Management of Penile Cancer

Educational Objectives

The goal of this program is to improve the management of penile cancer. After hearing and assimilating this program, the clinician will be better able to:

1. Select appropriate penile-preserving techniques for the treatment of patients with penile cancer.
2. Manage regional lymph nodes in patients with penile cancer.

Summary

Penile cancer: uncommon; typically presents with advanced disease (eg, bulky metastases to lymph nodes); despite multimodal therapy, disease often progressive and fatal

Treatment with penile-preserving approaches: resection of tumor with negative margins considered gold standard; adequate surgical margins have been variously defined as 2 cm or 0.5 cm; currently, any negative margin confirmed pathologically considered adequate; multicenter review of ≈1300 patients (Baumgarten et al, 2018) found ≈20% rate of recurrence after penile-preserving procedures in appropriately selected patients (≈43 mo follow-up); recurrences typically occur in first year; majority of recurrence can be treated with repeat penile-preserving approaches; outcomes related to type of treatment and clinical stage; treatment modalities include wide local excision, glansectomy, laser ablation, and topical therapy; prompt biopsy key to early identification of recurrence; majority of recurrences occur regionally, with local recurrences accounting for ≈33%; distant recurrences <25%; carcinoma in situ — ≈50% of recurrences occur <1 yr; laser therapy responsible for majority of recurrences (rate of recurrence ≈50%; rates of recurrence using other modalities 10% to 20%); topical therapy — 5-fluorouracil (5-FU) first-line therapy; imiquimod second-line therapy; results satisfactory with judicious use; speaker recommends 5-FU for first-line treatment of carcinoma in situ; obtain prompt biopsy for suspicion of recurrence; consider second-line topical therapy or wide local excision for treatment failures

Treatment of inguinal lymph nodes: practice in Netherlands to perform sentinel lymph node (SLN) biopsy for patients with nonpalpable lymph nodes and high-risk features; inguinal lymph node dissection (LND) performed for patients with positive SLN; Lont et al (2003) compared early LND in patients with positive SLN to delayed LND for subsequent recurrences; early LND associated with higher recurrence-free, disease-specific, and overall survival; timing of LND — Chipolini et al (2017) found increased rate of survival in patients who undergo LND <3 mo after surgery (penectomy); management of palpable inguinal nodes — classic dogma was to treat with antibiotics for 4 to 6 wk; currently recommended to perform fine needle aspiration (FNA) of any palpable lymph node in patient with penile cancer and absence of infection; if FNA positive, immediate LND recommended; complications of inguinal LND — incidence remains 50% to 60% (≈67% minor); risk for complications related to number of lymph nodes harvested and pathologic stage of nodes; minimally invasive LND — rates of complications lower than with open LND; important to obtain wide view by placing first trocar in distal location; identify saphenous vein; develop plane deep to fascia lata with balloon or manual dissection; speaker does not recommend minimally invasive surgery in patients following chemotherapy with bulky nodal disease or after radiation therapy

Multimodal treatment: Pagliaro et al (2010) treated 30 patients with clinical N2 and N3 disease with neoadjuvant chemotherapy; rate of response ≈50%; “no evidence of disease” achieved in 9 patients at mean follow-up of 34 mo; 11 patients with favorable response underwent surgery; positron emission tomography (PET)/computed tomography (CT) — PET increasingly utilized; PET detects small-volume occult disease; sensitivity sometimes better than CT or magnetic resonance imaging; PET/CT not intended to be first-line diagnostic test; appropriate for patients with palpable disease who have received neoadjuvant therapy to determine response; sensitivity and specificity for detecting occult disease 80% to 90%; radiation therapy — associated with improved recurrence-free and disease-specific survival in patients with metastases to pelvic lymph nodes; recommended in patients with locally advanced nonresectable disease, advanced disease following resection, and (in some cases) locoregional recurrences; anecdotal data suggest that response rate 3 to 4 times higher in patients with cancer associated with human papilloma virus

Metastases to other lymph node basins: pelvic node-positive disease — data from Milan show that rate of metastasis 50% to 60% in patients with ≥3 positive inguinal lymph nodes, inguinal nodes >3 cm in size, and extranodal disease; data from Netherlands show extranodal extension and metastases to ≥2 inguinal nodes predictive of pelvic lymph node metastases; presence of ≥4 positive inguinal lymph nodes 75% predictive of bilateral pelvic lymph node positivity

Management of recurrences: majority occur early; vigilance required; locoregional recurrences best treated by neoadjuvant chemotherapy followed by surgery

Readings

Baumgarten A et al: Penile sparing surgery for penile cancer: a multicenter international retrospective cohort. J Urol 2018 May;199(5):1233-1237; Chipollini J et al: Delay to inguinal lymph node dissection greater than 3 months predicts poorer recurrence-free survival for patients with penile cancer. J Urol 2017 Dec;198(6):1346-1352; Lont AP et al: Management of clinically node negative penile carcinoma: improved survival after the introduction of dynamic sentinel node biopsy. J Urol 2003 Sep;170(3):783-6; Master VA et al: Minimally invasive inguinal lymphadenectomy via endoscopic groin dissection: comprehensive assessment of immediate and long-term complications. J Urol 2012 Oct;188(4):1176-80; Pagliaro LC et al: Neoadjuvant paclitaxel, ifosfamide, and cisplatin chemotherapy for metastatic penile cancer: a phase II study. J Clin Oncol 2010 Aug 20;28(24):3851-7.

Disclosures

For this program, the members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Spiess was recorded at the 69th Annual Meeting of the Florida Urological Society, presented by the Florida Urological Society and held August 31-September 3, 2017, in Orlando, FL. For information on the 70th Annual Meeting of the Florida Urological Society, please visit flaurological.org. The Audio Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

UR411701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.