Sexual Outcomes after Conservative Management for Patients with Localized Penile Cancer

BACKGROUND

Men with localized invasive penile cancer (PC) can be treated with organ-sparing treatments with different functional and aesthetical outcomes. Thus, the aim of this study is to investigate sexual outcomes in patients with PC confined to the glans that underwent wide local excision (WLE) vs. glansectomy with urethral glanduloplasty.

METHODS

Complete data from 60 patients with PC were analyzed at our institution from 2017 to 2022. Patients were asked for personal habits and clinical features. PC was assessed with a clinical visit and imaging techniques. At the outpatient follow-up visit or phone call, all patients compiled the Changes in Sexual Function Questionnaire (CSFQ) and the International Index of Erectile Function in its short 5-item form (IIEF-5). Erectile function (EF) impairment was categorized using Cappelleri's criteria.

RESULTS

Overall, 34 patients with PC confined to the glans (c ≤ T2N0) were included. Of those, 12 underwent WLE and 22 underwent glansectomy with urethral glanduloplasty. Using multivariable logistic regression, glansectomy (OR: 3.49) and diabetes (OR: 2.33) were associated with erectile disfunction (IEEF < 22). Meanwhile, using multivariable linear regression analysis, younger patients (Coeff: -2.41) and those that underwent glansectomy (Coeff: -7.5) had a higher risk of sexual function impairment, according to the CSFQ.

CONCLUSIONS

Patients with PC ≤ T2N0 that underwent WLE have better outcomes in terms of sexual functioning than the patients who underwent glansectomy and uretheral gladuloplasty. Further research is needed to clarify the outcomes of penile-sparing surgery, to inform patients in pre-surgical counseling more comprehensively, and to meet their post-operative expectations more effectively.

Extra-mammary Paget's disease of the penis

Paget's disease was first described in 1874 as an eczematoid changes of the nipple associated with underlying breast carcinoma. Extra-mammary Paget's disease (EMPD) is rare with involvement of the male genitalia described in small case series and management options varying according to location and extent. The diagnosis of EMPD requires a high index of clinical suspicion and close liaison with the multidisciplinary team, particularly histopathology. We present two cases of EMPD affecting the male external genitalia that highlight important learnings in the presentation, diagnosis, and management of EMPD.

[Penile epithelioid hemangioma]

Epithelioid hemangioma is a benign vascular tumor. Complete surgical excision is curative, there is no tendency to recurrence or metastasize. Its penile occurrence is extremely rare, only 33 cases have been reported in English literature. A patient with epithelioid hemangioma of the deep dorsal vein of the penis is reported. To our knowledge, this is the first report of penile epithelioid hemangioma in Hungarian literature. The 64-year-old patient presented to our department with painful erection caused by a palpable penile mass. Physical examination revealed a mobile subcutaneous nodule on the dorsum of the penis. Penile ultrasound showed a 10 mm homogeneous, well circumscribed lesion superficial to the tunica albuginea of the corpora cavernosa without intralesional blood flow. Local excision was performed through a dorsal longitudinal penile incision. The deep dorsal vein was dissected circumferentially, then the lesion was removed following ligation of the vein proximal and distal to the mass. Histopathological examination revealed epithelioid hemangioma. At three months after surgery, the patient reported complete resolution of pain, his International Index of Erectile Function Score was 21. At four years after the operation, there were no signs of recurrence or metastasis. Successful treatment of epithelioid hemangioma of the penis requires in-depth knowledge of processes resulting in penile subcutaneous masses, therefore the differential diagnosis is detailed in discussion. Orv Hetil. 2023; 164(21): 836-840.

Indigenous Groin Board Immobilization Reduces Planning Target Volume Margins in Groin Radiotherapy

Purpose:

To quantify the relative motion of pelvic and groin lymph nodes (PLN and GLN) and define indicative margins for image-guided radiotherapy based on bony anatomy for the frog-leg position (FLP) and groin immobilization board (GIB).

Materials and Methods:

Twenty patients with planning computed tomography (CT) scan and on treatment cone beam CTs (median = 8) for groin and pelvic radiotherapy were included in the study. Of these nine were treated with FLP and eleven with GIB. The PLN and GLN regions on the left and right were outlined in each scan. Systematic and random uncertainties were determined along with correlations between the motions of these regions. The clinical target volume to planning target volume (PTV) margins required to take motion into account was calculated for each immobilization.

