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Locally Advanced Penile Carcinoma: Classic Emasculation Or Testis-Sparing Surgery? ______Lúcio Flávio Gonzaga-Silva, George R

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Locally Advanced Penile Carcinoma: Classic Emasculation Or Testis-Sparing Surgery? ______Lúcio Flávio Gonzaga-Silva, George R Vol. 38 (6): 750-759, November - December, 2012 ORIGINAL ARTICLE Locally advanced penile carcinoma: classic emasculation or testis-sparing surgery? ______________________________________________________________________________________________ Lúcio Flávio Gonzaga-Silva, George R. M. Lima, José M. Tavares, Vladmir O. Pinheiro, George A. Magalhães, Manoel E. Tomas, Cleto D. Nogueira, Marcos V. A. Lima Ceará Cancer Hospital (LFGS, JMT, VOP, GAM, MET, CDN, MVAL) and Federal University of Ceará (LFGS, GRML), Ceará. Brazil ABSTRACT ARTICLE INFO _________________________________________________________ ___________________ Purpose: The study evaluates the clinical and pathological fi ndings of 16 patients with Key words: locally advanced penile carcinoma (PC) submitted to emasculation, and discusses ques- Orchiectomy; Penile tions related to the usefulness of bilateral orchiectomy. Neoplasms; Carcinoma, Materials and Methods: Between 1999 and 2010, 172 patients with PC were treated. Squamous Cell; Penis Sixteen (9%) underwent emasculation. Data were retrieved from the institution’s da- tabase including age, ethnicity, date of surgery, residential setting, level of schooling, Int Braz J Urol. 2012; 38: 750-9 time to diagnosis, type of reconstruction, complications, tumor stage and grade, vas- __________________ cular and perineural invasion along with invasion of corpus cavernosum, corpus spon- giosum, testicles, scrotum and urethra. Submitted for publication: Results: A total of 16 patients (average: 63.1 years) with locally advanced PC were February 12, 2012 included. All were illiterate or semiliterate rural dwellers and 87% were white. The time __________________ to diagnosis was 8-12 months. The mean follow-up time was 31.9 months (1-119). By the time of the last follow-up, only seven patients (43.75%) were alive. Tumors were Accepted after revision: pT4 (n = 6), pT3 (n = 8), pT2 (n = 2), Grade I (n = 5) and Grade II (n = 11). The histopa- August 14, 2012 thological examination revealed invasion of the urethra (n = 13), scrotum (n = 5) and testicles (n = 1). The surgical margin was positive in one patient. Six patients (37.5%) had vascular invasion and 11 (68.7%) had perineural invasion. Currently, only one of the former is alive. Conclusions: The fi nding of focal microscopic testicular infi ltration in only one of 32 testicles, even in the presence of clinically apparent scrotal invasion, suggests that emasculation without bilateral orchiectomy is a safe treatment option for patients with locally advanced PC. INTRODUCTION than 1/100,000 in the US and Europe to more than 4/100,000 in Uganda and Brazil (4). Penile carcinoma (PC), a potentially fatal Brazil has one of the highest incidences of malignancy, is rare in developed countries (1). penile cancer in the world. The disease represents In the United States, for instance, it accounts for 2.1% of male neoplasms in the country, reaching only 0.4% of all male malignancies (2), while in 5.7% in the Northeast (5) where the human deve- less developed regions, especially in Asia, Africa, lopment index is very low. Not surprisingly, the and South America, the fi gure may be as high as region accounts for more than half (53.02%) of 10% (3). The incidence typically ranges from less the cases registered in Brazil. In comparison, whe- 750 IBJU | LOCALLY ADVANCED PENILE CARCINOMA: EMASCULATION OR TESTIS-SPARING SURGERY? reas 2 or 3 new cases of PC are observed every tion), scrotectomy and bilateral orchiectomy (14). month at the Ceará Cancer Hospital in Fortaleza The present study evaluates the clinical (Northeastern Brazil) (6), a British practicing uro- and pathological fi ndings of 16 patients with lo- logist may not see more than one new case every cally advanced penile squamous cell carcinoma other year. submitted to emasculation and discusses ques- The causes of penile cancer are not always tions related to surgical technique, patient follow- clear, but major risk factors include poor penis -up and the usefulness of bilateral orchiectomy. hygiene, phimosis, smegma retention, smoking and sexually transmitted diseases (7,8). In a recent MATERIALS AND METHODS Brazilian multicenter study, the practice of sex with animals was also identifi ed as a risk factor Between 1999 and 2010, 172 patients for this malignancy (9). with penile invasive squamous cell carcinoma Penile carcinoma metastasizes stepwise were submitted to surgical treatment at the Ceará via the lymphatic system: from the inguinal nodes Cancer Hospital in Fortaleza, Brazil. Of these, 16 to the pelvic nodes to the distant nodes (10). The advanced cases (9.3%) underwent