Hypomethylation at H19DMR in penile squamous cell carcinoma is not related to HPV infection

Penile squamous cell carcinoma (SCC) is a rare and aggressive tumour mainly related to lifestyle behaviour and human papillomavirus (HPV) infection. Environmentally induced loss of imprinting (LOI) at the H19 differentially methylated region (H19DMR) is associated with many cancers in the early events of tumorigenesis and may be involved in the pathogenesis of penile SCC. We sought to evaluate the DNA methylation pattern at H19DMR and its association with HPV infection in men with penile SCC by bisulfite sequencing (bis-seq). We observed an average methylation of 32.2% ± 11.6% at the H19DMR of penile SCC and did not observe an association between the p16INK4a+ (p = 0.59) and high-risk HPV+ (p = 0.338) markers with methylation level. The average methylation did not change according to HPV positive for p16INK4a+ or hrHPV+ (35.4% ± 10%) and negative for both markers (32.4% ± 10.1%) groups. As the region analysed has a binding site for the CTCF protein, the hypomethylation at the surrounding CpG sites might alter its insulator function. In addition, there was a positive correlation between intense polymorphonuclear cell infiltration and hypomethylation at H19DMR (p = 0.035). Here, we report that hypomethylation at H19DMR in penile SCC might contribute to tumour progression and aggressiveness regardless of HPV infection.

Single-cell Atlas of Penile Cancer Reveals TP53 Mutations as a Driver of an Aggressive Phenotype, Irrespective of Human Papillomavirus Status, and Provides Clues for Treatment Personalization

BACKGROUND AND OBJECTIVE

TP53 loss-of-function (TP53LOF) mutations might be a driver of poor prognosis and chemoresistance in both human papillomavirus (HPV)-independent (HPV-) and HPV-associated (HPV+) penile squamous cell carcinoma (PSCC). Here, we aim to describe transcriptomic differences in the PSCC microenvironment stratified by TP53LOF and HPV status.

METHODS

We used single-cell RNA sequencing (scRNA-seq) and T-cell receptor sequencing to obtain a comprehensive atlas of the cellular architecture of PSCC. TP53LOF and HPV status were determined by targeted next-generation sequencing and sequencing HPV-DNA reads. Six HPV+ TP53 wild type (WT), six HPV- TP53WT, and four TP53LOF PSCC samples and six controls were included. Immunohistochemistry and hematoxylin-eosin confirmed the morphological context of the observed signatures. Prognostic differences between patient groups were validated in 541 PSCC patients using Kaplan-Meier survival estimates.

KEY FINDINGS AND LIMITATIONS

Patients with aberrant p53 staining fare much worse than patients with either HPV- or HPV+ tumors and WT p53 expression. Using scRNA-seq, we revealed 65 cell subtypes within 83 682 cells. TP53LOF tumors exhibit a partial epithelial-to-mesenchymal transition, immune-excluded, angiogenic, and morphologically invasive environment, underlying their aggressive phenotype. HPV- TP53WT tumors show stemness and immune exhaustion. HPV+ TP53WT tumors mirror normal epithelial maturation with upregulation of antibody-drug-conjugate targets and activation of innate immunity. Inherent to the scRNA-seq analysis, low sample size is a limitation and validation of signatures in large PSCC cohorts is needed.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This first scRNA-seq atlas offers unprecedented in-depth insights into PSCC biology underlying prognostic differences based on TP53 and HPV status. Our findings provide clues for testing novel biomarker-driven therapies in PSCC.

PATIENT SUMMARY

Here, we analyzed tissues of penile cancer at the level of individual cells, which helps us understand why patients who harbor a deactivating mutation in the TP53 gene do much worse than patients lacking such a mutation. Such an analysis may help us tailor future therapies based on TP53 gene mutations and human papillomavirus status of these tumors.

High tumour mutational burden is associated with strong PD-L1 expression, HPV negativity, and worse survival in penile squamous cell carcinoma: an analysis of 165 cases

Penile squamous cell carcinoma (pSCC) is a rare tumour with a variable prognosis. More prognostic markers linked to mutational signatures and the tumour immune microenvironment are needed. A cohort made up of 165 invasive pSCC was retrospectively analysed using formalin-fixed, paraffin-embedded tumour tissue, focusing on tumour mutational burden (TMB), programmed death ligand 1 (PD-L1) expression, microsatellite instability (MSI), the number of tumour infiltrating lymphocytes (TILs) expressing cytotoxic T-lymphocyte-associated protein 4 (CTLA4), HPV status determined by p16 immunohistochemistry, and several traditional histopathological variables. High TMB (>10 mut/Mb) was associated with high PD-L1 expression (TPS 50-100%), and HPV-negative status. High PD-L1 expression was linked to HPV negativity, a high number of intratumoural CTLA4+ cells, and brisk lymphocytic infiltrate. High TMB was a significant predictor of shorter overall survival (OS) in both univariate and multivariate analysis when using a median cut-off value of 4.3 mut/Mb, but not when using an arbitrary cut-off of 10 mut/Mb. Low CTLA4+ cell infiltration at the tumour invasion front was a marker of shorter OS and cancer-specific survival in both univariate and multivariate analysis. PD-L1 expression had no significant impact on prognosis. Only two cases were MSI high. The results support the hypothesis of two aetiological pathways in pSCC cancerogenesis: (1) SCC linked to HPV infection characterised by low TMB, less common PD-L1 expression, and a lower number of TILs; and (2) SCC linked to chronic inflammation leading to a high number of acquired mutations (high TMB), HPV negativity, increased neoantigen production (i.e., PD-L1), and high immune cell infiltration.

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.

Insights into the management of penile squamous cell carcinoma: from conventional approaches to emerging novel therapies

INTRODUCTION

Penile squamous cell carcinoma (PSCC), a rare genitourinary cancer, is associated with poor outcomes due to limited treatment effectiveness, especially in advanced stages.

AREAS COVERED

While chemotherapy and/or surgery remain the standard of care, emerging therapies like immunotherapy, targeted therapy, and human papillomavirus (HPV) directed therapies show promise. Key to advancing treatment is understanding the immune microenvironment to gain insights into tumor resistance mechanisms and potential therapeutic targets. The scarcity of data on PSCC is a major obstacle in advancing research for this rare cancer.

