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Update on penile sparing surgery for penile cancer
Abstract
Purpose of review:
Penile sparing surgery (PSS) is considered the standard of care in penile cancer where appropriate, as preservation of the penis may enable the patient to maintain urinary and sexual function. This review will focus on the latest developments over the past two years.
Recent findings:
In this review, we discuss the latest findings in oncological outcomes in PSS, specifically glansectomy. We also introduce technology that may be useful in improving the precision of surgical resection margins in PSS. Finally, we consider the value of patient-reported outcome measures (PROMs) and consider how research in this area can be improved.
Summary:
A recent study has found a correlation between local recurrences (LR) and worse overall and cancer-specific survival in glansectomy, which challenges the belief that LR do not confer worse oncological outcomes. Despite numerous studies evaluating PROMs in penile cancer/PSS, few of these studies provide quality evidence of the 'supportive care needs'. A shift in research is required to identify those men at most risk of distress and to identify ways to support men diagnosed with penile cancer.
... Patients included in our study were treated with penile preservation in 30% (SEER database) and 13% (four tertiary hospitals in Gansu Province) of the cases, and the surgical modality was only associated with CSS, demonstrating that total penile excision had a greater impact on prognosis. Our findings were consistent with some previous analyses (Luzzago et al. 2021;Anastasiadis et al. 2022;Chavarriaga et al. 2022), with a greater proportion of partial penile excisions than partial lesion excisions or total excisions. However, in both datasets, radiotherapy and chemotherapy patients represented only one-tenth of all the patients. ...
Purpose
Penile cancer (PC) is a great impact on the quality of life and psychological status of patients. This study aimed to construct nomograms using data from the Surveillance, Epidemiology, and End Results (SEER) database to predict overall survival (OS) and cancer-specific survival (CSS) in patients with penile cancer (PC).
Methods
Patients were divided into a training cohort (n = 634) and a validation cohort (n = 272) in a 7:3 ratio. Independent risk factors influencing the prognosis of PC were screened using univariate and multivariate Cox analyses, and models for predicting PC were developed. Data from 203 patients with PC in four tertiary hospitals in Gansu Province from 2012 to 2021 were externally validated.
Results
Univariate analysis and multivariate analysis showed revealed that the OS-related factors were age, grade, T stage, N stage, M stage and tumor size (p < 0.05); the CSS-related factors were age, mode of surgery, T stage, N stage, M stage and tumor size (p < 0.05). The C-indices of the OS and CSS nomograms in the training cohort were 0.743 [95% confidence interval (CI) (0.714–0.772)] and 0.797 (0.762–0.832), respectively. The C-indices of the OS and CSS nomograms in the internal validation cohort were 0.735 (0.686–0.784) and 0.755 (0.688–0.822), respectively, and those in the external validation cohort were 0.801 (0.746–0.856) and 0.863 (0.812–0.914), respectively. Receiver operating characteristic (ROC) curves, calibration curves, and survival curves all demonstrated good predictive performance of the nomograms.
Conclusion
The nomograms for PC were developed using the SEER database. The accuracy and clinical usefulness of the model were validated through a combination of internal and external validations.
IntroductionPenile cancer (PeCa) is an orphan disease in European countries. The current guidelines are predominantly based on retrospective studies with a low level of evidence. In our study, we aimed to identify predictors for guideline-conform treatment and hypothesize that reference centers for PeCa and physicians' experience promote guideline compliance and therefore correct local tumor therapy.Methods
This study is part of the European PROspective Penile Cancer Study (E-PROPS), an international collaboration group evaluating therapeutic management for PeCa in Central Europe. For this module, a 14-item-survey was developed and sent to 681 urologists in 45 European centers. Three questions focused on therapeutic decisions for PeCa in clinical stage Tis, Ta-T1a, and T1b. Four questions addressed potential personal confounders. Survey results were analyzed by bootstrap-adjusted stepwise multivariate linear regression analysis to identify predictors for EAU guideline-conform local treatment of PeCa.ResultsFor local therapy of cTis 80.4% recommended guideline-conform treatment, for cTa-cT1a 87.3% and for cT1b 59.1%. In total, 42.4% chose a correct approach in all tumor stages. The number of PeCa patients treated at the hospital, a higher level of training of the physicians, resource-based answering and the option of penile-sparing surgery offered at the hospital matched with giving guideline-conform recommendations and thus accurate local tumor treatment.Conclusion
Patients with PeCa are best treated by experienced physicians, in centers with a high number of cases, which also offer a wide range of local tumor therapy. This could be offered in reference centers.
