Carcinoma of the penis. Experience with 153 cases

An update on treatment of penile cancer

Penile cancer is a rare malignancy, particularly in industrialized nations. In the United States, rates are approximately less than 1 per 100,000 men per year with just over 2000 new cases per year. However, there is significantly increased prevalence in developing nations, with limited treatment expertise and reduced access to care, further driving an unmet clinical need. The most noteworthy risk factor for penile cancer is the association with human papillomavirus infection, which may be present in up to 50% of all penile carcinomas. In addition to local primary tumor approaches, multimodality treatment strategies are vital to patients with clinical regional nodal disease, locally advanced disease. Presence and degree of lymph node involvement remains the most important prognostic factor and patients may benefit from multiple treatment strategies. Interim analysis data from the first randomized clinical trial is expected to yield results in mid/late 2024–early 2025. These treatment approaches include neoadjuvant chemotherapy, adjuvant therapy, including chemotherapy and radiation. Systemic therapy for distant recurrent or metastatic disease is primarily a platinum-based chemotherapy, however with poor overall response. As poor outcomes remain high, particularly in indigent populations, there remains an unmet need for these patients, particularly for high level randomized trials and novel therapeutics. In this review, we will highlight treatment updates for penile cancer. In addition to standard of care, we will review novel lines of therapies including immunotherapies and targeted therapies as well as sequencing approaches.

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.

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.

Locally advanced penile carcinoma: classic emasculation or testis-sparing surgery?

PURPOSE

The study evaluates the clinical and pathological findings of 16 patients with locally advanced penile carcinoma (PC) submitted to emasculation, and discusses questions related to the usefulness of bilateral orchiectomy.

MATERIALS AND METHODS

Between 1999 and 2010, 172 patients with PC were treated. Sixteen (9 %) underwent emasculation. Data were retrieved from the institution's database including age, ethnicity, date of surgery, residential setting, level of schooling, time to diagnosis, type of reconstruction, complications, tumor stage and grade, vascular and perineural invasion along with invasion of corpus cavernosum, corpus spongiosum, testicles, scrotum and urethra.

RESULTS

A total of 16 patients (average: 63.1 years) with locally advanced PC were included. All were illiterate or semiliterate rural dwellers and 87% were white. The time to diagnosis was 8-12 months. The mean follow-up time was 31.9 months (1-119). By the time of the last follow-up, only seven patients (43.75%) were alive. Tumors were pT4 (n = 6), pT3 (n = 8), pT2 (n = 2), Grade I (n = 5) and Grade II (n = 11). The histopathological examination revealed invasion of the urethra (n = 13), scrotum (n = 5) and testicles (n = 1). The surgical margin was positive in one patient. Six patients (37.5%) had vascular invasion and 11 (68.7%) had perineural invasion. Currently, only one of the former is alive.

CONCLUSIONS

The finding of focal microscopic testicular infiltration in only one of 32 testicles, even in the presence of clinically apparent scrotal invasion, suggests that emasculation without bilateral orchiectomy is a safe treatment option for patients with locally advanced PC.

Prognostic factors and biomarkers of penile carcinoma

Penile squamous cell carcinoma (SCC) is a rare malignancy with highest incidence in underdeveloped and developing countries. Oncogenic human papilloma virus (HPV) DNA, mainly types 16 and 18, are found in ∼ 100% of patients with uterine cervix carcinoma. The incidence of this virus in SCC and its variations range from 30.5 to 80%. Despite controversies, contrary to the cervical carcinoma, in the carcinogenesis and disease progression of SCC, HPV-dependent and HPV-independent tumors need to be considered. Lymphadenectomies continue to be the gold standard treatment of lymph node metastases. Undesirable accuracy on staging system methods and high rates of lymphadenectomy complications are the principal objections to these surgical procedures; therefore, the main issue in patients with SCC is to know who should or should not undergo lymphadenectomy. The search for primary tumor anatomopathological and biomarker risk factors for lymph node metastases, such as has occurred in other tumors, may be an important tool to select lymphadenectomies candidates better. Histological subtypes, tumor grade, growth pattern, tumor thickness, lymphatic embolization by neoplasic cells and depth of infiltration have been reported as important prognostic factors for lymph node metastases. In our series, lymphatic vascular permeation, palpable lymph node after primary tumor control (cN stage), pattern of invasion, p53 and PCNA immunoreactivity are independent lymph node metastases risk factors in the multivariate model. It is strongly recommended that patients be concentrated in specialized centers or cancer hospitals and multi-centric prospective studies carried out on tumor markers in this rare disease, in order to stage better lymph node disease and avoid unnecessary surgeries with high morbidity rates.

