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Keywords:

  • conservative surgery;
  • penile cancer;
  • surgical limit

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

OBJECTIVE

To evaluate the surgical excision margin required for local oncological control in primary penile cancers, as patients with penile cancer who undergo radical amputation suffer marked psychological, functional and cosmetic sequelae, and although organ-sparing surgery has improved the quality of life of these men, the optimum surgical excision margin to achieve oncological control is unknown.

PATIENTS AND METHODS

In all, 51 patients (mean age 61 years) diagnosed with squamous cell carcinoma of the penis between May 2000 and December 2004 were selected for treatment with conservative surgical techniques. All patients were staged before surgery using magnetic resonance imaging. Histopathological features of the tumours, including type, grade, stage and distance from the surgical excision margin, were evaluated. All patients were followed in the outpatient department according to European Association of Urology guidelines.

RESULTS

The median (range) follow-up of the men was 26 (2–55) months. Patients were treated by wide localized excision (nine), glans excision (26) and partial penectomy (16). The histopathological review included the analysis of 102 surgical margins (deep and skin) with 49 (48%) measured within 10 mm of the tumour edge and 92 (90%) within a <20-mm resection margin. Three patients (6%) had tumour involvement at the surgical margin and had further surgery. During follow-up two patients (4%) developed local tumour recurrence and were treated successfully with partial penectomy.

CONCLUSION

A traditional 2-cm excision margin is unnecessary for treating squamous cell carcinoma of the penis. Conservative techniques, involving excision margins of only a few millimetres, appear to offer excellent oncological control.


Abbreviations
SCC

squamous cell carcinoma

WLE

wide localized excision.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Penile carcinoma is a rare uro-oncological condition with considerable geographical variation. Rates vary from 1 per 100 000 people in Europe to three per 100 000 in Madras, India [1]. In Brazil the age-adjusted incidence is 8.3 cases per 100 000 people. In Uganda penile carcinoma is the most commonly diagnosed cancer, with 1% of men being diagnosed by 75 years of age.

The condition is increasingly treated in specialist tertiary referral centres with a view to conservative surgery but with no oncological compromise. Squamous cell carcinoma (SCC) is the predominant malignancy, accounting for 95% of cases [2]. The primary tumour is situated on the glans in 48% of cases, the prepuce in 21%, both glans and prepuce in 9%, the coronal sulcus in 6%, and <2% in the shaft [3]. Conservative techniques appear to result in improved cosmetic and functional outcomes. However, it is important to obtain adequate clearance of the tumour afforded by more radical procedures (subtotal and complete penectomy). It is still unknown what excision margin is required to achieve local control after surgery for penile cancer. Thus the aim of the present study was to review our experience of conservative surgery for penile cancer and to determine the excision margin required to achieve oncological control.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

In all, 51 patients (mean age 61 years, range 35–82) diagnosed with SCC of the penis on biopsy were selected for conservative surgery, based on clinical and radiological staging. All men were counselled regarding the therapeutic options available. The median (range) follow-up was 26 (2–55) months. All local tumours were staged before surgery using MRI and the 1997 TNM staging system.

Tumour resection was completed using conservative surgical techniques. These included wide localized excision (WLE) with glans reconstruction, partial glansectomy, complete glans excision or partial penectomy with split-skin grafting. Glans excision involves dissecting the glans from the corporal heads. A neoglans is constructed using split-skin grafting. This technique aims to preserve penile length and functional outcome, including erectile and voiding function (Fig. 1).

image

Figure 1. Glans excision, showing the dissection of the glans from the corporal heads (1) and reconstruction with a split-skin graft (2); the outcome is excellent (3).

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Patients were examined at the time of surgery and macroscopic clearance of the tumour undertaken. Cases suspicious for tumour involvement at the excision margins were analysed with peri-operative frozen-section analysis. Men with positive margins received further local surgery to complete tumour clearance.

All resected specimens were reviewed by one histopathologist, with surgical margins inked to aid microscopic analysis. Histopathological features, including tumour type, grade and stage, were also documented. The distance from the tumour edge to the nearest skin excision margin was measured using a Vernier scale. This process was repeated for the deep surgical limit (Fig. 2).

image

Figure 2. Diagrammatic representation of processing methods for glansectomy specimens (a). Measurements of depth of invasion and distance of tumour edge to deep resection limit (mm) (b). Measurement of distance of tumour edge from lateral skin excision margin (mm) (c).

