Penile Cancer: Epidemiology and Treatment

Multimodal Therapy of Locally-Advanced Penile Cancer: A Case Report With Literature Review

Cancer of the penis is a rare tumor that occurs in the elderly. Because of its rarity, it is often not diagnosed early, and its treatment poses difficulties for practicing oncologists. We report the case of an elderly patient treated for locally advanced squamous cell carcinoma (SCC) of the penis, with a review of the literature. A 71-year-old man, who had been complaining of pruritus on the penis two years ago, presented with an ulcerated lesion on the prepuce and the glans. A biopsy of the lesion with pathological study showed a SCC of the penis. Pelvic MRI showed tumor thickening centered on the glans of the penis, infiltrating the fascia and the spongy urethra with discrete upstream dilatation and bilateral inguinal adenomegaly. CT scan of the neck, chest, abdomen, and pelvis showed no secondary localizations. Treatment initially consisted of carcinological surgery by a partial penectomy with bilateral inguinal lymph node dissection. The tumor was therefore classified as pT3N3M0. A PET CT scan performed later was in favor of local and regional recurrence. Surgery was not feasible, so concomitant chemo-radiotherapy was indicated at a total dose of 70 Gy in 35 fractions of 2 Gy concomitantly with platinum-based chemotherapy, withgood evolution.

Tumor Location May Independently Predict Survival in Patients With M0 Squamous Cell Carcinoma of the Penis

Background

To determine the association between tumor location and both clinicopathological characteristics and the survival of patients with M0 squamous cell carcinoma of the penis (SCCP).

Methods

Data of 455 patients diagnosed with M0 SCCP between 1975 and 2018 were collected from the Surveillance, Epidemiology, and End Results (SEER) database of the United States National Cancer Institute. The effects of tumor location on overall survival (OS) and penile carcinoma-specific survival (PCSS) were analyzed using the Kaplan–Meier method. The Cox proportional hazards regression model was used to determine the impact of tumor location on PCSS.

Results

SCCP was more likely to occur in the prepuce or glans (90%). Although no significant difference was observed between the OS of patients with M0 SCCP in the prepuce or glans and those with M0 SCCP in the body of the penis (p = 0.307), the former had better PCSS (p = 0.024). Moreover, M0 SCCP in the prepuce or glans was also significantly associated with better PCSS in patients with advanced age (age ≥ 60 years, p = 0.011), other ethnicities (p = 0.003), T2–T4 stage (p = 0.036), larger tumors (≥3 cm, p = 0.001), no regional lymph nodes removed (p = 0.044), and radical surgery (p = 0.027). Multivariate analysis confirmed that tumor location is an independent prognostic factor for patients with M0 SCCP [hazard ratio (HR) 1.881, p = 0.026].

Conclusions

Tumor location is an independent prognostic factor for patients with M0 SCCP, and tumors in the prepuce or glans portend better PCSS.

Accuracy of MRI without intracavernosal prostaglandin E1 injection in staging, preoperative evaluation, and operative planning of penile cancer

PURPOSE

To evaluate the performance of non-erectile MRI in staging and preoperative evaluation of penile carcinomas, compared to postoperative histopathology.

METHODS

In this retrospective study, MRI scans of patients who had undergone surgery for penile carcinoma (n = 54) between January 2012 and April 2018 were read by two radiologists; and disagreement was solved in the presence of a third experienced radiologist. Data necessary for preoperative evaluation and staging were collected and compared with final postoperative histology and the type of surgery performed. All MRI had been performed without intracavernosal injection of prostaglandin E1 and with IV Gadolinium, as per local protocol.

RESULTS

54 patients were included in the study (mean age 57.52 ± 12.78). The number of patients with T1, T2, and T3 staging in histopathology were 32, 14, and 8. Moderate interobserver agreement was found for staging, disease-free penile length, and all subsites except urethra, which had weak agreement. Strong agreement of consensus MRI with final histopathological staging was found (49/54, weighted κ = 0.85), with high sensitivity and specificity. Sensitivity and specificity for involvement of corpus spongiosum, corpora cavernosa, and urethra were 95.5% and 93.8%, 87.5% and 97.8%, and 90.9% and 86.1%, respectively. Sensitivity (89.6%) and specificity (100%) of MRI for predicting adequate disease-free penile length were high.

