation for Squamous Carcinoma of the Penile Glans and Urethra

This study presents an approach to external beam radiation therapy for treating penile cancer using a small water bath. This modified technique involves the use of an acrylic, cuboid-shaped water bath with dimensions 6 × 6 × 8 cm3. The water bath is filled with readily available saline solution maintained at room temperature. The patient is positioned in the prone position, and the penis is placed within the water bath. The isocenter is set at the center of the water bath, and bilateral beams are positioned at 89.1° and 270.9°. The proposed technique was evaluated based on dose calculations, demonstrating a clinical target volume dose with a Dmax of 103.5% and a Dmin of 100.0% of the prescribed dose. Additionally, the method showed a low organs-at-risk dose, with a Dmean of only 1% for the testicles. The treatment zone inside the water bath also showed a uniform dose distribution. This technique not only offers high treatment efficiency and more accurate dose distribution to the targeted area but also provides additional benefits, including reduced toxicity to organs at risk and increased device utilization efficiency. In conclusion, the proposed modified external beam radiation therapy method presents a promising alternative for patients with penile cancer, enhancing treatment precision and safety.

Atezolizumab With or Without Radiotherapy for Advanced Squamous Cell Carcinoma of the Penis (The PERICLES Study): A Phase II Trial

PURPOSE

Patients with advanced penile squamous cell carcinoma have a poor prognosis (21% 2-year overall survival [OS] from diagnosis). We assessed the activity of atezolizumab (anti-PD-L1) in patients with advanced penile cancer, with or without radiotherapy (RT).

PATIENTS AND METHODS

A single-center, nonrandomized phase II study with two treatment arms was conducted in 32 patients with histologically confirmed advanced penile cancer. All patients received atezolizumab (1,200 mg) once every 3 weeks. Twenty patients, who were expected to benefit from RT for locoregional disease control, received additional irradiation. The primary end point was 1-year progression-free survival (PFS) for the complete cohort and was reached if the actual 1-year PFS was at least 35%. Secondary end points included OS, objective response rate (ORR), and tolerability. Exploratory biomarker analyses were conducted in pretreatment specimens.

RESULTS

Median follow-up was 29.1 months (IQR, 18.1-33.5). Grade 3-4 adverse events related to atezolizumab or RT were observed in 3/32 (9.4%) and 13/20 (65%) patients, respectively. One-year PFS was 12.5% (95% CI, 5.0 to 31.3), which did not meet the study's primary end point. Median OS was 11.3 months (95% CI, 5.5 to 18.7). In the objective response-evaluable population (n = 30; 93.8%), the ORR was 16.7% (95% CI, 6 to 35), including 2 (6.7%) complete responders and 3 (10%) partial responders. Improved PFS was observed in patients with high-risk human papillomavirus (hrHPV)-positive tumors (P = .003) and those with high infiltration of intratumoral CD3+CD8+ T cells (P = .037).

CONCLUSION

Although the primary end point of 1-year PFS was not met, durable antitumor activity to atezolizumab was observed in a subset of patients. Biomarkers, such as hrHPV and intratumoral CD3+CD8+ T-cell infiltration, may help to better select responders.

Organ sparing treatment for penile cancer using a 3D-printed high-dose-rate brachytherapy applicator

PURPOSE

We present a case study of the treatment of localized squamous cell carcinoma on the glans penis with a custom-fabricated high-dose-rate (HDR) brachytherapy applicator.

METHODS AND MATERIALS

A cylindrically shaped applicator was fabricated with eight embedded channels suitable for standard plastic brachytherapy catheters. An additional custom silicone bolus/sleeve was designed to be used with the 3D-printed applicator to provide an additional offset from the source to skin to reduce the surface dose and for patient comfort.

RESULTS

The patient (recurrent cT1a penile cancer) underwent CT simulation, and the brachytherapy plan was created with a nominal prescription dose of 40 Gy in 10 fractions given bidaily to the surface, and 35 Gy at 5 mm depth. Dose coverage to the clinical target volume was 94% (D90). Most fractions were treated with only 5-10 min of setup time. Follow up visits up to 1 year showed no evidence of disease with no significant changes in urinary and sexual function and limited cosmetic detriment to the patient.

CONCLUSIONS

Patient-specific organ-sparing HDR plesiotherapy using 3D printing technology can provide reliable and reproducible patient setup and may be effective in achieving disease control for superficial penile cancer, although preserving patient quality of life.

Radiotherapy for penile cancers

Penile cancers are uncommon and should be treated in expert center. Radiotherapy indications are mainly limited to exclusive brachytherapy for early stage penile glans cancer. Brachytherapy yields to excellent outcome for disease control and organ and function preservation. Only scarce data are available for external beam radiation therapy. It could be considered as palliative setting for irradiation of the primary tumor. For lymph node irradiation, external beam radiation therapy (with or without chemotherapy) could be discussed either as neoadjuvant approach prior to surgery for massive inguinal lymph node invasion or as adjuvant approach in case of high-risk of relapse. However, these cases should be discussed on an individual basis, as the level of evidence is poor. We present the recommendations of the French Society of Oncological Radiotherapy on the indications and techniques for external beam radiotherapy and brachytherapy for penile glans cancer.

