Brachytherapy for conservative treatment of invasive penile carcinoma in older patients: Single institution experience

Abstract

Background

No study has examined the possibility to perform an organ sparing strategy in older patients with penile carcinoma, and amputation is frequently proposed. We report our experience of interstitial brachytherapy for the conservative treatment of penile carcinoma confined to the glans in patients aged of 70 years and more.

Methods

A total of 55 patients candidates to conservative brachytherapy were identified. Median age was 73.8 years (range: 70–95 years). Patients underwent a circumcision then 3–4 weeks later, an interstitial brachytherapy was delivered, median dose of 65 Gy (range 55–74 Gy). Salvage surgery was discussed in patients with histological confirmation of residual/relapsed tumor.

Results

With median follow-up of 9.0 years, eight patients (14.5%) experienced a relapse, including five patients with local relapse. Three patients with local relapse only underwent salvage penile surgery, including two partial glansectomies and one total penectomy, and were in second complete remission at last follow-up. Among 55 patients analyzed for late side effects, seven patients (13.0%) presented pain or ulceration, 12 (22.2%) experienced urethral or meatal stenosis requiring at least one dilatation, two patients (3.7%) experienced both ulcerations and urethral complication. Three patients (5.5%) needed partial glansectomy for focal necrosis. At five years, estimated overall survival rate was 74.5% (95%CI: 62.0–87.0%) and local relapse free rate was 91.0% (95%CI: 82.6–99.4%).

Conclusion

Brachytherapy is feasible in selected older patients with penile carcinoma, with efficacy and toxicity rates comparable to that of other series in younger patients.

Introduction

Penile cancer is very rare entity (annual incidence rate of less than 1/100,000 in male European population) [1]. Most are squamous cell carcinoma, usually occurring in uncircumcised men and frequently associated with phimosis and with presence of human papillomavirus (HPV)-16. The incidence of penile cancer increases with age, with a peak incidence in men older than age 65 [1].

There is no randomized study to provide a high level of evidence on the optimal treatment in these patients, with only retrospectives studies including usually few patients. Total amputation is frequently proposed as first intent treatment. Although radical surgery results in to high local control rates, the functional loss is major, associated with urinary sequelae, and potentially a strong psychosexual impact. Therefore, alternative penile-sparing techniques have been proposed [2], [3], [4]. Interstitial brachytherapy delivers high irradiation doses directly inside the tumor, and its use has been associated with high probability of reaching complete remission while preserving the penis. Moreover, most local relapses can be salvaged by second-intent surgery [5], [6], [7], [8], [9], [10]. However, no study has specifically examined the possibility to perform an organ sparing strategy in older patients, probably because it is frequently believed that those would be less interested in esthetic and preservation of function than their younger counterparts, although this assumption remains to be proven [5], [6], [7], [8], [9], [10]. Older patients frequently present at an advanced stage of their disease, with a tumor that has been frequently neglected. Moreover, penile cancers occurring in older patients exhibit specific biological and histological features making it difficult to extrapolate data obtained in younger patients to the older population [11].

We report our institutional experience of interstitial brachytherapy for treatment of penile carcinoma confined to the glans or the prepuce in patients aged of 70 years and more. To our best knowledge, this is the first study examining the results of brachytherapy in this population. Patterns of relapse, toxicity rates, and prognostic factors were examined.