Case Series Report Review of Penile Cancer Patients Presented to University Teaching Hospital, (UTH) Lusaka. Mukosai .

S, Silumbe .M, Mapulanga .V, Kalo .K, Labib .M, Bowa .K University teaching Hospital, Department of Surgery, Urology Unit, Lusaka

We report on penile cancer patients presented to University Teaching Hospital (UTH), Lusaka for the period January 2008 to September 2010. UTH is a tertially highest referral Hospital in Zambia. Patients are referred from all the nine provinces in Zambia for specialist Treatment. It serves a population of over two point five (2.5) million. Most patients with penile cancer present with advanced disease to the hospital due to various reasons. The delay may be attributed to embarrassment, guilty, fear, ignorance and personal neglect. Patients often try to treat themselves with various skin creams and lotions, this may appear to be effective for a time, which further delays the diagnosis and worsen the prognosis. Keywords: Penile cancer, Tumour, Sexually Transmitted Diseases (STDS), Human Immunodeficiency Virus (HIV), Treatment option, Circumcision, Squamous Cell Carcinoma (SCC), Suprapubic cystostomy (SPC). Correspondence to: Dr Mukosai S ,Department of Surgery, Urology Unit, University Teaching Hospital ,P/B Rw1x, Lusaka. Zambia, Tel +260977848960, Email; smukosai@yahoo.com. Abstract Introduction Penile cancer is an uncommon malignancy in developed countries. In the United States, 1,530 cases occur per year. It accounts for 0.4 to 0.6% of all malignancies in the United States and Europe [1]. Penile cancer represents 20 to 30% of all cancers diagnosed in men who live in Africa, Asia, and South America [1]. Most Penile cancer commonly affects men between 50 and 70 years of age (Hopmann and Fraley 1978). Younger individuals are also affected; approximately 22% of patients are less than 40 years of age. It accounts for two to five percents of genitourinary malignancies [2]. Around 4000 cases are diagnosed each year. Predisposing factors include; Poor hygiene, lack of circumcision, phimosis infection by Human papillomavirus (HPV). Commonly found in men in their 6th decade, more in blacks than whites 2:1[1]. Treatment involves surgical resection with or without inguinal lymph node dissection. Prognosis depends on stage and grade of the tumour [3]. Patients and Methods: Twenty four patients were diagnosed with penile cancer between September 2008 and September 2010. All patients records were retrieved and the data recorded included the Jackson staging, histological grade and treatment option. End points were death, nodal progression, and local recurrence and lost to follow up.

Conclusion: The defining features of patients and disease in this series are significantly different to published series in Europe and America. The is also significant variability in the treatment modalities used in this series. Intemational data on penile cancer are retrospective and inconclusive with regard to best practice. There is an urgent requirement for randomized controlled trials to improve the outcome of these patients.

Case Series Report Table 1 Code Clinical Presentation Age STI Hx yes HIV Circum Histology Statu cised s _ No SCC Operation Out come Recurr ence & Died Died Lost to follow up Lost to follow Lost to follow up Lost to follow up Lost to follow up Lost to follow up Lost to follow up Lost to follow up Lost to follow up Lost to follow

001

Fungating tumour on glands & distal shaft

50

Partial Penectomy

002 003

Infected hard scrotal mass involving urethral Fungating foul mass distal penis, Inguinal LN+ 6/12 History of penile ulcer, inguinal Lymph node negative 8/12 Hx of Fungating penile mass eroding glans, shaft proximally 4/12 Hx of fungating mass on prepuce, glands penile shaft, inguinal LN+ fixed 10/12 Hx of fungating penile mass glans,prepuce Penile ulcer on glands

50 36

yes yes

+ +

No No

SCC Not available SCC

Resection + Radiotherapy Declined operation Partial Penectomy Total penectomy Total Penectomy Partial penectomy Excision

004

47

yes

No

005

52

No

No

SCC

006

70

yes

No

SCC

007

45

yes

No

SCC

008

39

yes

No

SCC

009

010

Fungating penile mass eroding glands, penile shaft, inguinal LN+ fixed Fungating penile mass ,prepuce & glands Fungating mass on prepuce & glands Penile ulcer on gland

57

yes

yes

SCC

47

No

N A +

No

SCC

SPC + palliative Radiotherapy Partial Penectomy Partial Penectomy Partial penectomy

011

40

yes

No

SCC

012

50

NA

yes

SCC

013

8/12 Hx of Fungating penile mass distal penis 6/12 Hx of wart-like growth on prepuce & glands 9/12 Hx of growth distal penis- prepuce, glands, inguinal LN+ Penile fungating mass

47

yes

No

SCC

Total amputation Excision Biopsy Partial Amputation Penile amputation Partial Amputation Partial amputation Partial penectomy Penectomy

014

72

NA

No

SCC

015

59

No

N A -

No

SCC

016

64

NA

Un known No

SCC

017

Fungating penile mass

58

NA

NA

018

Penile mass

78

NA

N A +

Un known No

NA

019

Fungating penile mass

53

yes

SCC

020

Penile mass

55

NA

Un known No Un known No

SCC

021 022

Fungating penile mass Fungating penile tumour

42 80

yes NA

+ -

SCC SCC

Amputation Partial amputation Partial Penectomy Partial penectomy

023

024

Fungating penile tumour prepuce,glans & distal penile shaft, inguinal LN+ Fungating penile mass

72

NA

SCC

38

yes

Un known

SCC

up Lost to follow up Nodal progre ssion Lost to follow up Lost to follow up Lost to follow up Lost to follow up Lost to follow up Lost to follow up Lost to Lost to follow up Lost to follow up Died

Eight (33.3%) patients were HIV positive and in three patients their HIV status was not documented shown in table 1. Eight Twenty (83%) of the patients were lost follow up. Thirteen (54.2%) has had history of STI before as shown in table 1.