Long-term multicentre experience of adjuvant radiotherapy for pN3 squamous cell carcinoma of the penis

OBJECTIVE

To present the long-term adjuvant radiotherapy outcomes of patients with pN3 squamous cell carcinoma of the penis (SCCp) treated at two UK centres.

PATIENTS AND METHODS

We conducted a retrospective audit of all pN3 SCCp patients, deemed suitable for adjuvant therapy by a specialist multidisciplinary team at St George's and Leeds Hospitals, who received adjuvant radiotherapy. Primary outcomes were recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Secondary outcomes were time to adjuvant treatment, frequency of in-field recurrence, site and side of recurrence, and dose and schedule of radiotherapy.

RESULTS

A total of 146 patients were included: 121 completed radiotherapy, 4 did not complete radiotherapy and 21 did not start it. The median (interquartile range [IQR]) age was 59 (54-70)years. The 5-year RFS was 51%, CSS was 51% and OS was 44%. Adjuvant radiotherapy was started at a median (IQR) of 75 (48-106) days. A dose of 45 Gy in 20 fractions was most commonly used. Of the 125 patients who started adjuvant treatment, 55 relapsed. Of these relapses, 30 occurred in an inguinal or pelvic nodal station and 26 of the 30 were in a radiation field. Relapses in 18 of the 55 cases were in visceral sites only and seven were in both nodal (non-irradiated sites) and visceral sites. Doses of <50 Gy were used more commonly before 2013 and higher doses (>50 Gy) were more commonly used after 2013.

CONCLUSIONS

Application of a standard radiotherapy protocol within a centralized supra-network setting has achieved survival outcomes that would appear better than those previously documented for either radiotherapy or chemotherapy in a cohort with solely pN3 disease. The addition of adjuvant chemotherapy may improve these outcomes further. These data suggest that adjuvant radiotherapy has a role to play in the management of men with pN3 SCCp.

Neurofibromatosis-1 and Rhabdomyosarcoma: An Unusual Recurrence

Neurofibromatosis-1 has a known increased risk of malignancy with rhabdomyosarcoma occurring in up to 6% of patients. Here we report on an 8-year-old male with a history of Neurofibromatosis-1 and previously treated stage 3, group III bladder/prostate embryonal rhabdomyosarcoma (diagnosed at 18 months old) who presented with penile swelling concerning for priapism. Imaging and subsequent biopsy confirmed embryonal rhabdomyosarcoma of the penile corporal bodies. Penile rhabdomyosarcoma is exceedingly rare, with less than 15 case reports in the literature. Our patient received chemoradiation per D9803 with organ preserving local control and is doing well 3 months after treatment.

Optimized penile surface mold brachytherapy using latest stereolithography techniques: A single-institution experience

PURPOSE

To describe a technique of penile surface mold high-dose-rate (HDR) brachytherapy and early outcomes.

METHODS AND MATERIALS

Five patients diagnosed with a T1aN0 squamous cell carcinoma of the penis were treated using a penile surface mold HDR brachytherapy technique. A negative impression of the penis was obtained using dental alginate. CT images were acquired of the penile impression; subsequently, a virtual model of the patient's penis was generated. The positive model was imported into a computer-assisted design program where catheter paths were planned such that an optimized offset of 5 mm from the penile surface was achieved. The virtual model was converted into a custom applicator. A total dose of 40 Gy was delivered in 10 fractions. Patients were followed at 1, 3, 6, and 12 months after treatment and then every 6 months thereafter. Toxicities were reported using Common Terminology Criteria for Adverse Events v4.0.

RESULTS

All patients tolerated treatment well. Acute Grade 2 skin reactions were observed within the first month after treatment. Median followup was 35 months. Late Grade 1 skin toxicities were observed. One patient experienced a urethral stricture requiring dilatation. Two patients developed local recurrence.

CONCLUSION

This technique allows the delivery of penile HDR brachytherapy as an outpatient procedure with minimal discomfort to the patient during each application and is a repeatable and accurate setup. This technique warrants validation in larger series with longer followup.

Boron neutron capture therapy for vulvar melanoma and genital extramammary Paget's disease with curative responses

BACKGROUND

Although the most commonly recommended treatment for melanoma and extramammary Paget's disease (EMPD) of the genital region is wide surgical excision of the lesion, the procedure is highly invasive and can lead to functional and sexual problems. Alternative treatments have been used for local control when wide local excision was not feasible. Here, we describe four patients with genital malignancies who were treated with boron neutron capture therapy (BNCT).

