Long-term trends in incidence, survival and mortality of primary penile cancer in England

Epidemiology of penile cancer in Poland compared to other European countries

OBJECTIVES

To examine the epidemiology of penile cancer in Poland compared to other European countries.

MATERIALS AND METHODS

Incidence and mortality data were acquired from the national cancer registries in Europe and WHO Mortality Database, respectively. The data are presented as age-standardised morbidity and mortality rates, calculated according to the standard population of the world. We utilised Joinpoint analysis to assess the trends in morbidity and mortality and calculated the average rate of increase or decrease (Annual Percentage Change, Average Annual Percentage Change). Additionally, we estimate the proxy survival rates for each country.

RESULTS

Our study is the first to cover the incidence of penile cancer in many European countries and estimates an approximate survival rate for large populations, which is rarely cited in the literature. The 40+ age group presented graphically in the article covered more than 90% of penile cancer cases and deaths. In the countries examined, there was an excess of deaths over incidence in the oldest age groups (75 years or older). Poland had intermediate incidence and mortality rates.

CONCLUSIONS

Unlike many European countries, Poland is witnessing an increasing trend of penile cancer mortality. The higher death toll among those aged 75 years or older may suggest a lack of recognition of cancer symptoms and inadequate attention to elderly patients by the healthcare system. There is also evidence of underreporting penile cancer cases. Establishing centralised healthcare systems for rare cancers is a commendable development that should be emulated by other European countries, including Poland.

Epidemiology of HPV-associated cancers past, present and future: towards prevention and elimination

Cervical cancer is the first cancer deemed amenable to elimination through prevention, and thus lessons from the epidemiology and prevention of this cancer type can provide information on strategies to manage other cancers. Infection with the human papillomavirus (HPV) causes virtually all cervical cancers, and an important proportion of oropharyngeal, anal and genital cancers. Whereas 20th century prevention efforts were dominated by cytology-based screening, the present and future of HPV-associated cancer prevention relies mostly on HPV vaccination and molecular screening tests. In this Review, we provide an overview of the epidemiology of HPV-associated cancers, their disease burden, how past and contemporary preventive interventions have shaped their incidence and mortality, and the potential for elimination. We particularly focus on the cofactors that could have the greatest effect on prevention efforts, such as parity and human immunodeficiency virus infection, as well as on social determinants of health. Given that the incidence of and mortality from HPV-associated cancers remain strongly associated with the socioeconomic status of individuals and the human development index of countries, elimination efforts are unlikely to succeed unless prevention efforts focus on health equity, with a commitment to both primary and secondary prevention.

Penile cancer care in the Netherlands: increased incidence, centralisation, and improved survival

OBJECTIVE

To evaluate penile squamous cell carcinoma (PSCC) incidence and centralisation trends in the Netherlands over the past three decades, as well as the effect of centralisation of PSCC care on survival.

PATIENTS AND METHODS

In the Netherlands PSCC care is largely centralised in one national centre of expertise (Netherlands Cancer Institute [NCI], Amsterdam). For this study, the Netherlands Cancer Registry, an independent nationwide cancer registry, provided per-patient data on age, clinical and pathological tumour staging, follow-up, and vital status. Patients with treatment at the NCI were identified and compared to patients who were treated at all other centres. The age-standardised incidence rate was calculated with the European Standard Population. The probability of death due to PSCC was estimated using the relative survival. Multivariable Cox regression analysis was performed to evaluate predictors of survival.

RESULTS

A total of 3160 patients were diagnosed with PSCC between 1990 and 2020, showing a rising incidence (P < 0.001). Annual caseload increased at the NCI (1% in 1990, 65% in 2020) and decreased at other (regional) centres (99% to 35%). Despite a relatively high percentage of patients with T2-4 (64%) and N+ (33%) at the NCI, the 5-year relative survival was higher (86%, 95% confidence interval [CI] 82-91%) compared to regional centres (76%, 95% CI 73-80%, P < 0.001). Patients with a pathological T2 tumour were treated with glans-sparing treatment more often at the reference centre than at the regional centres (16% vs 5.0%, P < 0.001). After adjusting for age, histological grading, T-stage, presence of lymph node involvement and year of diagnosis, treatment at regional centres remained a predictor for worse survival (hazard ratio 1.22, 95% CI 1.05-1.39; P = 0.006).

CONCLUSION

The incidence of PSCC in the Netherlands has been gradually increasing over the past three decades, with a noticeable trend towards centralisation of PSCC care and improved relative survival rate.

A study protocol for a feasibility randomised controlled trial investigating videoendoscopic radical inguinal lymphadenectomy versus open radical inguinal lymphadenectomy in patients with penile cancer (VELRAD)

BACKGROUND

Penile cancer is a rare male genital malignancy. Surgical excision of the primary tumour is followed by radical inguinal lymphadenectomy if there is metastatic disease detected by biopsy, fine needle aspiration cytology (FNAC) or following sentinel lymph node biopsy in patients with impalpable disease. However, radical inguinal lymphadenectomy is associated with a high morbidity rate, and there is increasing usage of a videoendoscopic approach as an alternative.

METHODS

A pragmatic, UK-wide multicentre feasibility randomised controlled trial (RCT), comparing videoendoscopic radical inguinal lymphadenectomy versus open radical inguinal lymphadenectomy. Patients will be identified and recruited from supraregional multi-disciplinary team meetings (sMDT) and must be aged 18 or over requiring inguinal lymphadenectomy, with no contraindications to surgical intervention for their cancer. Participants will be followed up for 6 months following randomisation. The primary outcome is the ability to recruit patients for randomisation across all selected sites and the rate of loss to follow-up. Other outcomes include acceptability of the trial and intervention to patients and healthcare professionals assessed by qualitative research and obtaining resource utilisation information for health economic analysis.

DISCUSSION

There are currently no other published RCTs comparing videoendoscopic versus open radical inguinal lymphadenectomy. Ongoing study is required to determine whether randomising patients to either procedure is feasible and acceptable to patients. The results of this study may determine the design of a subsequent trial.

TRIAL REGISTRATION

Clinicaltrials.gov PRS registry, registration number NCT05592639. Date of registration: 13th October 2022, retrospectively registered.

Incidence, risk factors, and temporal trends of penile cancer: a global population-based study

OBJECTIVES

To examine the global disease burden and country-specific trends of penile cancer incidence by age group and investigate its associations with several factors.

MATERIALS AND METHODS

The Global Cancer Observatory database was interrogated for penile cancer incidence. The 10-year cancer incidence rates were collected from the Cancer Incidence in Five Continents Plus. The country-specific data were extracted from the World Health Organization Global Health Observatory and Global Burden of Disease databases for conducting risk factors analysis. The penile cancer incidence was presented using age-standardised rates. Its associations with various factors were examined by linear regression, while the incidence trend was estimated using joinpoint regression and presented as average annual percentage change with 95% confidence intervals in different age groups.

RESULTS

There were an estimated 36 068 new cases of penile cancer in 2020. There was a considerable geographical disparity in the disease burden of penile cancer, with South America reporting the highest incidence. Overall, alcohol drinking, human immunodeficiency virus (HIV) infection, and unsafe sex were positively associated with a higher penile cancer incidence, while circumcision was found to be a protective factor. There has been a mixed trend in penile cancer incidence overall, but an increasing trend was found among younger males.

CONCLUSIONS

There was a global variation in the penile cancer burden associated with prevalence of alcohol drinking, HIV infection, unsafe sex, and circumcision. The increasing penile cancer incidence in the younger population is worrying and calls for early detection and preventive interventions.

