Penile cancer trends and economic burden in the Brazilian public health system / Tendências e carga econômica do câncer de pênis no sistema público de saúde brasileiro

ABSTRACT Objective: To gather information on penile cancer epidemiologic trends and its economic impact on the Brazilian Public Health System across the last 25 years. Methods: The Brazilian Public Health System database was used as the primary source of data from January 1992 to December 2017. Mortality and incidence data from the Instituto Nacional de Câncer José Alencar Gomes da Silva was collected using the International Classification of Diseases ICD10 C60. Demographic data from the Brazilian population was obtained from the last census by the Brazilian Institute of Geography and Statistics, performed in 2010 and its 2017 review. Results: There were 9,743 hospital admissions related to penile cancer from 1992 to 2017. There was a reduction (36%) in the absolute number of admissions per year related to penile cancer in 2017, as compared to 1992 (2.7versus 1.7 per 100,000; p<0.001). The expenses with admissions related to this condition in this period were US$ 3,002,705.73 (US$ 115,488.68/year). Approximately 38% of the total amount was spent in Northeast Region. In 1992, penile cancer costed US$ 193,502.05 to the public health system, while in 2017, it reduced to US$ 47,078.66 (p<0.02). Penile cancer incidence in 2017 was 0.43/100,000 male Brazilian, with the highest incidence rate found in the Northeast Region. From 1992 to 2017, the mortality rates of penile cancer in Brazil were 0.38/100,000 man, and 0.50/100,000 man in the North Region. Conclusion: Despite the decrease in admissions, penile cancer still imposes a significant economic and social burden to the Brazilian population and the Public Health System.

RESUMO Objetivo: Reunir informações sobre as tendências epidemiológicas do câncer de pênis e seu impacto econômico no Sistema Único de Saúde nos últimos 25 anos. Métodos: O banco de dados de informações do Sistema Único de Saúde foi utilizado como fonte primária de dados de janeiro 1992 a dezembro 2017. Os dados demortalidade e incidência do Instituto Nacional de Câncer José Alencar Gomes da Silva foram coletados usando a Classificação Internacional de Doença CID10 C60. Os dados demográficos da população brasileira foram obtidos do último censo do Instituto Brasileiro de Geografia e Estatística, realizado em 2010, e em sua revisão, de 2017. Resultados: Ocorreram 9.743 internações relacionadas ao câncer de pênis de 1992 a 2017. Houve redução (36%) nas internações anuais absolutas em 2017 em comparação com 1992 (2,7 versus 1,7 por 100.000; p<0,001). Os gastos com internações neste período foram de US$ 3,002,705.73 (US$ 115,488.68/ano). Cerca de 38% do valor total foi gasto na Região Nordeste. Em 1992, o câncer de pênis custou US$ 193,502.05 ao sistema público, enquanto em 2017 reduziu para US$ 47,078.66 (p<0,02). A incidência em 2017 foi de 0,43/100.000 brasileiro do sexo masculino, com a maior taxa de incidência encontrada na Região Nordeste. De 1992 a 2017, as taxas de mortalidade por câncer de pênis foram de 0,38/100.000 homem, sendo 0,50/100.000 homem na Região Norte. Conclusão: Apesar da diminuição nas hospitalizações, o câncer de pênis ainda impõe uma carga econômica e social significativa à população brasileira e ao Sistema Único de Saúde.

External validation of nomogram to predict inguinal lymph node metastasis in patients with penile cancer and clinically negative lymph nodes

ABSTRACT Introduction Penile cancer (PC) occurs less frequently in Europe and in the United States than in South America and parts of Africa. Lymph node (LN) involvement is the most important prognostic factor, and inguinal LN (ILN) dissection can be curative; however, ILN dissection has high morbidity. A nomogram was previously developed based on clinicopathological features of PC to predict ILN metastases. Our objective was to conduct an external validation of the previously developed nomogram based on our population. Materials and methods We included men with cN0 ILNs who underwent ILN dissection for penile carcinoma between 2000 and 2014. We performed external validation of the nomogram considering three different external validation methods: k-fold, leave-one-out, and bootstrap. We also analyzed prognostic variables. Performance was quantified in terms of calibration and discrimination (receiver operator characteristic curve). A logistic regression model for positive ILNs was developed based on clinicopathological features of PC. Results We analyzed 65 men who underwent ILN dissection (cN0). The mean age was 56.8 years. Of 65 men, 24 (36.9%) presented with positive LNs. A median 21 ILNs were removed. Considering the three different methods used, we concluded that the previously developed nomogram was not suitable for our sample. Conclusions In our study, the previously developed nomogram that was applied to our population had low accuracy and low precision for correctly identifying patients with PC who have positive ILNs.

Myiasis associated with penile carcinoma: a new trend in developing countries?

