Identification of Prognostic Pathologic Parameters in Squamous Cell Carcinoma of the Penis: Significance and Difficulties

Pathology of Squamous Cell Carcinoma of the Penis: Back to Square One

The landscape of squamous cell carcinoma of the penis (SCC-P) has undergone a significant transformation since the new World Health Organization classification of genitourinary cancers and recent European Association of Urology/American Association of Clinical Oncology guidelines. These changes emphasize the necessity to categorize SCC-P into 2 groups based on its association with human papillomavirus (HPV) infection. This shift has major implications, considering that prior knowledge was derived from a mix of both groups. Given the distinct prognosis, treatment options, and staging systems observed for HPV-associated tumors in other body areas, the question now arises: will similar patterns emerge for SCC-P?

Prognostic factors in Taiwanese patients with penile-invasive squamous cell carcinoma

In Taiwanese patients, carcinoma of the penis is an uncommon disease. We retrospectively reviewed potential prognostic factors in Taiwanese patients with invasive-penile squamous cell carcinoma (SCC). From 1997 to 2009, 52 patients were enrolled. The median patient age at diagnosis was 66.5 years and the peak incident occurred during the 6(th) and 7(th) decades of life. Thirteen patients (25%) died of penile cancer, with a mean follow-up time of 45 months (interquartile range: 15-64 months). The 5-year cumulative cancer-specific survival rate was 81%, with 100% for those with Stage I, 90% for those with Stage II, 60% for those with Stage III, and 14% for those with Stage IV. Eleven variables, including grade, tumor, node, metastasis (TNM) stage, involvement of corpus spongiosum or corpora cavernosa, lymphovascular or perineural invasion, lymphadenectomy, and palpable lymph node, with p < 0.05 using univariate analysis were chosen for multivariate regression analysis. Three of these potential prognostic factors, including histological grade, distant metastasis, and lymphovascular invasion, remained statistically significant. Our study is the first report using the latest TNM classification (2009) to determine these potential predictors with penile SCC in Taiwan.

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.

Comparison of morphologic features and outcome of resected recurrent and nonrecurrent squamous cell carcinoma of the penis: a study of 81 cases

Penile squamous cell carcinoma (SCC) is considered a loco-regional disease with a fairly predictable pattern of progression. Widespread dissemination occurs in at least one-third of the patients. Local recurrence (defined as the presence of tumor after a primary treatment affecting any remainder tissue, including skin, erectile corpora, or urethra) present in up to 30% of the patients increases the risk of regional inguinal and pelvic lymph nodes metastases. The aim of this study was to identify adverse pathologic prognostic factors in patients with recurrent tumors. Clinicopathologic features of 81 surgically treated patients (25 with recurrent and 56 with nonrecurrent SCC) were evaluated; 56 patients (19 with recurrent and 37 with nonrecurrent tumors) additionally received groin dissections. Follow-up (2 to 372 mo, mean of 71 mo) was obtained in all patients. Comparison of recurrent tumors at the time of the primary diagnosis and of recurrence showed that histologic subtype and grade were identical in 76% of the cases and converted to a higher grade tumor in 24% of the cases, especially, in patients treated with local excisions and circumcisions. Most of the recurrences (67%) seemed at or before 12 months. Comparison of recurrent and nonrecurrent tumors showed that high grade tumors (basaloid and sarcomatoid) tended to be significantly associated with recurrent tumors, whereas low grade variants (papillary, warty and verrucous) were more frequent in the nonrecurrent group; recurrent tumors invaded into deeper anatomic levels than nonrecurrent tumors. The incidence of inguinal lymph node metastasis was higher in recurrent tumors (79% vs. 49%, P=0.0272). Cancer-specific survival was of 46% versus 76% at 3 years of follow-up in recurrent and nonrecurrent tumors, respectively. Patients with recurrent tumors had a median survival of 2.9 years; no major changes in survival were noted after 3 years of follow-up. Mortality was higher in the recurrent group (56% vs. 29%, P=0.0188); 80% of patients with high-grade tumors (basaloid, sarcomatoid, and high grade usual or hybrid verrucous SCCs) died from penile cancer. Mortality in patients with usual SCC was higher in the recurrent group, but similar in basaloid and sarcomatoid SCCs. After 3 years there was no survival difference in patients with low-grade recurrent tumors; however, in the high grade recurrent group there was a progressive and gradual decrease in survival from 2 to 10 years (median survival of 2.5 y). In summary, histologic subtypes and grades of SCCs were similar in the majority of original and recurrent carcinomas. Inguinal metastasis and mortality were higher in recurrent than in nonrecurrent carcinomas. Basaloid, sarcomatoid, and mixed usual-verrucous variants and invasion of corpora cavernosa or preputial skin were significant adverse prognostic factors of recurrent carcinomas. Local excision and partial penectomy were not adequate procedures for sarcomatoid and basaloid penile carcinomas. Carcinomas of foreskin had a better prognosis. Conversion from low to high-grade carcinoma was related to significant mortality. The identification of the adverse prognostic factors found in this study should be the base for an aggressive initial therapy to prevent recurrence in a subset of penile cancers. Re-excision of the recurrent tumor permitted the control of the disease only in one-third of the patients.