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All patients were followed in the outpatient department to assess local tumour recurrence, as governed by current European Association of Urology guidelines and protocol.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Of the 51 men, nine were treated by WLE, 26 by glans excision and 16 by partial penectomy. The final histopathological diagnoses of the resected specimens are shown in Table 1. Three patients (6%) had positive surgical margins and had further local surgery. During the follow-up two patients (4%) developed tumour recurrence, which was treated by partial penectomy. These lesions were classified as G3T1 and G3T3 tumours.

Table 1.  The frequency distribution of histopathological and demographic variables in patients treated with conservative surgical techniques for penile cancer
VariableN
  1. NOS, not otherwise specified.

Age, years
 <406
 41–509
 51–609
 61–7014
 >7013
Surgery
 WLE9
 Glansectomy26
 Partial penectomy16
Grade
 Cis3
 110
 217
 321
Stage
 Tis3
 T120
 T226
 T32
Vascular invasion
 Negative35
 Positive16
Type
 NOS26
 Basaloid8
 Papillary7
 Verrucose4
 Mixed6

The review of the histopathological data in relation to the distance to the surgical excision margins (Table 2; Fig. 3) showed that 49 (48% of 102) margins were measured within 10 mm of the tumour edge and 92 (90%) with a <20-mm resection margin.

Table 2.  The number of patients for each distance from the tumour edge to the excision margins
GroupDistance tumour edge to excision margin, mm
0–56–1011–20>20Involved
WLE (n = 9)
 Skin 3 0 502
 Deep 5 2 301
Glansectomy (n = 26)
 Skin 4121200
 Deep14 2 1113
Partial penectomy (n = 16)
 Skin 3 0 520
 Deep 4 0 710
image

Figure 3. Histogram and pie chart illustrating the distribution of surgical resection distances from the tumour edge.

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DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Penile cancer is a rare tumour but has specific demographic and geographical distributions. Radical penile surgery (subtotal and total amputation) has been the conventional treatment to ensure local oncological control of the primary tumour. Historical teaching proposes a 2-cm macroscopic excision margin from the tumour edge. However, aggressive amputation can lead to substantial functional and psychological problems. These effects are compounded if patients have a pre-existing small phallus or obese body habitus. Organ-sparing surgical techniques have been developed to preserve penile tissue, through localized excision and penile reconstruction. However, oncological control is paramount in these patients, and there is little supportive data to confirm that these techniques are equivalent to traditional surgery [4–7] in achieving oncological control. Corroborative data for conservative surgery are available in guidelines, examining the treatment of primary cutaneous SCC, published through the British Association of Dermatologists and British Association of Plastic Surgeons [8]. This study benefits from a detailed histopathological analysis of the excision margins of each specimen, permitting a quantitative approach to evaluating the efficacy of conservative surgical techniques in treating penile cancer. In recent work Pietrzak et al.[5] proposed conservative surgery as a safe technique but failed to show the resection margins involved in that series.

Various other organ-sparing therapies have been implemented for treating localized penile cancer. These techniques include laser photocoagulation, radiotherapy, intratumoral chemotherapy and Mohs micrographic excision. These treatments destroy the tumour (small lesions of <1 cm) with minimal damage to surrounding tissues, and are associated with high rates of local recurrence. There is also significant morbidity associated with individual treatments, including urethral strictures after radiotherapy. These problems further hinder the routine implementation of these treatments in penile cancer [9–16].

Four large studies [9–13] have reviewed external beam radiotherapy compared with implanted radiotherapy and brachytherapy treatments. Local control varied from 57% to 85% in a multicentre trial [10]. Salvage surgery was often required, with necrosis rates of 3–16% and urethral stricturing in 9–30% of cases. Gotsadze et al.[14] showed that local control was achieved in 60% of patients after primary chemoradiotherapy, with an overall recurrence rate of 17.7%. These data compare poorly when compared with surgical outcomes. Local recurrence necessitates surgical intervention but preceding radiotherapy will also make salvage surgery more difficult, and impair functional and cosmetic outcome.

The present series suggests that recurrence rates are extremely low after conservative surgery, and are in accordance with published reports [3,5–7]. However, a longer follow-up is required to further assess this. There is an overall recurrence rate of 4% with these techniques, with a stage-specific split, i.e. T1, 5% (one of 20) and T3, one of four. There were no outstanding histopathological factors to distinguish those patients at higher risk of recurrence. It is imperative to stringently follow these patients, and for a prolonged period, as delayed local recurrences have been reported [17].

In summary, a compulsory 2-cm surgical excision margin is unnecessary in the treatment of localized penile cancer. With careful preoperative staging and patient selection, conservative techniques adequately treat these tumours. In most patients the surgical margins are within a few millimetres of the microscopic tumour edge, which does not jeopardise primary oncological control.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES