Brirrsh Journal of
Urology (19781, 50. 215-279
Carcinoma of the Penis A . A. KHEZRI, M. DUNN, P. J. B. SMITH and J. P. MITCHELL Departments of Urology, Bristol Royal Infirmary and Bath United Hospitals
Summary - Sixty-three patients with squamous cell carcinoma of the penis have been reviewed. The 3 year survival w a s 77%, and t h e 5 year survival w a s 59%. Prognosis w a s related to both clinical staging and histological grading. S t a g e I and II carcinomas were best treated by surgery alone. Stage Ill and IV carcinomas were best treated by local amputation of t h e penis combined with radiotherapy t o the inguinal nodes. Surgery a s a primary treatment for clinically positive nodes w a s successful in less than half the c a s e s treated, and in this series w a s always followed by wound infection and ly mphoedema. Tender, enlarged inguinal lymph nodes should be observed for up t o 3 months following primary treatment, a s a large percentage of these nodes are inflammatory and subside spontaneously. Carcinoma of the penis is an uncommon lesion and both general and urological surgeons may be undecided as to the best form of treatment. Primary surgery has been advocated by some authors including Lesser and Schwarz (1955), Staubitz et al. (1955), Savage (1957) and Marcia1 et a/. (1962). Others have advised radiotherapy as the initial treatment (Engelstad, 1948; Murrell and Williams, 1965). Finally, a combination of surgery and radiotherapy has been described by Lederman (1953), Cox (1954) and Ekstrom and Edsmyr (1 958). In view of these different opinions a retrospective review of 63 cases of carcinoma of the penis presenting in the Department of Surgery and Urology at the Bristol* and Bath United Hospitals over the period 1962-76 was carried out to try and determine which method of treatment to advise any future patients presenting with this lesion.
acceptable and were excluded (Table 1). The remaining 63 patients had primary squamous cell carcinoma of the penis. The age at presentation varied from 32 to 93 years with a mean age of 58 years. Thirty-two patients presented with a painful ulceration, a purulent or blood stained discharge and a nonretractile foreskin. Fifteen patients had swelling and inflammation with a non-retractile foreskin. Sixteen patients presented with a nodule on the glans penis. The duration of these features before presentation in hospital was from 3 weeks to 3 years with a mean duration of 21 weeks. Fiftynine patients were married and in the 55 patients where relevant information was available 5 1 were fertile. There was no change in the overall incidence of carcinoma of the penis during this 15 year period. The patients had a wide range of occupations, but in none was this significant in relation to aetiology. One patient had an
Patients and Methods
Table 1 Pathological Diagnosis in 73 Tumours of the Penis
During the 15 year period under review a total of 73 patients with lesions of the penis was considered. Of these, 10 cases were not considered * Rrisiol Royal Infirmary, Southmead Hospital and Frenchay Hmpital.
Received 4 November 1977. Accepted for publication 26 January 1978.
Primary squamous cell carcinoma of penis
Benign lesions Primary malignant melanoma of penis Transitional cell carcinoma of penis (arising from urothelium) Primary reticulum cell sarcoma of penis Carcinoma in situ Total
275
63 4
2 2 1 1
73
276
BRITISH JOURNAL OF UROLOGY
epispadias and in the remainder none had been circumcised before puberty. In the 53 cases where the information was available, 24 men had evidence Of previous Urinary infection. Seven patients had a history of venereal disease. In 1 1 patients leukoplakia had been found prior to the development of the carcinoma. The tumours were each staged according to the
Table 3 Histological Grading
classification described by Jackson (1966)(Table 2). The histological grading of the tumour is shown in Table 3.
Degree Of
No. of patients
Well differentiated
33
Moderately differentiated Poorly differentiated Awlastic
22
Total
63
7
I
Results Treatment In view of the length of the period of this retrospective review and the fact that these patients were treated by many surgical teams, it was not surprising that different methods of treatment of carcinoma of the penis had been employed (Table 4). Radiotherapy alone was used in 5 patients with Stage 1 carcinoma of the penis. The dose was 6OOO rads to the penis only, given over a 6 week period. Those patients with Stage I1 carcinoma who received radiotherapy did so at varying intervals following initial amputation either prophylactically* (5 patients) or as a result of recurrence proven histologically (6 patients). The radiotherapy was given to the groins only, in the dose of up to 60oO rads over a 6 week period. When radiotherapy was used in Stage I11 and IV carcinoma it was given after the amputation wound had healed in a dose of up to 60oO rads to groins or groins and penis (3 cases) over a 6 week period. Histological proof of inguinal node metastases was obtained in each case.
The overall results of this wide range of different treatments were encouraging. Forty-six of the 59 patients were alive at 3 years (77%) and 32 out of 54 at 5 years (59%). The mortality figures include 10 patients dying from causes, mainly cardiovascular, unrelated to the original tumour. Thus the corrected 5 year survival rate was 77%. The results of the different treatments have been analysed in relation to the clinical staging of the tumour and divided into 2 groups.
I.
Stage I and II Tumours (Tables 5 and 6)
* Although it has not been the policy of this centre, 5 patients had prophylactic radiation in this group.
Forty-three of the 63 patients (68Vo)in this series were Stage I and 11, that is, tumour confined to the penis. Twenty-six of these patients were treated by either local excision or partial amputation and 1 patient by cryosurgery. Seventeen of these patients were alive and well at 5 years, 2 at 4 years and 2 at 2 years. Five of the 9 patients who had surgery followed by radiotherapy were alive and well at 5 years and 2 at between 3 and 4 years. The 8 patients who died in these groups did so as a result of intercurrent disease (e.g. myocardial infarct, bronchopneumonia), with none dying as a result of carcinoma of the penis. Their age range was 52 years to 94 years, with a mean age of 80 years. Of the 5 patients who had
Table 2 Staging of Carcinoma of Penis
Table 4 Methods of Treatment No. of patients
~~
~
Tumour confined to glans or prepuce Tumour extending into the urethra or beyondthecorona Stage 111 Inguinal node invdlvement but nodes still mobile Stage IV Fixed involved inguinal nodes, direct extension of distant metastases Stage I Stage I I
17
26 16
4
No. of patients Local excision Partial amputation Partial amputation and radiotherapy Partial amputation and radiotherapy and block dissection Radiotherapy alone Cryosurgery alone Total amputation and radiotherapy Total amputation and block dissection
1 25 18
3 5 1 9
I
277
CARCINOMA OF THE PENIS
Table 5 Stage I Turnours ~~
No. of
Treatment used
Degree of differentiation
patients Well ~~
~~
0
-
1
1
0
3
7
6
0
-
I
I
1
I
3
2
10
10
-
Cryosurgery
I
1
-
-
Radiotherapy to penis alone t
5
3
2
-
~~
+
5 year survival
Poorly
1
Putial amputation*
Died of No. of intercurrent patients disease surviving
Moderate
1
Local excision
Died of carcinoma
~
One patient follow-up 4 years. One patient follow-up 2 years..
radiotherapy alone, 2 were alive and well at 5 years, 1 was alive and well at 2 years, but 1 patient died from carcinomatosis 3 years after treatment and another died from intercurrent disease.'Two patients who had undergone partial amputation of penis followed by radiotherapy subsequently developed positive inguinal lymph nodes 6 and 8 months later and then underwent block dissection. One of these patients developed gross lymphoedema but is alive and well at 6 years. The other died at 18 months as the result of disseminated carcinoma of the penis. This latter patient was the only one in Stage I and Stage I1 with a poorly differentiated tumour, the rest having a well or moderately well differentiated lesion.
