Intermediate analysis of a phase II trial assessing gemcitabine and cisplatin in locoregional or metastatic penile squamous cell carcinoma

Metastatic Penile Squamous Cell Carcinoma Responsive to Enfortumab Vedotin

Penile squamous cell carcinoma is a rare disease with very limited data to guide treatment decisions. In particular, there is minimal evidence for effective therapies in the metastatic setting. Here, we present a case of metastatic penile squamous cell carcinoma with response to the Nectin-4 inhibitor enfortumab-vedotin-ejfv (EV). EV was selected due to the evidence of the high expression of Nectin-4 in squamous cell carcinomas, including penile carcinoma. The patient had both radiographic and symptomatic improvement after two cycles of treatment, despite having been treated with multiple prior lines of traditional chemotherapy. This case provides support for the use of antibody-drug conjugates (ADC), including EV, in this disease with few other options in the advanced setting. Further studies examining Nectin-4 and ADCs in penile squamous cell carcinoma should be completed, as high-quality evidence is needed to guide treatment after initial progression for these patients.

[Systemic treatment of penile cancer: New concepts? New achievements?]

Systemic chemotherapy has been in use for metastatic penile carcinoma for years, but its success is limited. Its significance is largely associated with its role in multimodal treatment for lymphatic metastasis in the context of radical lymph node surgery. In cases of limited lymph node involvement, the combination of surgical treatment plus cisplatin- and taxane-based triple combinations may be curative. Advances in the understanding of molecular changes in penile cancer and the search for potential therapy targets have led to numerous studies. Although there is evidence of efficacy of immunotherapeutics, no significant therapeutic improvements have been seen in the clinical routine.

[Systemic treatment of locally advanced or metastatic penile cancer]

Penile cancers are rare, the vast majority is represented by squamous cell carcinoma, with HPV virus being found in 30 to 40% of cases. At a locally advanced or metastatic stage, first-line treatment relies on platinum and taxane based polychemotherapy. The prognosis for advanced or metastatic penile cancer remains poor, with overall survival ranging from 13.9 to 17.1 months. After the first line, guidelines recommend various chemotherapy treatments or targeted anti-EGFR therapies whose results as well as the level of evidence are limited. A better understanding of the oncogenic pathways involved in penile cancer and a frequent expression of PD-L1 are the rationale for the elaboration of new strategies. This review article presents the data, guidelines and ongoing studies in locally advanced or metastatic penile cancer.

[CCAFU french national guidelines 2016-2018 on penile cancer]

INTRODUCTION

The aim of this work is to establish guidelines proposed by the external genital organ group of the CCAFU for the diagnosis, treatment and follow-up of penile cancer.

MATERIAL AND METHODS

The multidisciplinary working party studied 2013 guidelines exhaustively reviewed the literature, and evaluated references and their level of proof in order to attribute grades of recommandation.

RESULTS

The most common histological type is squamous cell carcinoma. Clinical examination of the penis is usually sufficient to access local extension. It can be completed by MRI to assess deeper extension. Physical examination of both groins must evaluate inguinal regional lymph nodes involvement. In the presence of palpable lymph nodes, abdomen and pelvis computed tomography and ¹⁸F-FDG PET-CT are recommended. Sentinel lymph node biopsy is recommended in the case of penile cancer with high risk of lymph node extension with no palpable lymph nodes. Treatment of the primary tumour is usually surgical. It must be as conservative as possible while ensuring negative surgical margins. Brachytherapy or local treatment can be proposed in some cases. Bilateral inguinal lymph node areas must be systematically treated. Inguinal lymphadenectomy alone has a curative role in patients with metastatic invasion of a single node (stage pN1). In the case of more extensive lymph node involvement, multimodal management combining chemotherapy, surgery, and possibly radiotherapy has to be considered.

CONCLUSIONS

The treatment of penile cancer is usually surgical possibly in combination with chemotherapy in the presence of lymph node extension. The main prognostic factor is lymph node involvement, requiring appropriate management at the time of diagnosis.x © 2016 Elsevier Masson SAS. All rights reserved.

Emerging Systemic Therapies for the Management of Penile Cancer

Penile squamous cell carcinoma (PSCC) is a rare cancer, but is more common in developing countries. Locally advanced and metastatic PSCC is associated with significant morbidity and mortality, with the prognosis remaining extremely poor. The authors searched PubMed and published abstracts for metastatic PSCC studies to describe emerging therapies. Multimodality treatment using chemotherapy, radiation, and consolidative surgery are standard of care. Utilizing anti-EGFR therapies and novel immunotheraputic approaches may help improve outcomes in PSCC.

Phase II study of docetaxel, cisplatin, and fluorouracil in patients with distantly metastatic penile cancer as first-line chemotherapy

Purpose

Patients with distantly metastatic (M1) penile squamous carcinoma have extremely poor prognosis and few prospective clinical trials evaluating systemic treatment have ever been performed for this population.

Methods

Patients (aged ≥ 18 years) with histologically confirmed, distantly metastatic, measurable penile squamous carcinoma were enrolled. They were treated with docetaxel 75 mg/m² (day1), cisplatin 70 mg/m² (day1), and fluorouracil 500 mg/m²/d (days 1 to 5) every 3 weeks as first line chemotherapy. The primary endpoint was objective response rate (ORR).

Results

39 patients received chemotherapy with a median of four cycles (range two to six). The median follow-up time was 11 months. 15 patients had a confirmed objective response (38.5%, 95% CI 23.36–55.38), all of which were partial responses. The median progression-free survival (PFS) was 3 months (95% CI 2.92–3.09), and the median overall survival (OS) was 7 months (95% CI 5.99–8.03). Toxicity was manageable and the most frequently recorded adverse events of grade 3 or higher were neutropenia (13 of 39; 33%), nausea/vomiting (7 of 39;18%). There was no treatment-related death.

Conclusion

The palliative regimen of docetaxel, fluorouracil, and cisplatin induced moderate responses and can be used as a choice for the treatment of patients with distantly metastatic penile cancer. However, efforts to improve efficacy and minimize toxicity for this regimen should be made in the future.