SUO 2017: Trying to Salvage Problematic Initial Management of Penile Cancer
The initial case was of an 80 year old gentleman who underwent circumcision for phimosis 8 years prior. He recently noted a mass on the glans that began growing several months ago, however has now rapidly progressed and is interfering with voiding. A punch biopsy revealed squamous cell carcinoma. He does have additional comorbidities, including asymptomatic CHF (EF 45%), and type II diabetes. He has a 5cm fungating mass covering the glans, as well as a 4cm right inguinal lymph node. The panel agreed that because the mass was causing voiding symptoms, that either a partial or total penectomy was a rational start for treatment. He subsequently underwent a partial penectomy which revealed pT3 disease (involvement of corpora cavernosa). Margins were negative. His right inguinal lesion had grown in the interim to 5.2cm. The panel debated about whether or not to proceed with neoadjuvant chemotherapy, however, because the mass was felt to be resectable, he was taken for inguinal lymphadenectomy. Pathology revealed moderately differentiated squamous cell carcinoma with focal poorly differentiated areas with spindling of the cells, suggesting focal sarcomatoid differentiation. The patient later returned with a large recurrence at the base of his penile stump. After some debate, the panelists agreed that chemotherapy and radiation would likely be the best course of treatment, however, in reality, the patient instead underwent a wide local excision with skin grafting. Unfortunately this patient had a rapid recurrence. He was offered chemotherapy and radiation, however he declined.
The second patient was a 50 year old gentleman with type II diabetes and a body mass index (BMI) of 45 presented with a ulcerative glans and distal penile shaft lesion. He had no evidence of nodal disease and subsequently underwent a partial penectomy. Pathology revealed pT3 well-differentiated invasive squamous cell carcinoma with indeterminant vascular margins. Dr. Spiess commented that you need to talk with your pathologist if there seems to be a discrepancy between different aspects of the pathology report. He would advocate an up-front node inguinal lymphadenetomy. The patient was unfortunately lost to follow-up for 15 months, but eventually presented with a 2.3cm right inguinal node on imaging. The panel debated regarding proceeding with a inguinal lymphadenectomy at this point, as opposed to proceeding with neoadjuvant chemotherapy/ radiation. He did undergo a node dissection and there was unfortunately tumor spillage from the lymph node. The panel felt that due to the node spillage, he should receive adjuvant chemotherapy and radiotherapy. He unfortunately returned 1 year later with a right inguinal recurrence and subsequently underwent a salvage groin dissection with skin grafting. Pathology revealed recurrent squamous cell carcinoma. Unfortunately 3 months post-operatively he developed a few small satellite lesions in around the pubic skin. He panel agreed that the patient had limited treatment options. Dr. Sonpavde spoke briefly regarding the use of taxane chemotherapy as a second line treatment, but he noted he would strongly recommend to the patient that he consider enrolling in a clinical trial with PDL inhibitors or EGFR inhibitors.
The final case was a 46 year old man with multiple medical issues including Prune Belly syndrome and a history of renal transplant with a baseline creatinine of 2.4. He also had a history of testicular seminoma. He noted a ulcerative penile shaft lesion which grew rapidly. He was referred to a dermatologic Moh's surgeon who performed an excisional biospy revealing pT1b moderately differentiated squamous cell carcinoma. There was no palpable or radiographic evidence of nodal disease. He was felt to be high risk for nodal disease, however due to his renal insufficiency, he was only able to receive 3 cycles of single agent paclitaxel. He unfortunately developed a palpable inguinal node, which was PET avid. The panel agreed that he would be unable to receive platinum-based chemotherapy due to his renal insufficiency, and for this reason, it was recommended that he undergo a inguinal node dissection.
The panel members stressed the importance of taking a multidisciplinary approach for patients with advanced penile cancer so that they receive the best possible treatment and highest chance of cure. Penile cancer can be a challenging disease to treat, however, with a panel of experts who work together, we can improve patient outcomes.
Presented by: Viraj Master, MD, PhD, Professor of Urology, Associate Chair for Clinical Affairs and Quality, and Director of Clinical Research Unit, Emory University.
Juanita Crook, MD, FRCPC, Professor, Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Colombia.
Guru Sonpavde, MDGenitourinary Oncology, Director, Bladder Cancer, Dana Farber Cancer Institute
Philippe Spiess, MD, Genitourinary Oncology,associate professor of oncology and urology at the University of South Florida Morsani College of Medicine, Moffitt Center
Written by: Brian Kadow, MD, Fox Chase Cancer Center, Philadelphia, PA at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC