[Partial resection, inner thigh skin graft, and glans reconstruction for early-stage penile cancer: A report of 6 cases]

OBJECTIVE

To explore the optimal methods for the reconstruction and preservation of the glans after partial penis resection in the treatment of early-stage penile cancer.

METHODS

Between January 2012 and June 2015, we treated 6 cases of early- stage penile cancer by partial penis resection, inner thigh skin graft, and glans reconstruction and followed them up for 0.5-3 years.

RESULTS

The length of the penis before and after operation was ([6.5 ± 1.2] vs [4.5 ± 1.8] cm) in the flaccid state and ([12.8 ± 2.3] vs [9.1 ± 2.1] cm) in the erectile state. The sense of the reconstructed glans was completely recovered at 3 months after surgery. The glans skin was pale red and soft, nearly normal at 12 months, with no obvious graft contracture or scar formation. All the patients achieved normal erection and their partners were satisfied with their intercourse. No recurrence or metastasis was observed.

CONCLUSION

The strategy of partial penis resection, inner thigh skin graft and glans reconstruction, simple, effective, and with few complications, is one of the best treatments of early-stage penile cancer, which not only ensures radical removal of the tumor but also maximally reserves the function of the organ.

[Organ-sparing surgery in andrology]

Penile and testicular tumors, especially those of the malignant nature, usually require radical excision, which alters the organ image, affects sexual and urinary functions, and consequently undermines the self-confidence and quality of life of the patient. Recent studies show that organ-sparing surgery can be an alternative to radical excision for superficial tumors and small masses. Penis-sparing surgery (PSS) has been indicated for superficial penile cancer, such as Tis and T1a lesions, and testis-sparing surgery (TSS) is feasible for benign small bilateral or solitary testicular masses (TIN). Long-term follow-ups after PSS or TSS show that the patients may retain a satisfactory appearance of the organ as well as desirable sexual and reproductive functions.

Not all penile cancers are created equal

Warty carcinoma variant of squamous cell carcinoma of the penis is a rare condition, making up 7% to 10% of all penile carcinomas. We present a case of warty carcinoma variant of squamous cell carcinoma of the penis in a 43-year-old Caucasian. The tumor presented in a locally invasive manner, requiring a total penectomy. The primary lesion measured over 15 cm x 16 cm, covering the entire perineum. The clinical features, diagnosis, surgical treatment and pathology are reviewed. In light of the locally invasive nature of warty carcinoma of the penis and high recurrence rate, early diagnosis and aggressive treatment is necessary for this type of unique penile cancer.

MicroRNA Expression Profile in Penile Cancer Revealed by Next-Generation Small RNA Sequencing

Penile cancer (PeCa) is a relatively rare tumor entity but possesses higher morbidity and mortality rates especially in developing countries. To date, the concrete pathogenic signaling pathways and core machineries involved in tumorigenesis and progression of PeCa remain to be elucidated. Several studies suggested miRNAs, which modulate gene expression at posttranscriptional level, were frequently mis-regulated and aberrantly expressed in human cancers. However, the miRNA profile in human PeCa has not been reported before. In this present study, the miRNA profile was obtained from 10 fresh penile cancerous tissues and matched adjacent non-cancerous tissues via next-generation sequencing. As a result, a total of 751 and 806 annotated miRNAs were identified in normal and cancerous penile tissues, respectively. Among which, 56 miRNAs with significantly different expression levels between paired tissues were identified. Subsequently, several annotated miRNAs were selected randomly and validated using quantitative real-time PCR. Compared with the previous publications regarding to the altered miRNAs expression in various cancers and especially genitourinary (prostate, bladder, kidney, testis) cancers, the most majority of deregulated miRNAs showed the similar expression pattern in penile cancer. Moreover, the bioinformatics analyses suggested that the putative target genes of differentially expressed miRNAs between cancerous and matched normal penile tissues were tightly associated with cell junction, proliferation, growth as well as genomic instability and so on, by modulating Wnt, MAPK, p53, PI3K-Akt, Notch and TGF-β signaling pathways, which were all well-established to participate in cancer initiation and progression. Our work presents a global view of the differentially expressed miRNAs and potentially regulatory networks of their target genes for clarifying the pathogenic transformation of normal penis to PeCa, which research resource also provides new insights into future investigations aimed to explore the in-depth mechanisms of miRNAs and other small RNAs including piRNAs in penile carcinogenesis regulation and effective target-specific theragnosis.

Clinicopathological Pattern of Penile Cancer in a Tertiary Care Centre in Nepal

INTRODUCTION

Carcinoma of penis is an uncommon entity. The higher incidence in developing country may be because of poor hygiene, less common practice of circumcision and unsafe sexual practice. Timely diagnosis and intervention gives the patient a chance of cure. Data on penile cancer is sparse from Nepal so treatment of penile cancer in our centre is presented here.

METHODS

This was a retrospective cross-sectional study done at Urology unit of Department of Surgery of Tribhuvan University Teaching Hospital, Nepal from November, 2007 to December, 2013. Data was retrieved from case records and those with penile carcinoma were included. Patient demographics, lesion characteristics, mode of treatment with outcome measures were noted and analyzed.

RESULTS

Total 17 patients underwent treatment for primary penile lesion. Mean age of the patients was 51.5 years. Penile growth was the most frequent presentation with five patients coming with more than one symptom. The most common site was over glans of penis (n=13) with the mean size of 3.55 cm. Partial penectomy was offered in 16 with one patient undergoing circumcision only. Inguinal lymph node dissection was done in four patients. Squamous cell carcinoma was the histological diagnosis in 15 patients.

CONCLUSIONS

Penile carcinoma is primarily a disease of old. Growth over glans penis is the most common presentation and partial penectomy is feasible in most of the patients to allow oncological cure while preserving the organ for its native function.

Myopericytoma tumor of the glans penis

Myopericytoma is a low grade spindle cell neoplasm largely occurring in skin. We describe the first reported case of a penile myopericytoma. Histologically, the penile tumor was composed of a perivascular proliferation of tumor cells with ovoid shaped nuclei and abundant eosinophilic cytoplasm. Immunohistochemically, the tumor was reactive for markers of smooth muscle differentiation and vascular differentiation. The tumor was noted to be negative for BRAF by immunohistochemistry and wild-type upon gene sequencing using SnaPshot. Our finding serves to expand the anatomical distribution of myopericytoma and broadens the spectrum of primary mesenchymal neoplasms that may be encountered in the penis.

[A Case of Sarcomatoid Carcinoma of the Penis]

A 75-year-old man visited our hospital complaining of a foul smelling, painful swelling of the glans of the penis. Physical examination showed a true phimosis and a huge solid mass on the glans under the foreskin. After postectomy and penile tumor biopsy, we performed partial penectomy. Histologically, the tumor was composed of atypical spindle cells arranged in an epithelioid pattern and stained positive for both epithelial and mesenchymal markers. Therefore we diagnosed the tumor as sarcomatoid carcinoma of the penis. One month after surgery, advanced gastric cancer was discovered. Thereafter, cancer rapidly spread throughout the whole body, and he died six months postoperatively.

A switch from epithelial to mesenchymal properties correlates with lymphovascular invasion in squamous cell carcinoma of the penis

The purpose of the study was to assess the incidence and prognostic role of epithelial-to-mesenchymal-transition (EMT) in squamous cell carcinoma of the penis (SCCP). Sixty tumor specimens of surgically treated SCCP patients characterized by a central histopathologic review were stained with antibodies against E-cadherin, N-cadherin, β-catenin, and vimentin. Staining profiles were scored by two independent raters, and correlated with pertinent clinical and pathological parameters and cancer-specific mortality (CSM; median follow-up: 34 months, interquartile range: 6-60 months). Correlation statistics proved good interobserver agreement in staining evaluation (K-values between 0.62 and 1.00, all p<0.001). Based on consensus decision between both raters, 36 study cases (60%) showed a switch from E-cadherin to N-cadherin (as a hallmark of EMT), which correlated with the presence of lymphovascular invasion (ρ=0.287, p=0.026) while failing to interfere with CSM. Although cadherin switch was correlated with a loss of membranous β-catenin expression (ρ=0.629, p<0.001), none of the study cases showed nuclear β-catenin expression, and only three EMT cases (8.3%) had tumor buds revealing vimentin expression. Our data suggest that roughly half of surgically treated SCCP cases exhibit EMT, a parameter correlating with lymphovascular invasion. However, further studies are clearly needed to validate the so far unresolved possible role of cadherin switch in terms of predicting nodal spread in patients with SCCP. Moreover, the apparently complex mechanisms driving EMT in SCCP should be explored by future studies, as knowledge about these might provide a so far unexploited basis for the development of novel targeted therapies against SCCP with metastatic dissemination.

Modification of N staging systems for penile cancer: a more precise prediction of prognosis

BACKGROUND

The tumour-node-metastasis (TNM) classification is the most widely used tool for penile cancer. However, the current system is based on few studies and has been unchanged since 2009. We determined whether a modified pathological N staging system that incorporates the laterality and number of lymph node metastases (LNMs) increases the accuracy of the results in predicting survival compared with the 7th edition of the pathological N staging system of the American Joint Committee on Cancer (AJCC) for penile cancer.

