Total Margin Control Is Superior to Traditional Margin Assessment for Treatment of Low-Stage Penile Squamous Cell Carcinoma

Abstract

Purpose:Penile cancer is rare, with significant morbidity and limited literature assessing utility of peripheral and deep en face margin assessment (PDEMA) vs traditional margin assessment (vertical sections) on treatment outcomes.Materials and Methods:This was a 32-year retrospective multicenter cohort study at 3 academic tertiary care centers. The cohort consisted of 189 patients with histologic diagnosis of in situ or T1a cutaneous squamous cell carcinoma of the penis at Brigham and Women’s, Massachusetts General Hospital (1988-2020), and Memorial Sloan Kettering Cancer Center (1995-2020) treated with PDEMA surgical excision, excision/circumcision, or penectomy/glansectomy. Local recurrence, metastasis, and disease-specific death were assessed via multivariable Cox proportional hazard models.Results:The cohort consisted of 189 patients. Median age at diagnosis was 62 years. Median tumor diameter was 1.3 cm. The following outcomes of interest occurred: 30 local recurrences, 13 metastases, and 5 disease-specific deaths. Primary tumors were excised with PDEMA (N = 30), excision/circumcision (N = 110), or penectomy/glansectomy (N = 49). Of patients treated with traditional margin assessment (non-PDEMA), 12% had narrow or positive margins. Five-year proportions were as follows with respect to local recurrence-free survival, metastasis-free survival, and disease-specific survival/progression-free survival, respectively: 100%, 100%, and 100% following PDEMA; 82%, 96%, and 99% following excision/circumcision; 83%, 91%, and 95% following penectomy/glansectomy. A limitation is that this multi-institutional cohort study was not externally validated.Conclusions:Initial results are encouraging that PDEMA surgical management effectively controls early-stage penile squamous cell carcinoma.

Editorial Comment

“…In this large, retrospective, multi-institutional, longdated cohort study of 189 patients with histologic diagnosis of carcinoma in situ (pTis) or pT1a cutaneous squamous cell carcinoma of the penis (PSSC), O'Connell et al demonstrated that peripheral and deep en face margin assessment (PDEMA; ie, Mohs) had reduced local recurrence rates and higher local recurrence-free, progression-free, and metastasis-free survival rates over median follow-up of 4 years compared to traditional surgical techniques such as wide excision/circumcision and/or penectomy/glansectomy. 1 This study, therefore, validates PDEMA as a legitimate treatment option for low-stage PSCC, which is noninferior to more traditional surgery and can lead to great patient satisfaction and organ/ functional preservation when compared to more aggressive surgery. 2 Indeed, increased margin visualization and accuracy of PDEMA has been associated with higher cure rates in cutaneous squamous cell carcinoma, where PDEMA is well-established and utilized in the National Comprehensive Cancer Network guidelines.…”

Editorial Comment

“…The article by O'Connell and colleagues 1 supports the role of penile-preserving surgery in low-stage penile squamous cell carcinoma (PeSCC). Penilepreserving surgery delivers good oncological outcomes, if margins are >1 mm, 2 whilst, in many cases, maintaining good penile function.…”

“…The striking outcome of the data is that the 5-year local recurrence-free survival for patients (n [ 30) treated with PDEMA was 100%. 1 For standard excision/circumcision (n [ 110) it was 82% and for glansectomy or partial or total penectomy (n [ 49) it was 83%. The positive margin rates for the 3 groups were 0%, 11%, and 2%, respectively.…”

“…Penile-preserving surgery delivers good oncological outcomes, if margins are >1 mm, 2 whilst, in many cases, maintaining good penile function. This study 1 examines the role of surgery using peripheral and deep en face margin assessment (PDEMA), for example Mohs micrographic surgery.…”

“…The poorer disease-specific/progression-free survival reported with excision/circumcision and penectomy/glansectomy compared to PDEMA 1 may in part be due to the local recurrences but is likely to be influenced by selection bias. All patients in the PDEMA cohort had either in situ disease or well-differentiated pT1a tumors.…”