EXPERT OPINION

Future research should prioritize collaborative efforts across various research centers and countries. Enhancing data sharing and pooling resources can lead to a more comprehensive understanding of PSCC, ultimately supporting the development of precision medicine strategies tailored to this specific cancer type. This collaborative approach is essential for making significant strides in PSCC treatment and care.

Machine learning-based overall and cancer-specific survival prediction of M0 penile squamous cell carcinoma：A population-based retrospective study

Background

Penile cancer is a rare tumor and few studies have focused on the prognosis of M0 penile squamous cell carcinoma (PSCC). This retrospective study aimed to identify independent prognostic factors and construct predictive models for the overall survival (OS) and cancer-specific survival (CSS) of patients with M0 PSCC.

Methods

Data was extracted from the Surveillance, Epidemiology, and End Results database for patients diagnosed with malignant penile cancer. Eligible patients with M0 PSCC were selected according to predetermined inclusion and exclusion criteria. These patients were then divided into a training set, a validation set, and a test set. Univariate and multivariate COX regression analyses were initially performed to identify independent prognostic factors for OS and CSS in M0 PSCC patients. Subsequently, traditional and machine learning prognostic models, including random survival forest (RSF), COX, gradient boosting, and component-wise gradient boosting modelling, were constructed using the scikit-survival framework. The performance of each model was assessed by calculating time-dependent area under curve (AUC), C-index, and integrated Brier score (IBS), ultimately identifying the model with the highest performance. Finally, the Shapley additive explanation (SHAP) value, feature importance, and cumulative rates analyses were used to further estimate the selected model.

Results

A total of 2, 446 patients were included in our study. Cox regression analyses demonstrated that age, N stage, and tumor size were predictors of OS, while the N stage, tumor size, surgery, and residential area were predictors of CSS. The RSF and COX models had a higher time-independent AUC and C-index, and lower IBS value than other models in OS and CSS prediction. Feature importance analysis revealed the N stage as a common significant feature for predicting M0 PSCC patients' survival. The SHAP and cumulative rate analyses demonstrated that the selected models can effectively evaluate the prognosis of M0 PSCC patients.

Conclusion

In M0 PSCC patients, age, N stage, and tumor size were predictors of OS. In addition, the N stage, tumor size, surgery, and residential area were predictors of CSS. The machine learning-based RSF and COX models effectively predicted the prognosis of M0 PSCC patients.

New EAU/ASCO guideline recommendations on sentinel node biopsy for penile cancer and remaining challenges from a nuclear medicine perspective

INTRODUCTION

The European Association of Urology (EAU) and the American Society of Clinical Oncology (ASCO) recently issued updated guidelines on penile cancer, emphasising dynamic sentinel node biopsy (DSNB) as the preferred method for surgical staging among patients with invasive penile tumours and no palpable inguinal lymphadenopathy. This paper outlines the rationale behind this new recommendation and describes remaining challenges, as well as strategies for promoting DSNB worldwide.

MAIN TEXT

DSNB offers high diagnostic accuracy with the lowest postoperative complications compared to open or minimally invasive inguinal lymph node dissection (ILND), prompting its preference in the new guidelines. Nevertheless, despite its advantages, there are challenges hampering the widespread adoption of DSNB. This includes the false-negative rate associated with DSNB and the potential negative impact on patient outcome. To address this issue, improvements should be made in several areas, including refining the timing and interpretation of the lymphoscintigraphy and the single photon emission computed tomography/computed tomography images. In addition, the quantity of tracer employed and choice of the injection site for the radiopharmaceutical should be optimised. Finally, limiting the removal of nodes without tracer activity during surgery may help minimise complication rates.

CONCLUSION

Over the years, DSNB has evolved significantly, related to the dedicated efforts and innovations in nuclear medicine and subsequent clinical studies validating its efficacy. It is now strongly recommended for surgical staging among selected penile cancer patients. To optimise DSNB further, multidisciplinary collaborative research is required to improve SN identification for better diagnostic accuracy and fewer complications.

Impact of the Standardization of Penile Cancer Care on the Quality of Care, Outcomes, and Academic-driven Centralization in a Single eUROGEN Referral Center

BACKGROUND

Penile cancer (PeCa) represents a diagnostic and therapeutic challenge given the low patient volume, which may result in inadequate physician expertise and poor guideline adherence. Since 2015, we have developed a specific care pathway for PeCa in our tertiary referral center.

OBJECTIVE

To evaluate the impact of a dedicated PeCa care pathway on patient management, the adequacy of pathological reporting, and oncological outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively queried our institutional registry (S-66482) to identify patients who were surgically treated for PeCa between January 1989 and April 2022. The patient numbers were evaluated within a broader national context.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We compared patient, surgery, tumor, and pathological data before and after 2015. Kaplan-Meier analysis was used to compare local and regional recurrence rates and cancer-specific survival (CSS).

RESULTS AND LIMITATIONS

Overall, 313 patients were included, of whom 204 (65.1%) were surgically treated after 2015. The median number of patients treated yearly was significantly higher after 2015 (26 vs 5; p < 0.01). Patients treated after 2015 more frequently had no palpable lymph nodes at diagnosis, despite similar primary tumor stage. After adoption of the PeCa care pathway, organ-sparing surgery (OSS) was more commonly performed (79.9% vs 57.8%; p < 0.01) despite local staging being similar and without observing a significant increase in positive margins. Surgical staging in patients with European Association of Urology intermediate- or high-risk tumors was conducted more frequently after 2015 (90% vs 41%; p < 0.01). Pathology reporting was standardized, and there was more frequent reporting of p16 staining status (81.4% vs 8.3%; p < 0.01), lymphovascular invasion (93.8% vs 44.3%; p < 0.01), and perineural invasion (92.4% vs 44.3%; p < 0.01) following implementation.

CONCLUSIONS

Implementation of a standardized care pathway for PeCa resulted in higher rates of OSS and pathological nodal staging and more complete pathology reports. Considering that these changes were associated with an increase in the number of patients treated, academic-driven centralization may play a role in optimizing the management of these patients.

PATIENT SUMMARY

We evaluated the impact of a care pathway for patients with penile cancer on patient management, the completeness of pathology reporting, and cancer control. We found that implementation of this pathway was associated with an increase in the number of patients treated, higher rates of organ-sparing surgery and lymph node staging, and more complete pathology reports. Centralization of care may play a role in optimizing the management of penile cancer.