CONCLUSION

There were acceptable interobserver agreement and good diagnostic performance of MRI for staging and preoperative assessment without intracavernosal injection, especially for higher stages and higher degrees of invasion which require more extensive surgery.

Impact of Sexual Activity on the Risk of Male Genital Tumors: A Systematic Review of the Literature

Most cancers are related to lifestyle and environmental risk factors, including smoking, alcohol consumption, dietary habits, and environment (occupational exposures). A growing interest in the association between sexual activity (SA) and the development of different types of tumors in both men and women has been recorded in recent years. The aim of the present systematic review is to describe and critically discuss the current evidence regarding the association between SA and male genital cancers (prostatic, penile, and testicular), and to analyze the different theories and biological mechanisms reported in the literature. A comprehensive bibliographic search in the MEDLINE, Scopus, and Web of Science databases was performed in July 2021. Papers in the English language without chronological restrictions were selected. Retrospective and prospective primary clinical studies, in addition to previous systematic reviews and meta-analyses, were included. A total of 19 studies, including 953,704 patients were selected. Case reports, conference abstracts, and editorial comments were excluded. Men with more than 20 sexual partners in their lifetime, and those reporting more than 21 ejaculations per month, reported a decreased risk of overall and less aggressive prostate cancer (PCa). About 40% of penile cancers (PCs) were HPV-associated, with HPV 16 being the dominant genotype. Data regarding the risk of HPV in circumcised patients are conflicting, although circumcision appears to have a protective role against PC. Viral infections and epididymo-orchitis are among the main sex-related risk factors studied for testicular cancer (TC); however, data in the literature are limited. Testicular trauma can allow the identification of pre-existing TC. SA is closely associated with the development of PC through high-risk HPV transmission; in this context, phimosis appears to be a favoring factor. Sexual behaviors appear to play a significant role in PCa pathogenesis, probably through inflammatory mechanisms; however, protective sexual habits have also been described. A direct correlation between SA and TC has not yet been proven, although infections remain the most studied sex-related factor.

The prognostic significance of primary tumor size in squamous cell carcinoma of the penis

BACKGROUND

To evaluate the association of primary tumor size with clinicopathologic characteristics and survival of patients with squamous cell carcinoma of the penis (SCCP).

METHODS

This study analyzed the data of 1001 patients with SCCP, obtained from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2014. The Kaplan-Meier method and the Cox proportional hazards regression model were used to analyze the effects of primary tumor size on overall survival (OS) and penile carcinoma-specific survival (PCSS).

RESULTS

Advanced T stage (P < 0.001), lymph node metastasis (P < 0.001) and distant metastasis (P = 0.001) were more frequently associated with SCCP patients with tumor size ≥ 3 cm than those with tumor size  < 3 cm. In Kaplan-Meier analyses, the patients with large tumors (≥ 3 cm) exhibited an inferior OS and PCSS than those with small tumors (< 3 cm). Moreover, tumor size was identified to be an independent prognostic factor for OS [hazard ratio (HR) 1.665, P < 0.001] and PCSS (HR 2.076, P = 0.003) of patients with SCCP in multivariate analyses.

CONCLUSIONS

Large tumor size is associated with adverse clinicopathological characteristics of patients with SCCP. Besides, tumor size represents an independent prognostic factor for OS and PCSS. Therefore, clinical assessment of tumor size as a crucial prognostic factor might be highly beneficial for early intervention in patients with SCCP.

The Genotype of Human Papilloma Virus of Male Patient with Anogenital Warts

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections. HPV high risk (HPVHR) were HPV16,18 related with invasive penile carcinomas, and HPV low risk (HPVLR) were HPV6,11 related to anogenital warts. Male infection is usually asymptomatic that it would be explain increasing the incidence of HPV associated cancers. Identification HPV genotype is very important for predicting the development of the diseases, to be benign or malignant cancer. The objective of this study was to identify the genotype of HPV that infect men with anogential warts. This research used 12 biopsy specimens from men patient with anogenital warts at Outpatient clinic of Department Dermatology and Venereology, Dr. Soetomo General Hospital period 2016-2017. The specimens were diagnozed by pathologist and HPV gentoyping was done to detect 40 HPV genotype including HPVHR and HPVLR. The result showed that 58% (7/12) were positive for HPVLR and 42% (5/12) were positive for HPV LR/HR. The genotype HPV that infected men patient with anogenital warts is HPVLR (HPV6,11) and HPVHR (HPV18,51,52,82) with single infection of HPVLR or mutiple infection HPVLR/LR or HPVLR/HR. The infection of HPVHR would be develops to be malignant transformation. It suggested that HPV genotype needs to be checked the for the anogenital warts cases for predicting the development of the diseases.