Long-term outcomes of penile squamous cell carcinoma in men age ≤50 years old compared with men >50 years old from a single tertiary referral centre: a propensity score matched analysis

Penile cancer (PeCa) is rare, and the oncological outcomes in younger men are unclear. We aimed to analyse and compare oncological outcomes of men age ≤50 years (y) and >50 years with PeCa. A retrospective analysis of men ≤50 y with penile squamous cell carcinoma managed at a tertiary centre was performed. A propensity score matched cohort of men >50 y was identified for comparison. Matching was according to tumour, nodal stage and the types of primary surgery. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and metastasis-free survivals (MFS) were estimated using Kaplan-Meier plots and compared using log-rank tests. Between 2005-2020, 100 men ≤50 y (median (IQR) age, 46 y (40-49)) were identified and matched with 100 men >50 y (median (IQR) age, 65 y (59-73)). 10, 24, 32, 34 men age ≤50 y were diagnosed in 2005-2007, 2008-2012, 2013-2016 and 2017-2020 respectively. Median (IQR) follow-up was 53.5 (18-96) months. OS at 2 years: ≤50 y, 86%>50 y, 80.6%; 5 years: ≤50 y, 78.1%, >50 y, 63.1%; 10 years: ≤50 y, 72.3%, >50 y, 45.6% (p = 0.01). DSS at 2 years: ≤50 y, 87.2%>50 y, 87.8%; 5 years: ≤50 y, 80.9%>50 y, 78.2%; 10 years: ≤50 y, 78%, >50 y, 70.9% (p = 0.74). RFS was 93.1% in the ≤50 y group (vs. >50 y, 96.5%) at 2 year, and 90% (vs. >50 y, 88.5%) at 5 years, p = 0.81. Within the ≤50 y group, 2 years and 5 years MFS was 93% (vs. >50 y, 96.5%), and 89.5% (vs. >50 y, 92.7%) respectively, (p = 0.40). There were no statistical significance in DFS, RFS and MFS in men age ≤50 y and >50 y. PeCa in younger patients is fatal, public awareness and patient education are crucial for early detection and management.

Penile cancer in younger men-A more aggressive disease?

INTRODUCTION

Penile cancer (PC) in men under 45 is very rare with an incidence of 0.1 to 0.8/100,000. There is little published data on disease characteristics and outcomes of PC in younger men. Herein, we evaluate the disease characteristics and outcomes of penile cancer in younger men compared to an older cohort.

METHODS

This study included all men diagnosed with PC at our institution from 2016 to 2021. Primary outcomes included overall survival, cancer-specific survival, and disease-free survival. Secondary outcomes included disease characteristics and surgical management. Men aged ≤45 years (Group A) were compared with men aged >45 years (Group B) at diagnosis.

RESULTS

There were 90 patients treated for invasive PC over the study period. The median age at diagnosis was 64 (26-88). The mean length of follow-up was 27 (±18) months. There were 12 (13%) in Group A, and 78 (87%) patients in Group B. Group A had a worse cancer-specific survival compared to Group B (39 months vs. not reached, HR 0.1 (95%CI 0.02-0.85, P = 0.03). There was no significant difference in overall or disease-free survival between both groups. More men in Group A had lymph node metastases at the time of diagnosis (58% vs. 19%, P < 0.001). There was no significant difference in histopathological features including tumor subtype, grade, T stage, p53 status or presence of lymphovascular or perineural invasion.

CONCLUSION

In our study, younger men were more likely to have nodal involvement at time of diagnosis and had a worse cancer-specific survival.

Current trends in penile cancer survivorship amongst remote patients and Aboriginal people in Western Australia

BACKGROUND

Penile cancer is a rare urological malignancy, accounting for less than 1% of all cancers in males. Given its rarity, few studies exist reporting survival outcomes. The primary objective of this project was to review the mortality of patients diagnosed with penile cancer in Western Australia between 1992 and 2017 and to determine if Aboriginal and Torres Strait Islander people and patients in rural and remote regions experience discrepancies in survival outcomes.

METHODS

All cases of penile cancer recorded within the Western Australia Cancer Registry between 1992 and 2017 were reviewed. Analysis was performed using chi-squared test of association, binomial logistic regression and survival analysis was conducted using Kaplan Meier and Cox Regression analysis.

RESULTS

One hundred eighty-six cases of penile cancer were identified; 62 patients (33%) were from regional or remote locations and nine patients (4.8%) were Aboriginal. 13 of the regional or remote patients and 5 of the Aboriginal patients died from penile cancer. Patients who were Aboriginal (HR 6.512, CI 2.123-19.968; P = 0.001) or from regional or remote Western Australia (HR 2.382, CI 1.050-5.401; P = 0.038) were at an increased risk of penile cancer-specific mortality.

CONCLUSIONS

Aboriginal people with penile cancer and men from regional and remote Western Australia experience worse penile cancer-specific survival outcomes.

Epidemiology, Diagnosis and Management of Penile Cancer: Results from the Spanish National Registry of Penile Cancer

INTRODUCTION

Penile cancer (PC) is a rare malignancy with an overall incidence in Europe of 1/100,000 males/year. In Europe, few studies report the epidemiology, risk factors, clinical presentation, and treatment of PC. The aim of this study is to present an updated outlook on the aforementioned factors of PC in Spain.

MATERIALS AND METHODS

A multicentric, retrospective, observational epidemiological study was designed, and patients with a new diagnosis of PC in 2015 were included. Patients were anonymously identified from the Register of Specialized Care Activity of the Ministry of Health of Spain. All Spanish hospitals recruiting patients in 2015 were invited to participate in the present study. We have followed a descriptive narration of the observed data. Continuous and categorical data were reported by median (p25th-p75th range) and absolute and relative frequencies, respectively. The incidence map shows differences between Spanish regions.

RESULTS

The incidence of PC in Spain in 2015 was 2.55/100,000 males per year. A total of 586 patients were identified, and 228 patients from 61 hospitals were included in the analysis. A total of 54/61 (88.5%) centers reported ≤ 5 new cases. The patients accessed the urologist for visually-assessed penile lesions (60.5%), mainly localized in the glans (63.6%). Local hygiene, smoking habits, sexual habits, HPV exposure, and history of penile lesions were reported in 48.2%, 59.6%, 25%, 13.2%, and 69.7%. HPV-positive lesions were 18.1% (28.6% HPV-16). The majority of PC was squamous carcinoma (95.2%). PC was ≥cT2 in 45.2% (103/228) cases. At final pathology, PC was ≥pT2 in 51% of patients and ≥pN1 in 17% of cases. The most common local treatment was partial penectomy (46.9% cases). A total of 47/55 (85.5%) inguinal lymphadenectomies were open. Patients with ≥pN1 disease were treated with chemotherapy in 12/39 (40.8%) of cases.

CONCLUSIONS

PC incidence is relatively high in Spain compared to other European countries. The risk factors for PC are usually misreported. The diagnosis and management of PC are suboptimal, encouraging the identification of referral centers for PC management.

Global Pattern and Trends in Penile Cancer Incidence: Population-Based Study

Background

Penile cancer is a relatively rare genital malignancy whose incidence and mortality are rising in many countries.

Objective

This study aims to assess the recent incidence and mortality patterns and incidence trends of penile cancer.

Methods

The age-standardized incidence and mortality rates (ASIR and ASMR, respectively) of penile cancer in 2020 were estimated from the Global Cancer Registries (GLOBOCAN) database. Incidence trends of penile cancer from 1973 to 2012 were assessed in 44 populations from 43 countries using the Cancer Incidence in Five Continents plus (CI5plus) and the Nordic Cancer Registries (NORDCAN) databases. Average annual percentage change was calculated to quantify trends in ASIR using joinpoint regression.

Results

Globally, the estimated ASIR and ASMR of penile cancer were 0.80 (per 100,000) and 0.29 (per 100,000) in 2020, equating to 36,068 new cases and 13,211 deaths in 2020, respectively. There was no significant correlation between the ASIR (P=.05) or ASMR (P=.90) and Human Development Index. In addition, 15 countries saw increasing ASIR for penile cancer, 13 of which were from Europe (United Kingdom, Lithuania, Norway, Estonia, Finland, Sweden, Cyprus, Netherlands, Italy, Croatia, Slovakia, Russia, and the Czech), and 2 from Asia (China and Israel).