Results:

The mean shifts for PLN and GLN were lesser but not statistically lower using GIB over FLP. There was significant concordance in the vertical, longitudinal and lateral motion of the pelvis and right groin (P = 0.015, 0.09 and 0.049, respectively), pelvis and left groin (P = 0.001, 0.048, and 0.006, respectively) and between left and right groin (P = 0.013, 0.01 and 0.07, respectively) for FLP and not GIB. The PTV margins required by Van Herk and Stroom's formula were reduced from 11 mm and 9 mm to 6 mm and 5 mm for pelvis; 12 mm and 11 mm to 7 mm and 6 mm for groin, respectively, using FLP over GIB.

Conclusions:

GIB brings concordance in shifts between pelvis and groin and between bilateral groins, thereby reducing the required PTV margins.

Creation of a pioneering interdisciplinary genital dermatology unit for Hispanic men: First 269 patients

The role of circumcision in partially protecting against sexually transmitted infections (STIs) and other dermatoses has been documented. Neonatal circumcision is not routinely practiced in South America. Although it is logical to assume that male genital dermatoses are more prevalent in Hispanic men, they are underrepresented in the existing literature. Objective: To describe the epidemiological characteristics from our male genital dermatology unit in Montevideo (Uruguay), the diagnoses, and correlate them with circumcision status and comorbidities. Methods: A retrospective observational cohort study was conducted. A dermatologist and urologist evaluated all patients using standard questionnaires. In 3 years and 8 months, 269 patients were seen. Median age was 41, prevalence of neonatal circumcision was 0.7%, HIV was 4.2%, STIs were 24.9%, non-STIs were 63.9%, and both (STI + non-STI) were 11.2%. Most frequent entities: eczema/balanoposthitis (27.1%), condyloma (24.9%), and lichen sclerosus (15.6%). Data correlating circumcision and other diagnoses did not reach statistical significance. HIV was positively associated with other STIs (p < 0.05), and an association with balanoposthitis was seen; however, it did not reach statistical significance (p < 0.1). Main limitation was small sample size. This is the first study of its kind based on Hispanic patients. Collaboration between specialties proved to be fundamental. Further studies are needed in this demographic to find an association between circumcision, comorbidities, and genital dermatoses.

Characteristics of penile cancer in Japan: An analysis of nationwide hospital-based cancer registry data

OBJECTIVES

To investigate the clinical characteristics of patients with penile cancer in Japan using the nationwide hospital-based cancer registry database.

METHODS

Using hospital-based cancer registry data, we described the distribution of age, pathology, tumor-node-metastases classification, and first-course treatment in patients treated between 2012 and 2015. We compared the patterns of first-line treatment between elderly and non-elderly patients.

RESULTS

A total of 1012 patients were diagnosed with squamous cell carcinoma among 1773 patients with penile tumors who registered under topography code C60. The median age at diagnosis was 74 years, and 85.9% of patients were aged >60 years. The most common pathology was usual-type squamous cell carcinoma (91.9%), followed by verrucous carcinoma (5.0%), sarcomatoid carcinoma (1.1%), papillary carcinoma (0.7%), basaloid carcinoma (0.6%), adenosquamous carcinoma (0.4%), warty carcinoma (0.2%) and mixed carcinoma (0.1%). A total of 61.3% of patients were diagnosed with localized disease. In contrast, the proportions of patients with lymph node and distant metastases were 27.5% and 2.1% at diagnosis, respectively. The proportion of patients who were treated with chemotherapy as the first-course treatment was significantly lower among elderly patients (≥80 years) with clinical stage III (27.6% vs 7.1%, P = 0.0312) and clinical stage IV (53.2% vs 14.3%, P = 0.0086).

CONCLUSIONS

Most penile cancer patients in Japan are diagnosed with usual-type squamous cell carcinoma, and those with human papilloma virus-related squamous cell carcinomas are <1%. Chemotherapy for advanced penile cancer is administered less in Japanese elderly (≥80 years) patients.

Incidence of external genital lesions related to human papillomavirus among Mexican men. A cohort study

OBJECTIVE

To determine external genital lesion (EGL) incidence -condyloma and penile intraepithelial neoplasia (PeIN)- and genital HPV-genotype progression to these EGLs.

MATERIALS AND METHODS

Participants (healthy males 18- 74y from Cuernavaca, Mexico, recruited 2005-2009, n=954) underwent a questionnaire, anogenital examination, and sample collection every six months;including excision biopsy on suspicious EGL with histological confirmation.Linear array assay PCR characterized 37 high/low-risk HPV-DNA types. EGL incidence and cumulative incidence were calculated, the latter with Kaplan-Meier.

RESULTS

EGL incidence was 1.84 (95%CI=1.42-2.39) per 100-person-years (py); 2.9% (95%CI=1.9-4.2) 12-month cumulative EGL.Highest EGL inci- dence was found in men 18-30 years:1.99 (95%CI=1.22-3.25) per 100py. Seven subjects had PeIN I-III (four with HPV16). HPV11 most commonly progresses to condyloma (6-month cumulative incidence=44.4%, 95%CI=14.3-137.8). Subject with high-risk sexual behavior had higher EGL incidence.