METHODS

The four patients included one patient with vulvar melanoma (VM) and three with genital EMPD. They underwent BNCT at the Kyoto University Research Reactor between 2005 and 2014 using para-boronophenylalanine as the boron delivery agent. They were irradiated with an epithermal neutron beam between the curative tumor dose and the tolerable skin/mucosal doses.

RESULTS

All patients showed similar tumor and normal tissue responses following BNCT and achieved complete responses within 6 months. The most severe normal tissue response was moderate skin erosion during the first 2 months, which diminished gradually thereafter. Dysuria or contact pain persisted for 2 months and resolved completely by 4 months.

CONCLUSIONS

Treating VM and EMPD with BNCT resulted in complete local tumor control. Based on our clinical experience, we conclude that BNCT is a promising treatment for primary VM and EMPD of the genital region. Trial registration numbers UMIN000005124.

A Clinical Case Report of Priapism Treated with External RT

The aim of this short communication is to present an extremely uncommon case of penile metastases from rectal adenocarcinoma treated with an external beam radiotherapy technique. A 76-year-old man affected by very painful priapism from penile metastases was treated with radiotherapy (30 Gy) for symptom relief. In the course of the radiotherapy treatment the patient reported gradual and continuous pain reduction. One month after the end of radiotherapy both the priapism and the pain had disappeared. Although the long-term prognosis remains poor, good quality of life was achieved in this patient.

External beam radiotherapy of extramammary Paget disease

Extramammary Paget disease (EMPD) is an insidious intraepithelial neoplasm that is difficult to control with surgery, as large resections typically are required. An effective alternative is external beam radiotherapy (EBRT), which typically results in rapid resolution of EMPD. In this study, we analyzed long-term outcomes in 7 patients who were treated with EBRT for EMPD.

Dermo Beta Brachytherapy with 188Re in extramammary Paget's disease

AIM

Extramammary Paget's disease (EMPD) is a rare neoplastic pathology involving the vulva, scrotum, and perianal areas, and it is characterized by a slow and insidious course. EMPD may also be associated with internal malignancy, and its clinical presentation features long-standing pruritic lesions, eczema-like, refractory to any therapy. The pathogenesis is unclear, and univocal standardization of treatment is yet to be determined. As regard to the patients who suffer from it, women are more often affected than men. The therapeutic approach depends on the extent of involvement; wide surgical excision is the first choice among treatments, but other forms of therapy, alone or in combination, include imiquimod 5%, photodynamic therapy, Mohs surgery as well as external beam radiotherapy and Brachytherapy. In the present paper a new therapeutic alternative is proposed: Dermo-Beta-Brachytherapy (DBBT) with 188Re.

METHODS

Five patients with EMPD, one secondary and four primary cases, have been treated by Brachytherapy with DBBT. This therapy has been successfully used for non-melanocytic skin tumors and basically consists in the topical application of a specially designed, tailor-made mould containing a radioactive beta-emitting isotope, rhenium-188.

RESULTS

The patients healed completely, after one session in one case and after two sessions in four cases, with 34 months mean follow-up.

CONCLUSION

Brachyterapy could represent a new alternative therapy, instead than invasive treatments as surgery and conventional radiotherapy, capable to treat EMPD independently of its extension, with aesthetic and functional satisfactory results.

Brachytherapy for penile cancer: efficacy and impact on sexual function

PURPOSE

Penis brachytherapy (PB) remains an alternative in the cancer treatment. The objective of this study was to assess the oncologic outcomes, sexual function, and the sexual behavior of men treated by PB for a cancer of the penis.

METHODS AND MATERIALS

Between 1992 and 2009, 47 patients with a cancer of the penis were treated by PB ((192)Ir), in the Toulouse, Montpellier, and Barcelona cancer centers. The investigation into their sexuality was obtained by means of questionnaire. A total of 21 French patients were approached, of whom 19 (mean age=73.2 years) agreed to answer the questionnaire (participation rate=90.5%).

RESULTS

Oncologic data: The specific survival and the disease-free survival at 5 years was 87.6% (95% confidence interval, 72.4-94.7%) and 84% (95% confidence interval, 57.6-94.7%), respectively. The rate of preservation of the penis was 66% (n=31). Sexual data: Among the 17 patients sexually active before brachytherapy, 10 patients remained sexually active after treatment (58.8%). Of the 18 patients who had erections before PB, 17 still had them after treatment (94.4%). Age was the main predictive factor.

CONCLUSION

The PB seems to have a moderated impact on the sexual functions and the sexual behavior of the patients.

Surgery and radiation therapy for extramedullary plasmacytoma of the penile mucosa in a dog

A 10-year-old neutered male Italian greyhound dog was presented because it had a penile plasmacytoma. Surgery followed by radiation therapy resulted in local control and survival for 1688 days. This is the first report of surgery and definitive radiation therapy for curative intent therapy of extramedullary penile plasmacytoma in a dog. A 10-year-old neutered male Italian greyhound dog was presented because it had a penile plasmacytoma. Surgery followed by radiation therapy resulted in local control and survival for 1688 days. This is the first report of surgery and definitive radiation therapy for curative intent therapy of extramedullary penile plasmacytoma in a dog.