their carcinoma within 5 years, 1 patient was killed in a road traffic accident at 2 years, 7 patients were alive and well at 5 years, 1 patient at 4 years and 1 at 1 year. Nine patients had a partial amputation followed by radiotherapy and 5 patients had a total amputation followed by radiotherapy. One patient had a partial amputation and radiotherapy followed by block dissection, and the last patient had a total amputation with block dissection. Both patients who had a block dissection developed lymphoedema. Five of the 6 patients in this group who died had had a total amputation and radiotherapy, and the sixth patient had had a total amputation with a block dissection. Five of the 6 patients who died had either poorly differentiated or anaplastic tumours. The 4 patients with Stage IV disease were treated by total amputation and radiotherapy. All were dead within 3 years:
2. Stage III and IV Turnours (Tables 7 and 8) Sixteen patients in this series had Stage 111 car-
cinoma of the penis and 6 had died as a result of Table 6 Stage 11 Turnours Treatment used
No. of
Degree of dgferentiation
patients Well ~~
~~~~
~
Moderate ~
~
Died of carcinoma
Died of No. of intercurrent patients disease surviving
5 year survival
Poorly
I5
8
7
-
-
3
12
9
Partial amputation followed by radiotherapy to groin t
9
2
7
-
-
2
7
5
Partial amputation followed by radiotherapy to groin and later block dissection
2
-
1
I
I
-
1
1
Partial amputation*
* Three patients-follow-up
t Two patients-follow-up
between 2 years and 4 years. between 3 years and 4 years.
BRITISH JOURNAL OF UROLOGY
27 8 Table 7 Stage 111 Turnours Treatment used
No. of patients
Degree of differentiation
Died of Died of carcinoma interAnaptastic current disease
No. of patients surviving
5 year survival
Well
Moderate
Poorly
9
7
2
-
-
0
I
8
6
Partial amput at ion and radiotherapy and block dissection 1
1
-
-
-
0
0
I
I
Total amputation and block dissection
1
-
1
-
-
1
0
0
0
Total amputation and radiotherapy
5
-
-
4
I
5
0
0
0
Partial amputation and radiotherapy'
* Two patients-follow-up
I year and 4 years.
Table 8 Stage IV Turnours Treatment used
Total amputation and radiotherapy
No. of patients
4
Degree of differentiation Well
Moderate
Poorly
Anaplastic
-
2
2
-
Discussion The results in this series showed a 77% 3 year and a 59% 5 year survival and compare favourably with other published results. Cox (1954), using radium for the penis and a block dissection for clinically positive nodes, had a 37% 5 year survival in 60 patients. Lesser and Schwarz (1955). using surgery, had a 48.6% 5 year survival in 35 cases. Slightly better results were obtained by Lederman (1953) who used radiotherapy combined with surgery. His 5 year survival was 50.8% in 183 patients. Murrell and Williams (1965), using radiotherapy, had a 3 year survival of 50.2% and a 5 year survival of 40.4% in 108 patients. Marcia1 et al. (1962), using surgery had a 5 year survival rate of 50.8% in 183 patients. Frew el al. (1967) had a 53% 5 year survival in 46 patients with carcinoma of the penis treated by surgery. The best recorded results in the literature are those of Engelstad (1948) who, using radium for the penis and groins with surgery later for uncontrolled disease, had a 3 year survival of 70.8% in 72 patients and a 5 year survival of 66.7% in 57 patients. Ekstrdm and Edsmyr (1958). using surgery to the penis and clinically positive nodes and telegamma irradiation
Diedof carcinoma
Diedof No. of intercurrent patients disease surviving 5 years
4
-
0 (0%)
to clinically negative nodes, had a 5 year survival of 69% in 177 patients. The 5 year survival rate for Stage I and I 1 tumours in this series was .70%. This compares with Beggs and Spratt (1964), where the treatment was primarily surgical, who had a 72.5% 5 year survival in 57 patients. Murrell and Williams (1965) reported a 52% 5 year survival in patients with Stage I and I1 carcinoma of the penis treated by radiotherapy. Engelstad (1948) treated the penis by teleradium and radium mould, giving 3500-3700 rads in 3 days, and had a 5 year survival of 66%. In both series surgery was necessary for persistent or recurrent cases. Thus it would seem that radiotherapy alone does not control the primary carcinoma as effectively as surgery, and in particular radiotherapy is not likely to be effective in controlling the primary lesion where the tumour is either septic or invading the corpora or urethra. Furthermore, the advantage of the short hospital stay associated with surgical amputation compares favourably with 6 weeks radiotherapy treatment followed by 6-8 weeks discomfort due to the local tissue reaction. This is an important consideration, as many patients are elderly and infirm.