Penile Cancers Attributed to Human Papillomavirus Are Associated with Improved Survival for Node-positive Patients. Findings from a Norwegian Cohort Study Spanning 50 Years

BACKGROUND

Human papillomavirus (HPV) infection is a risk factor for the development of penile squamous cell carcinoma (PSCC). It remains inconclusive whether HPV-related PSCC has a different prognosis from non-HPV-related PSCC.

OBJECTIVE

To investigate the relationship between HPV status and survival as well as temporal changes in the proportion of HPV-related PSCC.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort of 277 patients treated in Norway between 1973 and 2022 was investigated for HPV DNA in tumor tissue. Clinicopathological variables and disease course were registered.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Kaplan-Meier curves and Cox regression were used to investigate the determinants of cancer-specific survival (CSS). The chi-square test for trend in proportions enabled investigation of temporal changes in the HPV-related proportion of PSCC patients treated in Western Norway (n = 211).

RESULTS AND LIMITATIONS

HPV DNA was detected in tumor tissue from 131 (47%) patients. Stratified by HPV status, 5-yr CSS did not differ between groups (p = 0.37). When investigating only node-positive patients, however, presence of HPV DNA was an independent predictor of better survival in multivariable Cox regression after adjustment for age, nodal stage, and adjuvant therapy (hazard ratio 0.54, 95% confidence interval: [0.30-0.99], p = 0.04). In cases from Western Norway, an increasing proportion of HPV-related cases over time was found (p = 0.01). The main limitation is the retrospective study design.

CONCLUSIONS

HPV DNA in tumor tissue was associated with significantly better CSS for node-positive patients. The proportion of HPV DNA-positive PSCC has increased significantly in Western Norway over the past 50 yr.

PATIENT SUMMARY

We investigated the impact of human papillomavirus (HPV) on the survival of penile cancer patients treated over a 50-yr period in Norway. We found that for patients with lymph node metastasis, survival was better for HPV-related cases. We also found that the proportion of cases due to HPV has increased in Western Norway.

Detection of variable genotypes in common human papillomavirus-associated invasive penile squamous cell carcinomas: a study of 177 human papillomavirus-positive cases

Human papillomavirus (HPV) is detected in 30-50% of invasive penile carcinomas, and it is frequently associated with basaloid and warty morphological features. Based on this heterogeneity and different clinical behaviors, we hypothesized a variation in their HPV genotypic composition. To test this, we evaluated 177 HPV-positive cases: basaloid (114), warty-basaloid (28), and warty (condylomatous) (35) invasive carcinomas. HPV DNA detection and genotyping was performed using the SPF-10/DEIA/LiPA25 system. Nineteen HPV genotypes were detected. High-risk HPVs predominated (96%), and low-risk HPVs were rarely present. Most common genotype was HPV16 followed by HPVs 33 and 35. According to the genotypes identified, 93% of the cases would be covered with current vaccination programs. There was a significant variation in the distribution of HPV16 and non-HPV16 genotypes according to histological subtype. HPV16 was significantly frequent in basaloid (87%) and was less frequent in warty carcinomas (61%). This molecular difference, along with their distinctive macro-microscopic and prognostic features, makes basaloid and warty carcinomas unique. The gradual decreasing frequency of HPV16 demonstrated in basaloid, warty-basaloid, and warty carcinomas suggest that the basaloid cell, present in those types in decreasing proportions, may be responsible for the differences.

Prognostic significance and immune correlates of FADD in penile squamous cell carcinoma

Penile squamous cell carcinoma (PSCC) with a poor prognosis lacks reliable biomarkers for stratifying patients. Fas-associated death domain (FADD) could regulate cell proliferation and has shown promising diagnostic and prognostic significance in multiple cancers. However, researchers have not determined how FADD exerts its effect on PSCC. In this study, we set out to investigate the clinical features of FADD and the prognostic impact of PSCC. Additionally, we also assessed the role of affecting the immune environment in PSCC. Immunohistochemistry was carried out to evaluate the protein expression of FADD. The difference between FADD^high and FADD^low was explored by RNA sequencing from available cases. The immune environment evaluation of CD4, CD8, and Foxp3 was performed by immunohistochemical. In this study, we found that FADD was overexpressed in 19.6 (39/199) patients, and the overexpression of FADD was associated with phimosis (p=0.007), N stage (p<0.001), clinical stage (p=0.001), and histologic grade (p=0.005). The overexpression of FADD was an independent prognostic factor for both PFS (HR 3.976, 95% CI 2.413-6.553, p<0.001) and OS (HR 4.134, 95% CI 2.358-7.247, p<0.001). In addition, overexpression of FADD was mainly linked to T cell activation and PD-L1 expression combined with PD-L1 checkpoint in cancer. Further validation demonstrated that overexpression of FADD was positively correlated with the infiltration of Foxp3 in PSCC (p=0.0142). It is the first time to show that overexpression of FADD is an adjunct biomarker with poor prognosis in PSCC and could also serve as a tumor immune environment regulator.

Challenges in Organ-sparing Surgery for Penile Cancer: What Are the Limits?

Organ-sparing surgery (OSS) is endorsed by the European Association of Urology (EAU) guidelines as the preferred treatment for distal primary penile cancer. The recommendation states that OSS should be used whenever possible, without exactly defining what constitutes "possible". This recommendation is based on findings showing that this approach has no detrimental impact on survival. At the same time, OSS results in preservation of quality of life (QoL) and of various functions of the penis. However, while narrow tumor-free margins (>1 mm) are deemed oncologically safe, there is a higher risk of local recurrence. Recent data have emerged that question the dogma that a local recurrence does not impact survival outcomes. In this mini review, we highlight areas of discrepancy in current guidelines and describe challenges for a surgical approach with a delicate balance between oncological safety on the one hand and maximal preservation of QoL and penile functions on the other. PATIENT SUMMARY: Organ-sparing surgery has been recommended as the preferred treatment for primary cancer of the penis, as quality of life and sexual function are maximally preserved. In this review we identify challenges and limitations in routinely adopting this approach.

Conversion therapy for advanced penile cancer with tislelizumab combined with chemotherapy: A case report and review of literature

BACKGROUND

Locally advanced penile squamous cell carcinoma with unresectable inguinal lymph node metastasis has a poor prognosis, and surgical treatment alone offers limited benefits. Effective conversion therapy regimens are urgently needed.