Initial symptoms and delay in patients with penile carcinoma

OBJECTIVE

This study aimed to assess initial symptoms and factors associated with patients' and doctors' delay in penile carcinoma.

MATERIAL AND METHODS

Fifty consecutive patients with penile carcinoma treated with an organ-sparing technique and nine with partial amputation were enrolled in a prospective study at the Department of Urology, Örebro University Hospital, between 2005 and 2009. Face-to-face structured interviews in combination with self-assessment forms were used for the patients' descriptions of clinical symptoms, treatment seeking and reasons for delay. Data were also extracted from the medical records confirming time-lag between GP assessment, specialist care and time for diagnosis.

RESULTS

Erythema, rash and eczema were the most common initial symptoms (35%). In total, 65% had a patients' delay of more than 6 months, and among these there was a small, but not statistically significant, predominance for pT1 and pTis tumours. Living with a stable partner did not affect the delay. The most common reason for patients' delay was the feeling of embarrassment over symptoms localized in a sexual body area. Nine patients had a doctors' delay of more than 3 months from first special visit to diagnosis. Eight of these patients consulted dermatologists and were subjected to repeated biopsies, leaving premalignant results.

CONCLUSIONS

A considerable proportion of the patients had a patients' delay of more than 6 months, perhaps due to benign initial symptoms as erythema, rash or eczema. Psychological factors such as embarrassment and denial may also be involved, as well as insufficient awareness or knowledge.

Clinicopathologic features and human papillomavirus dna prevalence of warty and squamous cell carcinoma of the penis

Squamous cell carcinoma (SCC) accounts for 95% of penile malignant neoplasms. A subtype of SCC, named warty carcinoma (WC), is a morphologically distinct verruciform tumor with features of human papillomavirus (HPV)-related lesions. Descriptions of the behavior and histologic features of this tumor are scarce in the literature. The aim of this report is to analyze the clinicopathologic features and HPV deoxyribonucleic acid status in 60 SCCs and 11 WCs. The mean patient age was 46.5 +/- 15.9 years for WC and 52.6 +/- 12.4 years for SCC. No significant differences in age (p = 0.154) and clinical staging (T, p = 0.649; N, p = 0.497) between the two groups of tumors were found. When compared with SCCs, WCs exhibited less lymphatic embolization (p = 0.001), nodal metastasis (p = 0.019), and corpora cavernosa and corpus spongiosum infiltration (p = 0.040). Lymph node metastases were found in 34 of 60 SCC patients (56.7%) and in two of 11 WC patients (18.2%). No patients with WC tumors died of the disease compared with 19 of 60 (5-year specific survival, 66.0%) in the SCC group (p = 0.032). HPV deoxyribonucleic acid was more likely to be associated with WC (five of 11, 45.5%) than SCC (16 of 60, 26.7%), although significance was not reached (p = 0.209). The results suggest that WC is less aggressive and confers a better prognosis than typical SCC of the penis.

Dermatoses of the glans penis and prepuce

A wide range of infectious, neoplastic, and inflammatory dermatoses can affect the glans penis or prepuce. Some are unique to the genitalia. Other more common dermatoses may have a unique appearance when they involve genital skin and mucosa. A thorough understanding of regional anatomy and a systematic diagnostic approach are helpful in the management of a refractory penile dermatosis. We review embryology and regional anatomy, drug-induced eruptions, allergic and irritant dermatitis, infection, neoplasia, and traumatic and inflammatory dermatoses as they relate to the glans and prepuce. Our discussion focuses on the clinical features, office laboratory studies, and histopathologic findings that assist in diagnosis and treatment.

Prognostic factors in carcinoma of the penis: multivariate analysis of 145 patients treated with amputation and lymphadenectomy

PURPOSE

The major issue in penile cancer is deciding who should or should not undergo lymph node dissection. Clinical and invasive methods are not reliable for staging. Clinical and pathological factors involved in lymph node metastases and prognosis were evaluated in 145 patients with penile carcinoma staged according to the 1978 TNM system, and treated with amputation and lymphadenectomy.

