Penile/Urethral Ca: Low adherence to lymph staging guidelines seen

Anne Kathryn Schuckman, MDOther take-home messages in penile/urethral cancer included discussion of proposed 2018 AJCC penile cancer guidelines as well as the finding that in women with primary urethral cancer, adenocarcinoma was the most common pathology. The take-homes were presented by Anne Kathryn Schuckman, MD, of the University of Southern California, Los Angeles.

In the U.S., guidelines on surgical inguinal lymph node staging for penile cancer were followed in only 25% of patients with T1b-T3 disease. This was significantly associated with treatment at a non-academic hospital, and those who did not undergo surgical inguinal node staging had worse overall survival. In Europe, adherence to treatment guidelines for primary therapy was 66% and for lymphadenectomy, the adherence rate was as high as 70%.

Under new American Joint Committee on Cancer (AJCC) staging, all urothelial carcinoma in situ has been collapsed into Tis as opposed to being confused with T4 disease. Clarification has been made between T1 and T4 disease and a distinction made between N1 (one lymph node positive) and N2 (greater than one node positive).

In proposed 2018 AJCC penile cancer guidelines, cavernosal involvement will upstage a patient to T3 disease.

An abstract examining the ability of this new penile cancer staging system to better predict lymph node involvement at the time of lymph node dissection found no difference in lymph node status among T3 versus T2 patients.

Penile-sparing surgical approaches for penile carcinoma including circumcision, wide local excision, laser therapy, glansectomy, and glans resurfacing generally provide adequate oncologic control. However, those treated with laser and wide local excision were at greater risk for recurrence.

Continue to the next page for more take-home messages.

• In an examination of the use of intraoperative frozen section during organ-sparing surgery for penile cancer, researchers examined their own local recurrence rates at 28 months. Using a policy to complete further resection until they had a negative frozen section margin, they were able to avoid recurrence locally in all patients.

• Node-positive penile cancer patients who underwent surgical staging of the lymph nodes and received pelvic radiation had improved overall survival, improved disease specific survival, and lower recurrence rates than those who did not receive pelvic radiation.

• Three- and 5-year overall survival among stage III penile cancer patients is improved with adjuvant inguinal radiation after inguinal lymph node dissection (ILND). The benefit was larger for patients who had N2 disease than for those who had N1 disease.

• A new radiologic model aimed at predicting complications at the time of ILND provided accurate risk estimation of overall and major complications after ILND for penile cancer.

• Patients with T2 penile cancer who underwent ILND had longer overall survival than those in whom ILND was omitted. But only 36% of patients underwent inguinal lymph node dissection for T2 disease.

• In women with primary urethral cancer, adenocarcinoma was the most common pathology (36% of patients). Women with adenocarcinoma were more likely to be younger, African-American, and present with an advanced stage.

• A large study found that patient knowledge is high when asked whether they know that HPV is related to cervical cancer. However, only 30% of survey respondents knew that HPV is related to penile cancer.

• The prevalence of HPV is very high in men at 45%, with high-risk HPV subtypes 16 and 18 present in 6%. Despite this high prevalence, vaccination rates are still very low.

• Patients who had neonatal circumcision were 3.2 times less likely to develop penile cancer at any time in their life. This benefit may be slightly lower for patients who have circumcisions as adults.

• The current recommendation is that all boys and all girls be vaccinated for HPV. Females should be vaccinated at any time from age 9 to 26 years, although it’s recommended that this take place in prepubertal setting; males should be vaccinated anytime through age 21. A new nonavalent vaccine being used in the United States covers more subtypes of HPV. Widespread vaccination should prevent nearly all genital warts and 90% of anogenital cancers if given prior to sexual debut.

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