Purpose
To report on the oncological outcome of organ-sparing surgery (OSS) compared to (total or partial) penectomy regarding recurrence patterns and survival in squamous cell carcinoma (SCC) of the penis.
Methods
This was a retrospective study of all patients with penile SCC and eligible follow-up data of at least 2 years at our institution. Patients with tumors staged ≥ pT1G2 underwent invasive lymph node (LN) staging by dynamic sentinel-node biopsy or modified inguinal lymphadenectomy. Radical inguinal lymphadenectomy was performed when LNs were palpable at diagnosis and in those with a positive LN status after invasive nodal staging. Follow-up visits were assessed, and local, regional and distant recurrences were defined and analyzed.
Results
55 patients were identified with a mean follow-up of 63.7 months. Surgical management was OSS in 26 patients (47.2%) and partial or total penectomy in 29 cases (52.8%). Histopathological staging was: pTis (12.7%), pTa (16.3%), pT1a (18.2%), pT1b (5.5%), pT2 (29.1%) and pT3 (18.2%), respectively. Patients in the penectomy group were significantly older (mean 68 vs. 62 years; p = 0.026) with a higher rate of advanced tumor stage (≥ pT2: 44.8% vs. 11.5%; p = 0.002). The local recurrence rate was 42.3% (n = 11) following OSS compared to 10.3% (n = 3) after penectomy (p = 0.007). Kaplan–Meier curves showed no significant differences between the two groups regarding metastasis-free and overall survival.
Conclusions
OSS is associated with a higher local recurrence rate compared to penectomy, yet it has no negative impact on overall and metastasis-free survival.
Background:
Current optical diagnostic techniques for malignancies are limited in their diagnostic accuracy and lack the ability to further characterise disease, leading to the rapidly increasing development of novel imaging methods within urology. This systematic review critically appraises the literature for novel imagining modalities, in the detection and staging of urological cancer and assesses their effectiveness via their utility and accuracy.
Methods:
A systematic literature search utilising MEDLINE, EMBASE and Cochrane Library Database was conducted from 1970 to September 2018 by two independent reviewers. Studies were included if they assessed real-time imaging modalities not already approved in guidelines, in vivo and in humans. Outcome measures included diagnostic accuracy and utility parameters, including feasibility and cost.
Results:
Of 5475 articles identified from screening, a final 46 were included. Imaging modalities for bladder cancer included optical coherence tomography (OCT), confocal laser endomicroscopy, autofluorescence and spectroscopic techniques. OCT was the most widely investigated, with 12 studies demonstrating improvements in overall diagnostic accuracy (sensitivity 74.5–100% and specificity 60–98.5%). Upper urinary tract malignancy diagnosis was assessed using photodynamic diagnosis (PDD), narrow band imaging, optical coherence tomography and confocal laser endomicroscopy. Only PDD demonstrated consistent improvements in overall diagnostic accuracy in five trials (sensitivity 94–96% and specificity 96.6–100%). Limited evidence for optical coherence tomography in percutaneous renal biopsy was identified, with anecdotal evidence for any modality in penile cancer.
Conclusions:
Evidence supporting the efficacy for identified novel imaging modalities remains limited at present. However, OCT for bladder cancer and PDD in upper tract malignancy demonstrate the best potential for improvement in overall diagnostic accuracy. OCT may additionally aid intraoperative decision making via real-time staging of disease. Both modalities require ongoing investigation through larger, well-conducted clinical trials to assess their diagnostic accuracy, use as an intraoperative staging aid and how to best utilise them within clinical practice.
Introduction:
Currently, (multiple) biopsies are taken to obtain histopathological diagnosis of suspicious lesions of the penile skin. Optical coherence tomography (OCT) provides noninvasive in vivo images from which epidermal layer thickness and attenuation coefficient (μoct) can be quantified. We hypothesize that qualitative (image assessment) and quantitative (epidermal layer thickness and attenuation coefficient, μoct) analysis of penile skin with OCT is possible and may differentiate benign penile tissue from (pre) malignant penile tissue.
Materials and methods:
Optical coherence tomography-imaging was performed prior to punch biopsy in 18 consecutive patients with a suspicious lesion at the outpatient clinic of the NKI-AVL. Qualitative analysis consisted of visual assessment of clear layers and a visible lower border of the lesions, quantitative analysis comprised of determination of the epidermal layer thickness and μoct. Results were grouped according to histopathology reports.
