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Case Report
*Corresponding Author: Carolina Alfonso, Manuel Quintela Clinics Hospital, Prof. Levin Martínez Chair of Urology, Montevideo, Uruguay.
Citation: Carolina Alfonso, (2024), Penile cancer, a pathology postponed by men, Clinical Research and Clinical Trials, 11(3); DOI:10.31579/2693-4779/217
Copyright: : © 2024, Carolina Alfonso. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 08 July 2024 | Accepted: 30 July 2024 | Published: 12 December 2024
Keywords: squamous cell carcinoma of the penis; penile cancer; penectomy; lymphadenectomy; carcinoma in situ
Objective: To describe eight cases of penile cancer, its presentation and management in
a reference center in Montevideo, Uruguay.
Methods: Retrospective and descriptive study of penile cancer cases from January 2022 to January 2023 presented at Hospital de Clinicals, Dr Manuel Quintela, Montevideo, Uruguay. All cases presented in that period of time were taken regardless of whether their management was surgical, in order to also reflect the increase in the incidence of this pathology.
Results: Eight patients with penile cancer with a confirmed anatomopathological diagnosis are described, 100% of whom have a delay of more than one year to access the health system, consultation when it is complicated, pathological anatomy mostly above T2, conservative treatment mostly with poor oncological and functional results.
Conclusions: Despite the infrequency of this pathology, an increase in the incidence linked to risk factors has been noted in recent years, it is important to raise awareness among the population in identifying and preventing risk factors, early consultation in the face of clinical findings in order to prevent lesion progression with mutilating surgical results and ominous specific cancer survival.
Squamous cell carcinoma of the penis is a rare disease, accounting for 0.4 to 0.6% of all malignancies among American and European men. The incidence is higher in developing countries in South America, Asia and Africa.
The most frequent age of presentation is between 50 and 70 years old.
Early diagnosis is of utmost importance, since it is a disease that can result in devastating mutilation and has a 5-year survival rate of approximately 50%, distinguishing between greater than 85% for those with negative lymph nodes and 29-40% for patients with positive lymph nodes, these being the determinants of cancer-specific survival. [1-2]
The last Uruguayan survey published was in the period of 2014-2018, presenting in those four years a total of 72 patients with penile cancer, predominating in the departments of the interior of the country. [3,4,5]
Risk factors for this pathology are phimosis, balanitis, chronic inflammation, penile trauma, smoking, lichen sclerosus, poor hygiene, HPV (human papillomavirus) infection, especially 6, 16, 18, zoophilia, among other widely known factors.
Most of the time it presents as a palpable or visible lesion on the penis, associated or not with pain, discharge, bleeding, stench. The lesion may be nodular, ulcerative, or fungal and may overlap in phimotic patients. In addition, it may present signs of more advanced disease such as palpable lymphadenopathy or constitutional symptoms as a general repercussion.
Treatment, in addition to having a role in sexual and voiding functioning, the fully functional penis is fundamental to the patient's sense of integrity and masculinity. Therefore, the therapeutic objectives are the complete removal of the primary tumor with the greatest possible organ preservation, without compromising oncological control. (1) (2)
Methodology:
A one-year retrospective descriptive study was carried out in which a search was carried out for patients with an anatomopathological diagnosis of penile cancer at the Hospital de Clínicas Dr Manuel Quintela, Montevideo, Uruguay in the period from January 2022 to January 2023.
All the cases presented had a complete medical history, a confirmatory pathological diagnosis and data regarding the evolution. (Table 1).
| EDAD | ANTECEDENTES PERSONALES | TIEMPO HASTA LA CONSULTA | PRESENTACION | cTNM | pTNM | ANATOMIA PATOLOGICA | TRATAMIENTO | EVOLUCION | |
| 71 | Tabaquista, enolista | 2 años | Úlcera ventral de 2.5cm sobreinfectada | T2N0M0 | T3NxM0 | CE bien a moderadamente diferenciado. No invasión perineural. Embolias vasculares, márgen menor a 1mm. | Penectomía parcial, sin LND. | Recidiva locorregional | |
| 65 | Tabaquista | 1 año | En contexto de gangrena de Fournier. | T2N0M0 | T2N0M0 | CE bien diferenciado, no invasión perineural ni embolias vasculares. Margen < 10mm> | Penectomía parcial, con LND superficial. | Buena evolución | |
| 78 | Tabaquista, obeso, HTA | 1 año | Tumor en glande y cuerpo abscedado | T2N3M0 | T3NxM0 | CE bien diferenciado, invasión perineural, embolias vasculares. | Penectomía radical, meato perineal, sin LND. | Buena evolución, bajo QT | |
| 67 | Tabaquista, CBP. | 2 años | Amputación distal del pene, miasis de base peneana | T3N3M0 | T3NxM0 | CE moderadamente diferenciado, embolias vasculares, invasión perineural. | Penectomía radical, meato perineal, sin LND. | Buena evolución, bajo QT | |
| 58 | Tabaquista, oligofrénico. | 6 meses | Placa necrótica ventral al glande | T1N0M0 | T1bN2M0 | CE bien diferenciado, grado I, bordes +, no asociado a HPV. N+ 2/26 | Penectomía parcial +LND inguinopélvica | Buena evolución, bajo QT | |
| 64 | Tabaquista, higiene deficitaria | 2 años | Amputación total del pene | T4N3M0 | Biopsica. CE muy bien diferenciado tipo papilar | Cistostomía suprapúbica, RT, QT | Mala evolución, en UCP | ||
| 68 | Tabaquista | 2 años | Úlcera en glande | T2N0M0 | T3N2M0 | CE bien diferenciado, invasor. Embolias linfaticas, borde libre de tumor. AP Extemporanea negaitva para ganglio centinela, AP definitiva positiva. | Penectomía parcial + ganglio centinela | Mala evolución, bajo QT y RT en UCP. | |
| 45 | HIV+, tabaquista, cancer de ano | 1 año | Amputación total del pene | T3N3M0 | Biopsia, CE bien diferenciado | Cistostomía suprapubica, RT, QT | Mala evolución, en UCP |
