(UroToday.com) In an oral presentation in the session examining Organ Preservation in Challenging Cases at the 12th European Multidisciplinary Congress on Urological Cancers (EMUC), Dr. Varkarakis and Dr. Parnham discussed the role of organ sparing approaches in penile cancer through a case-based approach.
Dr. Varkarakis began by highlighting the background of the patient in the selected case of a 59-year-old white Caucasian man. As described by Dr. Varkarakis, this man worked as a truck driver and was of lower socioeconomic status. Living on Santorini, this gentleman was also somewhat isolated from the mainland of Greece, and large medical centers. Further, as Dr. Varkarakis highlighted, based on his religion, this man was not circumcised. Further past medical history revealed a history of hypertension, a history of smoking, his former wife having had a history of cervical cancer and a social history notable for multiple partners with occasional unprotected sex without a history of sexually transmitted infections.
Five years ago, this man noted a smooth well-demarcated red plaque on his glans, without discharge or crusting. Following consultation with his general practitioner, he applied over the counter antibiotic and corticosteroid cream for 3 months without resolution.
Physical exam corroborated this history demonstrating an uncircumcised penis with a red, flat, well-demarcated lesion on the dorsal side of the glans. There was no palpable lymphadenopathy and the penile shaft and meatus were normal. He subsequently underwent circumcision with biopsy of the penile lesion with histopathologic diagnosis of Erythroplasia of Queyrat. Following post-operative healing, he was treated with topical chemotherapy using 5-fluorouracil cream BID every other day for 5 weeks.
Following initial improvement, 12 months later, he had a recurrence of a red penile plaque. This was treated with 5% imiquimod cream 5 days per week for 4 weeks. When no improvement was noted after 4 weeks, he underwent repeat biopsy which demonstrated low-grade T1a squamous cell carcinoma of the glans. The patient was offered three penile preserving options: laser treatment, partial glansectomy, and glans resurfacing with a split-thickness skin graft. The patient opted for glans resurfacing with a successful surgical outcome.
Following Dr. Varkarakis’s presentation, Dr. Parnham highlighted that the paradigm for the management of penile cancer has changed dramatically with a focus on organ preservation, without compromising chancer control. This has been driven by the confidence to take closer margins and increasing awareness and expectation to maintain function. Further, it has been recognized that local recurrence does not translate into mortality.
Dr. Parnham highlighted a variety of treatment options for patients with early-stage penile cancer, highlighting considerations as to why each may be particularly well suited to a given patient.
5-FU is an anti-metabolite which, with repeated treatment, is associated with reasonable rates of response, with good durability. However, a non-trivial proportion of patients will progress so careful monitoring is required. The other topical option, imiquimod, targets Tol-7 receptor to lead to cytokine secretion. Outcomes are similar to 5-FU with reasonable response rates with good durability. However, up to 20% of patients may progress.
Dr. Parnham then highlighted the role of Tm:YAG and holmium lasers in the management of superficial penile cancers. This approach is quite effective in Pein while it is somewhat less successful in patients with pT1-2 disease. Thus, it is less commonly used in these patients.
Glans resurfacing is an alternative with very low rates of recurrence and progression where negative surgical margins are obtained. Glansectmy is a somewhat more involved surgical approach. Following this, a split-thickness skin graft can be used to create a neoglans.
Presented by: Varkarakis Ioannis, MD, Ph.D., FEBU, ECFMG, Associate Professor of Urology, National and Kapodistrian University of Athens, and Arie Parnham, MBChB, FRCS(Urol), Urologic Surgeon and Andrologist, The Christie, Machester, Great Britain
Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical Center, Contact: @WallisCJD on Twitter at the 12th European Multidisciplinary Congress on Urological Cancers (EMUC) (#EMUC20 ), November 13th - 14th, 2020