CASE SUMMARY

We describe a locally advanced penile squamous cell carcinoma patient with bulky, fixed inguinal lymph node metastasis complicated with genital skin ulcers who underwent inguinal lymph node dissection and achieved a pathological complete response with conversion therapy comprising immunotherapy plus chemotherapy.

CONCLUSION

For unresectable locally advanced penile squamous cell carcinoma, neoadjuvant immunotherapy combined with chemotherapy is a potential treatment approach. Biomarkers of immunotherapy efficacy need to be explored, and clinical trials are needed to test these strategies.

Establishment and Characterization of Advanced Penile Cancer Patient-derived Tumor Xenografts: Paving the Way for Personalized Treatments

BACKGROUND

Systemic treatments for penile squamous cell carcinoma (pSCC) are toxic and inefficient. Patient-based preclinical models are essential to study novel treatments.

OBJECTIVE

To establish a library of patient-derived tumor xenograft (PDX) models of human papillomavirus-positive (HPV⁺) and -negative (HPV^-) pSCC and characterize these at the genomic and histological levels.

DESIGN, SETTING, AND PARTICIPANTS

Eighteen tumor samples from 14 patients with recurrent or metastatic pSCC were implanted in nude mice. A biobank of PDX tumors was established after passaging of patient samples (F0) for three generations (F1, F2, F3) and was characterized using histopathology and targeted next-generation sequencing (tNGS). Single-nucleotide polymorphism fingerprinting was used to confirm PDX genealogy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The engraftment rate, overall growth rate, and pSCC histomorphology were checked for each PDX generation. Staining for p40 (a pSCC marker) and p16 (a surrogate for HPV infection) was performed for F0 samples. The mutational profile according to a validated panel of 96 cancer genes was determined for F0 and F3 samples and compared to a larger tNGS database.

RESULTS AND LIMITATIONS

Including a previously established pilot model, 11 out of 18 tumor samples (61%) successfully engrafted in F1. The mean time from implantation in F1 to completion of F3 was 36 wk (standard deviation 18). Histological fidelity was demonstrated across generations. The patient mutational profiles were preserved in F3 and were representative of 277 pSCC samples in the Foundation Medicine database. The rapid progression of pSCC in patients from our selected high-risk cohort impeded the use of PDXs as avatars.

CONCLUSIONS

We successfully established the first library of 11 PDX models of HPV^- and HPV⁺ pSCC. Our PDX models showed high engraftment rates and histological and genomic fidelity to the tumor tissue of origin. These models may help in paving the way towards the development of novel treatments.

PATIENT SUMMARY

We established 11 animal models based on tumor tissue from patients with penile cancer. These models could play a vital role in selection of novel treatments according to genetic mutations. In the future, therapies with confirmed preclinical effects may have a profound impact on the development of personalized treatments in penile cancer.

Enhancing immune checkpoint blockade therapy of genitourinary malignancies by co-targeting PMN-MDSCs

Immune checkpoint blockade (ICB) as a powerful immunotherapy has transformed cancer treatment. The application of ICB to genitourinary malignancies has generated substantial clinical benefits for patients with advanced kidney cancer or bladder cancer, yet very limited response to ICB therapy was observed from metastatic castration-resistant prostate cancer. The efficacy of ICB in rare genitourinary tumors (e.g. penile cancer) awaits results from ongoing clinical trials. A potential barrier for ICB is tumor-infiltrating polymorphonuclear myeloid-derived suppressor cells (PMN-MDSCs) with their functions and mechanisms recently revealed. Preclinical studies suggest that successful therapeutic inhibition of PMN-MDSCs synergizes effectively with ICB to eradicate ICB-refractory genitourinary malignancies.

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.

p53 and p16ink4a As Predictive and Prognostic Biomarkers for Nodal metastasis and Survival in A Contemporary Cohort of Penile Squamous Cell Carcinoma

BACKGROUND

Human papilloma virus (HPV) infection is implicated in a proportion of invasive squamous cell carcinoma of the penis (PC). A subset of PC involves dysregulation of the p53 pathway. HPV in situ hybridization (ISH) and p16^ink4a positivity are surrogate markers for HPV infection, and p53 immunohistochemistry (IHC) denotes abnormality in the p53 pathway. There remains an ambiguity with regard to the contribution of both the pathways in the prognosis of PC. We sought to analyze the clinicopathologic characteristics of a cohort of Indian PC patients with respect to p16 ^ink4a and p53 expression.

PATIENTS AND METHODS

A cohort of 123 PC patients was studied for p16^ink4aand p53IHC and HPVISH. The results of these biomarkers were correlated with various clinicopathologic parameters.

RESULTS

p16^ink4a and HPV ISH were positive in 47% and 53% of the tumors, respectively. The proportion of warty, basaloid, or mixed warty-basaloid tumor subtypes showed significant p16^ink4apositivity (P < .0001) compared to other subtypes. Twenty-eight patients were dual negative (p53- /p16^ink4a-), 32 were dual positive (p53+/p16^ink4a+), 38 were p53+/p16^ink4a-, and 25 were p53-/p16^ink4a +. In patients where p16^ink4a was negative, a p53-positive phenotype had a higher propensity for lymph node metastases (OR, 5.42; 95% CI, 1.75-16.80; P = .003). Similarly, p53 positivity dictates nodal involvement in the p16^ink4a-positive subset of tumors (OR, 5.00; 95% CI, 1.23-20.17; P = .024). On multivariate analyses, pathologic subtypes (warty, warty-basaloid, and basaloid) (P < .0001), p16^ink4aexpression (P < .0001), and absence of nodal metastasis (P < .0001) were significant predictors of improved overall (OS) and cancer specific survival (CSS). In Kaplan-Meier analysis, the OS was significantly longer in patients with p16^ink4a + tumors (P < .0001), as was the CSS (P < .0001). Patients with dual positive tumors had a significantly higher OS (P < .001) and CSS (P = .012), in the entire cohort. In the node positive patients, dual positivity was associated with significantly higher OS (P < .0001); however, the median CSS for p53+/p16^ink4a+tumors were not significantly different compared to p53- /p16^ink4a- tumors (P = .064), although there was a trend towards improved CSS.