ABSTRACT Objectives The aim of this study is to report an unusual form of penile cancer presentation associated with myiasis infestation, treatment options and outcomes. Materials and Methods We studied 10 patients with suspected malignant neoplasm of the penis associated with genital myiasis infestation. Diagnostic assessment was conducted through clinical history, physical examination, penile biopsy, larvae identification and computerized tomography scan of the chest, abdomen and pelvis. Clinical and pathological staging was done according to 2002 TNM classification system. Radical inguinal lymphadenectomy was conducted according to the primary penile tumor pathology and clinical lymph nodes status. Results Patients age ranged from 41 to 77 years (mean=62.4). All patients presented squamous cell carcinoma of the penis in association with myiasis infestation caused by Psychoda albipennis. Tumor size ranged from 4cm to 12cm (mean=5.3). Circumcision was conducted in 1 (10%) patient, while penile partial penectomy was performed in 5 (50%). Total penectomy was conducted in 2 (20%) patients, while emasculation was the treatment option for 2 (20%). All patients underwent radical inguinal lymphadenectomy. Prophylactic lymphadenectomy was performed on 3 (30%) patients, therapeutic on 5 (50%), and palliative lymphadenectomy on 2 (20%) patients. Time elapsed from primary tumor treatment to radical inguinal lymphadenectomy was 2 to 6 weeks. The mean follow-up was 34.3 months. Conclusion The occurrence of myiasis in the genitalia is more common in patients with precarious hygienic practices and low socio-economic level. The treatment option varied according to the primary tumor presentation and clinical lymph node status.

Tumor histologic grade is the most important prognostic factor in patients with penile cancer and clinically negative lymph nodes not submitted to regional lymphadenectomy

ABSTRACT Introduction: The presence and extension of inguinal lymph node metastasis are the main prognostic factors in patients with penile cancer. Physical exam and image exams are not adequate to evaluate inguinal lymph nodes and many patients are submitted to non-therapeutic lymphadenectomies. However, it is known that not all patients with clinically or histologically negative inguinal lymph nodes evolve favorably. Casuistic and Methods: the authors evaluated the clinical and pathologic characteristics of 163 patients with penile carcinoma and clinically negative inguinal lymph nodes followed for three or more years and their impact on global survival (GS) and cancer-specific survival (CSS) in the 10-year follow-up. Primary pathologic tumor stage (p=0.025) and the presence of high grade of tumor differentiation (p=0.018) were predictive of CSS. The presence of high grade tumor was an independent specific prognostic factor of death risk (RR 14.08; p=0.019). Conclusion: high histologic grade was an independent predictive factor of specific death risk in patients with penile carcinoma and clinically negative lymph nodes followed for three or more years.

Multiple giant angiokeratoma of Fordyce on the shaft of the penis masquerading as keratoacanthoma

The term 'angiokeratoma' includes a wide range of dermatological conditions of hyperkeratotic vascular disorders with a similar histologic combination of hyperkeratosis and superficial dermal vascular ectasia. Angiokeratomas can be classified into localized and systemic forms. Angiokeratoma of Fordyce (AKF) is a localized form of angiokeratoma, clinically characterized by 1- to 6-mm, black, blue, or dark red, dome-shaped papules located on the scrotum, shaft of penis, labia majora, clitoris, inner thigh, and lower abdomen. We describe herein a case of giant angiokeratoma of Fordyce on shaft of the penis in an elderly man, clinically masquerading as keratoacanthoma.

Feasibility, complications and oncologic results of a limited inguinal lymph node dissection in the management of penile cancer

In patients with penile cancer (PeCa) and increased risk of inguinal lymphatic dissemination, inguinal lymphadenectomy offers a direct histological staging as the most reliable tool for assessment of the nodal metastasic status and a definitive oncologic treatment simultaneously. However, peri- and/or postoperative mutilating sequalae often occurn. We report on clinical outcome and complications of a limited inguinal lymph node (LN) dissection.

Epidemiological study of penile cancer in Pernambuco: experience of two reference centers

Objectives To investigate and analyze the epidemiological profile of penile cancer in the state of Pernambuco and compare this information with other studies related to the issue. Material and Methods We conducted a retrospective, observational and descriptive study of all patients with penile cancer in two reference centers in Pernambuco - Brazil, from 2007 to 2012. The variables studied were: age, region from the state, socio-economic situation, previous postectomy, smoking, time from the beginning of injury to diagnosis, staging of the primary lesion, tumor differentiation, treatment performed and death due to cancer. Results The total number of patients was 88. The highest prevalence was seen in those aged between 66 and 75 years. About the socio-economic situation, 67% worked informally and 64.8% received up to two minimum wages. Of all patients, 57% were married and 50% illiterate. The Metropolitan Region of Recife was the one with the highest number of cases, 41%. Tobacco smoking was reported in 48.9% of cases and prior postectomy in 3.4%. Most often it was observed an average period of six months from the onset of symptoms to diagnosis. And when the lesion was diagnosed, it usually had 2 to 5 cm (64.7%), stage T2 in 50% and well differentiated in 79.6%. Partial penectomy was performed in 76.1% and total in 17%. Death was observed in 27.3%. Conclusion The clinical profile and epidemiological characteristics found in this study are similar to other national and international studies related to the issue, i.e., typical of underdeveloped or developing countries. .