MATERIALS AND METHODS

Clinical factors studied were patient age, race, disease evolution time, symptoms, and clinical T and N stages. Pathological factors of the primary tumor considered were tumor thickness, histological grade, lymphatic and venous embolization, infiltration of the corpora cavernosa, corpus spongiosum and urethra, mononuclear and eosinophilic infiltrates, and cell alterations suggestive of human papillomavirus. All slides were reviewed by 1 pathologist. The Cox regression hazards method for multifactorial analysis was used.

RESULTS

Followup ranged from 0.7 to 453.2 months (mean 85.8, median 32.7). The 5-year disease-free and overall survival rates were 45.3 and 54.3%, respectively. Venous and lymphatic embolizations were the main factors affecting significantly the incidence of lymph node metastasis, which were the main risks factors for recurrence and death. Pathologically proved infiltration of the corpora cavernosa, urethra and adjacent structures, which corresponded to stages T2, T3 and T4 disease, respectively, of the current TNM classification, were not significant predictors for incidence of lymph node metastasis, disease-free and overall survival or risk factors for recurrence and death.

CONCLUSIONS

Because venous and lymphatic embolizations were related to greatest risk of lymph node metastasis, we propose their evaluation in staging and therapeutic planning of patients with infiltrative tumors of the penis.

Topographic distribution of inguinal lymph nodes metastasis: significance in determination of treatment margin for elective inguinal lymph nodes irradiation of low pelvic tumors

PURPOSE

To study the distribution of gross inguinal lymph node metastasis and, in particular, its correlation with major pelvic bony structures on a simulation film.

METHODS AND MATERIALS

Thirty-seven cases of low pelvic tumors having gross inguinal lymph node metastasis that were treated with radiation therapy between November 1987 and December 1992 were segregated for study. The patient's nodes were palpated and marked with lead wire before the simulation film was assumed to be the origin of the previously uninfested node. A total of 84 such labeled nodes was taken. The geometric center of the usually round or elliptical node on the film was obtained from these 37 cases. These centers were transferred to and mapped collectively on a new simulation film showing major pelvic bony structures of left hemipelvis and upper femur.

RESULTS

Distribution of gross inguinal lymph nodes was found confined to the following area, as related to major pelvic bony structure: laterally, just abutting the tangential line that passes through lateral border of the femoral head; medially: 3 cm away from the body's midline axis; superiorly: 1 cm below the line that joins both upper borders of the femoral head; inferiorly: 2.5 cm below the low borders of ischial tuberosity. According to this rectangular boundary, three nodes were out of the field, nine nodes near the border less than 1 cm margin. This area adequately covered 86% (72 of 84) of the studied nodes.

CONCLUSION

Distribution study is important in determining the treatment margin. In general, an additional 1-2 cm beyond the area described above is the recommended treatment margin for elective inguinal lymph nodes irradiation with high confidence level of coverage.

Surgical treatment of invasive squamous cell carcinoma of the penis: retrospective analysis of 350 cases

Between 1960 and 1987, 414 patients with invasive squamous cell carcinoma of the penis were referred to the Brazilian National Cancer Institute. Inguinal metastases were demonstrated by lymphadenectomy in 39% of the 23 patients with stage N0, 49% of 92 with stages N1 and N2, and 100% of 18 with stage N3 disease. We analyzed the followup of 350 patients who underwent surgical treatment. In 224 patients (64%) amputation or some form of penile surgery was done initially, while 102 (29%) underwent amputation and lymphadenectomy, and 24 (7%) underwent palliative surgery for advanced squamous cell carcinoma. The statistics revealed a better 5-year survival rate for the patients who underwent lymphadenectomy concomitantly with penile surgery compared to those who underwent delayed lymphadenectomy (p < 0.001). Patients in whom systematic lymphadenectomy was negative had a better prognosis than those with positive systematic lymphadenectomy results (p < 0.001). The latter patients had a better prognosis compared with those in whom delayed lymphadenectomy was positive (p = 0.0103). Patients with well and moderately differentiated carcinoma had a higher survival rate at 5 years than did those with poorly differentiated carcinoma (p < 0.001 and p = 0.003, respectively). All deaths from metastatic disease occurred within 24 months among the patients who underwent systematic lymphadenectomy and within 5 years after simple penile surgery. In the short term, surgical debulking combined with reconstruction techniques allowed for improved quality of life in patients with advanced local-regional disease.