METHODS

The clinical and histopathologic data from 111 patients with penile cancer with LNMs were analysed. Univariate and multivariate Cox proportional hazard regression analyses were used to determine the impact of the clinical and pathological factors on disease-specific survival of these patients. The predictive accuracy was further assessed using the concordance index.

RESULTS

According to the 7th edition of the pathological N classification, the 3-year disease-specific survival (DSS) rates for patients with pN1, pN2, and pN3 disease are 89.6%, 65.9%, and 33.6%, respectively (P(N1-N2)=0.030, P(N2-N3)<0.001, P<0.001). Under the modified pathological N category criteria, the 3-year DSS rates for pN1, pN2, and pN3 patients were 90.7%, 60.5%, and 31.4%, respectively (P(N1-N2)=0.005, P(N2-N3)=0.004, P<0.001). In separate multivariate Cox regression models, only modified N stages (hazard ratio: 4.877, 10.895; P=0.018, P<0.001) exhibited independent effects on the outcome. The accuracy of the modified pathological N category was significantly increased.

CONCLUSIONS

The modified pathological N staging system is a better reflection of the prognosis of patients with penile cancer. Our study should contribute to the improvement of prognostic stratification and systemic treatment to avoid overtreatment of patients.

AN UNUSUAL CASE OF EXTRAMAMMARY PAGET'S DISEASE

A patient, having been treated by total cystectomy and Bricker's conduit operation for prostatic duct carcinoma with intraepithelial extension into the prostatic urethra and bladder, developed an annular, psoriasiform eruption around the external orifice of the urethra two and one-half years later. A biopsy of this lesion showed pagetoid changes of the epidermis. Microscopic examination of the surgical specimen, consisting of the glans penis and corpus spongiosum, demonstrated intraepithelial-tumor permeation into the glans penis, penile urethra, and periurethral glands (Littre). It seems reasonable to conclude that this is an unusual case of Paget's disease of the glans penis which probably originated from a prostatic duct carcinoma.

[The efficacy of the use of acetic acid test in a case of local recurrence of penile carcinoma]

A 62-old-year male presented to our hospital with induration of the prepuce and bleeding from the glans penis that occurred during sexual intercourse. Scrape cytology was performed, which showed class V, suspected squamous cell carcinoma. Computed tomography showed no metastases, and magnetic resonance imaging revealed no invasion of the corpus spongiosum. Circumcision and resection of the glanstumor were performed. Histopathological examination revealed squamous cell carcinoma in situ. We diagnosed the case as penile carcinoma in situ (pTisN0M0, UICC stage 0, and Jackson stage I). At 6 months postoperatively, local recurrence of penile carcinoma was detected by visual inspection after 5% acetic acid staining, and tumor resection was performed. At 9 months postoperatively (after the 2nd resection), the patient has remained disease-free, with no evidence of recurrence.

Management of penile tumours during the Byzantine period

While conventional treatment of penile cancer consists of total penile amputation and bilateral lymphadenectomy, recently a more conservative strategy comprising penile-preserving surgery and selective lymphadenectomy has been applied in order to preserve the penis and to minimize unnecessary inguinal lymphadenectomy. A thorough literature survey was performed to see what was already known of the surgical treatment of penile tumours in ancient times. In the Byzantine period, surgery appeared to have been highly developed, as one may conclude from the surgical material included mainly in the works of Oribasius of Pergamus and Paul of Aegina. Being aware of cancer, they described in their medical encyclopaedias malignant and benign tumours of the prepuce and glans penis, as well as their surgical and non-surgical management. After local excision of malignant tumours, they strongly recommended burning to prevent relapse, whereas they discouraged simultaneous removal of external and internal preputial lesions, because of the risk of perforation of the prepuce. These surprisingly detailed descriptions prove that Byzantine surgery had reached a higher level than commonly supposed. Penile-preserving treatment, which has recently become the therapeutic strategy of choice, was already accomplished in ancient times by using adjuvant thermal or chemical burning after local tumour excision.

Cutaneous metastasis from penile squamous cell carcinoma resembling carcinoma en cuirasse

Penile squamous cell carcinoma is a rare malignancy seen more frequently in developing nations. Metastasis occurs in a predictable manner, with superficial lymph node involvement occurring first, followed by deep lymph node involvement, and then distant spread. Brain, lung, liver, and bone are the typical sites of distant metastasis. We present the unusual case of an 81-year-old man with penile squamous cell carcinoma requiring total penectomy who developed a confluent red to violaceous, indurated suprapubic plaque with satellite papules and bulky inguinal lymphadenopathy. The shield-like clinical presentation and infiltrating strands and cords on histology resembled carcinoma en cuirasse, a rare form of cutaneous metastasis frequently associated with breast cancer but not reported with penile squamous cell carcinoma.