Conservative treatment of penile carcinoma - a retrospective study of 10 years / Tratamento conservador do carcinoma do penis - estudo retrospectivo de 10 anos

Conservative treatment of penile squamous cell carcinoma has been advocated as a method of choice for tumours at early stages. Thirty patients with a mean age of 63.2 years were treated with CO2 laser ablation, radical local excision with preputial flap, direct closure or healing by secondary intention, circumcision alone or associated with CO2 laser and topical imiquimod. Sixteen patients had local recurrence. Partial penectomy was necessary in 3 patients. Conservative treatments of penile squamous cell carcinoma in early stages (< T1a) do not seem to compromise the survival rate, so it may be advisable for this subset of patients.

O tratamento conservador do carcinoma espinocelular do pênis tem sido o método de escolha para tumores em estádios iniciais. Trinta doentes com idade média de 63,2 anos, foram tratados com: ablação com laser CO2, excisão radical seguida de retalho prepucial, encerramento direto ou cicatrização por segunda intenção, circuncisão isolada ou associada a laser CO2 e imiquimod. Dezasseis doentes apresentaram recidiva local. No seguimento, houve necessidade de penectomia parcial em 3 doentes. O tratamento conservador do carcinoma espinocelular do pênis em estádio < T1a não parece comprometer a taxa de sobrevida, pelo que pode ser recomendável neste subgrupo de doentes.

Human Papilloma Virus: Prevalence, distribution and predictive value to lymphatic metastasis in penile carcinoma

Objectives To evaluate the prevalence, distribution and association of HPV with histological pattern of worse prognosis of penile cancer, in order to evaluate its predictive value of inguinal metastasis, as well as evaluation of other previous reported prognostic factors. Material and Methods Tumor samples of 82 patients with penile carcinoma were tested in order to establish the prevalence and distribution of genotypic HPV using PCR. HPV status was correlated to histopathological factors and the presence of inguinal mestastasis. The influence of several histological characteristics was also correlated to inguinal disease-free survival. Results Follow-up varied from 1 to 71 months (median 22 months). HPV DNA was identified in 60.9% of sample, with higher prevalence of types 11 and 6 (64% and 32%, respectively). There was no significant correlation of the histological characteristics of worse prognosis of penile cancer with HPV status. Inguinal disease-free survival in 5 years did also not show HPV status influence (p = 0.45). The only independent pathologic factors of inguinal metastasis were: stage T ≥ T1b-T4 (p = 0.02), lymphovascular invasion (p = 0.04) and infiltrative invasion (p = 0.03). conclusions HPV status and distribution had shown no correlation with worse prognosis of histological aspects, or predictive value for lymphatic metastasis in penile carcinoma. .

Locally advanced penile carcinoma: classic emasculation or testis-sparing surgery?

The study evaluates the clinical and pathological findings of 16 patients with locally advanced penile carcinoma (PC) submitted to emasculation, and discusses questions related to the usefulness of bilateral orchiectomy.

Between 1999 and 2010, 172 patients with PC were treated. Sixteen (9%) underwent emasculation. Data were retrieved from the institution's database including age, ethnicity, date of surgery, residential setting, level of schooling, time to diagnosis, type of reconstruction, complications, tumor stage and grade, vascular and perineural invasion along with invasion of corpus cavernosum, corpus spongiosum, testicles, scrotum and urethra.

A total of 16 patients (average: 63.1 years) with locally advanced PC were 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 pT4 (n = 6), pT3 (n = 8), pT2 (n = 2), Grade I (n = 5) and Grade II (n = 11). The histopathological 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.

The finding of focal microscopic testicular infiltration 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. .