Results:
Qualitative analysis showed a statistically significant difference (P = 0.047) between benign and (pre) malignant lesions. Quantitative analysis showed that epidermal layer thickness and attenuation coefficient was significantly different between benign and (pre) malignant tissue, respectively, P = 0.001 and P < 0.001.
Conclusion:
In this preliminary study, qualitative and quantitative analysis of OCT-images of suspicious penile lesions shows differences between benign lesions and (pre) malignant lesions. These results encourage further research in a larger study population.
Penile cancer is an uncommon malignancy with an incidence of 1 per 100,000. Conservative and radical treatments can be disfiguring and may have an impact on sexual function, quality of life (QOL), social interactions, self-image and self-esteem. Knowledge of how this disease affects patients is paramount to developing a global, multi-disciplinary approach to treatment.
A Medline/PubMed literature search was conducted using the terms "sexual function penis cancer"; "quality of life penis cancer" and "psychological effects penis cancer" from 1985 to 2008. Articles containing quantitative data on QOL, sexual function or psychological well-being were included.
128 patients from 6 studies were included. 5 studies contained retrospective data whilst 1 study collected prospective data on erectile function. In the 6 studies 13 different quantitative tools were used to assess psychological well-being, QOL and sexual function. The General Health Questionnaire (GHQ) showed impaired well-being in up to 40% in 2 studies. Patients undergoing more mutilating treatments were more likely to have impaired well-being. The Hospital Anxiety and Depression Score (HADS) demonstrated pathological anxiety up to 31% in 2 studies. 1 study used the Diagnostic and Statistical Manual of Mental Disorders of psychiatric illness (DSM III-R) with 53% exhibiting mental illness, 25% avoidance behaviour and 40% impaired well-being. 12/30 suffered from post-traumatic stress disorder. The IIEF-15 was the commonest tool used to assess sexual function. The results varied from 36% in 1 study with no sexual function to 67% in another reporting reduced sexual satisfaction to 78% in another reporting high confidence with erections.
The treatment of penile cancer results in negative effects on well-being in up to 40% with psychiatric symptoms in approximately 50%. Up to two-thirds of patients report a reduction in sexual function. This study demonstrates that penile cancer sufferers can exhibit significant psychological dysfunction, yet no standardised tools or interventional pathways are available. Therefore, there is a need to identify and assess adequate tools to measure psychological and sexual dysfunction in this group of patients.
With the passage of time, there has been a major paradigm shift in the surgical management of penile cancer from radical to organ preserving penile surgical techniques, with closer surgical margins which offer good oncological, cosmetic and functional outcomes with improved physical and psychosexual well-being. This article aims to provide an update of the current organ preserving surgical strategies for penile cancer.
Purpose
To systematically evaluate evidence regarding the unmet supportive care needs of men affected by penile cancer and their partners to create a holistic model of care and inform clinical practice guidelines.
Methods
We searched CINAHL, MEDLINE, PsychINFO, Embase, and the Cochrane Library (CCRT and CDSR) controlled trials databases and clinicaltrial.gov from 1990 to April 2020. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.
Results
18 articles were included, reporting the results from 17 studies. Included reports used qualitative (seven studies) and survey (ten studies). Across these studies, men reported that the diagnosis and subsequent treatment of penile cancer affected physical, psychological and sexual well-being with each facet impacting and being intertwined with the other at varying degrees. There was varying complexity of unmet needs in men and partners pre-surgery, post-surgery and into survivorship.
Conclusions
Moderate evidence exists that men affected by penile cancer experience a range of unmet supportive care needs across the international literature. Further work to evaluate the impact of penile cancer on partners is required.
Objective
To characterize the treatment trends and outcomes in clinical stage T1 penile cancer using the National Cancer Database (NCDB).
Methods
The National Cancer Database was queried for all men with cT1 penile cancer from 2004 to 2015. Patients were categorized as cT1a or cT1b. Treatment was categorized as no treatment, local therapy (including penile sparing therapies), partial penectomy, or radical penectomy. Trends in treatment were analyzed over time and in correlation with stage and demographic variables. Stage and treatment type were evaluated in respect to pathological outcomes and survival.