Radiotherapy for node positive penile cancer: experience of the Leeds teaching hospitals

PURPOSE

We studied the outcomes in patients with node positive penile cancer who received radiotherapy to inguinal and pelvic nodes. Although half of node positive cases are cured by lymphadenectomy, little data are available on the potential further benefits and toxicities of postoperative radiotherapy.

MATERIALS AND METHODS

We retrospectively audited the clinical notes and electronic records of 23 patients referred to a specialist center from 2002 to 2008 who received radiotherapy to the inguinal/pelvic nodes as adjuvant treatment after lymphadenectomy (14), or as high grade palliation for extensive/fixed nodes (8) or extensive local tumor (1). The primary outcome measure was overall survival. Secondary end points were locoregional recurrence-free survival and toxicity.

RESULTS

All 13 deaths were due to penile cancer. Patients with adjuvant therapy had better overall survival (66% vs 11%, p<0.001) and locoregional relapse-free survival (56% vs 22%, p=0.03) than those with high grade palliation. Six of 14 adjuvant cases and 7 of 9 with high grade palliation relapsed locoregionally. Of patients with adjuvant therapy and extracapsular spread 1 of 6 with N1, 1 of 4 with N2 and 3 of 4 with N3 disease relapsed (p=0.31). No life threatening toxicity was observed. It was difficult to determine the relative contributions of radiotherapy and surgery to leg/scrotal lymphedema. The study was limited by its small size, which reflects the rarity of this tumor.

CONCLUSIONS

Adjuvant radiotherapy appears to have a role after inguinal lymphadenectomy, particularly in patients with extracapsular nodal spread, in whom historically survival rates have been poor. Our findings warrant further investigation in larger series of patients.

Penile cancer: are there currently indications for radiotherapy?

Penile cancer is a radiocurable disease. The different types of radiotherapy (RT)-brachytherapy, plesiotherapy, external beam radiation therapy-have proven valid in the treatment of the primary tumor allowing preservation of the penis and sexual function. RT is even an option in candidates for surgery who reject surgery for clinical or personal reasons. A high nodal recurrence rate has been observed after inguinal lymphadenectomy, specially in patients at high risk of relapse. Technological advances in the field of RT, new imaging techniques, and more modern equipment enable RT to enhance local control and improve survival in patients with this condition. Palliative RT can exercise a decompressive effect that makes possible tumor size reduction in cases of inguinal-pelvic recurrence in patients with lymphedema and thus improve quality of life. In this article, we review the current role of RT in the treatment of penile cancer. We also present two cases that illustrate the main indications.

[New possibilities for elimination of human papillomavirus from the organism]

The variety of mechanisms of human papillomavirus (HPV) infection suggests that the success of treatment depends on the choice of a universal method, which combines the actions of etiotropic, pathogenetic and symptomatic approaches, without causing unwanted side effect. All these requirements are met by a drug based on the products of plant origin - Indinol. The observed patients with resistant forms of genital warts were divided into 3 groups: first group received the treatment according to the standard, conventional scheme; patients of the second group in addition to the standard scheme 2 times a day (for 90 days) received 2 capsules of Indinol (200 mg) and the patients of third group simultaneously with Indinol undergo infrared irradiation. The results of the observation have shown that the addition of Indinol to the standard treatment had a significant positive effect on the healing process of patients with resistant forms of genital warts. The effects of the Indinol in combination with infrared therapy revealed a statistically significant reduction (3 times) the frequency of relapses in cases of clinically sever forms of disease. Thus, during combined treatment of patients with recurrent, clinically severe forms of genital HPV, it is advisable to use the Indinol, which evidently has the well pronounced virus-eliminative and anti-recurrent actions.

The role of radiation therapy after incomplete resection of penile cancer

PURPOSE

To retrospectively assess the outcome in patients treated with adjuvant radiotherapy for penile cancer.

PATIENTS AND METHODS

Between 1987 and 2006, 24 patients (median age, 62.7 years; range, 35.5-90.4 years) with squamous cell carcinoma of the penis (T1, n = 10; T2, n = 11; T3, n = 3) received megavoltage external radiotherapy (n = 22) or (192)Ir high-dose-rate brachytherapy (n = 2) following total penectomy (n = 7), partial penectomy (n = 10), or local excision (n = 7); lymphadenectomy was performed in eight patients. In 14 patients, radiotherapy was delivered after incomplete tumor resection, and in 20 patients the planning target volume included the regional lymph nodes. Median total dose of external radiotherapy was 56 Gy/1.8-2 Gy (range, 50-60 Gy). Brachytherapy was given with a total dose of 45 Gy/3 Gy.