Conclusions

Although the developing countries still bear the higher incidence and mortality of penile cancer, the incidence is on the rise in most European countries. To mitigate the disease burden resulting from penile cancer, measures to lower the risk for penile cancers, including improving penile hygiene and male human papillomavirus vaccination, may be warranted.

Trends in Incidence, Mortality, and Survival of Penile Cancer in the United States: A Population-Based Study

Purpose

The aim of this study is to investigate the trends in incidence and mortality, and explore any change in survival of penile cancer in the United States.

Methods

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database (2000–2018) utilizing the SEER Stat software. The joinpoint regression was used to analyze the secular trend of incidence and incidence-based mortality (IBM) stratified by age, race, and summary stage. The 5-year relative survival rate was also calculated.

Result

The age-adjusted rates of penile cancer patients were 0.38 (0.37–0.39) and 0.21 (0.2–0.21) for overall incidence and IBM, respectively. The 5-year relative survival rates were 67.7%, 66.99%, and 65.67% for the calendar periods of 2000–2004, 2005–2009, and 2010–2014, respectively. No significant changes in incidence by era were observed from 2000 to 2018 [annual percentage change (APC) = 0.5%, p = 0.064]. The IBM rate of penile cancer showed an initial significant increase from 2000 to 2002 (APC = 78.6%, 95% CI, −1.7–224.6) followed by a deceleration rate of 4.6% (95% CI, 3.9–5.3) during 2002 to 2018. No significant improvement in 5-year relative survival was observed. The trends by age, race, and summary stage in incidence and IBM were significantly different.

Conclusion

This study, using population-level data from the SEER database, showed an increasing trend in IBM and no significant improvement in the 5-year relative survival rate. Meanwhile, the incidence of penile cancer exhibited a relatively stable trend during the study period. These results might be due to the lack of significant progress in the treatment and management of penile cancer patients in the United States in recent decades. More efforts, like increasing awareness among the general population and doctors, and centralized management, might be needed in the future to improve the survival of this rare disease.

Development and Verification of Prognostic Nomogram for Penile Cancer Based on the SEER Database

Aim

We aimed to establish a prognostic nomogram for penile cancer (PC) patients based on the Surveillance, Epidemiology, and End Results Program (SEER) database.

Methods

Data from 1643 patients between 2010 and 2015 were downloaded and extracted from the SEER database. They were randomly divided into the development group (70%) and the verification group (30%), and then, univariate and multivariate Cox proportional hazards regression, respectively, was used to explore the possible risk factors of PC. The factors significantly related to overall survival (OS) and cancer-specific survival (CSS) were used to establish the nomogram, which was assessed via the concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve. An internal validation was conducted to test the accuracy and effectiveness of the nomogram. Kaplan–Meier calculation was used to predict the further OS and CSS status of these patients.

Results

On multivariate Cox proportional hazards regression, the independent prognostic risk factors associated with OS were age, race, marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type, with a moderate C-index of 0.737 (95% confidence interval (CI): 0.713–0.760) and 0.766 (95% CI: 0.731–0.801) in the development and verification groups, respectively. The areas under the ROC (AUC) of 3- and 5-year OS were 0.749 and 0.770, respectively. While marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type were significantly linked to PC patients' CSS, which have better C-index of 0.802 (95% confidence interval (CI): 0.771–0.833) and 0.82 (95% CI: 0.775–0.865) in the development and verification groups, and the AUC of 3- and 5-year CSS were 0.766 and 0.787. Both of the survival calibration curves of 3- and 5-year OS and CSS brought out a high consistency.

Conclusion

Our study produced a satisfactory nomogram revealing the survival of PC patients, which could be helpful for clinicians to assess the situation of PC patients and to implement further treatment.

What is the medical evidence on non-therapeutic child circumcision?

Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.

Sentinel Node Methods in Penile Cancer - a Historical Perspective on Development of Modern Concepts

Malignant penile tumors are of squamous cell origin in more than 95% of cases and the occurrence of a distant metastasis without prior inguinal lymph node metastatic deposits is very rare. This makes inguinal lymph node staging very reliable and of great prognostic significance since undiscovered and untreated inguinal metastases may lead to a fatal clinical course. In lack of a sufficiently accurate noninvasive lymph node staging modality, penile cancer relies on surgical lymph node removal for regional staging. In this respect sentinel node biopsy offers a favourable minimally invasive alternative to prophylactic inguinal lymph node dissection which is associated with significant surgery-related morbidity. Today sentinel node biopsy is widely used in surgical oncology within high volume cancers such as breast cancer and melanoma. In rare cancers sentinel node biopsy is also emerging as a minimal invasive staging tool in patients with no obvious lymph node involvement. At several specialized units across Europe sentinel node biopsy has been practiced by dedicated specialist within vulva and penile cancer for more than two decades. In fact, the rare disease penile cancer was a model entity for development of the original sentinel node concept as early as the 1970'es due to work by the Paraguayan penile cancer pioneer, Cabañas, the sentinel node concept was subsequently successfully adapted in breast cancer and melanoma. This turned out mutually beneficial since the sequential development of sentinel node biopsy in penile cancer in the 1990s eventually adopted new insights and added conceptual details from the experiences harvested in the broader clinical application possible in these high-volume diseases. The prerequisite to conceptualising the sentinel node approach was the gradual anatomical and functional understanding of the lymphatic system which in western medicine rooted in ancient Greece and gradually increased in details and comprehension with significant contributions from many great notabilities during the last centuries including Hippocrates, Galen, Fallopio, Malpighi, Virchow, Starling, Cabañas, Hodgkin and Horenblas. Sentinel node biopsy in penile cancer is a complex multimodality procedure involving inguinal ultrasonography by radiologists, precise tracer-injection and interpretation of nuclear images by nuclear medicine physicians, radio-tracer- and dye guided open surgical biopsies by urologists and thorough step-sectioning, immunostaining and accurate lymph node specimen analysis by pathologists. This team effort requires well-tested protocols, experience and good collaboration and in rare diseases this calls for centralization of service.

Incidence and risk factors of second primary cancer after the initial primary human papillomavirus related neoplasms

Comprehensive studies in second primary cancer (SPC) after the initial primary human papillomavirus (HPV)-related cancer still remain warranted. We aimed to analyze the incidence and risk factors of SPC after HPV-related cancer. We identified 86 790 patients diagnosed with initial primary HPV-related cancer between 1973 and 2010 in the SEER database. Standardized incidence ratio (SIR) and cumulative incidence were calculated to assess the risk of SPC after HPV-related cancer. The SIR of SPC after HPV-related cancer was 1.60 (95% confidence interval [CI], 1.55-1.65) for male and 1.25 (95% CI, 1.22-1.28) for female. SIR of second primary HPV-related cancer (7.39 [95% CI, 6.26-8.68] male and 4.35 [95% CI, 4.04-4.67] female) was significantly higher than that of HPV-unrelated cancer (1.54 [95% CI, 1.49-1.60] male and 1.16 [95% CI, 1.13-1.19] female). The 5-year cumulative incidence of SPC was 7.22% (95% CI, 6.89-7.55%) for male and 3.72% (95% CI, 3.58-3.88%) for female. Risk factors for SPC included being married and having initial primary cancer (IPC) diagnosed at earlier stage for both genders, and IPC diagnosed at older age as well as surgery performed for female. Patients diagnosed with HPV-related cancer are more likely to develop another primary cancer, compared with the age-specific reference population.

Incidence of penile intraepithelial neoplasia and incidence and survival of penile cancer in Denmark, 1997 to 2018

PURPOSE

Squamous cell carcinoma (SCC) of the penis is rare. Some studies have suggested that the incidence is increasing but the available literature is equivocal. We examined the incidence of high-grade penile intraepithelial neoplasia (PeIN), the incidence and 5-year relative survival as well as mortality of penile SCC in Denmark over the latest 20 years.