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.

PD-L1 and p16 Expression in Penile Squamous Cell Carcinoma From an Endemic Region

BACKGROUND

Penile squamous cell carcinoma (PSCC) is a rare malignancy with higher incidence in developing countries. Treatment options include surgery, radiation therapy, and systemic chemotherapy. However, effective treatments for advanced disease are lacking. To understand the biology underlying PSCC may help the development of new therapeutic strategies. The objective of this study was to evaluate immunohistochemical expression of programmed death-ligand 1 (PD-L1) and p16 in PSCC and its association with clinicopathologic features and outcomes.

PATIENTS AND METHODS

A cohort of 40 patients with PSCC from an academic institution in Brazil was analyzed. Clinicopathologic features and outcomes were retrospectively collected. PD-L1 and p16 immunohistochemical expression were performed in formalin-fixed paraffin-embedded specimens. PD-L1 was positive with any staining in more than 1% of tumor, and p16 was positive in more than 10%. Associations were performed using the Mann-Whitney and Fisher exact test. Kaplan-Meier curves were used to estimate survival rates with log-rank.

RESULTS

Of 35 patients, 5 were excluded, 4 owing to a lack of data and 1 owing to no tumor available; 18 (51.4%) patients were PD-L1-positive (PD-L1⁺). PD-L1⁺ was associated with larger tumors (P = .027). There was an association between PD-L1⁺ and p16 expression (P = .002). PD-L1⁺ was more frequent in grade II and III disease than grade I (77.8% vs. 22.2%) and was expressed in all patients with grade III disease. Lymph node involvement was associated with PD-L1 expression (69.2% PD-L1⁺ vs. 30.8% PD-L1-negative). The 5-year mortality was 37.1%.

CONCLUSION

PD-L1 expression appears to be associated with p16 expression, larger tumors, and worse clinical outcomes in PSCC and may provide clinical data for new studies to evaluate anti-PD-L1 immune therapies.

Prognostic value of lymphovascular invasion in patients with squamous cell carcinoma of the penis following surgery

Background

To evaluate the prognostic value of Lymphovascular Invasion (LVI) in patients with squamous cell carcinoma of the penis (SCCP) following surgery.

Patients and methods

This retrospective study analyzed the data of 891 eligible patients with SCCP who were diagnosed between 2010 and 2014, obtained from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were categorized by LVI, age, grade, T stage, lymph nodes status, distant metastasis, regional lymph nodes removed, and surgery. Overall survival (OS) and penile carcinoma-specific survival (PCSS) were evaluated by Kaplan-Meier method and Cox proportional hazards regression model.

Results

The presence of LVI was significantly associated with increased risk of advanced T stage, high grade, lymph node metastasis, and distant metastasis (P < 0.001 for all). In Kaplan-Meier analyses, patients with the presence of LVI had significantly lower OS and PCSS than those with the absence of LVI (P < 0.001 for both,). The presence of LVI was also significantly associated with poorer OS and worse PCSS in patients with Tx + Ta + T1 stage (P = 0.007, P < 0.001), N0 stage (P < 0.001, P = 0.040), grade 1 (P = 0.001, P < 0.001), grade 2 (P = 0.001, P = 0.014), no distant metastasis (P < 0.001 for both), no regional lymph nodes removed (P < 0.001 for both), Non-radical surgery (P < 0.001 for both) and radical surgery(P = 0.037, P = 0.002). In multivariate analyses, the presence of LVI in patients with SCCP following surgery was found to be a significant independent predictor of decreased OS (hazard ratio 1.403, P = 0.039).

Conclusions

The LVI status might be a crucial prognostic indicator for overall survival in patients with SCCP.

The Prognostic Value of PIK3CA Copy Number Gain in Penile Cancer

OBJECTIVE

To determine whether phosphatidylinositol-4,5-bisphosphate 3- kinase, catalytic subunit alpha (PIK3CA) copy number gain in penile cancer has prognostic value and association with histopathological parameters, human papillomavirus (HPV), and clinical outcome.

