GSRGT 2020: Aggressive Surgical Approach for Tumors

(UroToday.com) To discuss aggressive surgical approaches for primary tumors, Dr. Chris Protzel joined the inaugural Global Society of Rare Genitourinary Tumors (GSRGT) 2020 Virtual Summit. Dr. Protzel notes that treatment of the primary tumor is the key to quality of life for these patients. Barriers to treatment of the primary tumor include fear (30%), social problems (35%), psychiatric problems (>50%), and sexual function concerns (77%). In line with these concerns, the National Comprehensive Cancer Network (NCCN) guidelines suggest that careful consideration should be given to penile-preserving techniques if the patient is reliable in terms of compliance and close follow-up. These techniques may include wide local excision, as well as Mohs surgery (plus reconstructive surgery) and laser therapy. Local recurrence after primary organ sparing surgery varies from 4-56% for patients with T1 disease and 4-34% for patients with T2 tumors:

local recurrence after primary organ sparing surgery

In a study assessing the association between local recurrence rates and surgical resection margins among 332 patients undergoing organ-preserving surgery, Sri et al. found that 64% of the patients had a <5 mm clear deep surgical margin, with 16% clear by <1 mm.¹ Additionally, these authors found an increased risk of local recurrence in the clear margin cohort of <1 mm compared to those of >1 mm (p < 0.001).

Dr. Protzel favors treatment of the primary tumor by a stage-based approach. For patients with carcinoma in situ, Bowen’s disease, or erythroplasia de Queyrat, treatment options include laser ablation with CO₂ or Nd:YAG laser ablation. For patients with Ta or T1a (grade 1-2), treatment options include wide local excision with circumcision, CO₂ or Nd:YAG laser ablation, glans resurfacing, or glansectomy with reconstructive surgery with or without skin grafting. Among patients with T1b (grade 3) or T2 tumors, treatment options include wide local excision plus reconstructive surgery, with or without skin grafting, or a glansectomy with circumcision and reconstruction. Patients with T3 disease confined to the distal aspect of the penis may be eligible for a glansectomy with resection of the infiltrated part of the corpora +/- reconstruction with skin grafting. Finally, patients with T3 or T4 disease should have a partial penectomy or total penectomy with a perineal urethrostomy, in addition to a potential role of neoadjuvant chemotherapy in this disease space.

Dr. Protzel concluded his presentation with the following take-home messages:

Organ-preserving surgery has to be considered in the early stages
Intraoperative control of margins should be managed initially with fresh frozen sections
Higher local recurrence rates are seen after penile-preserving surgery
Reconstructive surgery has to be discussed for more advanced cases

Presented by: Chris Protzel, MD, PhD, Head of Urology, University Hospital Rostock, Head of the Urological Clinic, HELIOS Kliniken Schwerin, Rostock, Germany

Written by: Zachary Klaassen, MD, MSc, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, Georgia, Twitter: @zklaassen_md during the 1st Global Society of Rare Genitourinary Tumors Virtual Summit, December 11-12, 2020

Reference:

1. Sri, Denosshan, Arunan Sujenthiran, Wayne Lam, Janice Minter, Brendan E. Tinwell, Catherine M. Corbishley, Tet Yap, Davendra M. Sharma, Benjamin E. Ayres, and Nick W. Watkin. "A study into the association between local recurrence rates and surgical resection margins in organ‐sparing surgery for penile squamous cell cancer." Bju International 122, no. 4 (2018): 576-582.

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