CONCLUSIONS

There is a strong concordance between p16^ink4aIHC and HPV ISH results. p16^ink4a status is an independent predictor of survival (OS and CSS) in our cohort of PCs. p53 is a predictor of nodal metastasis irrespective of p16 status. Dual positive tumors have a significantly better outcome in comparison to dual negative tumors.

c-MET receptor-targeted fluorescence on the road to image-guided surgery in penile squamous cell carcinoma patients

In penile squamous cell carcinoma (pSCC), primary surgery aims to obtain oncologically safe margins while minimizing mutilation. Surgical guidance provided by receptor-specific tracers could potentially improve margin detection and reduce unnecessary excision of healthy tissue. Here, we present the first results of a prospective feasibility study for real-time intraoperative visualization of pSCC using a fluorescent mesenchymal-epithelial transition factor (c-MET) receptor targeting tracer (EMI-137). Methods: EMI-137 tracer performance was initially assessed ex vivo (N = 10) via incubation of freshly excised pSCC in a solution containing EMI-137 (500 nM). The in vivo potential of c-MET targeting and intraoperative tumour visualization was assessed after intravenous administration of EMI-137 in five pSCC patients scheduled for surgical resection using a Cyanine-5 (Cy5) fluorescence camera. Fluorescence imaging results were related to standard pathological tumour evaluation and c-MET immunohistochemistry. Three of the five in vivo patients also underwent a sentinel node resection after local administration of the hybrid tracer indocyanine green (ICG)-^99mTc-nanocolloid, which could be imaged using a near-infrared fluorescence camera. Results: No tracer-related adverse events were encountered. Both ex vivo and in vivo, EMI-137 enabled c-MET based tumour visualization in all patients. Histopathological analyses showed that all pSCC's expressed c-MET, with expression levels of ≥70% in 14/15 patients. Moreover, the highest c-MET expression levels were seen on the outside rim of the tumours, and a visual correlation was found between c-MET expression and fluorescence signal intensity. No complications were encountered when combining primary tumour targeting with lymphatic mapping. As such, simultaneous use of Cy5 and ICG in the same patient proved to be feasible. Conclusion: Fluorescence imaging of c-MET receptor-expressing pSCC tumours after intravenous injection of EMI-137 was shown to be feasible and can be combined with fluorescence-based lymphatic mapping. This combination is unique and paves the way towards further development of this surgical guidance approach.

Pembrolizumab for advanced penile cancer: a case series from a phase II basket trial

BACKGROUND

Treatment options for unresectable, locally advanced or metastatic penile squamous cell carcinoma (SCC) are limited. Previous studies have shown that 40-62% of patients with penile SCC express PD-L1. We report three cases of locally advanced or metastatic penile SCC treated with pembrolizumab.

CASE PRESENTATIONS

Herein, we present three patients with recurrent, locally advanced or metastatic penile SCC who progressed on a platinum-based chemotherapy triplet and were treated with pembrolizumab, administered as part of a phase II clinical trial for rare tumors (NCT02721732). One patient with a microsatellite instability high (MSI-H) tumor experienced a durable partial response to pembrolizumab, underwent surgical consolidation, and remains disease-free 38.7 months later. Two patients experienced progressive disease within 3 months of beginning pembrolizumab. No one experienced a grade 3 or worse treatment-related adverse event.

CONCLUSION

In sum, single-agent pembrolizumab was well tolerated as salvage therapy in a small cohort of patients with unresectable, locally advanced or metastatic penile SCC. Pembrolizumab produced an objective response in an MSI-H tumor, yet it did not control disease in two patients with MSS penile SCC. Rationale combination therapies, including pembrolizumab, warrant further investigation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02721732 . Registered March 23, 2016.

Second line salvage systemic therapy for advanced penile cancer

Most patients with advanced penile cancer will have relapsed disease after cisplatin-based combination chemotherapy. Unfortunately, these patients have dismal outcomes with salvage chemotherapy, surgery, or radiation. In this review we will discuss the available chemotherapy and targeted therapies for salvage second line systemic treatment for patients with penile cancer. We will also summarize the ongoing interventional clinical trials using immune and human papilloma virus-based therapies.

A nomogram incorporating PD-L1, NLR, and clinicopathologic features to predict inguinal lymph node metastasis in penile squamous cell carcinoma

BACKGROUND

Accurate preoperative prediction of inguinal lymph node metastasis (LNM) aids in clinical decision making, especially for patients with penile cancer with clinically negative lymph nodes. We aim to develop a nomogram to predict the preoperative risk of LNM by incorporating clinicopathologic features and tumor biomarkers.

METHODS

Eighty-four patients with penile cancer with clinically negative lymph nodes were enrolled. The programmed death ligand 1 (PD-L1) expression profile was detected by immunohistochemistry. The neutrophil-to-lymphocyte ratio (NLR) was calculated based on parameters of a routine blood examination. Multivariate logistic regression analysis was utilized to construct predictive nomograms for LNM based on data of 64 patients. The nomogram performance was assessed for calibration, discrimination, and clinical use.

RESULTS

Tumor grade, lymphovascular invasion, PD-L1, and NLR were independent predictors of LNM. Then, 4 prediction models were constructed. Clinical model included tumor grade and lymphovascular invasion. NLR model was built by adding the NLR to clinical model. PD-L1 model was built by adding the PD-L1 to clinical model. Finally, a combined model was built by adding both PD-L1 and NLR to clinical model. Combined model showed the best performance compared with other models. It showed good discrimination with a C-index of 0.89, and good calibration. In addition, decision curve analysis suggested that model 4 was clinically useful.

CONCLUSIONS

We developed a nomogram that incorporated tumor grade, lymphovascular invasion, PD-L1, and NLR that could be conveniently used to predict the preoperative individualized risk of inguinal LNM in patients with penile cancer.

Recurrent Metastatic Penile Cancer Patient with Positive PD-L1 Expression Obtained Significant Benefit from Immunotherapy: A Case Report and Literature Review

Background

Penile squamous cell carcinoma (PSCC) bears poor prognosis due to its rarity and limited treatment options, especially after failure of standard treatments. Effective therapeutic options were desperately needed.