Extramammary Paget's Disease : Case Report of a Penoscrotal Presentation

We report the case of a 72 year old male with penoscrotal extramammary Paget's disease (EMPD). The patient presented with an eczematous lesion on the scrotum extending on to the base of the penis. Given the persistent and progressive nature of the lesion a biopsy was taken which revealed a malignant lesion suggestive of extramammary Paget's disease. After performing a CAT-scan of the lower abdomen and inguinal region, which was negative, a primary surgical approach with curative intentions was taken. One year after surgery the patient is doing well and shows no sign of local recurrence.

Angiokeratoma Fordyce of the Glans Penis: Combined Treatment with Erbium: YAG and 532 nm KTP (Frequency Doubled Neodynium: YAG) Laser

A rare case of angiokeratoma Fordyce localized on the margin of the glans penis in a 52-year-old Caucasian patient is reported. Combined treatment with Erbium: YAG and 532 nm KTP (frequency doubled Neodynium: YAG) laser led to excellent cosmetic results.

Giant condyloma acuminatum - Buschke-Lowenstein disease - a literature review

AIM

Buschke-Lowenstein disease or giant condyloma acuminatum represents a rare, sexually transmitted disorder, with a slow evolution and the tendency to infiltrate in the adjacent tissues; untreated, the outcome is unfavorable. The hallmark is the development of one or various prominent-sized vegetant tumors that usually ulcerate.

MATERIAL AND METHODS

The present article summarizes both the etiopathogenic features and the current approach of treatment management.

RESULTS

Minimally invasive surgery along with local and systemic therapy is adequate in patients with small-sized lesions or high intraoperative risk. The main treatment remains extensive surgery with wide resection and often reinterventions to complete the excision.

CONCLUSIONS

giant condyloma acuminatum represents a continuous surgical challenge, because of the need of exhaustive surgical procedures that should consider both the oncological principles and a better anatomical resolution. No standard treatment protocol can be established, because of the infrequency of the disease. Radical surgery including full thickness excision of the affected areas represents the "gold standard" therapy. Other known forms of treatment present unsatisfactory results without statistical significance, the studies having been conducted on small groups of patients. An adequate, long-term follow-up of Buschke-Lowenstein patients is highly recommended, because of the increased recurrence rate.

[Penile malignant melanoma of the glans penis]

We present the case of a patient with malignant melanoma of the glans penis, which was found in a 53-year-old man with two pigmented lesions on penis. The patient was referred to partial surgical excision of the glans. The defect was covered with a full-thickness skin graft followed by left inguinal lymphadenectomy as second procedure by which a melanoma metastasis was found. The patient was well-being until two years after the surgery, when a metastatic melanoma was discovered in his right lung and in his liver. Early diagnosis is of paramount importance, as the prognosis becomes very poor if the tumour stage is advanced.

Traumatic neuroma of the penis

Traumatic neuromas are tumors produced by a reactive process to regenerate injured nerves that result in a disordered proliferation of nerve bundles. These tumors are usually related to previous surgery or trauma. We describe a case of traumatic neuroma on the penis of a 24-year-old man; the tumor was initially suspected to be a condyloma. A shave biopsy was both diagnostic and curative.

[Surgical treatment of penile Paget's disease: a report of 10 cases]

OBJECTIVE

To investigate the clinical characteristics and surgical treatment of penile Paget's disease.

METHODS

We retrospectively analyzed the treatment and follow-up data of 10 cases of penile Paget's disease surgically treated in Jiangsu Provincial Government Hospital and Jiangsu Provincial People's Hospital from 2008 to 2012.

RESULTS

All the 10 patients received expanded local resection of the lesion with reconstruction of the defects with scrotal skin flaps or free skin flaps from the thigh. All surgeries were successful and the postoperative course was uneventful with complete graft survival and no lymph node metastasis. IIEF scores obtained before and 1 -2 months after surgery showed no statistically significant differences in the penile erectile function (P = 0.229), sexual orgasm (P = 0.761), and sexual satisfaction (P = 0.801) of the patients.

CONCLUSION

When penile skin lesions suggest the possibility of Paget's disease, biopsy should be performed and surgery should follow as soon as possible. The ideal surgical option is expanded local resection of the lesion with reconstruction of the defects with scrotal skin flaps or free flaps according to the patient's specific conditions.