METHODS

New cases of high-grade PeIN and penile cancer were identified from high-quality nationwide registries. Age-standardized (World) incidence rates per 100,000 person-years and average annual percentage change (AAPC) were estimated. For penile SCC, 5-year relative survival was calculated, and Cox regression was used to examine the effect of selected characteristics on mortality.

RESULTS

Altogether, 1,070 new cases of high-grade PeIN were diagnosed (1997-2018) and the incidence increased from 0.87 to 1.84 per 100,000 person-years from 1997-1998 to 2017-2018 (AAPC = 4.73; 95% CI: 3.54-5.94). We identified 1,216 penile cancer cases (1997-2018) (95.7% SCC). The incidence of penile SCC increased slightly from 0.85 per 100,000 person-years in 1997-1998 to 1.13 per 100,000 person-years in 2017-2018 (AAPC = 1.01; 95% CI: 0.24-1.79). The 5-year relative survival of penile SCC did not change substantially, whereas the mortality tended to decrease.

CONCLUSION

Penile SCC is increasing slightly in Denmark, while a pronounced increase in the incidence of high-grade PeIN is seen. The 5-year relative survival from penile cancer was relatively stable over time. Increasing exposure to HPV infection at the population level may have contributed to the observed increase in PeIN and penile SCC. Awareness of HPV may also have contributed to the increased detection of PeIN.

Long-term multicentre experience of adjuvant radiotherapy for pN3 squamous cell carcinoma of the penis

OBJECTIVE

To present the long-term adjuvant radiotherapy outcomes of patients with pN3 squamous cell carcinoma of the penis (SCCp) treated at two UK centres.

PATIENTS AND METHODS

We conducted a retrospective audit of all pN3 SCCp patients, deemed suitable for adjuvant therapy by a specialist multidisciplinary team at St George's and Leeds Hospitals, who received adjuvant radiotherapy. Primary outcomes were recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Secondary outcomes were time to adjuvant treatment, frequency of in-field recurrence, site and side of recurrence, and dose and schedule of radiotherapy.

RESULTS

A total of 146 patients were included: 121 completed radiotherapy, 4 did not complete radiotherapy and 21 did not start it. The median (interquartile range [IQR]) age was 59 (54-70)years. The 5-year RFS was 51%, CSS was 51% and OS was 44%. Adjuvant radiotherapy was started at a median (IQR) of 75 (48-106) days. A dose of 45 Gy in 20 fractions was most commonly used. Of the 125 patients who started adjuvant treatment, 55 relapsed. Of these relapses, 30 occurred in an inguinal or pelvic nodal station and 26 of the 30 were in a radiation field. Relapses in 18 of the 55 cases were in visceral sites only and seven were in both nodal (non-irradiated sites) and visceral sites. Doses of <50 Gy were used more commonly before 2013 and higher doses (>50 Gy) were more commonly used after 2013.

CONCLUSIONS

Application of a standard radiotherapy protocol within a centralized supra-network setting has achieved survival outcomes that would appear better than those previously documented for either radiotherapy or chemotherapy in a cohort with solely pN3 disease. The addition of adjuvant chemotherapy may improve these outcomes further. These data suggest that adjuvant radiotherapy has a role to play in the management of men with pN3 SCCp.

Temporal trends, tumor characteristics and stage-specific survival in penile non-squamous cell carcinoma vs. squamous cell carcinoma

PURPOSE

To compare Cancer-specific mortality (CSM) in patients with Squamous cell carcinoma (SCC) vs. non-SCC penile cancer, since survival outcomes may differ between histological subtypes.

METHODS

Within the Surveillance, Epidemiology and End Results database (2004-2016), penile cancer patients of all stages were identified. Temporal trend analyses, cumulative incidence and Kaplan-Meier plots, multivariable Cox regression and Fine and Gray competing-risks regression analyses tested for CSM differences between non-SCC vs. SCC penile cancer patients.

RESULTS

Of 4,120 eligible penile cancer patients, 123 (3%) harbored non-SCC vs. 4,027 (97%) SCC. Of all non-SCC patients, 51 (41%) harbored melanomas, 42 (34%) basal cell carcinomas, 10 (8%) adenocarcinomas, eight (6.5%) skin appendage malignancies, six (5%) epithelial cell neoplasms, two (1.5%) neuroendocrine tumors, two (1.5%) lymphomas, two (1.5%) sarcomas. Stage at presentation differed between non-SCC vs. SCC. In temporal trend analyses, non-SCC diagnoses neither decreased nor increased over time (p > 0.05). After stratification according to localized, locally advanced, and metastatic stage, no CSM differences were observed between non-SCC vs. SCC, with 5-year survival rates of 11 vs 11% (p = 0.9) for localized, 33 vs. 37% (p = 0.4) for locally advanced, and 1-year survival rates of 37 vs. 53% (p = 0.9) for metastatic penile cancer, respectively. After propensity score matching for patient and tumor characteristics and additional multivariable adjustment, no CSM differences between non-SCC vs. SCC were observed.

CONCLUSION

Non-SCC penile cancer is rare. Although exceptions exist, on average, non-SCC penile cancer has comparable CSM as SCC penile cancer patients, after stratification for localized, locally invasive, and metastatic disease.

Penile cancer in Ireland - A national review

OBJECTIVE

Penile cancer is a rare malignancy, with a reported incidence of 1.5/100,000 males in the Republic of Ireland in 2015. The aim of this study was to perform the first national review and to evaluate clinicopathological factors affecting survival.

SUBJECTS AND METHODS

All cases of penile cancer in Ireland between 1995 and 2010 were identified through the National Cancer Registry Ireland (NCRI) and analysed to identify factors affecting survival.

RESULTS

360 cases of penile cancer were identified, with a mean age at diagnosis of 65.5 years and 88% (n = 315) of cases occurred in those over 50. 91% (n = 328) of cases were squamous cell carcinomas (SCC). The majority of patients were treated surgically (n = 289), with 57% (n = 206) and 24% (n = 87) undergoing partial penectomy and total penectomy respectively. Only 18% (n = 65) received radiotherapy, and 8% (n = 27) received chemotherapy. Mean overall survival (OS) was 113 months, and five year disease specific survival (DSS) was 70% (95%CI: 59.1-77.8%). Age at diagnosis, nodal status and presence of metastatic disease were independent prognostic markers on multivariate analysis.

CONCLUSION

This study represents the first national review of penile cancer in Ireland. The annual incidence and survival rates are comparable to European figures, though superior DSS has previously been reported from our institution, highlighting the role for centralisation of care in Ireland.

LEVEL OF EVIDENCE

2b.

F-18 Fluorodeoxyglucose Positron Emission Tomography with Computed Tomography Has High Diagnostic Value for Pelvic and Distant Staging in Patients with High-risk Penile Carcinoma

BACKGROUND

For penile cancer patients with pelvic metastases, multimodal treatment is advised, but pelvic lymph node metastases are often found upon surgical resection only. Early selection for multimodal treatment requires reliable noninvasive staging.

OBJECTIVE

To evaluate the diagnostic value of ¹⁸F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) for staging pelvic lymph nodes and distant metastases in high-risk penile cancer patients.

DESIGN, SETTING, AND PARTICIPANTS

FDG-PET/CT scans performed in patients with clinically overt inguinal lymph node metastases and/or high-risk primary tumors (bulky T3 or T4) were retrospectively analyzed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

All scans were reviewed by two independent nuclear medicine physicians staging the pelvic nodes and distant metastases. FDG-PET/CT findings were compared with histology after node dissection if available, or with positive imaging or follow-up of at least 1 yr.

RESULTS AND LIMITATIONS

Between 2006 and 2016, 61 patients met the inclusion criteria. For staging of pelvic nodes, sensitivity was 85% (specificity 75%, negative predictive value [NPV] 90%, and positive predictive value [PPV] 65%). For the detection of distant metastases, FDG-PET/CT had a PPV of 93%. Results are limited by the retrospective design and the lack of direct comparison with CT scanning alone.