METHODS

PIK3CA copy number status was assessed with fluorescence in situ hybridization in tissue microarrays generated from archival paraffin embedded blocks of 199 patients with primary penile squamous cell carcinoma (PSCC). HPV DNA was detected with INNO-LiPA assay. Follow-up data were available for 174 patients. PIK3CA copy number status was correlated with histopathological parameters, high-risk HPV, cancer-specific survival and time to recurrence.

RESULTS

PIK3CA copy number gain was found in 84/199 (42%) of penile cancer cases. PIK3CA copy number gain was associated with tumor subtype, grade, and stage (P = .0028, P < .0001, and P = .0397, respectively), but not with lymph node status (P = .2902). PIK3CA copy number gain showed a tendency to associate with cancer-specific survival (HR = 1.76, 95% CI; 0.94-3.3; P = .0753). In multivariate analysis, PIK3CA copy number gain was found to have no prognostic value for cancer-specific survival (P = .677). Only lymph node metastasis, high tumor grade and stage were found to be independent prognostic factors for cancer-specific survival.

CONCLUSION

PIK3CA copy number gain could be used as a marker of high-risk disease as it correlates with more aggressive PSCC histological subtypes and higher tumor grade and stage. However, it shows no significant association with lymph node metastasis or prognostic value for cancer-specific survival in PSCC.

PIK3CA copy number aberration and activation of the PI3K-AKT-mTOR pathway in varied disease states of penile cancer

BACKGROUND

Therapeutic targeting of the PI3K-AKT-mTOR pathway may benefit patients with advanced penile squamous cell carcinoma (PSCC).

OBJECTIVES

To determine the prevalence of PIK3CA copy number gain and correlate this with the activity status of PI3K-AKT-mTOR pathway in pre-malignant penile intraepithelial neoplasia (PeIN) and invasive PSCC.

MATERIALS AND METHODS

Archival tissue blocks were obtained from 58 PeIN and 244 primary PSCC patients treated at St George's Hospital. PIK3CA copy number status (CNS) was assessed by fluorescence in-situ hybridisation. High-risk HPV DNA was detected with INNO-LiPA assay. p16INK4A, p-AKT and p-mTOR protein expression were assessed using immunohistochemistry (IHC).

RESULTS

Increased prevalence of PIK3CA copy number gain was seen in PSCC in comparison to PeIN (84/199 (42%) vs. 10/58 (17%); p = 0.0009). Analysis of the p-AKT and p-mTOR revealed a tendency to a more common expression of cytoplasmic p-AKT (p = 0.1318), nuclear p-AKT (p<0.0001) and cytoplasmic mTOR (p = 0.0006) in PeIN than PSCC. A significant association between p-AKT cytoplasmic immunoexpression and PIK3CA CNS (p = 0.0404) was found in PeIN.

CONCLUSION

Overall, PIK3CA copy number gain correlated with activation of the PI3K-AKT-mTOR pathway in PeIN and activation of this pathway is primarily involved in early penile carcinogenesis. Based on these results therapeutic targeting of this pathway in advanced PSCC is unlikely to produce significant clinical benefit. Future studies will need to focus on alternative therapeutic targets.

Analysis of the PI3K-AKT-mTOR pathway in penile cancer: evaluation of a therapeutically targetable pathway

Objectives

To determine whether phosphatidylinositol-4,5-bisphosphate 3- kinase, catalytic subunit alpha (PIK3CA) copy number gain is common and could prove a useful marker for the activation status of the PI3K-AKT-mTOR pathway in penile squamous cell carcinoma (PSCC).

Methods

Fresh frozen tissue and archival blocks were collected from 24 PSCC patients with 15 matched normal penile epithelium (NPE) tissue from St George’s Hospital. PIK3CA mutational and copy number status (CNS) was assessed via Sanger sequencing and fluorescence in-situ hybridisation, respectively. PIK3CA RNA expression was quantified using TaqMan gene expression assay. HPV DNA was detected with INNO-LiPA assay. p-AKT and p-mTOR protein expression were assessed using western blot and immunohistochemistry.