Squamous cell carcinoma of the penis. III. Treatment of regional lymph nodes

We analyzed the management of regional lymph nodes in 110 patients with squamous cell carcinoma of the penis treated at the Netherlands Cancer Institute between 1956 and 1989 with curative intent. Of 66 patients who presented with unsuspected nodes 57 were placed on a surveillance program, while lymph node dissection was performed in 5 (with adjuvant external radiation therapy in 1) and 4 were treated with external radiation therapy only. The management of 40 patients with clinically suspected nodes included surveillance in 5, lymph node dissection in 27 (with adjuvant radiotherapy in 11), biopsy in 4 and external radiation therapy in 4. Postoperative radiotherapy had been given if more than 2 nodes were involved or when extracapsular growth was observed. Overall, 25 patients had a regional recurrence, 5 of whom could be cured subsequently. All regional recurrences developed within 2 years after primary treatment. Analysis showed 100% survival in histologically proved node negative patients (stage pN0). The success of lymph node dissection was related to the extent of the metastatic spread and to the number of involved nodes. Patients with 1 positive node and unilateral inguinal involvement showed a statistically significant survival advantage compared to patients with more extensive spread. Considering the indications for node dissection we found a clear relationship among T category, grade and the probability of lymph node invasion. Patients with stage T1 tumors and stage T2, grades 1 and 2 tumors presented significantly less often with lymphatic invasion than those with other categories of disease and were less likely to have a regional recurrence after treatment of the primary tumor only. In these categories we recommend surveillance of the regional lymph nodes in patients who present with unsuspected nodes. However, patients with stage T2 grade 3, stage T3 and operable stage T4 tumors should undergo an immediate inguinal node dissection because of the high probability of clinically occult lymph node invasion (in our material more than 50%). With respect to the extent of the node dissection, we found that the likelihood of spread to the contralateral and/or pelvic regions was related to the number of invaded nodes in the inguinal region. We recommend contralateral node dissection and unilateral pelvic node dissection when 2 or more positive nodes are found in the dissected groin specimen. Primary pelvic node dissection should be performed in patients who present initially with cytologically or biopsy proved positive inguinal nodes.(ABSTRACT TRUNCATED AT 400 WORDS)

Carcinoma of the penis: the Indian experience

A total of 150 evaluable patients with carcinoma of the penis were treated at the Tata Memorial Hospital between 1984 and 1987. The majority of patients were in the 4th to 7th decades. All patients presented with a growth on the penis, the biopsy of which revealed squamous carcinoma. The primary lesions were T1 in 34, T2 in 73, T3 in 41, and T4 in 2 patients, respectively. The inguinal nodes were not palpable (N0) in 77 patients, palpable but histologically not metastatic in 39 patients, and metastatic in 34 patients. The treatment of the primary lesion was surgery in 142 patients and radiation therapy in 8 patients. Patients with nonpalpable nodes were kept under surveillance and those with pathologically metastatic nodes were subjected to bilateral ilioinguinal lymphadenectomy. The size related 5 year survivals were 83.3% for T1, 60.4% for T2, and 39.5% for T3 lesions. The 5 year survivals for patients with grade I lesions were 90.3%, for grade II 58.6%, and for grade III 16.7%. The 5 year survival rate for patients for N0 nodes was 75.4% while the 3 year survival rates for patients with N1 and N2 nodes were 40% and 38.8%, respectively. The factors signifying poor survival were perinodal extension and iliac node metastases. There were 8 penile stump recurrences, of which 6 could be salvaged. Metachronous inguinal node metastases developed in 16 patients among whom surgical lymphadenectomy was possible in 12 while 4 had unresectable metastases.

The role of ilioinguinal lymphadenectomy and significance of histological differentiation in treatment of carcinoma of the penis

We reviewed retrospectively the medical records of 58 patients treated for squamous cell carcinoma of the penis who were followed for more than 3 years or until they died. Tissue sections from all patients were reviewed. Of 15 patients with stage I disease 11 underwent partial penectomy, and 4 underwent partial penectomy and immediate ilioinguinal lymphadenectomy; none died of cancer. Nine patients with stage II and 9 with stage III disease underwent partial or total penectomy and immediate ilioinguinal lymphadenectomy, and 5-year survival was 100 and 75%, respectively. Of 20 patients with clinical stage II disease who did not undergo immediate ilioinguinal lymphadenectomy 18 had metastasis to the groin. Of these 18 patients 12 underwent delayed ilioinguinal lymphadenectomy but only 1 survived more than 5 years. We evaluated the possible significance of the degree of histological differentiation of the primary tumor to the course of the disease. Of the 23 cases of carcinoma in situ or well differentiated disease only 1 became metastatic, while of the 35 cases of moderately to poorly differentiated disease 31 metastasized to the groin. Vascular invasion of cancer cells in the primary tumor was another indicator for poor prognosis.

