Organ-sparing surgical and nonsurgical modalities in primary penile cancer treatment

Characteristics, trends, and management of Penile cancer in the United States: A population-based study

BACKGROUND

Penile cancer (PeCa) is a rare disease. HPV infection, smoking, phimosis, and lichen sclerosus represent well-known associated risk factors.

OBJECTIVES

Primary aim of our study is to evaluate the incidence and risk factors of PeCa and to outline the adopted diagnostic and therapeutic approaches. Secondary aim is to investigate risk factors associated with aggressive disease and to identify the complications arising from its surgical treatment.

MATERIALS AND METHODS

We conducted a retrospective analysis using the PearlDiver™ Mariner database, from January 1, 2011, to December 31, 2021, identifying all patients diagnosed with PeCa and PeIN, evaluating comorbidities, risk factors, and social and economic conditions. We evaluated the imaging modalities employed for staging as well as the treatment strategies. Finally, we evaluated the most frequent complications associated with inguinal lymphadenectomy (ILND).

RESULTS

During the study period, 17,494 patients were diagnosed with PeCa and 5,965 with penile intraepithelial neoplasia (PeIN). US was the most frequently utilized imaging modality, followed by PET and PET/CT. Use of CT and MRI was around 5%. Surgical treatment was the predominant strategy, utilized in 31.3% of PeCa and 22.9% of PeIN. Wide Local Excision/Glansectomy emerged as the most common surgical procedures. MLR analysis identified smoking as a risk factor for metastatic PeCa (OR; 95% CI = 1.49; 1.379-1.609), HPV infections were associated with a 35% decrease in risk (OR; 95% CI = 0.65; 0.562-0.744) (all P < 0.001). Lichen sclerosus and phimosis were associated with a doubled risk of demolitive surgery. Approximately 40% of patients experienced complications associated with ILND.

CONCLUSION

Despite advances in PeCa management, there's no significant move toward more conservative treatments. Surgical treatments are still marked by high rates of complications, potentially affect the sexual and psychosocial health of patients. These issues may foster a tendency toward avoidance behaviors, contributing to a delayed clinical presentation and treatment.

Clinical Outcomes and Prognostic Factors in Patients With Penile Carcinoma: A Sub-Analysis From Meet-URO 23 (I-RARE) Registry Study

INTRODUCTION

Penile squamous cell carcinoma (PSCC) is a rare tumor with an aggressive behavior. The Meet-URO 23/I-RARE registry includes rare genitourinary malignancies. We extracted patients with PSCC to conduct a retrospective study aimed at assessing clinical outcomes and prognostic factors.

PATIENTS AND METHODS

Primary endpoints were overall survival and progression-free survival. Prognostic factors for OS and PFS were analyzed using univariate and multivariate analysis. From the Meet-URO 23/I-RARE database, we extracted 128 patients with diagnosis of PSCC. About 48% of patients underwent first-line of therapy.

RESULTS

In the overall population, median OS from diagnosis was 34.6 months. Significant differences in median OS were observed according to ECOG PS at diagnosis (57.3 months vs. 8.3 months; P < .001), and median age (≤77y 88.8 months vs. >77y 26 months; P = .013). At multivariate analysis, ECOG PS 2-4 at diagnosis (HR 3.04) and lymph node metastases (HR 2.49) were independently associated with a higher risk of death. Among patients undergoing first-line therapy (n = 61), median OS was 12.3 months, and a statistically significant difference was found according to type of response to first-line (DCR 24.4 months vs. PD 7.1 months; P < .001). Multivariate analysis showed that only age >77 years was associated with a worse OS (HR 2.16). A statistically significant difference in PFS was found according to platinum plus 5-fluorouracil versus platinum plus taxane (4.9 vs. 3.4 months; P = .036) and regimens with 2 versus 3 drugs (3.4 vs. 8.6 months; P = .019). At the multivariate analysis only regimens with platinum plus taxane were associated with worse PFS (HR 2.83).

