Penile cancer: review of the recent literature:

Natural history of human papillomavirus and vaccinations in men: A literature review

BACKGROUND AND AIMS

Infection with high-risk (HR) genotypes of the human papillomavirus (HPV) is necessary for and causative of almost all cervical cancers and their precursor condition, cervical intraepithelial neoplasia. These conditions have been sharply reduced by cervical cytology screening, and a further decrease is expected because of the recent introduction of prophylactic HPV vaccinations. While significant attention has been given to gynecologic HPV disease, men can be affected by HPV-related cancers of the anus, penis, and oropharynx. This literature review aims to address disparities in HPV-related disease in men, and certain HR male subpopulations, compared with women.

DISCUSSION

Overall, immunocompetent men are far less likely than women to develop anogenital HPV-related cancers, despite harboring HR HPV infections at anogenital sites. On the other hand, men who have sex with men and men living with human immunodeficiency virus infection are at considerably higher risk of HPV-related disease. Historic rates of prophylactic HPV vaccination in males have trailed those of females due to numerous multilevel factors, although, in recent years, this sex gap in vaccination coverage has been closing. In the absence of routine HPV screening in males, therapeutic vaccinations have emerged as a potential treatment modality for preinvasive neoplasia and are in various phases of clinical testing.

CONCLUSION

Successful reductions in HPV disease morbidity at the population level must acknowledge and target HPV infections in men.

Myiasis associated with penile carcinoma: a new trend in developing countries?

Objectives

The aim of this study is to report an unusual form of penile cancer presentation associated with myiasis infestation, treatment options and outcomes.

Materials and Methods

We studied 10 patients with suspected malignant neoplasm of the penis associated with genital myiasis infestation. Diagnostic assessment was conducted through clinical history, physical examination, penile biopsy, larvae identification and computerized tomography scan of the chest, abdomen and pelvis. Clinical and pathological staging was done according to 2002 TNM classification system. Radical inguinal lymphadenectomy was conducted according to the primary penile tumor pathology and clinical lymph nodes status.

Results

Patients age ranged from 41 to 77 years (mean=62.4). All patients presented squamous cell carcinoma of the penis in association with myiasis infestation caused by Psychoda albipennis. Tumor size ranged from 4cm to 12cm (mean=5.3). Circumcision was conducted in 1 (10%) patient, while penile partial penectomy was performed in 5 (50%). Total penectomy was conducted in 2 (20%) patients, while emasculation was the treatment option for 2 (20%). All patients underwent radical inguinal lymphadenectomy. Prophylactic lymphadenectomy was performed on 3 (30%) patients, therapeutic on 5 (50%), and palliative lymphadenectomy on 2 (20%) patients. Time elapsed from primary tumor treatment to radical inguinal lymphadenectomy was 2 to 6 weeks. The mean follow-up was 34.3 months.

Conclusion

The occurrence of myiasis in the genitalia is more common in patients with precarious hygienic practices and low socio-economic level. The treatment option varied according to the primary tumor presentation and clinical lymph node status.

Update in the surgical principles and therapeutic outcomes of inguinal lymph node dissection for penile cancer

OBJECTIVES

Inguinal lymph node dissection (ILND) for the treatment of metastatic penile squamous cell carcinoma (SCC) has historically been associated with significant morbidity. This review addresses the surgical principles and techniques to decrease its perioperative morbidity, while optimizing its oncologic outcomes.

MATERIALS AND METHODS

A review of the English scientific literature from 1966 to present was conducted using the PubMed search engine as well as of additional cited works not initially noted in the search using as keywords penile cancer, inguinal lymph node dissection, inguinal lymph node metastasis, morbidity, and complications.

RESULTS

The contemporary outcomes of ILND in the context of penile cancer have built on the significant contributions made by surgeons and scientists worldwide. In this review, we provide a comprehensive overview of the principles of ILND optimizing oncological outcomes, while minimizing its attributable morbidity. It is hoped this review will serve as a benchmark for clinicians to approach this often highly aggressive tumor phenotype.

CONCLUSIONS

ILND remains an important diagnostic and therapeutic procedure for patients with penile SCC, as contemporary ILND series have reported a decrease in its associated morbidity, with the potential for further treatment outcomes in years to come. ILND can in appropriately selected patients render them disease-free, thus justifying its associated morbidity.

Epidemiologic study on penile cancer in Brazil

OBJECTIVES

To assess epidemiologic characteristics of penile cancer in Brazil.

MATERIALS AND METHODS

From May 2006 to June 2007, a questionnaire was distributed to all Brazilian urologists. Their patients' clinical and epidemiological data was analyzed (age, race, place of residence, history of sexually transmitted diseases, tobacco smoking, performance of circumcision, type of hospital service), as well as the time between the appearance of the symptoms and the diagnosis, the pathological characteristics of the tumor (histological type, degree, localization and size of lesion, stage of disease), the type of treatment performed and the present state of the patient.

RESULTS

283 new cases of penile cancer in Brazil were recorded. The majority of these cases occurred in the north and northeast (53.02%) and southeast (45.54%) regions. The majority of patients (224, or 78.96%) were more than 46 years of age while only 21 patients (7.41%) were less than 35 years of age. Of the 283 patients presenting penile cancer, 171 (60.42%) had phimosis with the consequent impossibility to expose the glans. A prior medical history positive for HPV infection was reported in 18 of the 283 cases (6.36%). In 101 patients (35.68%) tobacco smoking was reported. The vast majority of the cases (n = 207; 73.14%) presented with tumors localized in the glans and prepuce. In 48 cases (16.96%) the tumor affected the glans, the prepuce and the corpus penis; in 28 cases (9.89%) the tumor affected the entire penis. The majority of the patients (n = 123; 75.26%) presented with T1 or T2; only 9 patients (3.18%) presented with T4 disease.

