A RARE CLINICAL CASE OF AN ADVANCED PENILE CANCER IN A 52 YEAR-OLD MAN

Introduction

Penile cancer is not a particularly common malignancy. Both in Europe and North America it occurs in fewer than 1 per 100 000 males a year. In India it is 3, in Brazil 8,3 and in some African countries such as Uganda it reaches more than 10 [1]. Penile cancer is common in the regions with a high prevalence of human papillomavirus (HPV) [2]. Its incidence increases with patients’ age, and reaches its peak in the sixth decade of life, though it can occur in any age.
There are risk factors that are well established. Those include phimosis, chronic penile inflammation, e.g. balanoposthitis, lichen sclerosus, Sporalene and UVA phototherapy for various dermatological conditions such as psoriasis, smoking, HPV type 16 and 18 infections. What is interesting is that neonatal circumcision decreases the risk of getting a penile cancer. Therefore, Israeli Jews have the lowest incidence of this illness in the world. However, adult circumcision does not reduce risk of PC [3].
More than 95% cases of penile neoplasm are Squamous cell carcinoma (SCC) accounts, and the rest are caused mostly by basaloid carcinoma and melanoma. There are many mixed forms of SCC, including the warty-basaloid form (50-60% of mixed penile SCC), usual-verrucous (hybrid), usual-warty, usual-basaloid or usual-papillary and other rarer combinations. Some lesions can be sporadically associated with SCC, e.g. a cutaneous horn of the penis, bowenoid papulosis of the penis, lichen sclerosus. Some lesions that are premalignant and up to one-third can transform in SCC- Intraepithelial neoplasia G3, GIant condylomata, erythroplasia of Queyrat, Bowen’s disease and Paget’s disease [4,5,6,7].
Most cases of penile neoplasms are localised and treated at an early stage. An advanced form of the disease is visible only in about 5% cases of penile cancer.
The standard procedures that should be administered to the patient with advanced penile cancer T4 and positive lymph nodes at least N1 require a systemic approach. Neoadjuvant chemotherapy is performed before surgery. As an alternative, a palliative radiotherapy is an option. The operation covers total penectomy with perineal urethrostomy. The treatment of metastases in lymph nodes requires a systematic approach as well. Radical inguinal lymphadenectomy or even pelvic lymphadenectomy is an essential part of the procedure. It is usually postponed and performed as a 2nd part of the surgical treatment due to possible complications, e.g. healing of the wound and lymph leakage. Adjuvant chemotherapy in patients with positive nodules pN2 and pN3 is recommended. Adjuvant chemotherapy for pN1 nodules is currently in the phase of clinical trials.

Case description

A 52-year-old male patient came to the urology outpatient unit on 26th September 2014 with a lesion that covered the skin of the whole penis, scrotum and lower part of the abdomen skin. According to the patient, it appeared 3 to 4 months earlier.
To evaluate the stage of the disease, the patient underwent a CT scan and screening panel for determining sexually transmitted infections. There was also performed a TRU-CUT biopsy of lymph nodes and penile specimen for a histopathologic test.
The abdomen and pelvis CT scan was done on 1st October 2014. Although MRI would be a better option to evaluate the stage of disease, CT was performed because of notably better availability. It showed that both the retroperitoneal, peritoneal lymph nodes and pelvic lymph nodes were not enlarged. However, the inguinal lymph nodes were enlarged bilaterally – the right side dimensions up to 35x22 millimetres and the left side up to 34x29mm. There were no more radiological signs of metastases both in the bone structures and parenchymal organs.
Also, the STD panel was negative.
The histopathologic result of TRU-CUT biopsy was available on 16th October 2014, and it showed that bilateral inguinal lymph nodes are occupied by metastases of squamous cell carcinoma.
The treatment of the patient was divided into two parts. The first part aimed at performing radical penectomy, and the second one was reserved for radical pelvic lymphadenectomy that includes inguinal, iliac, obturatoral, sacral lymph nodes up to the bifurcation of the aorta. Although neoadjuvant chemotherapy was an option [8,9,10] of the treatment, it was not administered to the patient because of its long-term availability and the surgical procedures could not be delayed.
A radical penectomy with bilateral orchiectomy was performed on 21st October 2014. Both tests were removed because of the risk of infiltration to achieve a clean oncological margin. The urethra was prepared carefully up to the healthy part, and then it was implanted into crotch as urostoma.
The histopathologic result of the 1st part of the treatment showed an 11-cm tumour of squamous cell carcinoma. The penis, its corpus cavernosum and scrotum with subcutaneous tissue were infiltrated by the tumour. Both tests were not covered by the carcinoma infiltration. The edges of incision were free of carcinoma cells.
As indicated above, after 5 weeks there was performed the 2nd part of surgical treatment which covered radical pelvic lymphadenectomy that included inguinal, iliac, obturatoral, sacral lymph nodes up to the bifurcation of the aorta. After such extensive lymphadenectomy, there were expected complications such as skin necrosis above the inguinal canals and prolonged lymphatic leakage. To contraindicate these complications, we had to take some actions. Firstly, a part of the sartorius muscle was transplanted into the empty area of the inguinal canal after lymphadenectomy, and additionally, Spongostan material was placed to fulfil the space. Despite those measures, there was a prolonged lymphatic leakage that lasted for 45 days.
The histopathologic result of the 2nd part of the treatment showed that bilateral inguinal lymph nodes are occupied by metastases of squamous cell carcinoma. The right-sided iliac nodes were also occupied by metastases of squamous cell carcinoma. The remaining lymph nodes (left-sided iliac, obturatoral, sacral) were free of metastases.
After the whole surgical treatment, the patient was directed to a further oncologic therapy − adjuvant chemotherapy. However, he did not undergo the treatment because of personal reasons. Further, he did not appear for the surveillance, and no imaging scans were performed after the surgical procedure.

Conclusions

Although penile cancer is not a particularly common disease, its diagnosis is relatively easy. Male patients are aware of changes in the genitourinary area and usually come early to the urologic ambulatory. Hence most cases of penile cancer are diagnosed at early stages and can be treated radically. For all of those cases, an isolated resection of penile change or partial penectomy is usually a sufficient consideration. Histologically, penile cancer is very homogeneous and more than 95% of all cases concern squamous cell carcinoma. This feature simplifies proceeding both in treatment and follows-up. The outcomes of the treatment and prognosis at early stages are excellent. It is different with an advanced penile cancer. As presented above, it is very scarce and requires a systematic approach. Surgical treatment is not enough, and adjuvant chemotherapy is often needed. Even after combined treatment, a routine follow-up is necessary because of a high risk of recurrence of neoplastic process and progression of distant metastases. Moreover, outcomes are not as good. The median overall survival for the men at that stage was 86.5 months and the 5-year OS rate was 70.6%, for localised disease −77.9%, regional metastases − 58.2%, and for distant metastases − 16.7% [11].

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