Penile cancer in jamaicans managed at the university hospital of the West Indies / El cáncer de pene en jamaicanos tratados en el hospital universitario de West Indies

OBJECTIVES: The aim of this study is to determine the prevalence and clinicopathological correlates of penile cancer as well as the clinical outcomes in a sample of Jamaicans managed at the University Hospital of the West Indies (UHWI). METHODS: All available records of patients diagnosed with penile cancer from 1998-2008 at the UHWI were obtained. Patient demographics, circumcision status, sexually transmitted infection status, lesion duration, location and size, and lymph node status were obtained. Histology, differentiation and stage were recorded. Information was obtained regarding treatment and outcome. The current data were compared with a previous report from UHWI in 1959. RESULTS: The records of 22 of 26 patients with penile cancer were available for review. Mean (SD) age of patients was 68 (13) years. Eighteen (86%) patients were uncircumcised. Mean tumour size was 5.7 (2.6) cm; 8 (36%) lesions involved the entire penis. Sixteen (73%) lesions had clinically regional disease and 11 (52%) patients had advanced pathological stage. Surgical treatment was performed in 15 (68%) patients. Case fatality was 38%, with median survival following surgical intervention of 38 person-months. The major predictor of death in this series was increasing age (HR = 1.06, 95% CI 0.99, 1.1, p = 0.079). There was an increase in age and clinical stage of the cancer at presentation in the current series; however, there was no difference in survival. CONCLUSION: Penile cancer is an uncommon cancer, seen at an advanced stage in Jamaicans. Overall survival is poor and advanced age is a major predictor of death.

OBJETIVOS: El objetivo de este estudio es determinar la prevalencia y los correlatos clínico-patológicos del cáncer de pene así como los resultados clínicos en una muestra de jamaicanos tratados en el Hospital Universitario de West Indies (HUWI). MÉTODOS: Se obtuvieron todas las historias clínicas disponibles de los pacientes diagnosticados con cáncer de pene en el Hospital Universitario de West Indies en el período de 1998-2008. Se obtuvieron datos de los pacientes en relación con la demografía, estado de circuncisión, estado de infecciones de transmisión sexual, duración de la lesión, localización y tamaño, y condición de los nódulos linfáticos. Se registraron datos sobre la histología, la diferenciación y las etapas. Se obtuvo la información con respecto al tratamiento y la evolución clínica. Los datos corrientes se compararon con un informe anterior de UHWI en 1959. RESULTADOS: Las historias clínicas de 22 de 26 pacientes con cáncer de pene, estuvieron disponibles para su revisión. La edad promedio (SD) de los pacientes fue 68 (13) años. Dieciocho (86%) pacientes eran incircuncisos. El tamaño promedio del tumor fue 5.7 (2.6) cm; 8 (36%) lesiones involucraron el pene entero. Dieciséis (73%) lesiones tenían enfermedad regional clínicamente, y 11 (52%) pacientes estaban en la fase patológica avanzada. El tratamiento quirúrgico se realizó en 15 (68%) pacientes. La fatalidad de los casos fue de 38%, con una supervivencia promedio tras intervención quirúrgica de 38 persona-meses. El predictor mayor de muerte en esta serie fue la edad creciente (HR = 1.06, 95% CI 0.99, 1.1, p = 0.079). Se produjo un aumento en la edad y la fase clínica del cáncer con la presentación de la serie corriente. Sin embargo, no hubo ninguna diferencia en relación con la supervivencia. CONCLUSIÓN: El cáncer de pene es un cáncer raro, visto en una fase avanzada en jamaicanos. La supervivencia global es pobre y la edad avanzada es un predictor mayor de muerte.

Squamous cell carcinoma of the penis

Squamous cell carcinoma of the penis (CA Penis) is not a rare disease in P.R. We have reviewed all cases of CA penis diagnosed in our institution from Jan. 79 - Jan. 89. Pathology and hospital records were audited. The survival data on all patients was updated via telephone or record review up to May 89. A totoal of 18 pts were seen in the last decade. Of these 11.(61%) were seen in the last four years. Four of 18 patients were exluded from analysis due to lack of staging and therapy data. The median age 54.9 y (range 23-82y). The following risk factors were identified: phimosis 12/14 (86%) p=05, lekoplakia 8/14 (57%); prior venereal disease 1/4 (7%). The primary lesion appeared in the prepuce 8/14 (57%) and glans 6/14 (43%). TNM staging was done in all pts. Most pts presented with T3 or T4 disease 10/14 (71%) and palpable regional adenopathy (N1-N3) 9/14 (64%). O Of the mine pts with palpable adenopathy, in 5(56%) microscopic malignant disease was confirmed. A correlation between T3 or T4 disease and the presence of palpable adenopathy was seen (80%). The Stage at diagnosis of the 14 pts: I: 0/14 (29%), II: 5/14 (7%), III: 3/14 (21%), IV: 6/14; (43%). All pts were treated with partial penectomy and 7/14 had unilateral or bilateral inguinal lymphadenectomy. Long term survivors (LTS), greater than 12 mo., were seen 3/4 pts with Stage II disease, 1/3 Stage III, and 2/5 in Stage IV. The most important prognostic factor for LTS was malignant involvement of regional lymph nodes with ...