CONCLUSIONS

FDG-PET/CT has high sensitivity and a high NPV for staging of pelvic lymph nodes in high-risk penile cancer. It also has a high PPV for the detection of distant metastases, which were found in 23% of patients. Therefore, FDG-PET/CT enables early selection for multimodal treatment of patients with pelvic metastases and may help avoid futile treatment of patients with distant metastases.

PATIENT SUMMARY

We studied whether positron emission tomography with computed tomography (PET/CT) scans in patients with advanced penile cancer can detect metastases before lymph node surgery is done. PET/CT scans can detect or rule out pelvic lymph node metastases, and can detect distant metastases. This helps in making timely treatment decisions (before surgery).

Management of Advanced Penile Cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer, with approximately 2000 new cases in the United States and 35,000 globally every year. Multiple risk factors are involved in PSCC, but most importantly, the high-risk human papillomavirus infection is thought to be present in approximately 50% of cases. Penile squamous cell carcinoma presents as localized or locally advanced disease. Multiple prognostic markers have been explored over the past 3 decades, but lymph node status remains the strongest predictor of clinical outcomes. Surgical decisions are based on the primary tumor pathologic findings, nodal clinical examination, and imaging results. Most patients with high-risk advanced PSCC benefit from a multimodal treatment approach combining chemotherapy with consolidation surgical treatment. The role of neoadjuvant chemotherapy with radiation therapy has not been well explored in PSCC. Prospective clinical studies, like the International Penile Advanced Cancer Trial, have been launched to provide high-level evidence for multimodal treatment. The International Penile Advanced Cancer Trial is the first randomized clinical trial among patients with PSCC and is currently accruing, with the expectation to generate results in 2023. Unfortunately, most patients with high-risk locally advanced PSCC will have relapsed or refractory cancer after cisplatin-based combination chemotherapy. These patients have dismal outcomes with salvage chemotherapy, highlighting the major unmet need to expand our knowledge of the disease's biology and develop clinical trials that use novel systemic agents. This narrative review synthesizes relevant publications retrieved from PubMed. Our aim is to discuss current approaches in the management of PSCC, summarize ongoing efforts to improve care, and identify future areas for enhancing our understanding of the disease.

DaPeCa-9 - cohabitation and socio-economic conditions predict penile cancer-specific survival in a national clinical study from Denmark

BACKGROUND

Cohabitation and social conditions predict prognosis in several cancers; recent data suggest this might also be the case in penile cancer.

OBJECTIVE

To assess the prognostic significance of cohabitation, living arrangements and socio-economic conditions for cancer-specific survival (CSS) in patients with penile squamous cell carcinoma (pSCC).

METHODS

We retrospectively evaluated CSS in 429 pSCC patients from a 10-year period. We assessed cohabitation, living arrangements and socio-economic conditions(SEC) as prognostic predictors. Kaplan-Meier estimates and Cox hazard rates (HR) with 95% confidence intervals were used for analysis.

RESULTS

Out of 429 pSCC patients, 137 (32%) were living alone and 292 (68%) were cohabiting. With a Cox HR at 1.91 (95% CI 1.3-2.98) patients living alone had a significantly lower median five-year survival rate at 69% (95% CI 60-77%) compared to cohabiting patients at 83% (95% CI 78-87%), p = 0.002. Comparing 60 (14%) from higher to 202 (47%) from medium and 95 (22%) patients from lower socio-economic groups we found Cox HRs at 1, 2.4 (95% CI 1.0-5.7, p = 0.04) and 3.4 (95% CI 1.4-8.1, p < 0.01) respectively. When comparing living arrangements, the trend that patients living in apartments and institutions had poorer outcomes than patients living in a house did not reach statistical significance.

CONCLUSIONS

Living alone and in poor socio-economic conditions predict poor prognosis in penile cancer in this national study. We make the case for further research in efforts to minimize cancer inequality pSCC patients.

Prevalence and sociodemographic correlates of anogenital Human Papillomavirus (HPV) carriage in a cross-sectional, multi-ethnic, community-based Asian male population

Background

Addressing the burden of HPV-associated diseases among men is increasingly becoming a public health issue. The main objective of this study was to determine HPV prevalence among a healthy community-based Malaysian men.

Method

This was a cross-sectional study that recruited 503 healthy males from 3 community-based clinics in Selangor, Malaysia. Genital and anal samples were collected from each participant for 14 high risk and 2 low risk HPV DNA detection and genotyping. All participants responded to a set of detailed sociodemographic and sexual behaviour questionnaire.

Results

The median age at enrolment was 40 years old (IQR: 31–50). The anogenital HPV6/11 prevalence was 3.2% whereas high risk HPV prevalence was 27.1%. The genital HPV prevalence for HPV6/11 was 2.9% while high risk HPV was 18.8%. HPV6/11 prevalence in the anal canal was 1.6% and high risk HPV was 12.7%. HPV 18 was the most prevalent genotype detected in the anogenital area. There was a significant independent association between genital and anal HPV infections.

Conclusion

Anogenital HPV infection is common among Malaysian men. These findings emphasize the ubiquity of HPV infection and thus the value of population-wide access to HPV prevention.

Differences in site-specific incidence and relative survival of cutaneous and mucocutaneous genital squamous cell carcinoma in Germany, 2007-2015

Direct comparisons of the incidence and survival of cutaneous vs mucocutaneous genital squamous cell carcinomas (SCCs) are lacking even though they may bring important insights. We aimed to compare incidence rates and survival of cutaneous and mucocutaneous genital SCCs head-to-head, using the same source population, cancer registry methodology and statistical methods in a population of predominantly white Caucasian descent. Using data (2007-2015) from the population-based cancer registry of North Rhine-Westphalia, (population of 18 million people), we estimated age-specific and age-standardized (old European standard) incidence rates and age-standardized relative 5-year survival of SCC with the period approach for the period 2012 to 2015. Overall, 83 650 SCC cases were registered. The age-standardized incidence rates (per 100 000 person-years) of cutaneous SCCs were 36.5 (SE 0.17) and 17.0 (SE 0.11) among men and women, respectively, with corresponding rates for mucocutaneous genital skin, 1.3 (SE 0.03) and 4.5 (SE 0.06) for men and women, respectively. In all age groups, incidence rates of mucocutaneous genital SCCs were higher in women than men. Men had higher cutaneous SCC incidence at all nongenital subsites than women, with the exception of the lower extremities. Five-year relative survival was considerably lower for mucocutaneous genital SCCs (men: 71%, women: 75%), especially of the scrotal skin (67%) and labia majora (62%) than for SCC of nongenital skin (men: 93%, women: 97%). Given their relatively high incidence together with a lower survival probability, future studies are warranted to establish therapies for advanced mucocutaneous genital SCC, such as immune checkpoint inhibition.

DaPeCa5 - obesity at the time of diagnosis does not predict poor cancer-specific survival in patients with penile squamous cell carcinoma - a Danish National study

BACKGROUND

Conflicting data on the prognostic significance of obesity in penile cancer have been presented in recent years.

OBJECTIVE

The objective of this study was to investigate obesity as a prognostic factor in patients with penile squamous cell carcinoma (pSCC) in a large national Danish cohort. Furthermore we aimed to compare the BMI of pSCC patients to a large age-matched cohort of healthy men.

METHODS

We evaluated 429 patients with invasive pSCC from a national retrospective penile cancer cohort and defined a body mass index (BMI) at 30 kg/m² as obese. Furthermore, we considered if a fitted model for BMI and mortality could define a critical BMI tipping point for increasing mortality by the means of BMI categories of 1 kg/m² width. We compared 29 pSCC patients with reported unintended weight loss at diagnosis to 400 with no reported weight loss. Cox regression with 95% confidence intervals was used for penile cancer-specific survival analysis. The comparison between 325 age-matched pSCC patients and 11,238 healthy men from an existing contemporary health database was done by nonparametric tests.