RESULTS

During a median follow-up of 58.4 months, penile or perineal recurrence was found in four patients giving a 5-year local control rate of 74.8%. Regional failure occurred in two patients. 5-year metastases-free survival and progression-free survival rates were 86.7% and 64.5%, respectively. Four patients died due to tumor progression. The actuarial 5-year cause-specific and overall survival rates were 84.3 and 56.6%, respectively.

CONCLUSION

Radiation therapy is a successful method of treatment for penile cancer in terms of local control and organ preservation after microscopically incomplete surgery. Radiotherapy of the regional lymph nodes might also be effective in preventing regional recurrence and can be considered in case of high-risk features and following excision of extensive lymph node involvement.

Metastatic penile squamous cell carcinoma to the retroperitoneum in a man with human papillomavirus type 45

Squamous cell carcinoma of the penis is a rare cancer associated with smoking, genital warts, lack of neonatal circumcision, and human papillomavirus types 16 and 18. Metastasis of this condition is even rarer, occurring primarily in the lungs or liver. The current report describes a case of penile squamous cell carcinoma in an uncircumcised 63-year-old man who smoked cigarettes and who had genital warts and human papillomavirus type 45. Metastasis occurred in the abdominal cavity.

Reconstructive surgery for invasive squamous carcinoma of the glans penis

OBJECTIVES

We present medium-term outcome data for patients with invasive penile cancer treated with glansectomy and reconstruction with a split-thickness skin graft.

METHODS

A series of consecutive patients referred with penile malignancies over a 6-yr period were analyzed prospectively. A dedicated histopathologist reviewed all the specimens. After clinical staging, patients with tumours confined to the glans were offered glansectomy.

RESULTS

A total of 72 patients (32% of patients, 31% of procedures) underwent glansectomy for penile carcinoma. Of these, 65 patients were new diagnoses and seven were recurrences after radiotherapy. The mean follow-up period was 27 mo (range: 4-68 mo). There have been three late local recurrences (4%).

CONCLUSION

Glansectomy appears to be an oncologically safe and effective procedure for patients with glans-confined squamous cell tumours. It preserves maximum phallic length and results in a very satisfactory cosmetic penile appearance after reconstruction.

Treatment of penile carcinoma: To cut or not to cut?

PURPOSE

The aim of this study was to assess the outcome in patients with penile cancer.

METHODS AND MATERIALS

A total of 60 patients with penile carcinoma were included. Of the patients, 45 (n = 27) underwent surgery, and 51 underwent definitive (n = 29) or postoperative (n = 22) radiotherapy (RT). Median follow-up was 62 months.

RESULTS

Median time to locoregional relapse was 14 months. Local failure was observed in 3 of 23 patients (13%) treated with surgery with or without postoperative RT vs. in 19 of 33 patients (56%) given organ-sparing treatment (p = 0.0008). Of 22 local failures, 16 (73%) were salvaged with surgery. Of the 33 patients treated with definitive RT (n = 29) and the 4 patients refusing RT after excisional biopsy, local control was obtained with organ preservation in 13 (39%). In the remaining 20, 4 patients with local failure underwent salvage conservatively, resulting in an ultimate penis preservation rate of 17 of 33 (52%) patients treated with definitive RT. The 5-year and 10-year probability of surviving with an intact penis was 43% and 26%, respectively. There was no survival difference between the patients treated with definitive RT and primary surgery (56% vs. 53%; p = 0.16). In multivariate analysis, independent factors influencing survival were N-classification and pathologic grade. Surgery was the only independent predictor for better local control.

CONCLUSION

Based on our study findings, in patients with penile cancer, local control is superior with surgery. However, there is no difference in survival between patients treated with surgery and those treated with definitive RT, with 52% organ preservation.

External-beam radiotherapy in T1-2 N0 penile carcinoma

AIMS

To review the outcome of 41 patients with invasive carcinoma of the penis treated with external-beam radiotherapy using a consistent technique and dose.

MATERIALS AND METHODS

Forty-one patients with carcinoma of the penis treated at Christie Hospital, Manchester, UK, between 1995 and 2000 were reviewed retrospectively. Radiotherapy was delivered using 4 MV linear accelerators with a dose of 50 Gy or 52.5 Gy in 16 fractions over 22 days.

RESULTS

The distribution of patients according to stage was T1=37, T2=4, N0=40, N3=1. Median follow-up was 4.5 years. The local control rate was 62%, nodal relapse-free rate of 88%, relapse-free rate of 51% and overall survival of 88% at 5 years. All recurrences were salvaged by surgery. Penile ulceration occurred in 8% and urethral stenosis requiring dilatation in 29%. There were no penectomies for penile necrosis.

CONCLUSION

EBXRT may be offered for T1-2 cancer of the penis with close surveillance to detect local recurrences early for salvage surgery without jeopardising overall survival. It remains an alternative option to penis-preserving surgery and should be discussed in a multidisciplinary setting and with the patient.