279
CARCINOMA OF THE PENIS
One further fact of interest appeared from this study. The policy of deferring a decision on the treatment of inguinal lymph nodes until the primary lesion has been treated and the wound healed did not lead to any case passing from operable to inoperable stage. In 24 patients there were enlarged, tender, palpable inguinal nodes which resolved completely after surgery to the penile lesion. This confirms the findings of Cox (1954) and Beggs and Spratt (1964) that early prophylactic groin dissection led to a high percentage of unnecessary groin dissections and of Harlin (1952) who found careful observation of the groins was necessary to allow infection to subside. Provided that the nodes are not increasing in size or fixity one should be prepared to observe the patients at regular intervals. In the 4 patients where block dissection was performed, tumour deposits were present in 3 cases, of whom 2 died and 1 is still alive and well at 6 years. In the remaining patient where the nodes were negative, lyrnphoedema occurred subsequently, but the patient is still alive at 11 years.
Ekstrom, T. and Edsmyr, F. (1958). Cancer of the penis. A clinical study of 229 cases. Acta chirurgica Scandinavica. 115, 25-45. Engelstad. R. B. (1948). Treatment of cancer of the penis at the Norwegian Radium Hospital. Radiology, 60, 801-806. Frew, 1. D. O., Jefferies, J. D. and Swinney, J. (1967). Carcinoma of the penis. British Journal of Urology, 39, 398404. Harlin, H. C. (1952). Carcinoma of the penis. Journal OJ Urology, 61, 326-337. Jackson, S. M. (1966). The treatment of carcinoma of the penis. British Journal of Surgery, 53, 33-35. Lederman, M. (1953). Radiotherapy of cancer of the penis. British Journal of Urology, 25, 224-232. Lesser, J. H. and Schwarz, H. (1955). External genital cancer. Results of treatment at Ellis Fischel State Cancer Hospital. Cancer, 8, 1021-1025. Marcial, V. A., Figueroa-Colon, J., Marcial-Rojas, A. A. and Colon, J. 8. (1962). Carcinoma of the penis. Radiologia, 19, 209-220. Murrell, D. S. and Williams, J. L. (1965). Radiotherapy in the treatment of carcinoma of the penis. British Journal of Urology, 31, 2 1 1-222. Savage, C. R. (1957). The treatment and prognosis of carcinoma of penis. British Journal of Urology, 29, 69-71. Staubitz. W. J., Lent, M. H. and Oberkircher, 0. J. (1955). Carcinoma of the penis. Cancer, 8, 371-378.
Acknowledgement
The Authors
We would like to thank our other urological and general surgical colleagues in Bristol and Bath for permission to review their patients. We are indebted to Miss Michelle Dent for typing this manuscript.
A. A. Khezri, MD, Honorary Senior Registrar, Department
References Beggs, J. H. and Spratt, 1. S., Jr. (1964). Epidermoid carcinoma of the penis. Journal of Urology, 91, 166-172. Cox, R. (1954). Radiotherapy in malignant disease of the testicle and penis. British Journal of Urology, 26, 350-361.
of Urology, Bristol Royal Infirmary. M. Dunn, ChM. FRCS, Senior Registrar, Department of Urology, Bristol Royal Infirmary. P. J. B. Smith, ChM, FRCS, Consultant Urological Surgeon, Department of Urology, St Martin's Hospital, Bath. J. P. Mitchell, T D , MS, FRCS, FRCSE, Professor of Surgery, Department of Urology, Bristol Royal Infirmary. Requests for reprints to: Mr M. Dunn, Department of Urology, Southmead General Hospital, Westbury-on-Trym, Bristol BSlO 5NB.