Table 2 Age variation in penile cancer at UTH, 2008-2010 Age group in years 0-40 41-50 51-60 61-70 71-80 No. penile cancer 4 8 6 2 4 % Total 16.7 33.3 25 8.3 16.7

The age range was 38 to 80 years with the mean of 54 years and peak in the 41 to 50 year old groups as depicted in table 2 above.

Table 3 Anatomical distribution in penile cancer patients at UTH for period 2008 to 2010 Site of primary lesion Gland penis Gland & shaft penis Prepuce only Whole penis & scrotum Total No. of patients 4 14 2 4 24 % Total 16.3 58.3 8.3 16.3 100

The anatomical distribution indicates that 14 (58.3%) had glandular penile cancer with spread to the shaft, while 2 (8.3%) had cancer restricted the prepuce as shown in table 3.

Table 4 Circumcision status in penile cancer at UTH [2008-2010 Circumcision status Total Uncircumcised Circumcised as neonate Circumcision status unknown Circumcised as adult, adolescent, infant Total No. of Patients %

17 0 5 2 24

70.8 0% 20.8 8.3 100

Table 4 shows 17(70.8%) patients were uncircumcised and none were circumcised during neonate period. Two (8.3%) were circumcised during their adult or adolescent period. Table 5 Clinical stage of penile cancer at UTH [2008-2010] Jackson classification stage I II III IV No. of patients 2 2 14 6 % Total 8.3 8.3 58.3 25

Twenty patients had advanced disease (Jacksons stage III and IV) as shown in Table 5.

Table 6 Demographic pattern of patients with penile cancer at UTH Province Distance from Lusaka No. of patients Percentage (%) (Km) 500 850 400 450 800 600 650 0 800

Eastern Northern Central Copper belt Luapula Western Southern Lusaka North western

4 2 2 3 2 3 3 5 0

16.6 8.3 8.3 12.3 8.3 12.3 12.3 20.8 0

Majority of patients with penile cancer five (20.8%) came from Lusaka. The was no patient with penile cancer from Northwestern Province during period under review.

Discussion Penile cancer is relatively rare; other studies in parts of Africa, Uganda have shown its presence in only 3.5% were circumcision is not practiced [3]. Elshleman also reported penile cancer in only 4.0% of all malignant tumours reviewed at Shirati hospital in northern Tanzania [4]. Burkitt in 1965 reported cancer of the penis to be uniformly rare in some uncircumcised Ugandan tribes such as the Acholi and the Lugbara and some tribes of the southern highlands of Tanzania [5]. In our study the age range was 38 80 years with a mean of 54 years and peak incidence of 41- 50 year age groups which is not in conformity to other reported case series in Europe and America [60-65 years] [12]. It is however widely reported that squamous cell cancer of the penis is commoner in men in their sixth and seventh decades with an abrupt increase in incidence at 60 years and peaking at 80 years of age [6]. Cancer of the penis is usually an epidermoid tumour arising from the glans penis or the mucosal lining of the prepuce [7]. In this case series the majority 14 (58.3%) had glandular with spread to the penile shaft. The majority (58.3%) presented with advanced disease with either operable or inoperable inguinal lymphadenophy. The reason for this late presentation of penile cancer in this locality is due to the delay in seeking appropriate medical advice as a result of socio-cultural taboos and ignorance. The majority of patients (70.8%) were uncircumcised .This is in conformity with evidence that penile cancer is said to be common among uncircumcised males [8]. The development of tumour in the uncircumcised men has been attributed to the chronic irritative effects of smegma, a by product of bacterial action on desquamated cells that are within the preputial sac. Such exposure is accentuated by phimosis which is present in 25- 75% of patients in most large series [9]. Neonatal circumcision as practiced by the Jews is known to prevent the development of cancer of penis [10]. However, circumcision in adolescence and in adults does not prevent the development of penile cancer [11]. Sixteen patients had partial penectomy as a form of treatment while three had total penectomy with perineal urethrostomy. One patient declined surgery and was lost to follow up. Further more only one patient received palliative care due to terminally advanced penile disease. Twenty (83%) of the patients were lost to follow up and this could be attributed to the far to reach locations of these patients and poor economic status. The low incidence of penile cancer in North western Province could be attributed to the practice of male circumcision which is done as part of their tradition in early childhood. Conclusion The is variability in the patients and their defining features of their tumours in this case series with published data in Europe and America. The is also comparable variability in the treatment offered in this case series for each particular stage of penile cancer. This series does not have the power to determine guidelines. There remains a need for prospective, randomised, controlled trials (multicentre, in view of the scarcity of the disease) to clarify treatment options.

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