Results

PIK3CA copy number gain was found in 11/23 (48%) patients, with mutations present in only 2/24 (8%) patients. In comparison to NPE, PSCC showed significantly lower PIK3CA RNA expression (p=0.0007), p-AKT (Ser473) nuclear immunoexpression (p=0.026) and protein expression of p-AKT (Thr308) (p=0.0247) and p-mTOR (Ser2448) (p=0.0041). No association was found between PIK3CA CNS and p-AKT and p-mTOR protein expression.

Conclusion

Based on our results the PI3K-AKT-mTOR pathway is not a key driver in PSCC carcinogenesis and the therapeutic targeting of this pathway is unlikely to produce significant clinical benefit.

Long-term trends in incidence and survival of penile cancer in France

BACKGROUND

Penile cancer is rare, and few population-based studies have described changes in time trend. This study aims to determine whether there has been an evolution in incidence and survival of penile cancer over time in France.

METHODS

Rates of age world-standardized incidence (ASRW) and net survival (NS) between 1989 and 2011 were calculated using data from 16 French cancer registries. Time trend incidence and survival analysis were confined to the eight registries operating throughout the full period. Log-linear Poisson regression analysis was used to estimate the average annual percentage change (AAPC) in incidence rates. The incidence rate for the most recent period was also calculated from all 16 cancer registries operating during 2009-2011. Human papillomavirus (HPV) exposure was deduced from the morphological code. NS was estimated using the Pohar-Perme estimator of the net cumulative rate.

RESULTS

No significant change in incidence was observed between 1989 and 2011 (AAPC: 0.08%; 95%CI: -1.01%; +1.17%). The incidence increased with age. The ASRW in 16 registries operating in 2009-2011 was 0.59 per 100,000 (95%CI: 0.50-0.68). The proportion of cases potentially linked to HPV was nearly 11% and did not change significantly over time. NS decreased with age but did not change over time (around 65% at 5 years).

CONCLUSION

Penile cancer remains rare in France, but survival is still low - probably because of delays in diagnosis and limited improvements in care. International clinical trials are needed to develop care recommendations based on an adequate level of evidence.

Integrative miRNA and mRNA analysis in penile carcinomas reveals markers and pathways with potential clinical impact

Penile carcinoma (PeCa) is an important public health issue in poor and developing countries, and has only recently been explored in terms of genetic and epigenetic studies. Integrative data analysis is a powerful method for the identification of molecular drivers involved in cancer development and progression. miRNA and mRNA expression profiles followed by integrative analysis were investigated in 23 PeCa and 12 non-neoplastic penile tissues (NPT). Expression levels of eight miRNAs and 10 mRNAs were evaluated in the same set of samples used for microarray and in a validation set of cases (PeCa = 36; NPT = 27). Eighty-one miRNAs and 2,697 mRNAs were identified as differentially expressed in PeCa. Integrative data analysis revealed 255 mRNAs potentially regulated by 68 miRNAs. Using RT-qPCR, eight miRNAs and nine transcripts were confirmed as altered in PeCa. We identified that MMP1, MMP12 and PPARG and hsa-miR-31-5p, hsa-miR-224-5p, and hsa-miR-223-3p were able to distinguish tumors from NPT with high sensitivity and specificity. Higher MMP1 expression was detected as a better predictor of lymph node metastasis than the clinical-pathological data. In addition, PPARG and EGFR were highlighted as potential pathways for targeted therapy in PeCa. The analysis based on HPV positivity (7 of 23 cases) revealed five miRNA and 13 mRNA differentially expressed. Although in a limited number of cases, HPV positive PeCa presented less aggressive phenotype in comparison with negative cases. Overall, an integrative analysis using mRNA and miRNA profiles revealed markers related with tumor development and progression. Furthermore, MMP1 expression level was a predictive marker for lymph node metastasis in patients with PeCa.