Urology (19781, 50. 215-279
Carcinoma of the Penis A . A. KHEZRI, M. DUNN, P. J. B. SMITH and J. P. MITCHELL Departments of Urology, Bristol Royal Infirmary and Bath United Hospitals
Summary - Sixty-three patients with squamous cell carcinoma of the penis have been reviewed. The 3 year survival w a s 77%, and t h e 5 year survival w a s 59%. Prognosis w a s related to both clinical staging and histological grading. S t a g e I and II carcinomas were best treated by surgery alone. Stage Ill and IV carcinomas were best treated by local amputation of t h e penis combined with radiotherapy t o the inguinal nodes. Surgery a s a primary treatment for clinically positive nodes w a s successful in less than half the c a s e s treated, and in this series w a s always followed by wound infection and ly mphoedema. Tender, enlarged inguinal lymph nodes should be observed for up t o 3 months following primary treatment, a s a large percentage of these nodes are inflammatory and subside spontaneously. Carcinoma of the penis is an uncommon lesion and both general and urological surgeons may be undecided as to the best form of treatment. Primary surgery has been advocated by some authors including Lesser and Schwarz (1955), Staubitz et al. (1955), Savage (1957) and Marcia1 et a/. (1962). Others have advised radiotherapy as the initial treatment (Engelstad, 1948; Murrell and Williams, 1965). Finally, a combination of surgery and radiotherapy has been described by Lederman (1953), Cox (1954) and Ekstrom and Edsmyr (1 958). In view of these different opinions a retrospective review of 63 cases of carcinoma of the penis presenting in the Department of Surgery and Urology at the Bristol* and Bath United Hospitals over the period 1962-76 was carried out to try and determine which method of treatment to advise any future patients presenting with this lesion.
acceptable and were excluded (Table 1). The remaining 63 patients had primary squamous cell carcinoma of the penis. The age at presentation varied from 32 to 93 years with a mean age of 58 years. Thirty-two patients presented with a painful ulceration, a purulent or blood stained discharge and a nonretractile foreskin. Fifteen patients had swelling and inflammation with a non-retractile foreskin. Sixteen patients presented with a nodule on the glans penis. The duration of these features before presentation in hospital was from 3 weeks to 3 years with a mean duration of 21 weeks. Fiftynine patients were married and in the 55 patients where relevant information was available 5 1 were fertile. There was no change in the overall incidence of carcinoma of the penis during this 15 year period. The patients had a wide range of occupations, but in none was this significant in relation to aetiology. One patient had an
Patients and Methods
Table 1 Pathological Diagnosis in 73 Tumours of the Penis
During the 15 year period under review a total of 73 patients with lesions of the penis was considered. Of these, 10 cases were not considered * Rrisiol Royal Infirmary, Southmead Hospital and Frenchay Hmpital.
Received 4 November 1977. Accepted for publication 26 January 1978.
Primary squamous cell carcinoma of penis
Benign lesions Primary malignant melanoma of penis Transitional cell carcinoma of penis (arising from urothelium) Primary reticulum cell sarcoma of penis Carcinoma in situ Total
275
63 4
2 2 1 1
73
276
BRITISH JOURNAL OF UROLOGY
epispadias and in the remainder none had been circumcised before puberty. In the 53 cases where the information was available, 24 men had evidence Of previous Urinary infection. Seven patients had a history of venereal disease. In 1 1 patients leukoplakia had been found prior to the development of the carcinoma. The tumours were each staged according to the
Table 3 Histological Grading
classification described by Jackson (1966)(Table 2). The histological grading of the tumour is shown in Table 3.