Results
A total of 2,484 men were identified with cT1 penile cancer, 90.1% of which had cT1a disease. The most common treatments were local therapy for cT1a and partial penectomy for cT1b. Over the time period studied, use of local therapy decreased while use of partial or radical penectomy increased. Patients treated at low volume facilities were more likely to undergo no treatment (8.0% vs. 6.5% in high volume) or local therapy (49.9% vs. 41.5% in high volume, P < 0.001). Local therapy was associated with increased risk of positive margin (odds ratio 4.7, P < 0.001) and positive margin was associated with a trend toward decreased overall survival (P = 0.07).
Conclusions
In the past decade, there has been decreased use of local therapy and increased use of partial or radical penectomy in cT1 penile cancer. Men treated at low volume facilities are more likely to be treated with local therapy which is associated with increased rates of positive margins and may also be associated with a trend toward decreased overall survival. Centralization of care in T1 penile cancer may lead to improved outcomes.
Introduction and objectives
The local recurrence rate of penile cancer following surgical excision is reported in many series to be between 6 and 29%. Intra-operative frozen section (FS) is a useful tool to ensure safe microscopic margins in organ-sparing procedures in penile cancer. In this series, we assessed the rates of positive margins and patterns of local recurrence in a multicentre cohort of patients undergoing penile-preserving surgery assisted by intra-operative FS analysis.
Materials and methods
We reviewed all those patients for whom intra-operative FS was employed during penile-preserving surgery in three tertiary referral centres between 2003 and 2016. We assessed whether the use of FS altered the surgical technique and what affect it had on positive margins and recurrence rates.
Results
A total of 169 patients were identified. Of these, intra-operative FS examination of the surgical margin was positive in 21 (12%) cases. Final histological examination confirmed cancer-free margins in all but one patient (99.4%). Overall, 9 patients developed local recurrence (5.3%).
Conclusions
In this series, intra-operative FS contributed to a very low rate (5.3%) of local recurrence. We noted an extremely low positive margin rate (0.6%) which highlights the benefit of incorporating FS analysis into organ-preserving surgery for penile cancer.
Level of evidence
Not applicable for this multicentre audit.
Introduction:
Surgical management of penile cancer depends on accurate margin assessment and staging. Advanced optical imaging technologies may improve penile biopsy and organ-sparing treatment. We evaluated the feasibility of confocal laser endomicroscopy for intraoperative assessment of benign and malignant penile tissue.
Patients and methods:
With institutional review board approval, 11 patients were recruited, 9 with suspected penile cancer, and 2 healthy controls. Confocal laser endomicroscopy using a 2.6-mm fiber-optic probe was performed at 1 or 2 procedures on all subjects, for 13 imaging procedures. Fluorescein was administered intravenously approximately 3 minutes prior to imaging for contrast. Video sequences from in vivo (n = 12) and ex vivo (n = 6) imaging were obtained of normal glans, suspicious lesions, and surgical margins. Images were processed, annotated, characterized, and correlated with standard hematoxylin and eosin histopathology.
Results:
No adverse events related to imaging were reported. Distinguishing features of benign and malignant penile tissue could be identified by confocal laser endomicroscopy. Normal skin had cells of uniform size and shape, with distinct cytoplasmic membranes consistent with squamous epithelium. Malignant lesions were characterized by disorganized, crowded cells of various size and shape, lack of distinct cytoplasmic membranes, and hazy, moth-eaten appearance. The transition from normal to abnormal squamous epithelium could be identified.
Conclusions:
We report the initial feasibility of intraoperative confocal laser endomicroscopy for penile cancer optical biopsy. Pending further evaluation, confocal laser endomicroscopy could serve as an adjunct or replacement to conventional frozen section pathology for management of penile cancer.
Background:
In the field of uro-oncology, the assessment of quality of life (QoL) is considered an integral part of clinical research. Because of the rarity of penile cancer, there is currently no cancer-specific questionnaire module available to assess the tumor-specific loss of function and symptoms in terms of influencing QoL. The aim of the study was to apply a validated questionnaire (European Organization for Research and Treatment of Cancer [EORTC] QLQ-C30) in a population of patients diagnosed with penile cancer and to compare these results to reference data of the general population. We also developed a new unvalidated questionnaire (Quality of Life Questionnaire-Penile Cancer-Rostock, HRO-PE29) in this population to promote QoL research in the field of uro-oncology.
