Clinical Profile and Outcomes of Carcinoma Penis Patients Receiving Systemic Therapy at an Indian tertiary care Center: A Retrospective Observational Study

BACKGROUND

Penile cancer is a rare malignancy with scant data on the impact of systemic therapy on outcomes.

METHODS

Retrospective observational study of patients with a histological diagnosis of carcinoma penis treated with systemic therapy at the Tata Memorial Centre (Mumbai, India) between August 2010 and February 2018. Primary objective was overall survival (OS); secondary objectives included assessment of clinical characteristics, treatment approaches, and toxicity profiles.

RESULTS

We included 91 patients with penile carcinoma who received systemic therapy at our center. Intent of therapy was curative in 71 patients (78%), and palliative in 20 (22%). Median age was 57 years (interquartile range [IQR], 50-65.5) for curatively treated patients and 58.5 years (IQR, 44-65.2) for those with advanced disease. Common presenting symptoms were lumps (70%), and pain (57%). Neoadjuvant chemotherapy (NACT) with paclitaxel + platinum was administered to 19 patients (20.9%), of which 7 (37%) attained complete or partial response. Six patients (31.5%) underwent R0 surgery post-NACT. All 71 patients underwent primary surgery; 47 (66.2%) undergoing partial penectomy. Of the 20 patients treated with palliative first-line chemotherapy, 4(20%) attained a partial response. Median OS of patients treated in curative and palliative settings was 33.8 months (95% CI, 17.2-not recorded) and 11.4 months (95% CI, 9.53-23.3), respectively.

CONCLUSIONS

Patients with penile cancer treated with systemic therapy have poor outcomes. Little over a third of the patients respond to neoadjuvant chemotherapy and those with advanced disease have poor survival despite systemic therapy, emphasizing the need for early detection and optimum management of primary and nodal disease.

Inguinal Lymph-Node Ratio (LNR) as a predictor of Pelvic Lymph-Node Metastasis in squamous cell carcinoma of penis

OBJECTIVE

To determine the predictors of pelvic lymph-node metastasis in cases of squamous cell carcinoma (SCC) of penis.

METHODS

Data was retrospectively collected from 267 cases of SCC penis that presented at our institute between 2009 and 2019. Univariate and multivariate logistic regression models were used to identify independent significant factors. Receiver Operating Characteristic (ROC) curve was used to determine the cut-off of Lymph-Node Ratio (LNR) and discriminative ability of new model. Survival analysis was done using Kaplan Meier Curve.

RESULTS

Pelvic Lymph-Node Metastasis (PLNM) was pathologically detected in 56 groins (29.2%). A cut-off of 0.25 was calculated for LNR based on ROC. LNR >0.25 (p = 0.003), ENE (p = 0.037), and LVI (p = 0.043) were found significant on multivariate logistic regression. 71.5% showed PLNM in groins with positive LN (PLN) </ = 2 but LNR >0.25 whereas no PLNM was seen in groins with PLN >2 but LNR </ = 0.25. The AUC was 0.918 and 0.821 for LNR and PLN respectively. The probability of finding PLNM was 0% for patients with no risk factors which increased to 83% for 3 risk factors. The 5-year survival was 60% if no PLNM was found as compared to 12.7% if PLNM were found. The survival according to risk score was 81%, 43%, 16% and, 13% for 0, 1, 2 and, 3 risk score respectively.

CONCLUSION

LNR >0.25, LVI and, ENE are independent predictors of PLNM. The discriminative ability of LNR was better than PLN. PLND could be avoided if no risk factors are present.

Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL) and Video-Endoscopic Inguinal Lymphadenectomy (VEIL) versus Open Inguinal Lymph-Node Dissection (OILND) in carcinoma of penis: Comparison of perioperative outcomes, complications and oncological outcomes. A systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis evaluating the peri-operative outcomes, complications, and oncological outcomes of Robotic-Assisted Video-Endoscopic Inguinal Lymphadenectomy (RAVEIL)/Video-Endoscopic Inguinal Lymphadenectomy (VEIL) with Open Inguinal Lymph-Node Dissection (OILND) for management of inguinal lymph-nodes in carcinoma of the penis.

METHODS

A comprehensive literature search was performed in January 2021 using the PubMed, Embase, and Cochrane databases. Data from human studies comparing RAVEIL/VEIL vs. OILND in carcinoma of penis published in English was extracted and analyzed by two independent authors.