Degree Of
No. of patients
Well differentiated
33
Moderately differentiated Poorly differentiated Awlastic
22
Total
63
7
I
Results Treatment In view of the length of the period of this retrospective review and the fact that these patients were treated by many surgical teams, it was not surprising that different methods of treatment of carcinoma of the penis had been employed (Table 4). Radiotherapy alone was used in 5 patients with Stage 1 carcinoma of the penis. The dose was 6OOO rads to the penis only, given over a 6 week period. Those patients with Stage I1 carcinoma who received radiotherapy did so at varying intervals following initial amputation either prophylactically* (5 patients) or as a result of recurrence proven histologically (6 patients). The radiotherapy was given to the groins only, in the dose of up to 60oO rads over a 6 week period. When radiotherapy was used in Stage I11 and IV carcinoma it was given after the amputation wound had healed in a dose of up to 60oO rads to groins or groins and penis (3 cases) over a 6 week period. Histological proof of inguinal node metastases was obtained in each case.
The overall results of this wide range of different treatments were encouraging. Forty-six of the 59 patients were alive at 3 years (77%) and 32 out of 54 at 5 years (59%). The mortality figures include 10 patients dying from causes, mainly cardiovascular, unrelated to the original tumour. Thus the corrected 5 year survival rate was 77%. The results of the different treatments have been analysed in relation to the clinical staging of the tumour and divided into 2 groups.
I.
Stage I and II Tumours (Tables 5 and 6)
* Although it has not been the policy of this centre, 5 patients had prophylactic radiation in this group.
Forty-three of the 63 patients (68Vo)in this series were Stage I and 11, that is, tumour confined to the penis. Twenty-six of these patients were treated by either local excision or partial amputation and 1 patient by cryosurgery. Seventeen of these patients were alive and well at 5 years, 2 at 4 years and 2 at 2 years. Five of the 9 patients who had surgery followed by radiotherapy were alive and well at 5 years and 2 at between 3 and 4 years. The 8 patients who died in these groups did so as a result of intercurrent disease (e.g. myocardial infarct, bronchopneumonia), with none dying as a result of carcinoma of the penis. Their age range was 52 years to 94 years, with a mean age of 80 years. Of the 5 patients who had
Table 2 Staging of Carcinoma of Penis
Table 4 Methods of Treatment No. of patients
~~
~
Tumour confined to glans or prepuce Tumour extending into the urethra or beyondthecorona Stage 111 Inguinal node invdlvement but nodes still mobile Stage IV Fixed involved inguinal nodes, direct extension of distant metastases Stage I Stage I I
17
26 16
4
No. of patients Local excision Partial amputation Partial amputation and radiotherapy Partial amputation and radiotherapy and block dissection Radiotherapy alone Cryosurgery alone Total amputation and radiotherapy Total amputation and block dissection
1 25 18
3 5 1 9
I
277
CARCINOMA OF THE PENIS
Table 5 Stage I Turnours ~~
No. of
Treatment used
Degree of differentiation
patients Well ~~
~~
0
-
1
1
0
3
7
6
0
-
I
I
1
I
3
2
10
10
-
Cryosurgery
I
1
-
-
Radiotherapy to penis alone t
5
3
2
-
~~
+
5 year survival
Poorly
1
Putial amputation*
Died of No. of intercurrent patients disease surviving
Moderate
1
Local excision
Died of carcinoma
~
One patient follow-up 4 years. One patient follow-up 2 years..
radiotherapy alone, 2 were alive and well at 5 years, 1 was alive and well at 2 years, but 1 patient died from carcinomatosis 3 years after treatment and another died from intercurrent disease.'Two patients who had undergone partial amputation of penis followed by radiotherapy subsequently developed positive inguinal lymph nodes 6 and 8 months later and then underwent block dissection. One of these patients developed gross lymphoedema but is alive and well at 6 years. The other died at 18 months as the result of disseminated carcinoma of the penis. This latter patient was the only one in Stage I and Stage I1 with a poorly differentiated tumour, the rest having a well or moderately well differentiated lesion.