Case Presentation

We report a recurrent metastatic PSCC patient with positive programmed death ligand 1 (PD-L1) expression (≥10%) and tumor mutation burden (TMB) of 8.87 (Muts/Mb) who obtained significant response to immunotherapy, with progression-free survival (PFS) exceeding 10 months.

Conclusion

This is the first case presenting remarkable response to immunotherapy in a Chinese PSCC patient. The remarkable response might be associated with PD-L1 expression, indicating that PD-L1 expression could be a promising biomarker for immunotherapy in PSCC. TMB ranking may also contribute to patient selection. However, large clinical trials are needed to validate these notions.

Adherence to the EAU guideline recommendations for systemic chemotherapy in penile cancer: results of the E-PROPS study group survey

OBJECTIVES

To validate the adherence of urologists to chemotherapy recommendations given in the EAU guidelines on PeCa. The European Association of Urology (EAU) guidelines on penile cancer (PeCa) are predominantly based on retrospective studies with low level of evidence.

MATERIALS AND METHODS

A 14-item-survey addressing general issues of PeCa treatment was developed and sent to 45 European hospitals. 557 urologists participated in the survey of which 43.5%, 19.3%, and 37.2% were in-training, certified, and in leading positions, respectively. Median response rate among participating departments was 85.7% (IQR 75-94%). Three of 14 questions addressed clinical decisions on neoadjuvant, adjuvant, and palliative chemotherapy. Survey results were analyzed by bootstrap-adjusted multivariate logistic-regression-analysis to identify predictors for chemotherapy recommendations consistent with the guidelines.

RESULTS

Neoadjuvant, adjuvant, and palliative chemotherapy was recommended according to EAU guidelines in 21%, 26%, and 48%, respectively. For neoadjuvant chemotherapy, urologists holding leading positions or performing chemotherapy were more likely to recommend guideline-consistent treatment (OR 1.85 and 1.92 with p_(bootstrap) = 0.007 and 0.003, respectively). Supporting resources (i.e., guidelines, textbooks) were used by 23% of survey participants and significantly improved consistency between treatment recommendations and Guideline recommendations in all chemotherapy settings (p_(bootstrap) = 0.010-0.001). Department size and university center status were no significant predictors for all three endpoints.

CONCLUSIONS

In this study, we found a very low rate of adherence to the EAU guidelines on systemic treatment for PeCa. Further investigations are needed to clarify whether this missing adherence is a consequence of limited individual knowledge level or of the low grade of guideline recommendations.

Neoadjuvant docetaxel, cisplatin and ifosfamide (ITP) combination chemotherapy for treating penile squamous cell carcinoma patients with terminal lymph node metastasis

Background

Chemotherapy may be a valuable treatment option as neoadjuvant treatment for locally advanced penile cancer according to some previous studies, but the rarity of the sample and the Lack of large-scale clinical trials hampered the attempt to establish a solid evidence base for its routine use. The purpose of this study was to evaluate the efficacy of the neoadjuvant chemotherapy combined with a ITP regimen including docetaxel, cisplatin and ifosfamide for treating advanced penile cancer patients.

Methods

A total of 19 patients who were classified into advanced penile cancer (PN3) received neoadjuvant chemotherapy of ITP regimen from June 2009 to June 2016 in our hospital.

Results

After chemotherapy 12 patients had a partial response (PR), 5 had stable disease (SD) and progressive disease (PD) in 2 cases. The 12 responders underwent penectomy, bilateral inguinal lymphadenectomy (ILND) and pelvic lymph node dissection (LPLND). In contrast, 7 cases who were non-responsive received palliative local radiotherapy. After a median follow-up of 30.6 months, there was statistically significant improvement in median PFS and OS among patients who experienced an objective response to neoadjuvant chemotherapy (group A) compared with those patients who did not respond to chemotherapy (group B) (log-rank test; P < 0.001).

Conclusion

Neoadjuvant docetaxel, cisplatin and ifosfamide chemotherapy gave 63% (12/19) of patients who were diagnosed with stage n3 penile cancer the chance of radical resection of metastases, and their OS and PFS were significantly higher than those who could not be operated on and the therapeutic dose, toxic and side effects are acceptable in the Chinese Han population. Therefore, neoadjuvant ITP chemotherapy in the treatment of stage T3 penile cancer patients may have cheerful prospects in the Chinese Han population.

Current controversies and developments on the role of lymphadenectomy for penile cancer

Penile squamous cell carcinoma is a rare cancer in men. The main prognosticators of survival for penile cancer patients remain the presence and the extent of lymph node metastasis. While radical inguinal lymphadenectomy has been the cornerstone of regional lymph node management for many years, it is still associated with significant morbidity and psychological distress. Recent developments in penile squamous cell carcinoma management have been met with some controversy in the urologic oncology community. Herein, we review the current controversies and developments on the role of inguinal lymphadenectomy for penile cancer.

PD-L1 Expression in Men with Penile Cancer and its Association with Clinical Outcomes

BACKGROUND

It has been hypothesized that PD-L1 expression in tumor cells and tumor-infiltrating immune (TII) cells may contribute to tumor progression by inhibiting antitumor immunity.

OBJECTIVE

To investigate the association between PD-L1 expression in tumor cells and TII cells and clinical outcomes in penile cancer.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of 222 men treated for penile squamous cell carcinoma (SqCC) at Örebro University Hospital between 1984 and 2008 with long-term follow-up (median 34 mo) was evaluated for PD-L1 expression in tumor cells and TII cells via immunohistochemistry.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Association between clinicopathological features and PD-L1 expression was estimated using χ² and Fisher's exact tests. For survival analyses, Kaplan-Meier curves with log-rank tests and multivariate Cox proportional hazards regression models were used.

RESULTS AND LIMITATIONS

We found that 32.1% of the tumors and 64.2% of the TII cells expressed PD-L1. Our data demonstrate that penile SqCC patients with PD-L1-positive tumor cells or TII cells are at significant risk of lower cancer-specific survival and that the prognostic value of PD-L1 expression was strongest for tumor cell positivity. The use of tissue microarrays rather than whole sections may be viewed as a limitation.

CONCLUSIONS

Tumor PD-L1 expression independently identifies penile SqCC patients at risk of poor clinical outcomes.

PATIENT SUMMARY

We investigated how many patients with penile cancer had tumors that manufactured PD-L1, a protein that decreases the ability of the immune system to fight cancer. We found that up to one-third of penile tumors make this protein. Patients whose tumors make PD-L1 have more aggressive penile cancer and worse clinical outcomes.