CONCLUSION

In our registry study, PSCC is confirmed to be an aggressive disease. Poor ECOG PS, presence of lymph node metastases, and higher age at diagnosis appear to be associated with worse survival outcomes.

Organ-sparing treatment for T1 and T2 penile cancer: an updated literature review

PURPOSE OF REVIEW

Penile cancer (PeCa) is an orphan disease due to its rare incidence in high-income countries. Traditional surgical options for clinical T1-2 disease, including partial and total penectomy, can dramatically affect patient's quality of life and mental health status. In selected patients, organ-sparing surgery (OSS) has the potential to remove the primary tumor with comparable oncologic outcomes while maintaining penile length, sexual and urinary function. In this review, we aim to discuss the indications, advantages, and outcomes of various OSSs currently available for men diagnosed with PeCa seeking an organ-preserving option.

RECENT FINDINGS

Patient survival largely depends on spotting and treating lymph node metastasis at an early stage. The required surgical and radiotherapy skill sets cannot be expected to be available in all centers. Consequently, patients should be referred to high-volume centers to receive the best available treatments for PeCa.

SUMMARY

OSS should be used for small and localized PeCa (T1-T2) as an alternative to partial penectomy to preserve patient's quality of life while maintaining sexual and urinary function and penile aesthetics. Overall, there are different techniques that can be used with different response and recurrence rates. In case of tumor recurrence, partial penectomy or radical penectomy is feasible, without impacting overall survival.

High cardiovascular disease mortality after penile squamous cell carcinomas diagnosis: Results from the United States SEER population, 2005-2016

Background

Cancer survivorship care is an emerging and necessary component of oncology management. To explore cardiovascular disease (CVD)-specific mortality and prognostic factors among patients with penile squamous cell carcinomas (PSCC). These results aid clinicians in furtherly understand this disease’s prognosis.

Method

We analyzed Surveillance, Epidemiology and End Results Program data for 2668 PSCC cases diagnosed between 2005 to 2016. We calculated standardized mortality ratios (SMRs) of CVD and all-cause mortality, comparing PSCC patients with general population men. A cumulative mortality curve and competitive risk regression model were utilized to evaluate the prognostic factors of CVD-specific death.

Results

Death distribution is as follows: PSCC (42.4%), other causes (21.3%) CVD (19%), and other cancers (17.3%). PSCC patients are more like to die from CVD (SMR=3.2, 95%CI: 3.1-3.3) and all-cause death compared with the general population. Meanwhile, patients undergoing surgery show a relatively higher CVD-specific mortality than the general population (SMR=2.7, 95%CI: 2.4-3.2). In the competitive risk model, higher CVD mortality is associated with age, region, year of diagnosis, stage, and marital status (all P<0.05). Patients with the localized stage show a higher risk of CVD-specific death than those with regional or distant stage.

Conclusion

Our study mainly reveals that cardiovascular disease was the important cause of death and higher CVD-specific mortality among PSCC patients. Several associated factors related to CVD-specific death are also identified. In the future, more work in educating health care professionals on the components of survivorship care is needed to meet the long-term and late effects cancer patients experience.

Disparities in Healthcare Access, Education, and Geographical Factors That Affect Surgical Outcomes in Penile Cancer

Objectives: To establish the level of access to healthcare, education, social and geographical factors predisposing a negative surgical outcome and higher mortality rate in patients with penile cancer.

Methods: This is a retrospective, longitudinal and analytical study. Ninety-three medical records of adult male patients diagnosed with penile cancer were reviewed. Fisher’s exact test was performed to determine the association between the level of healthcare, social and geographical factors, and the outcomes for penile cancer.