Multidimensional integrative analysis uncovers driver candidates and biomarkers in penile carcinoma

Molecular data generation and their combination in penile carcinomas (PeCa), a significant public health problem in poor and underdeveloped countries, remain virtually unexplored. An integrativemethodology combin ing genome-wide copy number alteration, DNA methylation, miRNA and mRNA expression analysis was performed in a set of 20 usual PeCa. The well-ranked 16 driver candidates harboring genomic alterations and regulated by a set of miRNAs, including hsa-miR-31, hsa-miR-34a and hsa-miR-130b, were significantly associated with over-represented pathways in cancer, such as immune-inflammatory system, apoptosis and cell cycle. Modules of co-expressed genes generated from expression matrix were associated with driver candidates and classified according to the over-representation of passengers, thus suggesting an alteration of the pathway dynamics during the carcinogenesis. This association resulted in 10 top driver candidates (AR, BIRC5, DNMT3B, ERBB4, FGFR1, PML, PPARG, RB1, TNFSF10 and STAT1) selected and confirmed as altered in an independent set of 33 PeCa samples. In addition to the potential driver genes herein described, shorter overall survival was associated with BIRC5 and DNMT3B overexpression (log-rank test, P = 0.026 and P = 0.002, respectively) highlighting its potential as novel prognostic marker for penile cancer.

Comparison of efficacy between brachytherapy and penectomy in patients with penile cancer: a meta-analysis

We conducted a meta-analysis to compare the efficacy of brachytherapy and penectomy in patients with penile cancer. We searched the published articles in the PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang databases up to March 20, 2017. Twenty-two studies entered the final analyses. We used five-year overall survival rate, five-year local control rate, disease-free progression and lymph node positive rate to assess the efficacy. The meta-analysis found that patients who received penectomy had higher five-year local control rate (85% vs 80%, odds ratio = 0.72, 95% confidence interval: 0.58–0.90), five-year disease-free progression rate (77% vs 72%, odds ratio = 0.77, 95% confidence interval: 0.63–0.93) and lymph node positive rates (24% vs 20%, odds ratio = 0.79, 95% confidence interval: 0.64–0.98) than brachytherapy. No significant difference was observed for two group in five-year overall survival rate (76% vs 74%, odds ratios = 1.11 with the 95% confidence interval: 0.91–1.36). Both of penectomy and brachytherapy can improve the survival status. Penectomy provided better control efficacy, and not improved the survival status compared with brachytherapy solely. However, further research was required because of retrospective nature and potential bias of the data.

Epidermal growth factor receptor as an adverse survival predictor in squamous cell carcinoma of the penis

Penile carcinoma (PC) is more frequent in underdeveloped countries, generally is diagnosed at an advanced stage when therapeutic options are restricted, and thus is associated with high morbidity/mortality rates. Recent studies have demonstrated clinical benefits with epidermal growth factor receptor (EGFR)-targeted therapy in patients with PC, although there is no test that provides accurate patient selection. The aim of the present study was to evaluate the prognostic value of EGFR gene and protein status in tumor samples from patients with primary penile squamous cell carcinoma. We assessed the expression of wild-type and 2 mutant EGFR isoforms (delA746-E750 and mL858R) by immunohistochemistry in 139 samples, of which 49 were also evaluated for EGFR copy number by fluorescence in situ hybridization (FISH). Positive immunohistochemical staining of wild-type and mutant EGFR was evidenced by complete and strong membranous staining. For FISH analysis, cases were considered unaltered, polysomic, or amplified, as determined by signals of the EGFR gene and chromosome 7. An independent cohort of 107 PC samples was evaluated for mutations in EGFR, KRAS, and BRAF. Protein overexpression was noted in nearly half of the cases and was associated with cancer recurrence (P=.004) and perineural invasion (P=.005). Expression of the 2 mutated EGFR isoforms was not observed. The FISH status was not associated with protein expression. Altered FISH (polysomy and gene amplification) was an independent risk factor for dying of cancer. Only 1 patient of 107 presented KRAS mutations, and no mutations of EGFR or BRAF were observed.

Epithelial-mesenchymal transition (EMT) phenotype at invasion front of squamous cell carcinoma of the penis influences oncological outcomes

OBJECTIVE

Our aims were to evaluate epithelial-mesenchymal transition (EMT) as a useful prognostic marker in penile carcinoma (PC), and establish an objective criterion to define EMT in PC specimens.