Treatment of angiokeratoma of Fordyce with pulsed dye laser

BACKGROUND

Angiokeratomas of Fordyce are typically asymptomatic vascular lesions characterized by blue-to-red papules with a scale surface, most often located on the scrotum. Although considered benign, the lesions may bleed, either spontaneously or secondary to rupture, leading to patient anxiety and social embarrassment.

OBJECTIVE

The objective was to determine the safety and effectiveness of 585-nm pulsed dye laser for the treatment of angiokeratomas of Fordyce.

METHODS

Twelve patients with Fitzpatrick skin type II to IV were treated for angiokeratomas of Fordyce with pulsed dye laser (5.5-8.0 J/cm(2)) in two to six sessions. Lesion clearance was evaluated by two specialists on the basis of digital photographs taken before the first treatment and 2 months after the last treatment.

RESULTS

Seven patients had an excellent response (clearance rating 75%-100%) and five patients had a good response (clearance rating 50%-75%). Transient purpura and pain were present in all patients. Bleeding during treatment occurred in five patients. There were no permanent side effects.

CONCLUSION

Pulsed dye laser is effective and safe for the treatment of angiokeratoma of Fordyce, with minimum side effects, providing an additional nonablative therapeutic option.

Extramammary Paget's disease of the penis and scrotum

A 64-year-old Chinese man presented to the Bellevue Hospital Center Department of Dermatology with a 2-year history of an enlarging mass in his suprapubic region, which measured 7 cm x 9 cm and involved the penis and scrotum. A biopsy specimen showed extramammary Paget's disease. Twenty years earlier, while living in China in 1983, this patient had a suprapubic skin cancer which was excised, and he received radiation to the region. Extramammary Paget's disease is a rare cutaneous adenocarcinoma of epidermal origin, which is frequently associated with adnexal carcinoma and internal malignant conditions. Clinically, extramammary Paget's disease is characterized by a red, moist, eroded plaque in the anogenital region. Extramammary Paget's disease usually behaves as a slow-growing intraepithelial adenocarcinoma; however, it may become invasive and may metastasize through dermal lymphatics. The treatment of choice is wide excision.

[Radiation assisted diagnosis and complex treatment of penile carcinoma]

Recurrence-free survival rate after conservative treatment of penile carcinoma was as high as 81%. The best results were obtained with use of combined radiotherapy (monotherapy and telegamma therapy concurrent with penile resection or circumcision) (91.6 and 75%, respectively). Organ-saving treatment was most effective in T1-T2 penile carcinoma while MRI yielded the most reliable diagnostic evidence on depth of primary tumor invasion and regional lymph node involvement.

A three-dimensional definition of nodal spaces on the basis of CT images showing enlarged nodes for pelvic radiotherapy

PURPOSE

To demonstrate that margins of each pelvic chain may be derived by verifying the bony and soft tissue structures around abnormal nodes on computed tomography (CT) slices.

METHODS AND MATERIALS

Twenty consecutive patients (16 males, 4 females; mean age, 66 years; range, 43-80 years) with radiologic diagnosis of nodal involvement by histologically proved cervix carcinoma (two), rectum carcinoma (three), prostate carcinoma (four), lymphoma (five), penis carcinoma (one), corpus uteri carcinoma (one), bladder carcinoma (two), cutis tumor (one), and soft-tissue sarcoma (one) were retrospectively reviewed. One hundred CT scans showing 85 enlarged pelvic nodes were reviewed by two radiation oncologists (M.P., S.B.), and two radiologists (C.P., G.A.).

RESULTS

The more proximal structures to each enlarged node or group of nodes were thus recorded in a clockwise direction.

CONCLUSION

According to their frequency and visibility, craniocaudal, anterior, lateral, posterior and medial margins of common iliac, external and internal iliac nodal chains, obturator and pudendal nodes, and deep and superficial inguinal nodes were derived from CT observations.

Sildenafil citrate-aided radiotherapy for the treatment of Kaposi's sarcoma of the penis

We report a case of classical Kaposi's sarcoma involving multiple sites of the penis in a 62-year-old male who was treated with sildenafil citrate-aided electron beam therapy, resulting in complete resolution of the lesions.

Penile brachytherapy: results for 49 patients

PURPOSE

To report results for 49 men with squamous cell carcinoma (SCC) of the penis treated with primary penile interstitial brachytherapy at one of two institutions: the Ottawa Regional Cancer Center, Ottawa, and the Princess Margaret Hospital, Toronto, Ontario, Canada.

