Washington, DC (UroToday.com) Penile cancer is among the most disfiguring diseases encountered by the urologist in clinical practice. Treatment of this disease requires a careful balance of oncologic outcomes with preservation of sexual function, urinary function, and cosmesis. In this session, Dr. Philippe Spiess, a urologic oncologist from Moffit Cancer Center, presented options for organ preservation in penile cancer.
Dr. Spiess began his talk with a brief nod to some of the techniques implemented in his practice for maximizing functional penile length. In patients with a prominent prepubic fat pad, liposuction may be performed before a resection to reduce fat around the penile base and thereby increase the visually apparent penile length without altering the penis itself. A second technique to achieve a similar result is the ventral phalloplasty, in which penoscrotal webbing is eliminated in order to increase apparent penile length. Dr. Spiess presented one case in which the combination of these techniques with surgical resection of the primary tumor itself resulted in the patient being more satisfied with his cosmesis and function than he had before cancer surgery. It is unclear how often this desirable outcome occurs in practice, but an emphasis of the talk was the familiarity with reconstructive techniques has a clear ability to improve functional and cosmetic outcomes.
There are, of course, degrees of organ preservation in penile carcinoma, as there are a range of valid treatment available including topical therapy, laser therapy, circumcision, wide local excision, radiation therapy, and partial penectomy. How much of the organ can be preserved is in part determined by the width of margins necessary to achieve recurrence-free cure. Dr. Spiess presented retrospective data which suggests that recurrence rates are similar as long as margins are at least 1mm. In the largest overall retrospective published cohort in penile cancer, local recurrence rates were 21% overall, so it seems there remains room for improvement in this aspect of care.
With regards to local control, Dr. Spiess highlighted some emerging data suggesting that while glans resurfacing with split thickness skin grafting and glansectomy are equivalent, patients treated with laser ablation as monotherapy show a distinct trend towards higher recurrence rates. In one study recurrence rates with laser therapy was 48% compared to 10% for glansectomy, 25% for wide local excision, and 4.5% for glans resurfacing. Randomized data in this space is not forthcoming, but relatively large differences seen in retrospective cohorts like this one may be enough to sway some surgeons in their choice of treatment modality.
Finally, Dr. Spiess emphasized the role of topical therapy for carcinoma in situ. While he emphasized that it is reasonably burdensome – requiring application of 5-FU for 12 hours every 48 hours for 28 days as first line standard of care – and can be associated with significant local discomfort during thereapy, his group has seen complete responses in 57% of patients without the need for surgery.
At least partial organ preservation is the standard of care in penile cancer for most patients. Optimizing the balance of organ preservation with oncologic safety in this rare disease requires expert knowledge of the disease process, careful patient selection, and sometimes utilization of advanced reconstructive techniques.
Presented by: Philippe Spiess, MSc, MD, Moffit Cancer Center
Written by: Marshall Strother, MD, Society for Urologic Oncology Fellow, Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia PA, @mcstroth, at the 2019 Society for Urologic Oncology Annual Meeting – December 4-6, 2019 – Washington, DC