their carcinoma within 5 years, 1 patient was killed in a road traffic accident at 2 years, 7 patients were alive and well at 5 years, 1 patient at 4 years and 1 at 1 year. Nine patients had a partial amputation followed by radiotherapy and 5 patients had a total amputation followed by radiotherapy. One patient had a partial amputation and radiotherapy followed by block dissection, and the last patient had a total amputation with block dissection. Both patients who had a block dissection developed lymphoedema. Five of the 6 patients in this group who died had had a total amputation and radiotherapy, and the sixth patient had had a total amputation with a block dissection. Five of the 6 patients who died had either poorly differentiated or anaplastic tumours. The 4 patients with Stage IV disease were treated by total amputation and radiotherapy. All were dead within 3 years:
2. Stage III and IV Turnours (Tables 7 and 8) Sixteen patients in this series had Stage 111 car-
cinoma of the penis and 6 had died as a result of Table 6 Stage 11 Turnours Treatment used
No. of
Degree of dgferentiation
patients Well ~~
~~~~
~
Moderate ~
~
Died of carcinoma
Died of No. of intercurrent patients disease surviving
5 year survival
Poorly
I5
8
7
-
-
3
12
9
Partial amputation followed by radiotherapy to groin t
9
2
7
-
-
2
7
5
Partial amputation followed by radiotherapy to groin and later block dissection
2
-
1
I
I
-
1
1
Partial amputation*
* Three patients-follow-up
t Two patients-follow-up
between 2 years and 4 years. between 3 years and 4 years.
BRITISH JOURNAL OF UROLOGY
27 8 Table 7 Stage 111 Turnours Treatment used
No. of patients
Degree of differentiation
Died of Died of carcinoma interAnaptastic current disease
No. of patients surviving
5 year survival
Well
Moderate
Poorly
9
7
2
-
-
0
I
8
6
Partial amput at ion and radiotherapy and block dissection 1
1
-
-
-
0
0
I
I
Total amputation and block dissection
1
-
1
-
-
1
0
0
0
Total amputation and radiotherapy
5
-
-
4
I
5
0
0
0
Partial amputation and radiotherapy'
* Two patients-follow-up
I year and 4 years.
Table 8 Stage IV Turnours Treatment used
Total amputation and radiotherapy
No. of patients
4
Degree of differentiation Well
Moderate
Poorly
Anaplastic
-
2
2
-
Discussion The results in this series showed a 77% 3 year and a 59% 5 year survival and compare favourably with other published results. Cox (1954), using radium for the penis and a block dissection for clinically positive nodes, had a 37% 5 year survival in 60 patients. Lesser and Schwarz (1955). using surgery, had a 48.6% 5 year survival in 35 cases. Slightly better results were obtained by Lederman (1953) who used radiotherapy combined with surgery. His 5 year survival was 50.8% in 183 patients. Murrell and Williams (1965), using radiotherapy, had a 3 year survival of 50.2% and a 5 year survival of 40.4% in 108 patients. Marcia1 et al. (1962), using surgery had a 5 year survival rate of 50.8% in 183 patients. Frew el al. (1967) had a 53% 5 year survival in 46 patients with carcinoma of the penis treated by surgery. The best recorded results in the literature are those of Engelstad (1948) who, using radium for the penis and groins with surgery later for uncontrolled disease, had a 3 year survival of 70.8% in 72 patients and a 5 year survival of 66.7% in 57 patients. Ekstrdm and Edsmyr (1958). using surgery to the penis and clinically positive nodes and telegamma irradiation
Diedof carcinoma
Diedof No. of intercurrent patients disease surviving 5 years
4
-
0 (0%)
to clinically negative nodes, had a 5 year survival of 69% in 177 patients. The 5 year survival rate for Stage I and I 1 tumours in this series was .70%. This compares with Beggs and Spratt (1964), where the treatment was primarily surgical, who had a 72.5% 5 year survival in 57 patients. Murrell and Williams (1965) reported a 52% 5 year survival in patients with Stage I and I1 carcinoma of the penis treated by radiotherapy. Engelstad (1948) treated the penis by teleradium and radium mould, giving 3500-3700 rads in 3 days, and had a 5 year survival of 66%. In both series surgery was necessary for persistent or recurrent cases. Thus it would seem that radiotherapy alone does not control the primary carcinoma as effectively as surgery, and in particular radiotherapy is not likely to be effective in controlling the primary lesion where the tumour is either septic or invading the corpora or urethra. Furthermore, the advantage of the short hospital stay associated with surgical amputation compares favourably with 6 weeks radiotherapy treatment followed by 6-8 weeks discomfort due to the local tissue reaction. This is an important consideration, as many patients are elderly and infirm.