Prognostic Value of Neutrophil-to-Lymphocyte Ratio in Penile Squamous Cell Carcinoma Patients Undergoing Inguinal Lymph Node Dissection

BACKGROUND

Further biomarkers are warranted to improve prognostic stratification of penile squamous cell carcinoma (PSCC) patients undergoing inguinal lymph node dissection (ILND).

OBJECTIVE

To assess the prognostic value of pretreatment neutrophil-to-lymphocyte ratio (NLR) in PSCC patients undergoing ILND and to investigate its role in predicting pathologic node-positive (pN+) disease.

DESIGN, SETTING, AND PARTICIPANTS

In total, 84 consecutive patients undergoing ILND for PSCC at our institution between 1994 and 2014 were identified. Sixty-eight patients with a complete blood count and differential prior to surgery were included. Median follow-up was 35.5 mo.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS

Cut-off point analysis of NLR was performed using the Contal and O'Quigley method. Estimates of overall survival (OS), cancer-specific survival, and recurrence-free survival stratified by NLR were provided by the Kaplan-Meier method. Cox regression models were performed to determine predictors of survival and recurrence. Logistic regression models were used to identify factors associated with pathologic node-positivity.

RESULTS AND LIMITATIONS

The cut-off point value was determined to be 3. Median OS was significantly shorter for patients with NLR ≥3 than those with NLR <3 (30 vs 158 mo, p<0.001). NLR ≥3 was an independent predictor of worse OS (hazard ratio=2.48; 95% confidence interval [CI]: 1.02-6.06, p=0.046). On univariable analysis, NLR ≥3 was associated with an increased risk of pN+ disease (odds ratio [OR]=3.75; 95% CI: 1.30-10.81, p=0.014). However, on multivariable analysis adjusted for primary tumor grade, lymphovascular invasion, clinical N stage, and neoadjuvant treatment receipt, the association between NLR and pN+ disease was no longer significant (OR=3.66; 95% CI: 0.82-16.42, p=0.091). The retrospective design and limited size of the study are acknowledged limitations.

CONCLUSIONS

Pretreatment NLR is an independent predictor of OS in PSCC patients undergoing ILND and highlights the association between systemic inflammation and survival. Our data suggests that a simple biomarker of inflammation can serve as a prognosticator in PSCC.

PATIENT SUMMARY

Penile cancer is a rare malignancy in North America and Europe. Therefore, there is a lack of prognostic parameters to help predict oncologic and survival outcomes. In this report, patients with an elevated neutrophil-to-lymphocyte ratio had an increased risk of mortality.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Beyond chemotherapy for advanced disease-the role of EGFR and PD-1 inhibitors

Penile squamous cell carcinoma (SCC) is a rare malignancy with limited treatment options when the tumor is unresectable and/or chemorefractory. Triplet systemic chemotherapy regimens including taxane and cisplatin are recommended, but the response duration can be short and the treatment-related toxicity high. Only a small proportion of patients survive 1 year or longer with the current standard treatment paradigm. Beyond chemotherapy, the use of novel targeted agents, either alone or in combination with traditional chemotherapeutic agents, has appeared to have promising efficacy in patients with platinum-refractory penile cancer. The frequent overexpression of PD-L1 in advanced penile SCC indicates the potential efficacy of PD-1 inhibitors. Upcoming clinical trials using the immune check-point inhibitors may provide exciting landscape and change the paradigm for patients in the future.

E2F1 Signalling is Predictive of Chemoresistance and Lymphogenic Metastasis in Penile Cancer: A Pilot Functional Study Reveals New Prognostic Biomarkers

BACKGROUND

For penile cancer (PC) there are no known molecular predictors of lymphatic spread and/or chemoresistance.

OBJECTIVE

To identify functional biomarkers that can predict malignant progression and treatment responsiveness.

DESIGN, SETTING, AND PARTICIPANTS

We used four patient-derived PC cell lines and measured invasion and capillary tube formation, chemoresponsiveness, and mRNA and protein expression. Data were further validated in E2F1 transcription factor knockdown and overexpression experiments. We quantified E2F1 transcript levels in a set of nonmetastatic tumours (NM), metastasised primary tumours (PT), and lymph node metastases (M) from 24 patients. E2F1 immunohistochemistry was performed in another set of 13 PC biopsies.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships between different parameters were analysed using Student t tests. Transcript levels in patient samples were compared using Mann-Whitney U tests. Significance was set at p<0.05.

RESULTS AND LIMITATIONS

In cell lines established from lymph node metastases, E2F1 was more abundantly expressed, pRB was inactivated, and CDK2, CDK4, and cyclins D and E were elevated in comparison to cells from primary PC. Overexpression of E2F1 enhanced migratory capacity and lymphatic endothelial tubule formation, while depletion reduced invasiveness and increased chemosensitivity. VEGFR-3 and VEGF-C and mesenchymal markers were upregulated by high E2F1. E2F1 was clearly upregulated in infiltrative and metastatic primary tumours and metastases (NM vs PT, p<0.05; NM vs M, p<0.0005). E2F1 Quick scores increased from grade I to grade III tumours. A limitation of the study is the small number of patients.

CONCLUSIONS

E2F1 is a driver of invasion and lymphatic dissemination and promotes chemoresistance. E2F1-related biomarkers might assist in stratifying PC patients for different treatment regimens.

PATIENT SUMMARY

The availability of penile cancer cell lines allows molecular research on the mechanisms underlying metastasis and chemotherapy. A critical pathway involved in both features has been identified and may lead to better patient stratification for treatment selection.

Complete Remission of Locally Advanced Penile Squamous Cell Carcinoma after Multimodality Treatment

Treatment of locally advanced penile squamous cell carcinoma (pSCC) remains highly controversial secondary to disease rarity and lack of prospective randomized controlled trials. The current mainstays of care are multi-modality treatment with neoadjuvant chemotherapy and surgery. However, clinicians often have difficulty making recommendations for patients unable to tolerate chemotherapy or surgery due to scarcity of data to guide clinical decision-making. We report two cases of locally advanced pSCC that achieved complete remission after treatment with cisplatin-based neoadjuvant chemotherapy and surgery in one case, and concurrent cisplatin chemoradiation in a second, supporting the use of chemotherapy as part of first-line multimodal therapy. We also discuss additional treatment options for patients unable to tolerate traditional chemotherapy regimens.