CONCLUSION

Penile cancer is a very frequent pathology in Brazil, predominantly affecting low income, white, uncircumcised patients, living in the north and northeast regions of the country.

Optionen der palliativen Therapie des Peniskarzinoms

Penile cancer, with an incidence of 0.1-0.9/100,000 males/year, is one of the least common malignant tumors. Most patients are over 50 years old and the tumor is slow growing. Therapeutic success is highly dependent on lymph node status. Cancer related death is usually due to local complications such as arrosion bleeding caused by the tumor or infected inguinal metastases. The therapy for advanced penile cancer and its complications represents a challenge. Taking into consideration quality of life, the therapeutic strategy should be based on the patient's age, his sexual function, motivation and psychological condition, as well as previous illnesses and tumor biology. Palliative therapy requires good interdisciplinary work between oncologists, radiologists, plastic surgeons, physiotherapists and psychologists.

Die systemische Therapie des Peniskarzinoms

Penile cancer is a rare tumor in Europe with an incidence of 0.1-0.9 per 100,000 men per year. The success of our therapy is mainly influenced by the presence of lymph node metastases. At first diagnosis 17-45% of patients already harbor lymph node metastases. Bilateral inguinal and pelvic lymphadenectomy is a curative measure in these patients. In cases of gross inguinal metastases neoadjuvant chemotherapy leads to a remission rate of 21-60% and improves the resectability. The influence on survival is not proven. The same holds true for adjuvant therapy following lymphadenectomy. Polychemotherapy rarely leads to long-lasting complete remission in patients with distant metastases. The protocols consist usually of cisplatin, bleomycin, methotrexate, and 5-fluorouracil. The overall remission rate is around 15-32%. Because of the low efficacy of the present chemotherapy regimens, one should follow new strategies, comparable to those initiated for squamous cell cancer of other organs.

Sexual function after partial penectomy for penile cancer

OBJECTIVES

To compare sexual function and satisfaction before and after partial penectomy and to evaluate possible dysfunctions that could modify postoperative sexual functioning.

METHODS

A total of 18 patients underwent a personal interview and answered the International Index of Erectile Function questionnaire to determine erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction with sexual life. Domain scores were computed by summing the scores for individual answers, and the final scores were compared before and after partial penectomy.

RESULTS

The median patient age was 52 years. The medium penile length after partial penectomy was 4 cm in the flaccid state; 55.6% of patients reported erectile function that allowed sexual intercourse. The main reason for not resuming sexual intercourse appeared to be related to feelings of shame owing to the small penis size and the absence of the glans penis found in 50% of sexually abstinent patients. Surgical complications also compromised the resumption of sexual activity after amputation in 33.3% of these patients. However, 66.7% sustained the same frequency and level of sexual desire as before surgery, and 72.2% continued to have ejaculation and orgasm every time they had sexual stimulation or intercourse. Only 33.3% maintained their preoperative sexual intercourse frequency and were satisfied with their sexual relationship with their partners and their overall sex life.

CONCLUSIONS

The preoperative and postoperative scores were statistically different for all domains of sexual function after partial penectomy.

Lymphadenektomie beim Peniskarzinom

Lymphadenectomy is an essential part of diagnosis and treatment of the squamous cell carcinoma of the penis. Lymphadenectomy is performed depending on various characteristics of penile cancer such as depth of invasion, tumor grade, invasion into the corpora cavernosa, invasion into vascular and lymphatic vessels. In case the inguinal lymphnodes are not palpable a modified lymphadenectomy is indicated. The limits of lymphadenectomy are extended to the radical type of dissection when the frozen section indicates cancer. Inguinal lymphadenectomy is always performed on both sides. Are more than 2 nodes positive the lymphnodes in the true pelvis have to be resected as well. The dynamic sentinel lymphnode dissection may replace the modified approach in case randomized prospective studies will confirm the initial positive results and morbidity can be reduced as well. The immediate lymphadenectomy is superior to the delayed lymphadenectomy (palpable nodes during followup) in terms of local recurrence and survival. According to the risk profile patients with palpable inguinal lymphnodes can be initially managed conservatively. In case the lymphnodes remain palpable, lymphadenectomy is indicated. In this situation it is reasonable to perform imaging studies of the pelvis and abdomen for adequate planning of the surgical approach. Neoadjuvant chemotherapy is reasonable for patients with bulky nodes fixed to the skin or fascia because this improves respectability, freedom from local recurrence and increases survival. Adjuvant chemo- and/or radio-therapy are reserved for extended disease or palliative situations.

EAU Guidelines on Penile Cancer

OBJECTIVES

The European Association of Urology (EAU) consensus group on penile cancer has prepared these guidelines to help urologists assess the scientific evidence for the management of penile cancer and to incorporate recommendations into their clinical practice.

METHOD

References used in the text have been assessed according to the level of scientific evidence involved and guideline recommendations have also been evaluated according to the Agency for Health Care Policy and Research [Clinical Practice Guidelines Development: Methodological Perspectives. Washington DC: US Department of Health and Human Services, Public Health Service; 1992, pp. 115-127].

RESULTS

The diagnosis, treatment and follow-up of patients suspected of, or diagnosed with, penile cancer is listed as an easy reference text.

CONCLUSION

A guidelines text is presented which aims at aiding medical specialists in determining the most optimal diagnostic and treatment options for this pathology.