Autopsy Findings in 14 Patients With Penile Squamous Cell Carcinoma

The aim of this study was to describe pathologic features found at autopsy of 14 patients with penile cancer. Nine patients died from disseminated disease; 5 of them presented local/regional recurrences. Five patients died from other causes, 2 of them postoperatively. Local recurrence sites were corpus cavernosum, Buck’s fascia and urethra, regional skin, and prostate. Metastatic sites were lymph nodes (9 cases), liver (7 cases), lungs (6 cases), heart (5 cases), adrenals, bone and skin (3 cases each), thyroid and brain (2 cases each), and pancreas, spleen, and pleura (1 case each). Patients with heart metastasis had arrhythmias. Patients who died and who did not die from penile cancer had different profiles: low-grade superficial tumors with usual and warty subtypes versus high-grade deeply invasive basaloid or hybrid verrucous/sarcomatoid carcinomas. A natural history model for penile cancer routes of spread is proposed: local intrapeneal, regional and systemic nodes, regional skin, liver, lungs, heart, and other multiple sites.

Prognostic factors in invasive squamous cell carcinoma of the penis: analysis of 196 patients treated at the Brazilian National Cancer Institute

PURPOSE

We evaluated the role of primary tumor histopathological features for predicting regional metastasis and the prognosis in patients with penile squamous cell carcinoma.

MATERIALS AND METHODS

From April 1996 to January 2007, 202 consecutive patients with penile carcinoma underwent surgical treatment at our institution. Of these patients 196 were studied to identify prognostic factors. All histological specimens were examined by the same pathologist. We considered certain histological parameters, including histological grade, invasion depth, lymphovascular embolization, perineural infiltration, infiltration of the corpus cavernosum or spongiosum, urethral infiltration and koilocytosis.

RESULTS

Variables significantly associated with regional metastasis on univariate analysis were stage stratification (p = 0.0338), histological grade (p = 0.0112), invasion depth (0.0114), lymphovascular embolization (p <0.0001), perineural infiltration (p = 0.0092), corpora cavernosa infiltration (p = 0.0005) and koilocytosis (p = 0.0013). In the multivariable model lymphovascular embolization and absent koilocytosis were independent risk factors for lymphatic metastasis (p = 0.001 and 0.009, respectively). We also found a better survival rate in patients with koilocytosis and without lymphovascular embolization (p = 0.001 and 0.005, respectively).

CONCLUSIONS

Lymphovascular embolization and absent koilocytosis were independent prognostic factors for the risk of lymphatic metastasis. Patients with koilocytosis and without lymphovascular embolization had better 5-year survival.

Histologic grade and perineural invasion are more important than tumor thickness as predictor of nodal metastasis in penile squamous cell carcinoma invading 5 to 10 mm

Penile squamous cell carcinomas (SCCs) invading to a depth inferior to 5 mm usually have very low risk for regional metastasis, whereas tumors thicker than 10 mm have a high metastatic potential. A significant number of squamous cell carcinomas, however, belong to an intermediate category (5 to 10 mm in thickness) in which the incidence of regional lymph node metastasis is very difficult to predict. Consequently, a frequent clinical dilemma is whether to perform or not inguinal dissection in this group of lesions. The objective of this study was to evaluate multiple risk factors for regional metastasis in tumors 5 to 10-mm thick. One hundred thirty-four partial penectomies with invasive carcinomas 5 to 10-mm thick, all of which with corresponding inguinal lymph node dissection, were evaluated. Factors evaluated were--patient's age, anatomic site, histologic grade, tumor thickness, anatomic levels of invasion, and vascular and perineural invasion. Grades were classified as 1, well; 2, moderately; and 3, poorly differentiated. To evaluate independent significance of various prognostic factors, a logistic regression analysis was performed, and a nomogram was prepared to evaluate metastatic risk according to histologic grade and perineural invasion. Groin metastasis was found in 66 of 134 patients (49%). High histologic grade and perineural invasion were statistically significant pathologic factors associated with groin metastasis. Nodal metastases were found in 2 of 25 grade 1 (8%), 24 of 46 grade 2 (52%), and 40 of 63 grade 3 carcinomas (63%) (P value 0.0001). Of 48 patients with perineural invasion, metastasis was found in 33 cases (69%) (P value 0.001). The average tumor thickness, anatomic level of invasion, and presence of vascular invasion were not statistically significantly different in metastasizing and nonmetastasizing neoplasms. Fifty percent of tumors invading 5 to 10 mm were not associated with metastasis and may be spared a nodal dissection. In this subset of patients, high histologic grade and perineural invasion were significant and useful risk factors associated with regional metastasis. The probability of inguinal node metastasis in patients with grade 1 tumors without perineural invasion is almost nonexistent whereas for high-grade tumors associated with perineural invasion is near 80%.