Emerging Systemic Therapies for the Management of Penile Cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer, but is more common in developing countries. Locally advanced and metastatic PSCC is associated with significant morbidity and mortality, with the prognosis remaining extremely poor. The authors searched PubMed and published abstracts for metastatic PSCC studies to describe emerging therapies. Multimodality treatment using chemotherapy, radiation, and consolidative surgery are standard of care. Utilizing anti-EGFR therapies and novel immunotheraputic approaches may help improve outcomes in PSCC.

Gene Expression Profiling of Advanced Penile Squamous Cell Carcinoma Receiving Cisplatin-based Chemotherapy Improves Prognostication and Identifies Potential Therapeutic Targets

In men with advanced penile squamous cell carcinoma receiving first-line chemotherapy, visceral metastases (VM) and Eastern Cooperative Oncology Group performance status ≥1 are poor prognostic factors for overall survival (OS). We hypothesized that tumor gene expression profiling may enhance prognostic stratification and identify potential therapeutic targets. In this retrospective study, RNA extracted from macrodissected tumors underwent profiling for the expression of 738 genes using NanoString. Univariate and multivariate analyses assessed the association of genes, VM, and performance status with OS. Tumors were available from 25 men who received first-line cisplatin-based chemotherapy. In univariate analysis, upregulated MAML2 (p=0.004), KITLG (p≤0.0001), and JAK1 (p=0.029) genes were associated with poor OS, and upregulated FANCA was associated with better OS (p=0.024). In stepwise multivariate analyses, VM (hazard ratio=12.75, p=0.0001) and MAML2 (hazard ratio=10.411, p=0.003) were associated with poor OS. The presence of none, one, and both of these poor risk factors was associated with significantly different median OS of 18.4 mo, 7.2 mo, and 2.1 mo, respectively. Unsupervised clustering demonstrated two major molecular subtypes with trend for different survivals (p=0.052). Validation of results is necessary. PATIENT SUMMARY: The expression of the MAML2 gene in penile cancers from men receiving first-line cisplatin-based chemotherapy predicted overall survival independent of clinical factors.

Prognostic risk stratification derived from individual patient level data for men with advanced penile squamous cell carcinoma receiving first-line systemic therapy

BACKGROUND

Prognostic factors in men with penile squamous cell carcinoma (PSCC) receiving systemic therapy are unknown. A prognostic classification system in this disease may facilitate interpretation of outcomes and guide rational drug development. We performed a retrospective analysis to identify prognostic factors in men with PSCC receiving first-line systemic therapy for advanced disease.

PATIENTS AND METHODS

Individual patient level data were obtained from 13 institutions to study prognostic factors in the context of first-line systemic therapy for advanced PSCC. Cox proportional hazards regression analysis was conducted to examine the prognostic effect of these candidate factors on progression-free survival (PFS) and overall survival (OS): age, stage, hemoglobin, neutrophil count, lymphocyte count, albumin, site of metastasis (visceral or nonvisceral), smoking, circumcision, regimen, ECOG performance status (PS), lymphovascular invasion, precancerous lesion, and surgery following chemotherapy. The effect of different treatments was then evaluated adjusting for factors in the prognostic model.

RESULTS

The study included 140 eligible men. Mean age across all men was 57.0 years. Among them, 8.6%, 21.4%, and 70.0% of patients had stage 2, 3, and 4 diseases, respectively; 40.7% had ECOG PS ≥ 1, 47.4% had visceral metastases, and 73.6% received cisplatin-based chemotherapy. The multivariate model of poor prognostic factors included visceral metastases (P<0.001) and ECOG PS ≥ 1 (P<0.001) for both PFS and OS. A risk stratification model constructed with 0, 1, and both poor prognostic factors was internally validated and demonstrated moderate discriminatory ability (c-statistic of 0.657 and 0.677 for OS and PFS, respectively). The median OS for the entire population was 9 months. Median OS was not reached, 8, and 7 months for those with 0, 1, and both risk factors, respectively. Cisplatin-based regimens were associated with better OS (P = 0.017) but not PFS (P = 0.37) compared with noncisplatin-based regimens after adjusting for the 2 prognostic factors.

CONCLUSIONS

In men with advanced PSCC receiving first-line systemic therapy, visceral metastases and ECOG PS ≥ 1 were poor prognostic factors. A prognostic model including these factors exhibited moderate discriminatory ability for outcomes and warrants external validation. Patients receiving cisplatin-based regimens exhibited better outcomes compared with noncisplatin-based regimens after adjusting for prognostic factors.

Clinicopathologic characteristics and outcomes of penile cancer treated at tertiary care centers in the Western United States

BACKGROUND

This article reports on the experience with penile squamous cell carcinoma (PSCC) in a unique multiethnic patient population from Los Angeles, California, with regard to treatments rendered and clinical outcomes.

PATIENTS AND METHODS

Available clinical, pathologic, and treatment information for PSCC patients treated at 3 hospitals associated with the University of Southern California from 1991 to 2011 was retrospectively reviewed. Associations of patient variables with prognosis were assessed using univariable and multivariable analyses.

RESULTS

Of the 95 PSCC patients identified, clinicopathologic and outcome information was available on 89 men (median age, 53 years; median follow-up, 23 months). National minorities comprised 76.4% of the cohort with 57.3% Hispanics accounting for all patients. Presence of poorly differentiated tumors was associated with higher tumor stage (P = .020), nodal metastasis (P = .016), distant metastasis (P = .004), and advanced AJCC disease stage (P = .001). Univariate analysis showed that tumor (P = .008), nodal (P = .033), and metastasis (P < .001) stage, and tumor differentiation (P = .010) were associated with survival. When categorized according to the AJCC classification, patients with ≥ stage III disease had worse outcomes (P = .006). Type of primary therapy delivered did not affect outcomes. AJCC disease stage was independently prognostic in multivariable analysis (P = .035).

CONCLUSION

These results confirm associations of several clinicopathologic factors with PSCC outcomes, although the presented population differs from others previously described from the United States with a relatively higher proportion of Hispanic men. This highlights the need for studies on the effects of race, cultural, health, and behavioral patterns on PSCC outcomes in multiethnic populations.