Results: Patients without primary care access had a higher chance of having lymphovascular invasion at the time of diagnosis (OR=37.5, P<0.0001), a higher mortality rate at 24 months after diagnosis (OR=19.2, P=0.005), a lack of high school diploma or equivalent (OR=3.8, P=0.049) and a higher likelihood of referral from a provincial hospital (OR=10.1, P<0.0001). Patients without a favorable surgical outcome (radical penectomy) were more likely to have been referred from a provincial hospital (OR=6.8, P<0.0001) and not have access to a primary care center (OR=149.5, P<0.0001), a tertiary care center (OR=20.7, P=0.003), and a high school diploma (OR=7.9, P=0.004). 

Conclusions: The lack of access to primary care is strongly associated with vascular invasion at diagnosis, lower educational level, a referral from provincial zones, and a higher mortality rate at 24 months. Patients who did not have access to primary and tertiary care, a high school diploma, and were referred from the province were more likely to have a radical penectomy.

Immunotherapeutic Approaches for the Treatment of HPV-Associated (Pre-)Cancer of the Cervix, Vulva and Penis

Human papillomavirus (HPV) infection drives tumorigenesis in almost all cervical cancers and a fraction of vulvar and penile cancers. Due to increasing incidence and low vaccination rates, many will still have to face HPV-related morbidity and mortality in the upcoming years. Current treatment options (i.e., surgery and/or chemoradiation) for urogenital (pre-)malignancies can have profound psychosocial and psychosexual effects on patients. Moreover, in the setting of advanced disease, responses to current therapies remain poor and nondurable, highlighting the unmet need for novel therapies that prevent recurrent disease and improve clinical outcome. Immunotherapy can be a useful addition to the current therapeutic strategies in various settings of disease, offering relatively fewer adverse effects and potential improvement in survival. This review discusses immune evasion mechanisms accompanying HPV infection and HPV-related tumorigenesis and summarizes current immunotherapeutic approaches for the treatment of HPV-related (pre-)malignant lesions of the uterine cervix, vulva, and penis.

Incidence and treatment strategies of Penile Intraepithelial Neoplasia in Sweden 2000‐2019

Objectives

Materials and methods

Results

Conclusions

Penile cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer with orphan disease designation and a prevalence of 0.1-1 per 100,000 men in high-income countries, but it constitutes up to 10% of malignancies in men in some African, Asian and South American regions. Risk factors for PSCC include the absence of childhood circumcision, phimosis, chronic inflammation, poor penile hygiene, smoking, immunosuppression and infection with human papillomavirus (HPV). Several different subtypes of HPV-related and non-HPV-related penile cancers have been described, which also have different prognostic profiles. Localized disease can be effectively managed by topical therapy, surgery or radiotherapy. As PSCC is characterized by early lymphatic spread and imaging is inadequate for the detection of micrometastatic disease, correct and upfront surgical staging of the inguinal lymph nodes is crucial in disease management. Advanced stages of disease require multimodal management. Optimal sequencing of treatments and patient selection are still being investigated. Cisplatin-based chemotherapy regimens are the mainstay of systemic therapy for advanced PSCC, but they have poor and non-durable responses and high rates of toxic effects, indicating a need for the development of more effective and less toxic therapeutic options. Localized and advanced penile cancers and their treatment have profound physical and psychosexual effects on the quality of life of patients and survivors by altering sexual and urinary function and causing lymphoedema.

Penile Cancer: Managing Sexual Dysfunction and Improving Quality of Life After Therapy

PURPOSE OF REVIEW

To review the most current literature on how the treatment for penile cancer can affect quality of life and to discuss current treatment options to overcome sexual dysfunction and ultimately improve patient wellbeing.

RECENT FINDINGS

Multiple medical and surgical therapies exist to address the high incidence of sexual dysfunction following penile cancer treatment. Advancements and refinements in the neophalloplasty, penile prosthesis, and penile lengthening procedures have opened the door to improved long-term outcomes. Additionally, studies continue to highlight the severe psychological toll that penile cancer treatment can have on patients. We explore the potential options for addressing the inherent psychologic effects of these treatments and highlight the need for further research in this domain. Although rare, it is important for all urologists to be familiar with the treatments and post-treatment sequelae of penile cancer. Penile cancer is associated with dramatic decline in quality of life and sexual function. Multiple medical and surgical therapies exist that addresses these concerns. Additionally, urologists must also be mindful of the psychologic component regarding surgical disfigurement and the decline in sexual function.