Treatment of cancer of the penis--a review

Cancer of the penis is a rare neoplasm and physicians should be aware of this condition. Early diagnosis and prompt treatment can lead to excellent results for low stage, low grade lesions. Herein, we discuss the clinical features, staging and management guidelines for this tumour.

Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results

The controversy surrounding the management of patients with invasive carcinoma of the penis and clinically negative nodes is discussed. The rationale, technique and preliminary results of a modified inguinal lymphadenectomy in which the lateral and caudal extents of nodal excision are reduced, and the saphenous veins are preserved also are presented. This modified lymphadenectomy has been performed in 6 patients with invasive carcinoma of the penis or distal urethra without major or troublesome complications.

Penile cancer. Aspiration biopsy cytology for staging

Appropriate management and prognosis of patients with penile carcinoma depends on an accurate knowledge of the regional node status. The usefulness of clinical and radiologic examinations in detecting the nodal spread of the disease is limited by the high rates of false-positive and false-negative results. On the other hand, routine or prophylactic lymphadenectomy is associated with 30% to 50% of the major morbidity and 3% of the mortality rate, so that caution is advisable for its use in patients with disease-free nodes. Even bilateral sentinel lymph node biopsy, as proposed by Cabanas, does not warrant an adequate selection of patients candidates to surgical treatment. The role of aspiration biopsy cytology in the management of penile carcinoma was evaluated in a study of 29 cases from the authors' institutions. Aspiration under fluoroscopic or computed tomographic guidance was performed using a 22-23-gauge Chiba needle. The accuracy of aspiration biopsy cytology in identifying the true stage of the disease was 100%. On histologic control, only one node contained malignant cells that were not detected by aspiration biopsy cytology, but this finding did not alter the stage of the patient. Positive cytology is conclusive of Stage III disease and, in this case, a curative lymphadenectomy may be attempted. Negative aspirations do not warrant the absence of metastatic nodal involvement as can be seen in two patients in this series. In such cases, however, a policy of "wait and watch" may be adopted, with repeated aspiration biopsies or surgical biopsy of the sentinel node area.

Cancer of the penis. Prognosis and treatment plans

Sixty-one patients with clinical low-stage (Jackson Stage I) and 22 patients with clinical high-stage (Jackson Stage II or III or T3-4N0-1M0) carcinoma of the penis who were seen between 1952 and 1979 and followed for at least 3 years or until death were reviewed. The majority of patients with Stage I cancer were treated with partial penectomy, either with or without ilioinguinal lymphadenectomy. The remainder of patients with these early small lesions were treated with local excision or circumcision. Forty-one of the patients with this early penile cancer (Jackson Stage I or Tcis, T1N0M0 or T2N0M0) survived at least 3 years and were considered cured. The other 20 patients died of cancer (12 cases) or unrelated disease (8 cases). If the patients who died of other diseases are excluded, the corrected 5-year survival rate was 77%. Treatment failure was primarily due to metachronous inguinal metastases after initial treatment of the primary tumor and failure of response of metastatic disease to salvage treatment. Four factors probably were associated with a poor prognosis: large primary tumor, moderately to poorly differentiated cancer, younger age at onset, and inadequate initial treatment. In advanced (Jackson Stages II and III) disease, treatment by partial or total penectomy alone or in combination with radiation to inguinal nodes after penectomy produced 3-year or longer survival in only 2 of 9 patients, whereas treatment by early extended excision of both the primary lesion and the ilioinguinal lymph nodes produced 3-year or longer survival in 11 of 13 patients. The results suggest that local excision is appropriate only for carcinoma in situ. Partial penectomy and monthly follow-up for at least 1 year is appropriate for patients with small, well-differentiated primary tumors. Patients who have large or moderately to poorly differentiated primary tumors probably should undergo partial or total penectomy and immediate ilioinguinal lymphadenectomy.