RESULTS

Two Randomised Controlled Trials and 6 cohort studies were included in the meta-analysis. RAVEIL/VEIL group exhibited increased operative time (Mean Difference [MD] = 15.28 [14.19; 16.38], P < 0.001), shorter hospital stay (MD = -1.06 [-1.14; -0.98], P < 0.001), and decreased duration of drainage (MD = -2.82 [-3.21; -2.43], P < 0.001), wound infection (Odds Ratio [OR] = 0.15 [0.08; 0.27], P < 0.001), skin necrosis (OR = 0.12 [0.05; 0.28], P < 0.001), lymphedema (OR = 0.41 [0.24; 0.72], P = 0.002), and major complications (OR = 0.11 [0.05; 0.24], P < 0.001) as compared to OILND group. Recurrence rate and number of deaths were comparable in both the groups. RAVEIL/VEIL groups showed slightly larger lymph-node yield (MD = 0.44 [0.18; 0.70], P < 0.001) as compared to OILND group.

CONCLUSION

RAVEIL/VEIL has lesser skin complications, lymphedema, and better lymph-node yield as compared to OILND. It is comparable in terms of lymphocele and recurrence. It has lesser hospital stay and duration of drainage but owing to heterogeneity, the results should be interpreted with caution. Further studies are required to determine long-term oncological outcomes like overall survival and disease-specific survival.

A proposed Clino-radio-pathological Risk Scoring System (CRiSS) for prediction and management of inguinal lymph-nodes metastasis in squamous cell carcinoma of the penis

OBJECTIVE

To develop a risk scoring system for prediction of inguinal lymph-node involvement and to suggest a management strategy according to the risk groups based on clinical, radiological and pathological parameters in squamous cell carcinoma (SCC) of penis.

MATERIALS AND METHODS

A retrospective analysis of all patients of SCC penis from 2014 to 2020 at our institute was done. The patients were divided into derivation cohort (2014 to 2019) and validation cohort (2019 to 2020). A total of 10 predictors were analysed in univariate analysis and those found significant were further subjected to multivariate analysis to derive regression coefficient for each. CRiSS scores were assigned based on the coefficients and three groups were created which were correlated with nodal metastasis. The predictive accuracy of the model was assessed by ROC analysis of the derivation cohort and validation cohort.

RESULTS

A total of 102 patients were identified in derivation cohort and 23 patients in validation cohort. Size of the primary >3cm, ulceroinfiltrative growth, involving shaft, ultrasound size of lymph-nodes >1cm, loss of fatty hila, moderate and poor differentiation, and lypmphovascular/perineural invasion were independent predictors of inguinal lymphnode metastasis in multivariate analysis. CRiSS could achieve AUROC of .910 and .887 in derivation and validation cohort respectively. The rate of metastatic lymphadenopathy was 0%, 41.4%, and 89.5% in low, intermediate, and high-risk groups respectively.

CONCLUSIONS

CRiSS can effectively predict inguinal lymph-node metastasis in SCC penis. We suggest a management strategy based on risk groups that will avoid morbidity of groin dissection in many patients.

Role of dynamic sentinel node biopsy in carcinoma penis with or without palpable nodes

Introduction:

We aimed to evaluate the role of dynamic sentinel node biopsy (DSLNB) in patients diagnosed with carcinoma penis and clinically N0 disease using superficial inguinal dissection as the standard staging modality.

Materials and Methods:

Twenty consecutive men (40 groins) with carcinoma penis having clinically N0 status were enrolled in the study. Patients underwent DSLNB if fine needle aspiration cytology from the groin nodes was negative, followed by injection of radiocolloid and blue dye. The sentinel lymph node(s) were harvested. The inguinal incision was then extended and a modified superficial inguinal dissection was performed and all nodes were labeled separately and sent for frozen section. A completion deep inguinal with pelvic dissection was performed if any of the nodes were reported positive for malignancy.

Results:

The median age of the patients was 52.5 years. Ten patients were smokers. Phimosis was present in five patients. Lesions were present over the glans penis and shaft in 18 and two patients, respectively. Wide local excision, partial penectomy and total penectomy were performed in one, 15 and four patients, respectively. Clinically palpable nodes were found in 19 groins. Median follow-up was 26 months. Nodes were positive in 10 groins. DSLNB missed the sentinel node in one groin. The accuracy and false-negative rate of DSLNB was 97.5% and 10%, respectively.

Conclusion:

DSLNB is a useful and reliable technique to identify the involved node(s) in patients diagnosed as having carcinoma penis with clinical N0 status (with or without palpable nodes). It helps to avoid the morbidity associated with a staging inguinal dissection in these patients.