MATERIALS AND METHODS

A total of 149 consecutive cases surgically treated for PC were retrospectively selected. E-cadherin (E-CAD) and vimentin immunohistochemical expressions were evaluated. A combined analysis was performed using both markers to determine EMT status. To establish a normal control to E-CAD expression, we included 14 cases from circumcisions from patients without any neoplastic disease and 77 cases of tumor-free margins. The analyses of tumor samples were evaluated in 2 different areas of the tumor. The first one was in the tumor core. The second analyses were performed on the deepest infiltrative edge of the tumor, nominated invasion front. Cases were classified into EMT absent group, partial EMT group and complete EMT group. Overall survival (OS) and cancer-specific survival (CSS) were analyzed. Kaplan-Meier curves and the log-rank test were used. Cox proportional hazards model was used to determine which variables influenced survival.

RESULTS

Tumor specimens presented a significant loss of expression of E-CAD when compared with normal epithelium. Vimentin expression in more than 10% of tumor cells was observed in 50 cases. EMT status was associated with histologic grade, pattern of invasion, lymph node metastasis, and perineural and vascular invasion. Further, 10-year OS and CSS rates in patients with presence and absence of complete EMT status were 38.0% and 55.6%; and 48.0% and 91.9%, respectively. EMT status significantly affected CSS and OS rates even after patients were grouped based on lymph node involvement status. The presence of complete EMT status was associated with both CSS and OS rates. Patients in the complete EMT group had a higher risk of death from cancer (hazard ratio = 7.6, P<0.001) and overall death (hazard ratio = 3.0, P<0.001).

CONCLUSION

Our study represents an evidence of the prognostic effect of EMT in PC. We encourage the study of EMT markers in other centers to validate our findings and confirm its importance in such tumors.

Genome-wide methylation and transcriptome analysis in penile carcinoma: uncovering new molecular markers

BACKGROUND

Despite penile carcinoma (PeCa) being a relatively rare neoplasm, it remains an important public health issue for poor and developing countries. Contrary to most tumors, limited data are available for markers that are capable of assisting in diagnosis, prognosis, and treatment of PeCa. We aimed to identify molecular markers for PeCa by evaluating their epigenomic and transcriptome profiles and comparing them with surrounding non-malignant tissue (SNT) and normal glans (NG).

RESULTS

Genome-wide methylation analysis revealed 171 hypermethylated probes in PeCa. Transcriptome profiling presented 2,883 underexpressed and 1,378 overexpressed genes. Integrative analysis revealed a panel of 54 genes with an inverse correlation between methylation and gene expression levels. Distinct methylome and transcriptome patterns were found for human papillomavirus (HPV)-positive (38.6%) and negative tumors. Interestingly, grade 3 tumors showed a distinct methylation profile when compared to grade 1. In addition, univariate analysis revealed that low BDNF methylation was associated with lymph node metastasis and shorter disease-free survival. CpG hypermethylation and gene underexpression were confirmed for a panel of genes, including TWIST1, RSOP2, SOX3, SOX17, PROM1, OTX2, HOXA3, and MEIS1.

CONCLUSIONS

A unique methylome signature was found for PeCa compared to SNT, with aberrant DNA methylation appearing to modulate the expression of specific genes. This study describes new pathways with the potential to regulate penile carcinogenesis, including stem cell regulatory pathways and markers associated to a worse prognosis. These findings may be instrumental in the discovery and application of new genetic and epigenetic biomarkers in PeCa.

Prognostic factors in patients with penile carcinoma and inguinal lymph node metastasis

OBJECTIVES

To identify prognostic factors in patients with penile carcinoma and confirmed lymph node metastasis.

METHODS

Patients were selected from a historical series of patients with penile carcinoma. An experienced pathologist reviewed all cases. Information regarding the total number of lymph nodes excised, the number of positive lymph nodes and the presence of extranodal extension were used. Lymph node ratio was categorized as <0.15 and >0.15.

RESULTS

The 5-year recurrence-free survival and disease-specific survival rates were 55.3% and 64.1%, respectively. Lymphovascular invasion, lymph node ratio and pN status influenced survival rates in univariate analysis. Lymphovascular invasion and lymph node ratio remained as independent predictors of disease-specific survival and recurrence-free survival in the multivariate analysis. A risk stratification of death and tumor recurrence was observed when patients were grouped into three categories: absence of risk factors; the presence of one risk factor; and the presence of two or more risk factors.

CONCLUSIONS

The presence of one or more of the following parameters is correlated with a significantly higher risk of death and tumor recurrence in patients with penile carcinoma and inguinal lymph node metastasis: extranodal extension, lymph node ratio >0.15 and lymphovascular invasion.