Patients and methods:
Cross-sectional evaluation of patients with penile cancer after local surgical treatment (n = 76) was performed using EORTC QLQ-C30 and HRO-PE29. The QLQ-C30 provides information on QoL, functional scales, symptom scales, and 6 individual items (inappetence, insomnia, dyspnea, constipation, diarrhea, financial difficulties). Cancer-specific functional and symptom scales (HRO-PE29) were then established for use in different disease states and forms of treatment. These provide information on QoL as well as on cancer-specific function and symptom scores.
Results:
The global QoL score was 54, which corresponds to an average QoL (score 0-100) and was well below the age-standardized average for German patients. For the general function scores, the following mean values were determined: physical (x¯ = 73), social (x¯ = 61), emotional (x¯ = 60), cognitive functioning (x¯ = 69), and role function (x¯ = 63). With regard to the general symptom scores and the individual items, the following values were found: fatigue (x¯ = 35), nausea (x¯ = 6), pain (x¯ = 27), dyspnea (x¯ = 23), insomnia (x¯ = 41), loss of appetite (x¯ = 25), constipation (x¯ = 19), diarrhea (x¯ = 10), and financial difficulties (x¯ = 25). The following mean values were found for the cancer-specific functional scores: voiding (x¯ = 77), sexuality (x¯ = 69, function and pleasure), body image (x¯ = 64), lymphedema (x¯ = 75), future prospects (x¯ = 72), and adverse effects of systemic treatment (x¯ = 73).
Conclusion:
Defects of the external genitalia have implications for identity, personality, and interpersonal relationships. The mental stress of these patients results from the diagnosis of cancer as well as the partly mutilating treatment. Reconstructive surgery in penile cancer patients promises to maintain sexual and micturition function and thus improve QoL. Cancer-specific functional losses can be sufficiently named and their influence on QoL determined.
Background
Organ sparing surgery (OSS) in the treatment of penile squamous cell cancer (SCCp) is well established. A 5 mm margin has previously been considered oncologically safe.
Objective
To evaluate the significance of close surgical margins in OSS and clinico‐pathological factors that may influence local recurrence.
Patients and Methods
At our tertiary referral centre, between March 2001 and September 2012, 332 patients treated with OSS for SCCp had clear surgical margins. As the focus was the impact of close clear margins on local recurrence, patients with positive margins were excluded for the purpose of this study. Our overall positive margin rate for OSS in penile cancer is 7.6% (42 patients). Analysis was carried out on an on‐going prospective database, including prospective accurate pathological recording of surgical margins. Patients underwent OSS following multidisciplinary team discussion. Local recurrence was the primary outcome measured and Fisher's exact test and time to recurrence curves were used in analysis. All local recurrences were scrutinised by the MDT and were categorised into true recurrences or metachronous new occurrences (i.e. tumours arising from a background of PeIN and forming on an epithelial surface not related to the site of initial resection). A multivariate analysis was also conducted to elucidate other factors influencing local recurrence.
Results
64% had < 5mm clear deep surgical margin with 16% clear by <1mm.
Overall, 4% of patients had a true local recurrence, with a median time to recurrence of 6 months. 53% were due to embolic spread, with residual occult local disease accounting for 47%. There was a statistically significant relationship between cavernosal involvement (p = 0.014), lymphovascular invasion (p = 0.001) and local recurrence. Although multivariate analysis revealed that the extent of clear margin was not a predictor of disease (p=0.405), we observed an increased risk of local recurrence in the clear margin cohort of <1mm compared to those of >1mm (p=0.0003). Those patients considered to have metachronous tumours were scrutinised by our multidisciplinary panel, and 8 patients (2.4%) were found to have new occurrences. Our overall proportion of patients therefore needing further treatment for either new occurrences or recurrent disease following OSS stands at 6.4%.
Conclusions
Overall the presence of local recurrent disease in OSS in our experience is low (4%). We report an embolic mechanism of local recurrence, strongly suggested by the presence of cavernosal involvement and lymphovascular invasion. We conclude that a deep clear margin of greater than 1mm has a very low risk of local recurrence in organ sparing surgery.
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Purpose:
To evaluate recurrence outcomes of penile sparing surgery (PSS) in the largest multicenter cohort of patients to date.
Methods:
We retrospectively identified patients treated with PSS from May 1990 to July 2016 at five tertiary referral institutions. Treatments consisted of circumcision, wide local excision, laser therapy with or without local excision, partial or total glansectomy, and glans resurfacing. Primary endpoint was local recurrence free survival (LRFS) and defined from initial treatment to time of local recurrence and estimated with the Kaplan-Meier method.