METHODS AND MATERIALS

From September 1989 to September 2003, 49 men (mean age, 58 years; range, 22-93 years) had brachytherapy for penile SCC. Fifty-one percent of tumors were T1, 33% T2, and 8% T3; 4% were in situ and 4% Tx. Grade was well differentiated in 31%, moderate in 45%, and poor in 2%; grade was unspecified for 20%. One tumor was verrucous. All tumors in Toronto had pulsed dose rate (PDR) brachytherapy (n = 23), whereas those in Ottawa had either Iridium wire (n = 22) or seeds (n = 4). Four patients had a single plane implant with a plastic tube technique, and all others had a volume implant with predrilled acrylic templates and two or three parallel planes of needles (median, six needles). Mean needle spacing was 13.5 mm (range, 10-18 mm), mean dose rate was 65 cGy/h (range, 33-160 cGy/h), and mean duration was 98.8 h (range, 36-188 h). Dose rates for PDR brachytherapy were 50-61.2 cGy/h, with no correction in total dose, which was 60 Gy in all cases.

RESULTS

Median follow-up was 33.4 months (range, 4-140 months). At 5 years, actuarial overall survival was 78.3% and cause-specific survival 90.0%. Four men died of penile cancer, and 6 died of other causes with no evidence of recurrence. The cumulative incidence rate for never having experienced any type of failure at 5 years was 64.4% and for local failure was 85.3%. All 5 patients with local failure were successfully salvaged by surgery; 2 other men required penectomy for necrosis. The soft tissue necrosis rate was 16% and the urethral stenosis rate 12%. Of 8 men with regional failure, 5 were salvaged by lymph node dissection with or without external radiation. All 4 men with distant failure died of disease. Of 49 men, 42 had an intact and tumor-free penis at last follow-up or death. The actuarial penile preservation rate at 5 years was 86.5%.

CONCLUSIONS

Brachytherapy is an effective treatment for T1, T2, and selected T3 SCC of the penis. Close follow-up is mandatory because local failures and many regional failures can be salvaged by surgery.

Metastatic penile cancer in a young Caucasian male: impact of delayed diagnosis

Penile cancer is an uncommon malignancy in the developed world, with only 1200 estimated cases per year in the United States. This is usually a cancer of older men and often the diagnosis is delayed because of lack of suspicion on the part of the patient or primary care provider. We report a case of penile cancer in a young Caucasian male in whom a delay in diagnosis had a deleterious impact on outcome. We describe and illustrate how, to palliate his symptoms, the patient required a hemipelvectomy plus a total pelvic exenteration. We present this case to alert physicians of the possibility of penile cancer in young Caucasian males as well as to demonstrate the significant morbidity and mortality that can ensue from a delay in diagnosis.

Priapism due to sacrococcygeal chordoma metastasis treated with radiation therapy

We are reporting the first case of priapism due to a sacrococcygeal chordoma metastasis treated with radiation therapy as palliative treatment.

Tumeurs du pénis : techniques et indications

Although penis epidermoid carcinoma is a relatively rare tumour, early identification and treatment are necessary to avoid mutilating and sometimes morbid surgery. Awareness of disease epidemiology is mandatory for preventing the evolution of an underlying tumour (absent or insufficient hygiene, congenital or acquired phimosis, preepitheliomathous lesions such as Bowen's disease). Conservative surgical or radio-therapeutic techniques may be considered, provided the lesion is superficial and with a diameter < 30 mm. In all other cases, penis amputation is necessary. Penis epidermoid carcinoma spreads by vascular and lymphatic diffusion. Dynamic scintigraphy for the identification of a sentinel node and screening of subclinical metastasis is currently under evaluation. In case of palpable inguinal adenopathy, inguinal lymphadenectomy should be proposed if technically performable. Although superficial lymphadenectomy is associated with a low morbidity rate (about 3% of mild complications) deep inguinal Lymphadenectomy is far more morbid and disabling. Compliance with pre- and post-operative measures, and total patient compliance are necessary to minimize as far as possible such morbidity.

A case of tumor of the penis: interstitial brachitherapy after conservative surgical therapy

The neoplasms of the penis are extremely rare and have an incidence of 1400 new cases for year in the United States. Higher is the percentage of incidence in Africa and Asia (10-20%) and in some areas of Brasil where the cancer of the penis constitutes 17% of all the male tumors. In Israel this neoplasm is rare, less than 0.1/100000 menfor year, because in Jewish population men are circumcised prematurely. Recently it has been placed attention to the possible aetiologic role of human papillomavirus (HPV-16 and HPV-18) in penis carcinoma. In fact, in the tumoral cells, DNA of this virus has been found with a percentage that varies from the 30 to 82%. Traditional surgical approach is total or partial penis resection basing on the extension of the disease. This procedure is associated to remarkable psycosessuals problems that greatly affect the quality of life. We bring back a case with organ sparing conservative treatment.

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.