Reappraisal of the role of radiotherapy and surgery in the management of carcinoma of the penis

The iridium mould technique was used as the method of choice whenever possible in a series of 80 cases of cancer of the penis. When the growth was confined to the glans penis the survival rate was 89% but local recurrence called for subsequent amputation in 22%. When tumour had invaded the corpus cavernosum, irradiation improved the survival rate but amputation was required in 75 to 80%. Prognosis correlated well with histology, patients with a "cord" pattern having the worst prognosis.

The treatment of bilateral ulcerated lymph node metastases from carcinoma of the penis. A case report

A 44-year-old patient with histologically proven bilateral ulcerated lymph node metastases from a carcinoma of the penis was treated by sequenced combined chemotherapy and radical irradiation. Methotrexate and bleomycin were administered at weekly intervals for 5 weeks, followed by radiation with a split-course coning-down technique. The patient remains well and clinically disease-free 63 months after commencing therapy.

Management of regional lymph nodes in penile carcinoma. Five-year results following therapeutic groin dissections

Twenty-two patients with squamous carcinoma of the penis underwent groin dissections for histologically proved inguinal lymph node metastases, either around the time that the primary tumor was treated (early therapeutic dissection, 14 patients) or later, after they had been clinically judged free of regional nodal metastases at diagnosis (late therapeutic dissections, 8 patients). Three- and five-year survival rates for the patients who underwent early therapeutic dissections were 71 per cent and 57 per cent, respectively, as opposed to 50 per cent and 13 per cent, respectively, for patients who underwent late therapeutic dissections. These findings suggest that a "wait and watch" policy in patients with clinically negative nodes at diagnosis is no longer justified.

Elective ilioinguinal lymph node irradiation

Most radiologists accept that modest doses of irradiation (4500-5000 rad/4 1/2-5 weeks) can control subclinical regional lymph node metastases from squamous cell carcinomas of the head and neck and adenocarcinomas of the breast. There have been few reports concerning elective irradiation of the ilioinguinal region. Between October 1964 and March 1980, 91 patients whose primary cancers placed the ilioinguinal lymph nodes at risk received elective irradiation at the University of Florida. Included are patients with cancers of the vulva, penis, urethra, anus and lower anal canal, and cervix or vaginal cancers that involved the distal one-third of the vagina. In 81 patients, both inguinal areas were clinically negative; in 10 patients, one inguinal area was positive and the other negative by clinical examination. Tumor doses most commonly used were 4500-5000 rad/5 weeks (180 rad to 200 rad per fraction). With a minimum two-year follow-up, there were only two regional failures in patients whose primaries were controlled; both failures occurred outside of the radiation fields. The single significant complication was a bilateral femoral neck fracture. The inguinal areas of four patients developed mild to moderate fibrosis. One patient with moderate fibrosis had bilateral mild leg edema that was questionably related to irradiation. No other instances of leg or genital edema were noted. Complications were dose-related. The advantages and disadvantages of elective ilioinguinal node irradiation versus elective inguinal lymph node dissection or no elective treatment are discussed.

Carcinoma of the penis: analysis of 219 cases

Carcinoma of the penis is rare in this country. A total of 219 patients diagnosed to have carcinoma of the penis were analyzed retrospectively. The primary penile lesion was treated by partial amputation in 160 patients. Forty-two patients had inguinal node dissection. Forty-six patients received radiation therapy to the inguinal region. Sixty-five per cent of the patients with no palpable nodes at initial diagnosis survived for six or more years. Twenty-eight per cent of the patients with palpable nodes survived for three to five years, and 15% for six or more years. Ten per cent of the patients died of a second primary tumor.

Unreliability of sentinel lymph node biopsy for staging penile carcinoma

We present a patient in whom unresectable lymph node metastases developed within 6 months of negative bilateral sentinel lymph node biopsies. The management of regional lymph nodes of patients with carcinoma of the penis is discussed.

Primary carcinoma of the female urethra

The clinical and morphological features in 81 cases of carcinoma of the female urethra were reviewed. The over-all 5 and 10-year survival rate for the entire group was 32 per cent. Survival expectations for patients with squamous carcinoma, transitional cell carcinoma and adenocarcinoma were similar when analyzed according to stage and all cell types appeared to respond equally to irradiation. Prognosis was related directly to the clinical stage of the disease. A plea is made for more accurate assessment of the disease status. The high incidence of local recurrence noted for all forms of single modality therapy (46 to 64 per cent) suggests the need for clinical trials with combination preoperative irradiation followed by definitive surgical procedures.