Results:
After exclusion criteria, a total of 1,188 patients were included in the analysis. Over a median follow-up of 43.0 months, there were 252 (21.2%) local recurrences with 39.3% (99/252) occurring in the first year. Median time to local recurrence was 16.3 months and the 5-year LRFS was 73.6%. When stratified by stage, 5-yr LRFS were 75.0%, 71.4%, and 75.9% for Ta/Tis, T1, and T2 cases, respectively (log-rank p=0.748). The majority (58.3%) of recurrences were treated with repeat organ sparing procedures and the secondary partial (total) penectomy rate was 19.0%. Only margin status was significantly associated with a local recurrence on multivariate analysis (p=0.001). Limitations include retrospective design and heterogeneous clinical approach.
Conclusions:
PSS can provide excellent local control for superficial penile tumors as well as for appropriately selected invasive lesions. A strict follow-up in the early post-operative period is highly recommended.
Purpose:
Although penile cancer (PC) only represents 1% of all male cancers, the traditional treatment of total or subtotal penectomy carries devastating psychological and functional outcomes. Organ sparing surgery (OSS) in PC is an attractive option if it can provide satisfactory cancer control equivocal or near equivocal to standard techniques. In fact, these techniques are meeting increasing acceptance. Accordingly, the need to evaluate these options objectively is crucial in a comprehensive review is timely in order to increase awareness of these procedures, their applicability and provide guidance to the practicing urologist.
Materials and methods:
A PubMed® search was conducted using key words organ sparing/conserving in penile cancer alone or in combination with, partial penectomy, glansectomy, glans resurfacing, penile reconstruction, laser, Mohs, outcomes and quality of life.
Results:
Many techniques of OSS in PC were described over the years. To be practical and useful, a pre-requisite in all these is to achieve complete tumor excision confirmed by a negative intra operative frozen section and final pathological margins. Although OSS carries higher risk of local recurrence than penile amputation, overall patient survival was generally unaffected. Following strict indications and appropriate patient selection, cancer specific survival in OSS is equivalent to that of established techniques with added benefits of improved quality of life and more acceptable morbidity.
Conclusions:
In properly selected patients with PC, OSS in PC provides comparable oncological outcomes to conventional techniques including total and subtotal amputations. Many patients are able to urinate while standing and significant percentage is able to have intercourse.
Objective
Penile cancer services were centralised in England in 2002. Has this had an impact on treatments for penile cancer and survival?
Patients and methods
All cases of penile cancer from 1990 to 2009 were identified from national cancer registry data. Mortality data were obtained from the Office for National Statistics and survival data were extracted from a national population-based database, the Cancer Information System. Socioeconomic deprivation was calculated using a national income deprivation score and surgical treatments were obtained from Hospital Episode Statistics (HES) data.
Results
The number of penile cancer cases recorded rose from 300 to 400 per year during the early period of centralisation. There was a significant rise in the age-standardised incidence of penile cancer from 1.2 per 100,000 to 1.4 per 100,000 during this period. Mortality remained stable at 0.3 per 100,000. One-year and five-year relative survival remained stable after centralisation at 88% and 72% respectively. The incidence and mortality of penile cancer was significantly higher in the most deprived quintile of the population. Following centralisation, the number of total penile amputations was low at 11% but only 39% of men were recorded as having lymph node surgery, although this may reflect poor compliance with coding rather than true practice.
Conclusions
The incidence of penile cancer in England is rising, but mortality and survival remains stable. Incidence and mortality is higher in more deprived areas, and greater public awareness of this disease and its risk factors are needed. By 2009, rates of penile amputation were low but potentially the proportion of lymph-node surgery remained low. This may change with the uptake of inguinal sentinel lymph-node sampling.
Objective:
To assess the potential benefit of centralization of care in penile cancer. Centralization of care in other disease processes standardizes treatment and improves outcomes. Since penile cancer is a rare malignancy with unchanged mortality rates over the last two decades, we hypothesize that there may be a benefit to centralization.
Materials and methods:
We identified surgeon, patient, and hospital characteristics captured by the National Cancer Data Base (1998-2012) and American Board of Urology case logs (2003-2013) for all penile cancer cases and procedures. Differences in patient demographics, stage of disease, referral patterns, and surgical quality indicators were assessed between academic and non-academic hospitals.