279
CARCINOMA OF THE PENIS
One further fact of interest appeared from this study. The policy of deferring a decision on the treatment of inguinal lymph nodes until the primary lesion has been treated and the wound healed did not lead to any case passing from operable to inoperable stage. In 24 patients there were enlarged, tender, palpable inguinal nodes which resolved completely after surgery to the penile lesion. This confirms the findings of Cox (1954) and Beggs and Spratt (1964) that early prophylactic groin dissection led to a high percentage of unnecessary groin dissections and of Harlin (1952) who found careful observation of the groins was necessary to allow infection to subside. Provided that the nodes are not increasing in size or fixity one should be prepared to observe the patients at regular intervals. In the 4 patients where block dissection was performed, tumour deposits were present in 3 cases, of whom 2 died and 1 is still alive and well at 6 years. In the remaining patient where the nodes were negative, lyrnphoedema occurred subsequently, but the patient is still alive at 11 years.
Ekstrom, T. and Edsmyr, F. (1958). Cancer of the penis. A clinical study of 229 cases. Acta chirurgica Scandinavica. 115, 25-45. Engelstad. R. B. (1948). Treatment of cancer of the penis at the Norwegian Radium Hospital. Radiology, 60, 801-806. Frew, 1. D. O., Jefferies, J. D. and Swinney, J. (1967). Carcinoma of the penis. British Journal of Urology, 39, 398404. Harlin, H. C. (1952). Carcinoma of the penis. Journal OJ Urology, 61, 326-337. Jackson, S. M. (1966). The treatment of carcinoma of the penis. British Journal of Surgery, 53, 33-35. Lederman, M. (1953). Radiotherapy of cancer of the penis. British Journal of Urology, 25, 224-232. Lesser, J. H. and Schwarz, H. (1955). External genital cancer. Results of treatment at Ellis Fischel State Cancer Hospital. Cancer, 8, 1021-1025. Marcial, V. A., Figueroa-Colon, J., Marcial-Rojas, A. A. and Colon, J. 8. (1962). Carcinoma of the penis. Radiologia, 19, 209-220. Murrell, D. S. and Williams, J. L. (1965). Radiotherapy in the treatment of carcinoma of the penis. British Journal of Urology, 31, 2 1 1-222. Savage, C. R. (1957). The treatment and prognosis of carcinoma of penis. British Journal of Urology, 29, 69-71. Staubitz. W. J., Lent, M. H. and Oberkircher, 0. J. (1955). Carcinoma of the penis. Cancer, 8, 371-378.
Acknowledgement
The Authors
We would like to thank our other urological and general surgical colleagues in Bristol and Bath for permission to review their patients. We are indebted to Miss Michelle Dent for typing this manuscript.
A. A. Khezri, MD, Honorary Senior Registrar, Department
References Beggs, J. H. and Spratt, 1. S., Jr. (1964). Epidermoid carcinoma of the penis. Journal of Urology, 91, 166-172. Cox, R. (1954). Radiotherapy in malignant disease of the testicle and penis. British Journal of Urology, 26, 350-361.
of Urology, Bristol Royal Infirmary. M. Dunn, ChM. FRCS, Senior Registrar, Department of Urology, Bristol Royal Infirmary. P. J. B. Smith, ChM, FRCS, Consultant Urological Surgeon, Department of Urology, St Martin's Hospital, Bath. J. P. Mitchell, T D , MS, FRCS, FRCSE, Professor of Surgery, Department of Urology, Bristol Royal Infirmary. Requests for reprints to: Mr M. Dunn, Department of Urology, Southmead General Hospital, Westbury-on-Trym, Bristol BSlO 5NB.