[Organ-saving treatment of penile cancer]

Conservative penis-salvage treatment provides a complete local effect in 55% cases, preservation of the penis in 51.4% patients without a fall in long-term specific and recurrence-free survival compared to penectomy and can be recommended as an alternative to penis amputation in patients with stages Tis-T2. Removal of a penile tumor raises efficacy of salvage treatment and insignificantly increases survival. Application of surgical treatment only is associated with a high rate of local recurrences. Chemoradiotherapy in penile cancer is significantly more effective vs each method alone. Radiation in a total focal dose more than 60 Gy improves local control over the tumor. Most effective are schemes of chemotherapy based on bleomycin. Polychemotherapy has no advantages over monochemotherapy with bleomycine.

High-Dose-Rate Interstitial Brachytherapy for the Treatment of Penile Carcinoma

BACKGROUND

Interstitial low-dose-rate (LDR) brachytherapy allows conservative treatment of T1-T2 penile carcinoma. High dose-rate (HDR) is often considered to be dangerous for interstitial implants because of a higher risk of complications, but numerous reports suggest that results may be comparable to LDR. Nevertheless, there are no data in the literature available regarding HDR interstitial brachytherapy for carcinoma of the penis.

CASE REPORT

A 64-year-old man with T1 N0 M0 epidermoid carcinoma of the glans is reported. Interstitial HDR brachytherapy was performed using the stainless hollow needle technique and a breast template for fixation and good geometry. The dose delivered was 18 x 3 Gy twice daily.

RESULTS

After 232 days from brachytherapy, the patient was without any evidence of the tumor, experienced no serious radiation-induced complications, and had a fully functional organ.

CONCLUSION

HDR interstitial brachytherapy is feasible in selected case of penis carcinoma, when careful planning and small single fractions are used.

[Conservative treatment for the penis carcinoma]

No explicit recommendation has been determined in a treatment for the verified squamous cell penis carcinoma till now. The application of ionizing radiation is included in traditional treatment methods for this disease, in addition to surgical operations and chemotherapy cure. It is possible to apply external radiotherapy or brachy-radiotherapy (a moulage or an intersticial application) as well as their combination. In individual cases it is possible to use chemo-radiotherapy. In the case of the localized tumor a curative radiotherapy can be used as it is more save towards this organ. Radiotherapy has its place in the neoadjuvans treatment with the goal to reduce the disease extent. It can be also used as an adjuvans--postoperatively and paliatively. This review is describing principles of the radiotherapy treatment for this disease.

Contemporary management of penile cancer including surgery and adjuvant radiotherapy: an experience in Taiwan

This retrospective study reports on the treatment outcomes of 45 men with penile cancer and seeks to address the issue concerning the treatment of inguinal lymph nodes (LN). Of these 45 patients, five had verrucous carcinoma and the other 40 had squamous cell carcinoma. Eighteen patients had inguinal lymph nodes (LNs) metastasis and received treatments of inguinal LNs involving bilateral inguinal LN dissection or unilateral inguinal LN dissection with or without postoperative radiotherapy. The median follow-up was 37 months. The ultimate local and regional controls for patients with verrucous carcinoma were 100 and 100%, respectively. Among the 40 patients with squamous cell carcinoma, the overall local control rate was 90%. The 5-year overall survival (OS) and disease-free survival (DFS) rates of patients without or with pathological inguinal LN metastasis were 70 vs. 22% (p=0.01), and 55 vs. 16% (p=0.004), respectively. The regional failure rates after inguinal LN dissection for pathological inguinal LN metastasis were 11% (1/9) and 60% (3/5) in patients with and without adjuvant radiotherapy. This study demonstrates that verrucous carcinoma shows excellent treatment outcomes following surgery alone. Squamous cell carcinoma of the penis is associated with a high incidence of inguinal lymph node metastasis. Elective groin dissection is indicated for all penile cancer patients except those with verrucous carcinoma and pT1 cancer with well-differentiated tumor. For patients with pathologically positive inguinal LN metastasis, adjuvant radiotherapy can increase inguinal control in this study. It warrants further prospective trial to prove the value of adjuvant radiotherapy in patients with pathological documented inguinal LN metastasis in penile cancer.

Current issues in the management of advanced squamous cell carcinoma of the penis

Effective treatment of penile carcinoma incorporates three modalities: surgery, radiation and chemotherapy. Surgery alone may offer a high cure rate in early stages of the disease. In certain patients radiation therapy may be utilized to eradicate the tumor and allow organ preservation. For patients with locally advanced disease, multi-modality approaches incorporating adjuvant or neoadjuvant chemotherapy and radiation therapy need to be studied. This approach may confer a survival benefit to a group that would otherwise have a poor prognosis. Finally, in the setting of metastatic disease, less toxic and more effective combination chemotherapy are sought. Novel targeted therapies that have been successful in squamous cell carcinoma at other sites must also be studied in this disease. We believe that multi-institutional trials should be designed in order to obtain prospective benchmark data from which to make valid comparisons of outcome.

Carcinoma prostate with penile metastases. A case report

Prostatic carcinoma metastasizing to the penis is rare. The prognosis is also poor. A case of carcinoma prostate with penile metastases where successful palliation was achieved with external radiation therapy is reported.