Results:
Using case-logs to evaluate the distribution of penile cancer care, we found that only 4.1% of urologists performed a penile surgery and 1.5% performed a lymph node dissection. Academic centers treated higher-stage cancers and saw more cases/year than non-academic suggesting informal centralization. Two guideline-based quality indicators demonstrated no difference in use of penile-sparing surgery but a higher likelihood of having a LND performed at an academic center (48.4% vs. 26.6%). The total LN-yield was significantly greater at academic centers (18.5 vs. 12.5). Regression modeling demonstrated a 2.29 increased odds of having a LND at an academic center.
Conclusion:
Our data provides the first evidence for centralization of penile cancer in the US. At the time of diagnosis, equal number of patients are treated with penile-sparing surgery but there is greater use of LND and higher LN yield at academic center. Ultimately, longer follow-up is necessary to determine if this improves survival of patients with penile cancer.
Management of squamous cell carcinoma of the penis (SCCp) has changed over the last decades in favor of penile sparing surgery. Our purpose was to assess whether penile sparing therapies were increasingly applied in our SCCp cohort over time and whether penis sparing affected five-year cancer-specific survival (CSS).
Records of 1000 patients treated between 1956 and 2012 were reviewed, 859 patients with invasive tumors were eligible for analysis. Tumors were staged according to the 2009 TNM-classification. Binary logistic regression was used to assess penile preservation versus amputation in time. CSS was analyzed using Kaplan-Meier method and multivariable Cox proportional hazards model; a competing risk analysis was used for local recurrence.
Over time, significantly less penile amputations were carried out. The 5-year cumulative incidence of local recurrences as first event after penis preservation was observed in 27% (95%-CI:23-32), while after (partial) penectomy it was 3.8% (95%-CI:2.3-6.2, Gray's test p<0.0001). Patients treated with penile preservation showed no significant difference in survival compared to patients treated with (partial) amputation after adjusting for relevant covariables. Factors associated with CSS were pathological T-stage, pathological N-stage and lymphovascular invasion on multivariable analysis. In the penile preserving treated group, local recurrence as a time dependent variable in a Cox model was not associated with CSS (HR0.52, 95%-CI:0.21-1.24, p=0.13).
Significantly more penile preserving therapies were performed in more recent years. Although patients treated with penile preservation experienced more local recurrences, 5-year CSS was not jeopardized.
We assessed the oncological outcome of penile conserving surgery and identified parameters predicting local recurrence, including resection margins.
A total of 179 patients with invasive penile cancer treated with organ sparing surgery at a tertiary center between 2002 and 2010 fulfilled our study criteria. Demographic, histopathological, management and followup data were recorded in a prospective database. Local, regional and distant recurrence rates, time to recurrence and survival rates were calculated. Survival analysis was performed by the Kaplan-Meier method. Multivariate analysis was used to identify predictors of local recurrence.
Mean followup was 42.8 months (range 4 to 107). Local, regional and distant metastatic recurrence developed in 16 (8.9%), 19 (10.6%) and 9 patients (5.0%) at a mean of 26.1, 26.8 and 11.7 months, respectively. The 5-year disease specific survival rate after recurrence was 54.7% (95% CI 46.1-63.3). For patients with isolated local recurrence the 5-year disease specific survival rate was 91.7% compared to 38.4% for those with regional recurrence. The overall 5-year local recurrence-free rate was 86.3% (95% CI 82.6-90.4). Tumor grade (p = 0.003), stage (p = 0.021) and lymphovascular invasion (p = 0.014) were identified as predictors of local recurrence on multivariate analysis.
Penile conserving surgery is oncologically safe and a surgical excision margin of less than 5 mm is adequate. Higher local recurrence rates are associated with lymphovascular invasion, and higher tumor stage and grade. Local recurrence has no negative impact on long-term survival.
The Improving Outcomes Guidance (IOG) for patients with carcinoma of the penis states that treatment should be provided supraregionally to populations of 4 million or greater who treat over 25 cases of penis cancer each year. This study assesses the impact of this guidance on the management and outcomes of patients with the disease in our region.
We retrospectively compared the records of 44 patients with carcinoma of the penis treated in our institution between 1969 and 1990 with 101 patients treated between 2002 and 2006, i.e. after supraregional centralisation of the service.
There was no significant change in the stage or grade of the tumours. However, the results show that, in modern times, there was a significant increase in the amount of penis-preserving and nodal surgery as well as a fall in mortality. The improved survival is greatest in patients with poorly-differentiated disease who may, therefore, have benefited from aggressive nodal surgery.