CONCLUSIONS

In Mexico, anogenital HPV infection in men is high and can cause condyloma. Estimation of EGL magnitude and associated healthcare costs is necessary to assess the need for male anti-HPV vaccination.

Painful Penile Plaques: A Rare Case Report of Rectal Adenocarcinoma with Cutaneous Metastasis to the Penis

Despite the rich vascularization of the penis and its close proximity to other pelvic organs, cutaneous manifestations of metastatic disease to the penis are an uncommon occurrence. Penile lesions suspected for malignancy should alert clinicians to differentiate between primary and secondary tumors. While the majority of metastatic malignancies arise from the genitourinary tract, we present a unique case report of a 51-year-old male with penile metastasis of primary rectal adenocarcinoma. A thorough diagnostic evaluation was performed including imaging studies, colonoscopy, as well as penile biopsies with associated immunohistochemistry panel. The patient was diagnosed with penile metastases secondary to invasive rectal adenocarcinoma. Due to the aggressive nature of the patient's presentation, systemic chemotherapy was initiated for palliative measures as the patient declined any radical surgical intervention.

Histological subtype is a significant predictor for inguinal lymph node metastasis in patients with penile squamous cell carcinoma

The present study aimed to investigate the relationship between histopathological subtype and the probability of inguinal lymph node metastasis (ILNM) in patients with penile squamous cell carcinoma (PSCC). The clinical records of 198 consecutive patients with PSCC were analyzed retrospectively. Primary lesions were reevaluated according to the 2016 World Health Organization (WHO) histopathological classification. We retrieved the clinicopathological factors from the medical records including age, clinical lymph node stage, pathological tumor stage, lymphatic invasion, and nerve invasion. Uni- and multivariate logistic regression analyses were used to explore the risk factors of ILNM. Multivariate analyses identified clinical lymph node stage (P = 0.000), pathological tumor stage (P = 0.016), histologic grade (P = 0.000), and risk group of histological subtypes (P = 0.029) as independent predictors for ILNM. Compared with the low-risk group of PSCC subtypes, the intermediate- (HR: 3.66, 95% CI: 1.30–10.37, P = 0.021) and high-risk groups (HR: 28.74, 95% CI: 2.37–348.54, P = 0.008) were significantly associated with ILNM. In conclusion, the histopathological subtype of the primary lesion is a significant predictor for ILNM in patients with PSCC.

Proposal for reclassification of N staging system in penile cancer patients, based on number of positive lymph nodes

In the present study, we aim to compare the rationality of proposed N classification based on the number of metastatic lymph nodes (LNs) with the current one. A total of 509 penile cancer patients at our institute were analyzed. Univariable and multivariable statistical analyses were used to assess cancer-specific survival (CSS) in 2 staging systems. Harrell's concordance index was applied to evaluate predictive accuracy of the current and proposed N classification in predicting CSS. We propose a new classification: pN1 (metastasis in 1-2 regional LNs), pN2 (metastasis in 3 regional LNs, or 3 or fewer regional lymph nodes with extranodal extension), and pN3 (metastasis in 4 or more regional LNs). According to the current and proposed N classification, the 5-year CSS of penile cancer patients with pN1, pN2 and pN3 was 85.8%, 39.0%, and 19.7%; and with pN1, pN2 and pN3 was 79.8%, 39.3% and 15.3%, which almost all showed significant difference (P < .001, P = .259) (P < .001, P < .001). Multivariable predictive accuracy of the proposed and current N staging was 76.48% and 70.92% (5.56% gain; P < .001). With a multivariable model of clinical features, both current (hazard ratio [HR], 7.761, 10.612; P < .001, P < .001) and proposed N stages (HR, 3.792, 3.971; P < .001, P < .001) exhibited independent effects on survival. The proposed N classification is superior to the current one, which is simpler and provides more accurate prognosis.

More precise prediction in Chinese patients with penile squamous cell carcinoma: protein kinase CK2α catalytic subunit (CK2α) as a poor prognosticator

Purpose

In this study, we assess the CK2α expression in human penile squamous cell carcinoma (SCC) and its clinical significance.

