Joniau_EU Urology 17/03/2010 15:13 Page 27
Organ-preserving Surgery for Penile Cancer
Table 1: Local Recurrence Rates and Disease-specific Survival of Surgical Treatment for Penile Carcinomas
Study, Year n FU (months) Modality Stage LR (%) DSS (%)
Bissada, 2003
15
30 Range: 12–360 PE NR 10 96.7
Pietrzak, 2004
16
10 16 PE Ta–T3 10 100
29 GE, GE + DC 0 100
McDougal, 2005
23
7 Range: 12–60 PE T1–T2 14 100
Minhas, 2005
14
51 26 PE, GE, PP Tis–T3 4 100
Hadway, 2006
21
8 30 TGR Tis 0 100
Lont, 2006
18
13 106 NR T1 23 NR
11 T2 36
Gulino, 2007
20
17 13 GE, GE + DC T1–T2 0 100
Palminteri, 2007
22
12 32 TGR, GE, GE + DC Tis–T2 0 100
Leijte, 2008
24
415 60 PE (25%) Tis–T2 27.7* NR
Laser (70%)
Radiation (5%)
Albersen, 2008
17
40 11 PE, GE, PP Tis–T3 45 90
Morelli, 2009
19
15 36 GE Ta–T3 0 100
DC = distal corporectomy; DSS = disease-specific survival; FU = follow-up; GE = glansectomy; LR = local recurrence; NR = not reported; PE = primary excision; PP = partial penectomy;
TGR = total glans resurfacing.
*27.7% overall local recurrence in penile-conserving surgery, including PE, laser and radiotherapy.
Another option for resection of the glans epithelium is total glans Table 2: Local Recurrence Rates and
resurfacing, in which the glans is skinned and the residual glans tissue
Disease-specific Survival of Mohs Micrographic
Surgery for Penile Carcinoma
is covered by a split-thickness skin graft. This procedure was first
described by Depasquale et al. for the treatment of balanitis xerotica
obliterans.
25
The procedure results in excellent cosmetic and functional
Study, Year n FU (months) LR (%) DSS (%)
Mohs, 1985
28
31 60 6 81
results, and was recently proposed as a treatment for superficial
Brown, 1987
30
20 36 6 95
malignant and pre-malignant lesions.
21,22
Treatment of the total glans
Shindel, 2007
31
33 36 32 96
surface combined with circumcision is particularly advised in multifocal
DSS = disease-specific survival; FU = follow-up; LR = local recurrence.
superficial lesions, which are responsible for 15% of recurrences.
8
The noticeably low recurrence rates for total glansectomies compared over a 50-year period. Considering local oncological control, in tumours
with other types of organ-preserving procedure may reflect a confined to the glans penis there was an 86% local-recurrence-free
predisposed state of the glans epithelium in which a penile cancer is five-year survival, compared with 63% when involvement of the penile
prone to develop, due to genetic mutations already present in the glans- shaft was noted. Another important factor in local control in this series
lining squamous epithelium adjacent to a tumour, without showing was the size of the tumour, with a 50% local recurrence rate when the
morphological changes of the tissue at the time of resection, but tumour size was more than 3cm and no local recurrences when
causing recurrent carcinoma at a later time-point.
18
Local recurrences the tumour was smaller than 2cm. Overall, 74% showed no evidence of
may therefore not only be the result of retained cancerous cells after disease at five-year follow-up in Mohs’ report. A limitation of this study
inadequate resection, but may also reflect a higher susceptibility of the in terms of comparability with other reports is that the Jackson score
glans epithelium to malignant transformation in penile cancer patients, instead of the TNM classification was used for the reporting of tumour
a theory that is further supported by the fact that a relatively high stage, although given that none of the patients had in situ SCC, it is
number of local recurrences are found on the glans but outside the likely that all patients had T1, T2 or T3 disease.
29
primary treated area.
26
Brown and associates reported on a series of 20 patients, of whom
Mohs Micrographic Surgery seven had stage Tis, one had stage Ta, 11 had invasive SCC and one
Mohs micrographic surgery was first reported by Frederick E Mohs had a leiomyosarcoma. Of the 17 patients for whom three-year
in 1941 and was initially developed as an in situ tissue-fixation follow-up was available, one (6%) suffered a local recurrence. Regional
technique for skin cancer excision.
27
The technique eventually evolved recurrence in the inguinal lymph nodes was noted in 24% and one
into fresh-tissue techniques utilising frozen-section margin evaluation, patient died of metastatic disease. Overall recurrence-free survival in
leaving out the time-consuming in situ fixation step. It now consists of this series was 71%.
30
successive serial layered excisions utilising horizontal sections and
precise micrographic mapping of the tumour. Because resection The most recent report on Mohs surgery for penile SCC was published
margins are minimal and microscopically controlled intra-operatively, by Shindel et al., who performed 41 Mohs procedures in 31 patients.
this type of surgery is considered to maximally preserve healthy Tumour stage was Tis in 26 cases, T1 in four, T2 in seven and T3 in four.
penile tissue. Eight patients (32%) were diagnosed with local recurrence at a mean
follow-up of 36 months, with the lowest percentage of recurrence in
The technique was first adopted for the treatment of penile cancer by Tis (21%). Of the four cases of T3 disease, two patients (50%) had local
Mohs et al. in a case series of 29 patients. A five-year cure rate of 68% recurrences necessitating partial penectomy, of which one was
was observed in this study.
28
In a more recent publication, Mohs et al. proximal T3 and the other was distal, or glandular T3. The remaining
reported on micrographic surgery in 35 patients who were operated on two T3 patients both had distal urethral lesions. In contrast to Mohs et
EUROPEAN UROLOGICAL REVIEW
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