The centralisation of surgery for carcinoma of the penis results in improved outcomes both in terms of penis preservation and improved survival and this supports the IOG guidance.
Nd:YAG laser coagulation is possible for superficial tumors of the penis. The value of photodynamic diagnosis (PDD) and autofluorescence imaging (AF) in detecting malignant lesions on the penis was evaluated. Twelve patients with biopsy-confirmed squamous cell cancer (SCC) of the penis were examined with PDD and AF. For the PDD and AF the penis was illuminated with the blue excitation light from a xenon arch lamp. Biopsies were taken from suspicious lesions detected by PDD or AF and then treated with Nd:YAG laser coagulation. Neoplastic lesions presented with a positive red fluorescence under PDD or a diminished appearance under AF. The HPV-analysis was positive in eight of the 12 lesions. Fluorescence diagnosis is used for the detection of neoplastic lesions. It assists the urologist in detecting neoplastic and preneoplastic lesions, ensuring a more reliable destruction of all tumor material in penile sparing surgery.
To evaluate the surgical excision margin required for local oncological control in primary penile cancers, as patients with penile cancer who undergo radical amputation suffer marked psychological, functional and cosmetic sequelae, and although organ-sparing surgery has improved the quality of life of these men, the optimum surgical excision margin to achieve oncological control is unknown.
In all, 51 patients (mean age 61 years) diagnosed with squamous cell carcinoma of the penis between May 2000 and December 2004 were selected for treatment with conservative surgical techniques. All patients were staged before surgery using magnetic resonance imaging. Histopathological features of the tumours, including type, grade, stage and distance from the surgical excision margin, were evaluated. All patients were followed in the outpatient department according to European Association of Urology guidelines.
The median (range) follow-up of the men was 26 (2-55) months. Patients were treated by wide localized excision (nine), glans excision (26) and partial penectomy (16). The histopathological review included the analysis of 102 surgical margins (deep and skin) with 49 (48%) measured within 10 mm of the tumour edge and 92 (90%) within a <20-mm resection margin. Three patients (6%) had tumour involvement at the surgical margin and had further surgery. During follow-up two patients (4%) developed local tumour recurrence and were treated successfully with partial penectomy.
A traditional 2-cm excision margin is unnecessary for treating squamous cell carcinoma of the penis. Conservative techniques, involving excision margins of only a few millimetres, appear to offer excellent oncological control.
Current follow-up recommendations for patients with penile carcinoma are based on small numbers of patients.
To give further insight into the recurrence patterns of penile carcinoma in different treatment settings and provide recommendations for follow up. DESIGNS, SETTING, AND PARTICIPANTS: In this retrospective study, we analysed 700 patients from two referral centres for penile carcinoma for recurrences.
Recurrences were categorized as local, regional, or distant. The rate of local recurrences was compared between patients undergoing penile-preserving treatments and partial/total amputation. Regional recurrences were compared between patients surgically staged as pN0 or pN+ and clinically node-negative (cN0) patients subjected to a wait-and-see policy. The total recurrence rate, type of recurrence, time to recurrence, and survival were calculated.
205 out of 700 patients (29.3%) had a recurrence, consisting of 18.6% local, 9.3% regional, and 1.4% distant recurrences. Of the recurrences, 92.2% occurred within 5 yr after primary treatment. All regional and distant recurrences occurred within 50 and 16 mo, respectively. The local recurrence rate was 27.7% after penile-preserving therapy and 5.3% after amputation. The regional recurrence rate was 2.3% in patients staged as pN0, 19.1% in patients staged as pN+, and 9.1% in patients undergoing a wait-and-see policy. The 5-yr disease-specific survival was 92% after a local recurrence and 32.7% after a regional recurrence. All patients with a distant recurrence died within 22 mo. Although the number of analysed patients is substantial, the results do not necessarily reflect those of other centres using different techniques for the management of penile carcinoma.
Patients undergoing penile-preserving therapy, patients surgically staged as pN+, and those undergoing a wait-and-see policy for the nodal status are at high risk of developing a recurrence. Follow-up recommendations are provided based on the risk and impact on survival of a recurrence.
Predictors of local recurrence and its impact on survival after glansectomy for penile cancer: time to challenge the dogma?
- Roussel
Predictors of local recurrence and its impact on survival after glansectomy for penile cancer: time to challenge the dogma?
- E Roussel
- E Peeters
- J Vanthoor
Trends in treatment of cT1 penile cancer: analysis of the National Cancer Database
- May