RESULTS

There was no difference in cancer specific survival between patients with a BMI below and above 30 kg/m², cox hazard ratio (HR) 0.74 (0.47-1.18), p = .20, but 37 kg/m² was a tipping point for increasing mortality, HR = 2.10 (1.06-4.18), p = .035. Unintentional weight loss prior to diagnosis significantly predicted worse cancer specific outcome, cox hazard ratio 6.0 (3.5-10.0), p < 001 and cox hazard ratio adjusted for American Joint Committee of Cancer (AJCC)-stage at 1.8 (1.1-3.1), p = .03. Age-matched pSCC patients had a significantly higher BMI than healthy males, 28.4 ± 5.5 kg/m² vs. 26.2 ± 3.6 kg/m², p < .0001 and were more likely to smoke, p < .0001, and report alcohol intakes over 14 units/week, p < .0001.

CONCLUSION

In this Danish cohort, BMI above 30 kg/m² at diagnosis does not affect prognosis, but BMI at and above 37 kg/m² at diagnosis predicts poor prognosis. Unintentional weight loss is a predictor of high stage and poor prognosis. PSCC patients have a significantly higher BMI than age-matched healthy males.

Conditional survival after surgery for patients with penile cancer

BACKGROUND

Penile cancer represents a rare pathology whose natural history of treatment is poorly understood.

OBJECTIVE

To illustrate the dynamic survival profiles in surgically treated patients with squamous cell carcinoma of the penis (SCCP) using the conditional survival (CS) estimates.

MATERIALS AND METHODS

Patients with non-metastatic SCCP were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Conditional 3-yr overall survival (OS) rate and 3-yr cancer-specific survival (CSS) rate represented the primary outcomes of interest and were calculated using the Kaplan-Meier method. The multivariable Cox regression model was employed to calculate proportional hazard ratios for the prediction of mortality.

RESULTS

A total of 1887 SCCP patients who had undergone surgeries were identified. Given a 1-, 2-, 3-, 4-, and 5-yr survivorship, the 3-yr OS rates were, respectively, improved by + 9.8 (72.6%), +18.2 (78.1%), +23.4 (81.6%), +27.8 (84.5%), and + 26.6% (83.7%) from those calculated at baseline (time zero). As compared with the baseline calculations, patients who had survived 1, 2, 3, 4, or 5 yr after surgery could, respectively, harvest a + 7.8 (84.7%), +14.8 (90.2%), +19.5 (93.9%), +22.1 (96.0%), and + 22.4% (96.2%) improvement in 3-yr CSS. Patients with the most aggressive disease at baseline ultimately benefited the most from event-free survivorship. Multivariable Cox regression analyses showed that the impact of adverse pathological parameters (G2-3, ≥ pT2, pN+) on OS and CSS mostly showed a decreasing trend over time and some could disappear after a minimum of 1-yr survivorship.

DISCUSSION AND CONCLUSION

The survival probability of SCCP patients increases with post-operative survival. Patients with aggressive disease at baseline ultimately benefit the most from event-free survivorship and may expect a better prognosis once they survive the critical few years after surgery. The recorded observations have crucial implications regarding patient counseling and follow-up.

Assessment of selected quality of life domains in patients who have undergone conservative or radical surgical treatment for penile cancer: an observational study

Background Surgery is the standard treatment for organ-restricted penile cancer, but it is also a disfiguring procedure that can profoundly affect quality of life. Using a survey, in this study we assessed the effect of different surgical invasiveness on satisfaction in selected life domains of patients who underwent penile-sparing surgery and partial penectomy.

METHODS

Forty patients who underwent penile-sparing surgery (n=13) or partial penectomy (n=27) were enrolled in the study. The response rate was 71%. Information was obtained after surgery on sexuality, self-esteem, masculinity and partner relationships using the International Index of Erectile Function, the Self-Esteem Scale and the Conformity to Masculinity Norms Inventory questionnaires. We evaluated the effect of primary surgery type on selected domains of quality of life and correlations between study variables after surgery.

RESULTS

High self-esteem, satisfactory erectile function and masculinity results in both groups were comparable to those in the published literature. Men who underwent less disfiguring treatment had a significantly higher sense of masculinity than those who underwent partial penectomy (P=0.05). No significant differences were observed in erectile dysfunction and self-esteem. The level of aggressiveness of a surgical procedure was a predictor of sense of masculinity (P=0.01), but was not associated with self-esteem and sexual dysfunction (P=0.28 and P=0.55 respectively); 83% of patients were able to satisfactorily maintain partner relationships.

CONCLUSIONS

Disfiguring treatments for penile cancer significantly interfere with the sense of masculinity, but sexual functioning and self-esteem do not differ according to the type of surgical procedure. Most men maintained stable partner relationships after surgery, regardless of surgery type.

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.

The relationship between chronic diseases and number of sexual partners: an exploratory analysis

BACKGROUND

We investigated sex-specific associations between lifetime number of sexual partners and several health outcomes in a large sample of older adults in England.

METHODS

We used cross-sectional data from 2537 men and 3185 women aged ≥50 years participating in the English Longitudinal Study of Ageing. Participants reported the number of sexual partners they had had in their lifetime. Outcomes were self-rated health and self-reported limiting long-standing illness, cancer, coronary heart disease, and stroke. We used logistic regression to analyse associations between lifetime number of sexual partners and health outcomes, adjusted for relevant sociodemographic and health-related covariates.

RESULTS

Having had 10 or more lifetime sexual partners was associated with higher odds of reporting a diagnosis of cancer than having had 0-1 sexual partners in men (OR 1.69, 95% CI 1.01 to 2.83) and women (OR 1.91, 95% CI 1.04 to 3.51), respectively. Women who had 10 or more lifetime sexual partners also had higher odds of reporting a limiting long-standing illness (OR 1.64, 95% CI 1.15 to 2.35). No other statistically significant associations were observed.

CONCLUSIONS

A higher lifetime number of sexual partners is associated with increased odds of reported cancer. Longitudinal research is required to establish causality. Understanding the predictive value of lifetime number of sexual partners as a behavioural risk factor may improve clinical assessment of cancer risk in older adults.

Angiolymphatic invasion and absence of koilocytosis predict lymph node metastasis in penile cancer patients and might justify prophylactic lymphadenectomy

To analyze possible clinical-pathological parameters and predictors of lymph node metastasis and evaluate the impact of lymphadenectomy in the survival of these patients.A retrospective study of patients diagnosed with penile cancer and submitted to regional lymphadenectomy at two reference hospitals in Maranhão, Northeast, Brazil, an area where the disease has a high incidence. We described here clinical and histopathological characteristics of patients diagnosed between January 2009 and September 2017.Fifty-five patients with an average age of 55.4 years (range: 25-84 years) were analyzed, with 24.4 months being the average time between the onset of symptoms and start of treatment. Among patients without palpable lymph nodes at the first examination, 51% were affected by inguinal metastasis. In the multivariate analysis, the presence of angiolymphatic invasion (P = .029) and absence of koilocytosis (P = .001) were found to be predictive factors for lymph node metastasis. Patients submitted to prophylactic lymphadenectomy presented with a disease-free period of 25.4 months (±5.81), whereas those who underwent therapeutic lymphadenectomy presented with a disease-free period of 19.9 months (±3.12).Angiolymphatic invasion and absence of koilocytosis appeared to be predictive factors for lymph node metastasis. Therefore, the submission of patients with metastatic risk to prophylactic lymphadenectomy may improve their survival. Thus, prophylactic lymphadenectomy in patients at risk for inguinal metastasis may create a positive impact in survival rates.

A phase II trial of cabazitaxel as second line chemotherapy in relapsed locally advanced and/or metastatic carcinoma of the penis

Objectives

To assess the efficacy and tolerability of cabazitaxel in relapsed penile cancer.