Methods

A total of 157 human penile SCC tissue samples were immunohistochemically analyzed. In addition, 12 human penile SCC and adjacent normal tissues were examined for CK2α protein and mRNA expression by Western blotting and real-time quantitative PCR, respectively. Survival was analyzed using the Kaplan-Meier test and the log-rank test. Multivariate Cox proportional hazard regression analysis was performed to determine the impacts of CK2α expression and the clinicopathological features on patient disease-specific survival (DSS). Likelihood ratios (LRs), Akaike information criterion (AIC) values, and concordance indexes (C-indexes) were investigated to evaluate the accuracies of the factors. Bootstrap-corrected C-indexes were used for internal validation (with sampling 1000 times).

Results

A significant difference in the distribution of CK2α was observed between the normal and penile carcinoma tissues (P<0.001). CK2α expression was associated with the pathological T and N stages in the penile cancer tissues (P<0.001). High CK2α expression was with significantly poorer DSS compared with low expression one (P<0.001). Western blotting and real-time quantitative PCR also confirmed that CK2α expression was increased in the penile cancer tissues. In multivariate Cox regression analysis, CK2α overexpression still was one of independent prognostic factors for penile SCC (P=0.005). The predictive accuracy of CK2α was verified by analysis of the C-indexes.

Conclusion

High protein kinase CK2α expression is associated with several prognostic factors and is thus a significant indicator of poor prognosis for penile cancer.

Development of a New Classification Method for Penile Squamous Cell Carcinoma Based on Lymph Node Density and Standard Pathological Risk Factors: The ND Staging System

Object: In this study, we evaluated the role of lymph node density (LND) and validated whether LND increases the accuracy of survival prediction when combined with the American Joint Committee on Cancer (AJCC) pathological node (N) staging system for penile cancer (7^th edition).

Methods: A total of 270 Chinese penile cancer patients treated between March 1999 and October 2014 were retrospectively analyzed. LND was analyzed as a trichotomous variable for the prediction of DSS in this cohort. We developed a new prediction model, which we refer to as the ND staging system, that is based on LND and pathological N staging. The predictive accuracy of this model was further assessed using the concordance index.

Results: LND was correlated with the laterality of lymph node metastasis, extranodal extension, pelvic lymph node metastases, and pathologic tumor (T) and N stages (P<0.05). In separate multivariate Cox regression models, the LND (hazard ratio [HR], 1.966, 95% confidence interval [CI], (1.112-3.473, P=0.020) yielded independent effects on the outcome. According to the LND classification, the 3-year disease-specific survival (DSS) rates for patients with LNDs <7.0%, 7.0 to 16.9%, and ≥17.0% were 90.9%, 66.5%, and 22.2%, respectively (P_{<7.0%; 7.0%-16.9%}=0.006; P_{7.0-16.9%; ≥17.0%}=0.001). The corresponding rates were 95.7%, 76.7%, and 28.1% for the ND1, ND2, and ND3 patients, respectively (P_ND1-ND2=0.047; P_ND2-ND3<0.001). The indexes indicated that the accuracy of the pathological ND category that incorporated LND was significantly increased.

Conclusion: LND was associated with some prognosticators and is thus a prognostic factor. The ND staging system that incorporates the LND better reflects the prognoses of penile cancer patients.

Clinical significance of preoperative C-reactive protein and squamous cell carcinoma antigen levels in patients with penile squamous cell carcinoma

OBJECTIVE

To evaluate the relevance of C-reactive protein (CRP) and squamous cell carcinoma antigen (SCC-Ag) levels in relation to clinicopathological factors and prognosis in penile cancer.

PATIENTS AND METHODS

A total of 124 Chinese patients with penile squamous cell carcinoma (SCC), treated between November 2007 and October 2014, were analysed retrospectively. Receiver-operating characteristic curves were used to identify the combination of markers with the best sensitivity and specificity for prognosis prediction. Statistical data analysis was performed using a non-parametric method, and survival analysis was performed using the log-rank test and Cox proportional hazard model.

RESULTS

Levels of CRP ≥4.5 mg/L and SCC-Ag ≥1.4 ng/mL were both significantly associated with lymph node metastasis (LNM) laterality (chi-squared trend test, P = 0.041), extranodal extension (chi-squared trend test, P < 0.001), pelvic LNM (chi-squared trend test, P = 0.024), pathological tumour status (chi-squared trend test, P = 0.002), pathological nodal status (chi-squared trend test, P < 0.001), and disease-specific survival (DSS; log-rank test, P < 0.001). Moreover, the influence of CRP and SCC-Ag levels on DSS (P = 0.033, hazard ratio 3.390, 95% confidence interval 1.104-10.411) remained after adjusting for smoking history, phimosis, tumour status, tumour cell differentiation and nodal status.

CONCLUSIONS

The present study shows that the combined measurement of preoperative CRP and SCC-Ag levels may serve as an independent biomarker for LNM, advanced tumour stage and DSS in patients with penile SCC.