Albersen, Maarten

Abstract Introduction This study investigated the efficacy and safety of neoadjuvant chemotherapy for locally advance penile squamous cell carcinoma for which current evidence is lacking. Methods Included patients had locally advanced penile squamous cell carcinoma with clinical lymph node metastasis treated with at least 1 dose of neoadjuvant chemotherapy prior to planned consolidative lymphadenectomy. Objective response rates were assessed using Response Evaluation Criteria in Solid Tumors v1.1. The primary and secondary outcomes were overall survival and progression-free survival, estimated by the Kaplan–Meier method. Treatment-related adverse events were graded per the Common Terminology Criteria for Adverse Events v5.0. Results A total of 209 patients received neoadjuvant chemotherapy for locally advanced and clinically node-positive penile squamous cell carcinoma. The study population consisted of 7% of patients with stage II disease, 48% with stage III, and 45% with stage IV. Grade 2 treatment-related adverse events occurred in 35 (17%) patients, and no treatment-related mortality was observed. Of the patients, 201 (97%) completed planned consolidative lymphadenectomy. During follow-up, 106 (52.7%) patients expired, with a median overall survival of 37.0 months (95% confidence interval [CI] = 23.8 to 50.1 months) and median progression-free survival of 26.0 months (95% CI = 11.7 to 40.2 months). Objective response rate was 57.2%, with 87 (43.2%) having partial response and 28 (13.9%) having a complete response. Patients with objective response to neoadjuvant chemotherapy had a longer median overall survival (73.0 vs 17.0 months, P < .01) compared with those who did not. The lymph node pathologic complete response rate was 24.8% in the cohort. Conclusion Neoadjuvant chemotherapy with lymphadenectomy for locally advanced penile squamous cell carcinoma is well tolerated and active to reduce the disease burden and improve long-term survival outcomes.

Zusammenfassung Hintergrund Aktuell wurde mit dem Tetrafecta-Score das erste Instrument zur Beurteilung der Behandlungsqualität in der chirurgischen Primärtherapie des Peniskarzinoms (PECa) publiziert. Eine externe wissenschaftliche Auseinandersetzung mit den ihn definierenden Einzelkriterien steht bislang noch aus und bildet das Studienziel. Material und Methode Es wurde eine internationale Arbeitsgruppe bestehend aus 12 Urologen und einem Onkologen mit klinischer und akademisch-wissenschaftlicher Expertise auf dem Gebiet des Peniskarzinoms gegründet. In einem modifizierten vierstufigen Delphi-Prozess wurden unter Einbeziehung der Tetrafecta-Kriterien insgesamt 13 Kriterien für PECa-Patienten in den klinischen AJCC-Stadien 1–4 (T1–3N0–3, aber M0) definiert, von denen in einer geheimen Abstimmung jeder der Experten 5 auswählen musste, um dadurch einen individuellen Pentafecta-Score zu generieren. Anschließend wurde das Rating der Experten aggregiert ausgewertet und dadurch ein finaler Pentafecta-Score gebildet. Ergebnisse Keines der ursprünglichen Tetrafecta-Kriterien wurde in den finalen Pentafecta-Score übernommen, der sich aus den folgenden Kriterien zusammensetzt: 1.) Organerhalt, sofern immer möglich (≤T2), jedoch stets unter Wahrung eines negativen chirurgischen Schnittrandes, 2.) beidseitige inguinale Lymphadenektomie (ILAE) ab pT1G2N0, 3.) perioperative Chemotherapie sollte erfolgen, sofern durch die Leitlinien indiziert, 4.) ILAE sollte, sofern indiziert, in einem zeitlichen Abstand von maximal 3 Monaten zur Primärtumorresektion erfolgen und 5.) die behandelnde Klinik sollte im Minimum 15 chirurgische Primärtherapien bei PECa-Patienten durchführen. Nur 7 der 13 Experten (54%) zeigten eine starke Korrelation ihres individuellen mit dem finalen Pentafecta-Score (rsp >0.60). Schlussfolgerung Auf der Basis eines moderierten Abstimmungsprozesses unter internationalen PECa-Experten wurde ein Pentafecta-Score als Qualitätssicherungs-Instrument für die chirurgische Primärtherapie gebildet, der nun anhand von patientenrelevanten und patientenberichteten Endpunkten zu validieren ist.

We read with great interest the manuscript by Brassetti et al. recently published in your journal and hope it will encourage discussion and debate around the optimization of the surgical management of patients with penile cancer (PECa) [...]

9 Background: The efficacy of neoadjuvant platinum-based chemotherapy (NAPC) in penile squamous cell carcinoma (PSCC) was provided by small clinical trials, leaving clinicians with scant evidence-based guidance. Thus, we aimed to analyze real-world outcomes of patients with PSCC who received NAPC prior to surgical resection. Methods: Patients from 9 tertiary care centers who had undergone NAPC prior surgical resection for PSCC were included with locally advanced (cTany, cN+), non-metastatic (M0) disease. The primary and secondary outcomes were overall survival (OS) and progression-free survival (PFS), Response was determined via best overall response measured with RECIST 1.1 criteria. Results: 167 patients were included, 137 (84%), of which received TIP prior to surgical resection. Ninety-two (55%) patients died during follow up, and the mean follow up for survivors was 57 months. The median OS was 42 months, while the median PFS was 17 months. The table details the response rates to NAPC, the associated survival, and Cox Proportional Hazards Modelling of OS and PFS. Predictors for OS and RFS included lymphovascular invasion, positive number of lymph nodes, extranodal extension, downstaging, best overall response, and ypN status. Figure 1 demonstrates OS outcomes by RECIST best response after chemotherapy, presence of downstaging after NAPC, ypN stage, and presence of extranodal extension. Conclusions: Upfront NAPC is effective in patients with lymph node metastases from penile carcinoma. Unsurprisingly, patients who demonstrated a robust response to therapy had improved survival outcomes compared to those who had not—as measured by RECIST criteria, tumor downstaging, pN staging, and presence of extranodal extension. This study represents the largest conglomeration of multi-institutional penile carcinoma patients treated with NAPC, and provides further supportive data for multimodal therapy for advanced penile cancer patients while prospective clinical trials complete accrual. [Table: see text]

Objectives To develop and externally validate a risk calculator for prediction of any cancer recurrence in patients with penile squamous cell carcinoma (pSCC) and inguinal lymph node metastases (ILNM), as to date no validated prognostic tool is available for patients with pSCC and ILNM. Patients and Methods The development cohort included 234 patients from seven referral centres. The external validation cohort included 273 patients from two additional referral centres. Cox regression identified predictors of any recurrence, which were used to develop a risk calculator. The risk‐calculator grouped the development and the validation cohorts according to the individual risk of any recurrence at 24 months (24m‐R). Adjuvant treatment effects were tested on overall survival (OS) according to the derived tertiles, within the development and validation cohorts. Results Positive surgical margins, pN 3 , and ILNM ratio were associated with higher recurrence rate. The 2‐year OS rates were lower for patients with high (>37%) and intermediate (19–37%) compared to low (<19%) 24m‐R risk of recurrence, for both the development (43% and 58% vs 83%, P < 0.001) and validation cohort (44% and 50% vs 85%, P < 0.001). Results were confirmed in the subgroup of patients who did not receive adjuvant treatment ( P < 0.001), but not in patients who did receive adjuvant treatments in both the development and validation cohorts ( P > 0.1). Conclusion Adjuvant treatment planning is crucial in patients with pSCC with ILNM, where only weak evidence is available. The current tool proved to successfully stratify patients according to their individual risk, potentially allowing better tailoring of adjuvant treatments.