emasculation presence and extent of lymph node metastases are (Table-1). the most important predictors of survival (4). His- Complete preoperative, operative and pos- tological grade and vascular and perineural inva- toperative patient data were retrieved from the sion have been correlated with poor prognosis and institution’s prospective database and from a re- unfavorable outcomes (11). view of the respective medical records. The infor- Surgical management of malignant PC de- mation included patients’ age, ethnicity, date of pends on the grade and stage of the disease (12). surgery, residential setting (rural or urban), level The National Institute for Clinical Excellence (U.K) of schooling, time from appearance of fi rst lesion recommends managing PC at centers with a ca- to defi nitive diagnosis, type of reconstruction, du- tchment area of 4 million. Each center receives ration of follow-up and date of last follow-up vi- approximately 25 new cases annually. Advanced sit. The median follow-up time was calculated as cases of PC are referred to a supra-regional center the median observation time among patients and for multidisciplinary curative and palliative treat- the overall survival time was estimated using the ment, including reconstructive surgery (13). Kaplan-Meier method. At our service, PC patients with proximal Specimens were obtained from all patients corpus cavernosum invasion and scrotal skin ero- and evaluated by a single pathologist with regard sion are routinely referred to emasculation, in- to tumor stage and grade, inguinal lymph node cluding total penectomy (complete penis amputa- status, vascular and perineural invasion, invasion Table 1 - Cases of penile squamous cell carcinoma submitted to surgical treatment at the Ceará Cancer Hospital between 1999 and 2009. Surgical technique Cases (n) Percent (%) Wide local excision or circumcision 5 3% Partial penectomy 125 73% Total penectomy 26 15% Emasculation 16 9% Total 172 100% 751 IBJU | LOCALLY ADVANCED PENILE CARCINOMA: EMASCULATION OR TESTIS-SPARING SURGERY? of corpus cavernosum, corpus spongiosum, testi- Pelvic lymphadenectomy was performed in four cles, scrotum and urethra. patients. The pathological nodal status was defi ned All 16 patients were submitted to emas- as: N0 = no evidence of lymph node metastasis; N1 culation, including total penectomy, scrotectomy = metastasis in a single inguinal lymph node; N2 = and bilateral orchiectomy. The technique consis- metastasis in multiple or bilateral superfi cial lymph ted of an elliptical abdominoscrotal incision with nodes and N3 = unilateral or bilateral metastasis large skin margin and partial preservation of the in deep or pelvic lymph nodes. The excised tumors posterior surface of the scrotum. With the corpus were clinically and pathologically staged according cavernosum and corpus spongiosum exposed, the to the guidelines of the International Union Against urethra was dissected and mobilized. The corpus Cancer (2002 TNM UICC) (17). cavernosum was disinserted from the ischial tu- The study was previously approved by the berosity followed by en bloc removal of the penis, Institutional Ethics Committee and the principles of scrotum and testes. The urethra was tunneled wi- the Helsinki Declaration were followed in all study thout angulation, spatulated and externalized in procedures. the perineum, as described by Campbell (15). The surgical wound was closed with a RESULTS scrotal fl ap in 9 patients. Seven patients required two forms of reconstruction: 1) a vertical rectus The 16 patients undergoing emasculation abdominis myocutaneous fl ap was made through were aged 63.1 years on the average (range: 40- a midline abdominal incision, preserving the pos- 78). Fourteen patients (87%) were white and two terior layer of aponeurotic and inferior epigastric (13%) were black. All were illiterate or semiliterate vessels. The skin grafts were rotated to achieve rural dwellers (Table-2). The time from the appe- complete wound closure; 2) an eliptical incision arance of the fi rst penile lesion to the defi nitive was made in the medial aspect of the thigh, star- diagnosis was 8-12 months. ting 10 cm below the ischium, in order to preserve Radical bilateral inguinal lymphadenec- the medial circumfl ex femoral arteries, followed tomy was performed in 11 patients 3-4 weeks af- by wound closure with a gracilis myocutaneous ter emasculation. Due to extensive loco-regional fl ap. Both reconstruction techniques were perfor- disease, in fi ve patients treatment was limited to med with the assistance of a plastic surgery team. surgical debulking for palliative and hygiene pur- Four patients who had previously under- poses, followed by reconstruction (Figure-1). gone partial penectomy required emasculation The pathological nodal status of the 11 pa- due to tumor recurrence (at 6,2,9 and 13 months, tients undergoing radical inguinal lymphadenec- respectively). The previous
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