Commentary (Shipley): Current Management of Unusual Genitourinary Cancers

In this two-part article, Krieg and Hoffman review the management of patients with cancer of the penis and those with cancer of the urethra, respectively. Both of these cancers are uncommon, and, when they present as small, early, circumscribed lesions, both can be cured (with organ preservation) by radiation therapy. Also following organ preservation by radiation therapy, these patients must continue to be followed closely because 25% to 35% will develop a local recurrence and can be cured by prompt salvage surgery.

Squamous Carcinoma of the Penis

With respect to the management of patients with squamous carcinoma of the penis, Krieg and Hoffman clearly demonstrate that any man with early-stage penile cancer who wishes to preserve both his penis intact and his sexual function can do so by receiving well-administered radiation therapy and, if close surveillance is used, without risk to his life. The authors summarize several studies that support this contention. Further recently published evidence not mentioned by the authors is a report of 101 patients treated for squamous carcinoma of the penis at the Royal Marsden Hospital and the associated Institute for Cancer Research in London and Sutton.[1] Even though these researchers found a 30% local recurrence rate in patients treated with ³ 60 Gy of external-beam radiation, local control was eventually achieved in 71 of 74 patients with stage T1 disease following retreatment with salvage surgery in the 17 patients who had local recurrences after radiation.

The authors also discuss quality-of-life issues following curative local treatment with radiation therapy, with particular emphasis on sexual function. Not all series, unfortunately, provide good information on sexual performance. However, another recent study from the Norwegian Radium Hospital addressed this issue by conducting a formal prospective analysis.[2] This study found that overall sexual function was preserved or only slightly diminished in 10 of the 12 radiation-treated patients. However, the analysis showed that overall sexual function was normal in only one of five men following wide local excision and two of nine after partial penectomy.

Urethral Carcinoma in Women

In their review of the management of patients with carcinoma of the urethra, the authors rightly point out that radiation therapy can achieve local tumor eradication, with preservation of a functional urinary bladder, in women with low-grade urethral carcinoma. However, patients with more advanced and certainly more proximal tumors are not good candidates for this approach. The concurrent administration of chemotherapy and radiation, while not yet well tested in patients with more advanced proximal tumors, seems to be a much riskier approach because no prechemoradiation debulking surgery can be carried out without compromising urinary continence.

Grigsby recently reported on a large experience treating urethral cancer in women at the Washington University School of Medicine.[3] His results clearly demonstrated that tumors less than 2 cm in diameter can be very well managed by radiation therapy or surgery, with an 88% cause-specific survival rate. Furthermore, in this series of 44 women, none of the 13 women who had adenocarcinoma of the urethra survived, regardless of the treatment that they received.

Multivariate analysis of this series showed that both cause-specific survival and local control of the pelvic tumor are favorably influenced if the tumor is less than 2 cm in diameter at diagnosis and if it is a squamous cell carcinoma rather than transitional cell carcinoma or adenocarcinoma. With a median follow-up of over 7 years, Grigsby reported a 32% local control rate with external-beam radiation therapy alone; severe local complications occurred in 21% of patients, including four fistulae.

In general, patients with the more advanced tumors were treated with combined aggressive surgery and radiation therapy. Of this group of 12 patients, only 44% were alive at 5 years, and half developed a local recurrence despite aggressive treatment.

This study suggests that a combined-modality regimen should be used for tumors greater than 2 cm in diameter, if possible, and that such a regimen should include chemotherapy if the patient can tolerate it. The specific chemotherapeutic drugs administered will likely depend on tumor histology.

The Memorial Sloan-Kettering Cancer Center has reported some encouraging results in both women and men with urethral transitional cell carcinoma using combined-modality therapy that includes chemotherapy, surgery, and radiation therapy.[4]

Urethral Carcinoma in Men

For an even rarer tumor-carcinoma of the urethra in men-the authors correctly state that control with radiation therapy is less likely without disruption of urinary flow, and that both radiation therapy and chemotherapy are more reasonably considered as adjuvant treatments to surgical excision, which only rarely is likely to be organ-conserving. Phallus reconstruction in combination with radical excision has led to preservation of the appearance of the male genitalia.[5]

References:

1. Farin R, Norman AR, Steele GG, et al: Treatment results and prognostic factors in 101 men treated for squamous carcinoma of the penis. Int J Radiat Oncol Biol Phys 38:713-722, 1997.

2. Opjordsmoen S, Waehre H, Aass N, et al: Sexuality in patients treated for penile cancer: Patients’ experience and doctors’ judgment. Br J Urol 73:554-560, 1994.

3. Grigsby PW: Carcinoma of the urethra in women. Int J Radiat Oncol Biol Phys 41:535-541, 1998.

4. Scher HI, Yagoda A, Herr HW, et al: Neoadjuvant M-VAC chemotherapy for extravesical urinary tract tumors. J Urol 139:475-477, 1988.

5. McDougal WS, Kock MO: Phallic reconstruction during extensive surgery for invasive urethral carcinoma. J Urol 141:1201-1203, 1989.