SOD2 immunoexpression predicts lymph node metastasis in penile cancer

BACKGROUND

Superoxide dismutase-2 (SOD2) is considered one of the most important antioxidant enzymes that regulate cellular redox state in normal and tumorigenic cells. Overexpression of this enzyme in lung, gastric, colorectal, breast cancer and cervical cancer malignant tumors has been observed. Its relationship with inguinal lymph node metastasis in penile cancer is unknown.

METHODS

SOD2 protein expression levels were determined by immunohistochemistry in 125 usual type squamous cell carcinomas of the penis from a Brazilian cancer center. The casuistic has been characterized by means of descriptive statistics. An exploratory logistic regression has been proposed to evaluate the independent predictive factors of lymph node metastasis.

RESULTS

SOD2 expression in more than 50% of cells was observed in 44.8% of primary penile carcinomas of the usual type. This expression pattern was associated with lymph node metastasis both in the uni and multivariate analysis.

CONCLUSIONS

Our results indicate that SOD2 expression predicts regional lymph node metastasis. The potential clinical implication of this observation warrants further studies.

Pathologic and imunohistochemical characterization of tumoral inflammatory cell infiltrate in invasive penile squamous cell carcinomas: Fox-P3 expression is an independent predictor of recurrence

Penile carcinomas (PeCa) are relatively rare, but devastating neoplasms, more frequent among people of underprivileged socioeconomic status. There is mounting evidence that immune cells may trigger various mechanisms that enhance tumor growth and metastasis, but no data on the peritumoral inflammation is available for PeCa. The objectives of the present study are to evaluate the immunohistomorphology of tumoral inflammation in PeCa, and to correlate it with clinicopathological parameters, which could contribute to the prognostic evaluation. One hundred and twenty-two patients with the diagnosis of usual-type squamous cell penile carcinoma were included. Paraffin-embedded tissue was submitted to immunohistochemical evaluation of p16 protein, CD3, CD4, CD8, CD20, CD68, CD138, granzyme B, and Fox-P3. The Fisher's exact test was employed for comparison between histological variables and parameters, and the Kaplan-Meier method for the analysis of survival. Improved 5-year overall survival was significantly associated to age ≤60 years, stage I + II, tumor size T1 + T2, lymph node status N0, and absent perineural invasion. In a multivariate analysis age ≥60 years, presence of lymph node metastasis, urethral invasion, and high histologic grade retained a significantly more unfavorable outcome. Improved 5-year failure free survival was associated to stage of the disease I + II, lymph node status N0, absence of perineural, vascular, and urethral invasion, and Fox-P3 expression. In a multivariate analysis, presence of lymph node metastasis, perineural and vascular invasion, and of Fox-P3-positive lymphocytes together with low inflammatory infiltrate retained a significantly more unfavorable outcome. These results support the prognostic value of determining the levels of Fox-P3-positive lymphocytes by immunohistochemistry in PeCa, as this parameter adds value to the traditional clinicopathological features.

Penile cancer

OBJECTIVES

To review the risk factors, prevention, treatment, and management of the patient with penile cancer.

DATA SOURCES

Publications; clinical experience.

CONCLUSION

Penile cancer is a rare malignancy in the United States, but is more common in developing countries. The disease is so uncommon in the United States that there are oncology nurses who have never cared for a patient with this diagnosis.

IMPLICATIONS FOR NURSING PRACTICE

With significant psychosocial implications for the patient with penile cancer and partner, it is important that the nurse have an understanding of the diagnosis, treatment, and care of these patients.

Combination of docetaxel and cetuximab for penile cancer: a case report and literature review

Guidelines on the treatment of metastatic squamous cell carcinoma of the penis are limited to a few prospective trials. Cisplatin-based regimens represent the standard of treatment with promising activity of taxanes. Recently, epidermal growth factor receptor overexpression has been shown in these patients. We treated an elderly man with a docetaxel-cetuximab combination after failure of the cisplatin regimen. We observed a necrosis of the inguinal lymph nodes and a reduction of (18)F-fluorodeoxyglucose uptake at PET/CT scan. Only mild mucositis and skin toxicity had been detected. Our case report, the first in the literature, shows that this combination is active and well tolerated in penile squamous cell carcinoma.