Methods

This Phase II single-arm trial was designed to recruit 17 patients with relapsed penile cancer. The primary endpoint was objective (complete + partial) response rate (ORR; Response Evaluation Criteria in Solid Tumours [RECIST] v1.1). Treatment comprised six 21-day cycles of cabazitaxel with restaging after cycles 2 and 4. The planned interim analysis was based upon the premise that if none of the first nine patients achieved ORR, trial would be stopped (α = 0.05, Simon’s 2-stage design).

Results

Nine patients were recruited from four UK centres between December 2014 and August 2016. The median age was 61 (range, 27–73.6) years, and seven patients had metastases. Patients received a median of two chemotherapy cycles (range, 2–5). None of the nine patients achieved ORR and the trial was stopped. Cabazitaxel was well tolerated with no dose reductions or delays. Three patients had grade 3/4 adverse events (anaemia, vomiting, or neutropenic sepsis). The median progression-free and overall survival were 1.3 and 5.6 months, respectively.

Conclusions

The trial did not reach the threshold for further continuation of single-agent cabazitaxel. However, the observed tolerability profile supports its further investigation in combination with other agents to improve patient outcomes.

Identifying an optimal lymph node yield for penile squamous cell carcinoma: prognostic impact of surgical dissection

OBJECTIVE

To evaluate the prognostic impact of lymph node yield (LNY) on survival outcomes for penile squamous cell carcinoma (SCC).

PATIENTS AND METHODS

In all, 532 patients who underwent inguinal LN dissection (ILND) across tertiary referral centres from Europe, China, Brazil and North America were retrospectively evaluated. From this cohort, 198 patients received pelvic LND (PLND).We identified threshold values for ILND and PLND using receiver operating characteristic curves. We tested prognostic value of LNY for recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS) using the Kaplan-Meir method and Cox proportional hazard regression models.

RESULTS

The median (interquartile [IQR]) age was 59 (49-68) years and the median (IQR) follow-up after ILND was 28 (12-68.2) months. Overall, 85% of the patients had bilateral dissections. The median (IQR) number of inguinal LNs removed was 15 (10-22). Of those receiving PLND, The median (IQR) number of LNs was 13 (8-19). A LNY of ≥15 was used for dichotomisation of ILND patients, and a LNY of ≥9 was used in the PLND cohort. Patients with a LNY ≥15 had significantly better 5-year OS vs patients with a LNY <15 (70.1% vs 58.7%). On multivariable analyses, a LNY ≥15 was a predictor of OS (hazard ratio [HR] 0.68, P = 0.029). For cN0 patients, a LNY ≥15 was an independent predictor of RFS (HR 0.52, P = 0.043) and OS (HR 0.53, P = 0.021). In the PLND cohort, a LNY ≥9 was a predictor of RFS (HR 0.53, P = 0.032).

CONCLUSIONS

Using one of the largest LND datasets to date, we found LNY to be a significant predictor of outcomes after lymphatic staging for penile SCC. Prospective validation is warranted.

Familial Clustering, Second Primary Cancers and Causes of Death in Penile, Vulvar and Vaginal Cancers

Data on familial risks in penile and vulvar/vaginal cancers and in second primary cancers (SPCs) following these cancers are limited. We used the Swedish Family-Cancer Database from years 1958 through 2015 to identify 3641 penile and 8856 vulvar/vaginal cancers and to calculate relative risks (RRs) and 95% confidence intervals (CIs) for these cancers according to site-specific cancer in family members; additionally risk for SPCs was calculated. The familial RR for concordant (same) penile cancer was 3.22 (1.34-7.74), and it was 2.72 (1.69-4.39) for vulvar/vaginal cancer; RRs were increased for vulvar/vaginal cancer in families of anal cancer patients. RR for second penile cancer after penile cancers was 11.68 (7.95-17.18), while that for concordant vulvar/vaginal cancer was 9.03 (7.31-11.15). SPCs were diagnosed in 16.8% of penile cancer patients and in them 45.9% of deaths were caused by SPC (other than penile cancer). In vulvar/vaginal cancer patients with SPC, 36.4% of deaths were due to SPC. The results showed that these genital cancers might run in families and as SPCs are associated with human papilloma virus and smoking related cancers. Risk for these genital and anal SPCs are high and a follow-up plan should be agreed at diagnosis of these cancers.

Primary urethral squamous cell carcinoma: a unique manifestation of a penile tumor

This case report describes a unique manifestation of a primary urethral squamous cell carcinoma (SCC) as the underlying pathology in an 80-year-old male patient who underwent partial penectomy due to an enlarging penile mass. Persistent pain in the right knee was discovered to be a pathologic fracture using magnetic resonance imaging. Computed tomography-guided biopsy confirmed metastatic SCC. Whole-body positron emission tomography revealed systemic dissemination to multiple sites. Orthopedic knee replacement was performed in combination with local radiotherapy. Palliative chemotherapy was rejected due to poor performance status. Primary urethral SCC is rare and an uncommon cause of advanced penile cancer. These findings could be of great interest to clinicians for two reasons. First, a tumor's appearance can be misleading. Consequently, histological work-up in accordance with clinical guidelines is necessary for accurate diagnosis. Second, a more comprehensive investigation is required when clinical symptoms persist despite the use of conventional treatment. Our case is an instance in which persistent pain masked the presence of downstream metastasis. We believe that these aforementioned points are of significant clinical importance and present a salient learning opportunity.

Review of cutaneous penile lesions

Introduction:

Penile lesions often go undiagnosed and are difficult to identify for general practitioners and specialists, yet the stakes could be high. Indeed, the condition is highly varied and includes physiological variants, specific skin entities, genital dermatoses, genital ulcers, balanitis, premalignant lesions, and, finally, cancerous lesions. Knowledge of these entities can help to prevent overlooking potentially progressive lesions and diagnose cancerous lesions early so that patients can be offered conservative treatment, improving chances of survival. We review here these different lesions.

Materials and methods and authors personal experience:

A literature review was carried out in December 2016 using the Medline/Pubmed database, without any restrictions regarding the time period but limiting the review to studies in English or French. The main keywords used were “penile lesion”, “penile cancer”, “balanitis” and “premalignant lesion”. A specific review was performed for each type. All the pictures and cases came from our personal practice in our specific uro-dermatological consultation. All the patients gave us their informed consent for the utilization of their pictures.

Results:

We studied 66 references covering the field of benign and malignant lesions and their respective treatment. It is essential to take a medical history and perform a clinical examination, despite the fact that some lesions are not specific. A biopsy must be performed systematically in the case of all suspicious lesions.

Conclusion:

Lesions on genital organs in men are very diverse. Some are difficult to diagnose and treat, with the main challenge being early diagnosis of lesions with a high progressive potential in order to prevent dissemination and the need for mutilating surgery.

Zonal mapping of sentinel lymph nodes in penile cancer patients using fused SPECT/CT imaging and lymphoscintigraphy

PURPOSE

To define the anatomical location of sentinel lymph nodes (SLN) in penile cancer patients based on Daseler's original zonal description using a combination of single photon emission computed tomography-computed tomography (SPECT-CT), cross sectional imaging and lymphoscintigraphy and characterise the limits of Zone V.

MATERIALS AND METHODS

Patients with primary penile cancer ≥T1G2 were included in the study. A total of 113 groins with impalpable inguinal lymph nodes (cN0) underwent planar lymphoscintigraphy and SPECT-CT. The sentinel lymph nodes were mapped on cross sectional imaging according to Daseler's anatomical description. Using measurements from fixed anatomical landmarks, a custom-made software program mapped the SLNs. SLNs were mapped to the previously undefined Zone V using 3 approaches to avoid observational bias: (a) as perceived by the uroradiologist, (b) limiting Zone V to a 5 mm radius from the sapheno-femoral junction or (c) using a 10 mm radius from the sapheno-femoral junction.

RESULTS

Using SPECT-CT, drainage to the groins was seen in 109 of the 113 cN0 groins (96.5%). The majority of the SLNs were located in the central and superior quadrants with 38.2% lying within Zone I, 45% in Zone II and 13% in Zone V. More importantly, sentinel lymph nodes were still localised to the inferior zones with 3% located in Zone III and 0.8% in Zone IV.