Penile sparing therapy for penile cancer

Penile cancer is a rare malignancy with a reported incidence of 0.66–1.44 per 100,000 men, and a reported mortality of 0.15–0.37 per 10,000 men. Expert clinical examination and histological diagnosis from biopsy is required to determine the extent and invasion of disease, which is paramount in planning of appropriate treatment. Management of loco-regional penile cancer can be divided into management of primary tumour and management of regional lymph nodes. This review article will focus on the management of the primary penile tumour with particular focus on penile sparing therapies. The aim of primary penile tumour management is to completely remove the tumour whilst preserving as much organ function as possible. Preservation of the penis is important as it allows patients to maintain urinary and sexual function, as well as quality of life. With the majority of penile cancer confined to the glans and foreskin, most penile cancers can be managed with organ-preserving therapy. A wide variety of treatment options are available, and this review aims to describe each of the options including the reported oncological and functional outcome for the different therapies for penile cancer.

Penile cancer: potential target for immunotherapy?

PURPOSE

Penile cancer (PeCa) is a rare malignancy with a poor prognosis in advanced disease. There is still a limited understanding of the biological mediators that are important in the prognosis and therapy of the disease. This review aims to provide a summary of the immune micro-environment, molecular oncogenesis and the role of HPV in the disease applying to the potential of the use of immunotherapy.

METHODS

Narrative, non-systematic review based on publications retrieved by PubMed and EMBASE search.

RESULTS

The molecular mechanisms underlying penile carcinogenesis are complex, and human papillomavirus (HPV) infection is a well-characterized driver of penile cancer. Up to 50% of the penile carcinomas are HPV related. There is potential to improve prevention, treatment and follow-up strategies pertaining to the role of HPV in penile cancer. Immune response modifiers such as toll-like receptor agonists are being used in a topical fashion for penile intraepithelial neoplasia while immune checkpoint inhibitors are currently under clinical investigation for its application in penile cancer.

CONCLUSIONS

The knowledge of prognosis-relevant biological pathways in penile cancer is expanding. HPV plays an important role in the carcinogenesis. This can lead to the identification of therapeutic targets which could significantly influence the prognosis of advanced penile cancer. Clinical trials are being conducted to pave the way for immune-modifying treatment modalities.

Localized disease: types of reconstruction/plastic surgery techniques after glans resurfacing/glansectomy/partial/total penectomy

PURPOSE OF REVIEW

The aim of this article is to provide an overview of the current literature specific to surgery for localized penile cancer including novel reconstructive techniques.Centralization of penile cancer services in many European countries and in particular the United Kingdom has resulted in an increased proportion of men undergoing organ-sparing surgery (OSS) rather than partial or total penectomy. In this review, we focus on reconstructive techniques following surgery for the primary penile tumour.

RECENT FINDINGS

The widespread adoption of penile preserving techniques in Europe and North America has shown both oncological safety as well as good cosmetic and functional outcomes. Recent evidence has suggested that narrower surgical margins do not affect overall cancer-specific survival or local recurrence rates. Therefore, excellent cosmetic and functional outcomes can be achieved using techniques such as glans resurfacing using split-thickness skin grafts, dorsal or ventral V-Y skin advancement and urethral centralization after partial penectomy. For patients requiring more radical surgery such as total penectomy, phallic reconstruction is a suitable option using free flaps or pedicled flaps.

SUMMARY

The use of OSS has transformed the lives of penile cancer patients who can avoid the significant clinical and psychological consequences of more radical surgical treatments. Careful case selection and preoperative counselling is advised prior to reconstructive techniques. Close postoperative clinical surveillance is necessary for early detection of local recurrence.