TABLA 1
| T=TUMOR PRIMARIO | cN=GANGLIOS LINFATICOS REGIONALES CLINICOS | pN=GANGLIOS LINFATICOS REGIONALES PATOLOGICOS | M=METASTASIS A DISTANCIA |
| Tx= El tumor primario no puede ser evaluado | Nx= no pueden evaluarse los ganglios regionales | Nx= no pueden evaluarse ganglios metastásicos | |
T0= No hay evidencia de tumor primario Tis= Carcinoma in situ o PeIN | N0= no hay ganglios palpables ni visibles | N0= no hay ganglios metastásicos | M0= no hay metástasis a distancia |
T1= Tumor invade lamina propia (glande). Tumor invade dermis, lamina propia o dartos (prepucio). Tumor invade tejido conectivo mas allá de su localización, con o sin invasión linfovascular y perineural, con o sin alto riesgo (eje) | N1= ganglio inguinal | N1= dos o menos ganglios inguinales unilaterales metastásicos | M1= hay metátasis a distancia. |
| T1a= Tumor sin invasion linfovascular ni perineural, no alto grado | N2=metástasis en mas de dos ganglios inguinales uni o bilaterales | ||
| T1b= Tumor con invasión linfovascular o perineural o es sarcomatoide | N3= metástasis en ganglios pelvicos uni o bilaterales, o extraganglionar | ||
| T2= Tumor invade cuerpo esponjoso con o sin invasión uretral | |||
| T3= tumor invade cuerpo cavernoso con o sin invasión uretral | |||
| T4= Tumor invade estructuras adyacentes |
Tabla 2: se adjunta la clasificación TNM de la American Joint Committee on Cancer (AJCC) TNM Staging System for Penile Cancer (8th ed, 2017)
The average age at diagnosis of the patients analyzed was 64 years, with a range from approximately 45-70 years.
In relation to personal history, we highlight that 100% of the patients were active smokers, mostly since adolescence. Regarding the pathological diagnosis, 100% of the patients presented a positive anatomy for squamous cell carcinoma, only one of the anatomies differentiated the status with respect to HPV regardless of whether it had been requested from the pathologist. In reference to the time from symptomatic onset to urology consultation, the average was one year, with 80
According to the results of the present research, the average age of onset of penile cancer in our patients was between 50-70 years; This is consistent with the most current evidence reporting an average age of between 50-70 years, however, some patients are outside this limit established in our series. As for the incidence in our country, the last record reported by the cancer commission was in 2018, so it was interesting to publish the current incidence evaluated in one year in a urological reference center such as the Hospital de Clínicas Dr Manuel Quintela.
Uruguay is one of the developing countries in Latin America that is among the subgroups most affected by this pathology. (10)
When talking about risk factors for this disease, the literature agrees on the absence of circumcision in childhood, phimosis, personal hygiene deficit, smoking, zoophilia, HPV infection, among others.
In this descriptive study we were able to report that 100% of the patients had a history of smoking, and a percentage of more than 80% had deficient personal hygiene, the latter linked to the vulnerability of the patients who use this center.
We did not know in most of them their status with respect to HPV, only in one piece of anatomy pathology was it reported.
In reference to the clinical presentation, we highlight the presence of superinfected tumors or amputation of the organ as the most frequent evaluated. 50% of the patients in this series presented with palpable lymphadenopathy at diagnosis, and latency in the clinic was highlighted as the main factor to be modified in these patients. 100% of them had a latency of more than one year from symptomatic onset to urological control.
Regarding therapeutics, the greatest preservation of the organ was tried whenever possible, maintaining the therapeutic pillars previously described. In most of this series, if surgical treatment was indicated, partial penectomy was performed whenever possible. Lymphadenectomy was not performed in all patients due to advanced presentations of the disease, with no benefit in surgical approach, and in one patient the sentinel lymph node technique was performed, presenting unfavorable results due to a confirmatory pathological
diagnosis for malignancy not consistent with the contemporary diagnosis. This patient, from initial surgery to definitive pathological diagnosis, presented a rapid lesion progression, which was not indicated for surgery. [8-9]
Advanced-stage systemic treatments, as seen in this series, were based on current cisplatin-based chemotherapy regimens by oncology colleagues. Radiotherapeutic symptomatic treatment was also carried out by colleagues in this specialty.
Our pathological results showed that 100% of the series corresponded to squamous cell carcinomas of the penis, which confirms that it is the most common lineage in this pathology.
Regarding the survival of these patients, assessing their evolution, we confirm again that their survival is determined by their lymph node stage, although at the end of the study 100% of them were alive.
Despite penile cancer being an infrequent pathology, we can denote that in recent years there has been an increase in the cases that have been consulted in this academic center.
The analysis of this series demonstrates the importance of knowing the risk factors and presenting optimal adherence to health controls.
The stigma associated with this disease leads to the postponement of these patients in consultation, presenting in the evolution with more advanced stages of the disease, with indications for mutilating treatments and with gloomy prognoses for survival.
This pathology, its stigma and the consequent therapeutic mutilation make it necessary to jointly participate a psychological and social team for the follow-up of these patients.
The authors declare that they have no conflict of interest.
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