CONCLUSIONS

Using a hybrid of SPECT-CT, cross sectional imaging and lymphoscintigraphy we have demonstrated that SLNs may be located in the inferior zones. We also define the limits of Zone V as an area of 5 mm radius from the sapheno-femoral junction.

Trends in incidence, mortality and survival of penile squamous cell carcinoma in Norway 1956-2015

We examine trends in incidence, mortality and survival of penile squamous cell carcinoma (SCC) in Norway over 60 years. Data on all cases of penile cancer diagnosed in Norway during 1956-2015 were obtained from the Cancer Registry of Norway. Trends in age-standardized rates of penile SCC incidence, mortality and 5-year relative survival were assessed by the annual percentage change statistic and joinpoint regression. A total of 1,596 penile cancer cases were diagnosed during 1956-2015, among which 1,474 (92.4%) were SCC. During 2011-2015, the age-standardized incidence and mortality of penile SCC were 0.91 (95% confidence interval (CI): 0.78; 1.05) and 0.50 (0.42; 0.60) per 100,000, respectively, and the 5-year relative survival was 61.6% (41.9; 76.4). The incidence of SCC increased during 1956-2015, with an average annual percentage change (AAPC) of 0.80% (0.46; 1.15). The increase was strongest among men diagnosed at a relatively early age (age<=64 years; AAPC: 1.47% (0.90; 2.05)). Mortality also increased over the study period (AAPC: 0.47% (0.10; 0.85)), whereas 5-year relative survival did not change (AAPC: 0.08% (-0.19; 0.36)). We conclude that the incidence of penile SCC has increased at a moderate and constant rate during 1956-2015, and that the most consistent increase occurred among younger men. Mortality also increased during the study period. However, survival did not change, thus changes in diagnostics and treatment had little impact on survival from penile SCC. Since a substantial proportion of penile SCC is caused by human papillomavirus (HPV), the incidence increase may in part be attributed to increased exposure to HPV in the population.

Long-term incidence trends of HPV-related cancers, and cases preventable by HPV vaccination: a registry-based study in Norway

OBJECTIVES

Examine long-term incidence trends of human papillomavirus (HPV)-related cancer in Norway, and estimate the number of cancer cases preventable by vaccines against HPV 16/18 or HPV 16/18/31/33/45/52/58.

DESIGN

Observational registry-based study. We extracted incident cases of HPV-related cancer during 1953-2015 from the Cancer Registry of Norway. Tumour HPV prevalence estimates from large international meta-analyses or from Norway were used to estimate the protective potential of HPV vaccines.

PARTICIPANTS AND SETTING

The Norwegian population.

PRIMARY OUTCOME MEASURES

Incidence trend analyses during 1953-2015 for squamous cell carcinoma (SCC) of the cervix, vulva, vagina, oropharynx, anus and penis, and adenocarcinoma of the cervix. Additionally, the number of cancer cases preventable by HPV vaccination.

RESULTS

Among women, incidences of SCC of the anus, oropharynx, vulva and cervical adenocarcinoma increased, while vaginal SCC showed no trend. For these cancers combined, the average annual percentage change (AAPC) during 1953-2015 was 1.2 (95% CI 0.7 to 1.6). The incidence of cervical SCC generally decreased during 1976-2004 and remained stable thereafter. Among men, incidences of SCC of the anus, oropharynx and penis increased. The AAPC during 1953-2015 combined for all male HPV-related cancer was 1.9 (95% CI 1.3 to 2.5). A vaccine against HPV 16/18 might yearly prevent 402 (95% CI 382 to 420) cancers. A vaccine against HPV 16/18/31/33/45/52/58 might yearly prevent 478 (95% CI 464 to 490) cancers, of which 206 (95% CI 202 to 209) occur in non-cervical organs, and 113 (95% CI 110 to 115) occur among men.

CONCLUSIONS

The incidences of HPV-related cancers that are not effectively prevented by screening have generally increased during 1953-2015. HPV vaccination can prevent a substantial number of cancers in Norway, in cervical and non-cervical organs, among women and men.

Impact and Cost-effectiveness of Selective Human Papillomavirus Vaccination of Men Who Have Sex With Men

Background.

Men who have sex with men (MSM) have a high lifetime risk of anogenital warts and cancers related to infection with human papillomavirus (HPV). They also benefit less from herd protection than heterosexual males in settings with female-only HPV vaccination.

Methods.

We evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM who visit genitourinary medicine (GUM) clinics. We used a mathematical model of HPV 6/11/16/18 sexual transmission within an MSM population in England, parameterized with sexual behaviour, GUM attendance, HPV prevalence, HIV prevalence, warts, and cancer incidence data. Interventions considered were offering HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, for age bands 16–25, 16–30, 16–35, and 16–40 years.

Results.

Substantial declines in anogenital warts and male HPV-related cancer incidence are projected to occur following an offer of vaccination to MSM. MSM not attending GUM clinics will partially benefit from herd protection. Offering vaccination to HIV-positive MSM up to age 40 is likely to be cost-effective if vaccine procurement and administration costs are below £96.50 a dose. At £48 a dose, offering vaccination to all MSM up to age 40 is likely to be cost-effective.

Conclusions.

Quadrivalent HPV vaccination of MSM via GUM clinics is likely to be an effective and cost-effective way of reducing the burden of HPV-related disease in MSM.

Incidence of penile cancer worldwide: systematic review and meta-analysis

OBJECTIVE

To determine the global incidence of penile cancer.

METHODS

A systematic review and meta-analysis of observational studies was performed, with no limits on their language of publication. Analyses were performed using Stata 13 statistical software. A random-effects model was used, according to the heterogeneity found in the studies. The main outcome was expressed in terms of age-standardized incidence.

RESULTS

A total of 23 studies were eligible, with 71 156 penile cancer patients in 86 countries. According to the review conducted, the estimated age-standardized incidence of penile cancer worldwide is 0.84 cases per 100 000 person-years (95% confidence interval: 0.79-0.89). Romania reported the highest incidence, 7.26 per 100 000 person-years, between 1983 and 1987; however, some countries in Latin America and Africa reported an incidence of between 2.0 and 5.7 per 100 000.

CONCLUSIONS

Penile cancer is considered a rare malignancy due to its already-known, particularly low incidence rate. The estimated age-standardized incidence rate by the world standard population today is 0.84 cases per 100 000 person-years. There were no significant differences in the incidence rate of penile cancer with respect to the distribution by continent or the trend over time.

Updates on the epidemiology and risk factors for penile cancer

Penile cancer is a rare neoplasm representing less than 1% of all malignancies in the USA and Europe but is a significant public health hazard in the developing world. Male neonatal circumcision has been associated with a dramatic decrease in penile cancer rates with countries such as Israel, where circumcision is widely performed, having the lowest incidence in the world at <0.1% of malignancies. Many risk factors have been identified for penile cancer including phimosis, lack of circumcision, obesity, lichen sclerosis, chronic inflammation, smoking, UVA phototherapy, socioeconomic status, human papillomavirus (HPV) infection and immune compromised states. The relationship between these factors and invasive disease varies and continues to be investigated. Our objective was to present a contemporary overview of the epidemiology and risk factors for invasive penile cancer.

Relationship between human papillomavirus and penile cancer-implications for prevention and treatment

Penile cancer is a rare disease in the United States, but rates are increasing, causing concern. Several risk factors have been associated with the disease, including human papillomavirus (HPV) infection. Knowledge of HPV pathogenesis has led to the development of a vaccine, which has proven instrumental in reducing the incidence of female HPV-related cancers, but results in men have yet to be elucidated. Fortunately, rates of vaccination are up-trending in both males and females in the past several years. In addition, targeted therapies are the focus of several ongoing research efforts. Some of these therapeutics are currently in use, while several are in trials. With continued patient education and research, both treatment and prevention of HPV-related pre-malignant lesions and penile cancer will likely diminish.