Journal of Surgical Oncology 7:243-248 (1975)
Carcinoma of the Penis .......................................................................... .......................................................................... BURTON H. BAKER, M.D.,* and FRANK R. WATSON, Ph.D.** Presently there are six clinical staging systems in use for carcinoma of the penis. We propose a method which compares these systems by means of a check list type of format. With the aid of this device, any penile carcinoma can readily be staged in terms of all six systems. Advantages of multiple system staging include comparing series of patients which have been discussed only in terms of a single staging system and selecting the appropriate therapeutic modality in terms of the stage of disease.
......................................................................................... ......................................................................................... KEY WORDS: staging systems, carcinoma, penis
Carcinoma of the penis comprises less than 1% of the malignancies in the male in the United States (DeKernion et al., 1973), but it is significantly more common in Asia and Africa (Ackerman and del Regato, 1970). In the past ten years, only a few large series of cases have appeared in the world literature (Beggs and Spratt, 1964; Murrell and Williams, 1965; Jackson, 1966; Duncan and Jackson, 1972; Hardner et al., 1972; DeKernion et al., 1973; Derrick et al., 1973). As has been previously noted, there are a number of different opinions regarding the treatment of such lesions (Murrell and Williams, 1965). Many authors discuss the staging of the disease (Murrell and Williams, 1965; Jackson, 1966; Whitmore, 1970; Duncan and Jackson, 1972; and Hardner et al., 1972), and some base the selection of the therapeutic modality on the stage of the disease (Hueser and Pugh, 1969; Duncan and Jackson, 1972). Yet, there is no uniform staging system for malignancies of the penis. A similar problem was noted by one of the authors in dealing with breast cancer. In that case there were eight breast cancer staging systems in current use (Watson and Glass, 1972). Currently, for carcinoma of the penis, there are six staging systems in use. One system is specifically for use in staging cases of malignant melanoma of the penis (Bracken and Diokno, 1974), and the staging is the same as that used for melanoma in other areas of the body (DeCosse and McNeer, 1969). The remainder of the staging systems are for “carcinoma of the penis.” Table I lists the six staging systems and compares the descriptive terminology used *Staff Surgeon, Department of Surgery, Ellis Fischel State Cancer Hospital, Columbia, Missouri 65201 **Chairman, Department of Biomathematics, Cancer Research Center, Columbia, Missouri 65201 Address all correspondence and reprint requests to: Burton H. Baker, M.D.
243
@ 1975 Alan R Liss, Inc., 150 Fifth Avenue, New York, N.Y. 10011
Nodes
Tumor
TABLE 1.
IV
IV
D
111
D
D
C
4
16
I1
Dist. metastases
c
15
IV
Local spread beyond penis; infiltrating neighboring structures
I11
14
~
2, 2a
lb
Inoperable
B
3
I1
13
c
Fixed
111
1, l a
2b
I1
3
12
8
Deep infiltration, including urethra
3
2
1
1s
0
Bilateral, contains growth
I
> 5 cm
A
0
N
11
6
> 2 cm
I1
I
0
T
Bilateral (palpable)
5
Involving shaft
B
A
0
WFW
10
4
Corpora
I
0
GJH D&D
Contains growth
3
Superficial or exophytic
I
0
SMJ
9
2
Cancer
0
M&W
UICC
Palpable
1
No tumor (no node)
Penis Cancer Staging Check List
I
0
M
24 5
Staging Carcinoma of the Penis
for each stage of the disease, Murrell and Williams introduced their staging system in 1965. It refers to the various stages with the Roman numerals I-IV, as does the staging system of Jackson (1966). However, the descriptive terminology used varies sufficiently to create stages with the same numerical designation that do not correspond clinically. The staging system of Whitmore (1970) and that used by Prout (1973) are almost identical, and both use the letter designations A, B, C, and D. Hardner and colleagues (1972) use the same designations as Whitmore and Prout but descriptive phrases vary and discrepancies arise in three stages. The sixth staging system is the TNM system developed by the International Union Against Cancer (UICC~=Union International Contre le Cancer) in 1968. Table I has been set up in order to establish the various relationships that exist between the six staging systems currently in use. The left hand column contains the descriptive terminology that has been used in each system. The terms were combined only when there was no question as to the usage in the staging systems. Disseminated melanoma is considered a stage of the disease that is comparable to distant metastases, although the term distant metastases has not been clarified to the point of enabling one to determine whether or not it includes nodal involvement of other than the regional nodes. Numerous other problems exist in the various staging systems. The importance of each problem will vary with the frequency of use of that category of a staging system. The TNM system utilizes more divisions and categories than the others; yet problems still exist. One such problem is that the TNM staging does not differentiate between the bilateral multiple node and bilateral multiple nodes where one contains a growth and the other does not. This may be more confused when both nodes contain a growth. Perhaps enlarging the system still further with a stage 2ab is necessary. Another problem that this system has is apparent when one looks at the regional node category N. Here the subdivisions a and b are used in spite of the fact that stage 1 corresponds exactly to stage la, and stage 2 corresponds exactly to stage 2a. Condensation of the list of items to be evaluated was generally avoided. In three instances terms were considered to be synonymous. “Primary tumor extending off the shaft of the penis” (Jackson) was accepted as equivalent to “infiltration of neighboring structures” (Whitmore; TNM). “Lesion superficial on the glans or foreskin” (Hardner et al.) was accepted as comparable to “tumor localized to the penis and without demonstrable node metastases” (Murrell and Williams). And finally, “preinvasive carcinoma, so called carcinoma in situ” (TNM) was taken to mean “lesion superficial on the glans or foreskin,” as suggested by Jackson. The distinct advantage of using a chart that compares the various staging systems becomes readily apparent when one wants to evaluate the results of the various therapeutic modalities used in cases of carcinoma of the penis. Since carcinoma of the penis is not a common disease, pooling of data greatly facilitates the dissemination of data gathered from large series of patients. Such data are more valuable to the physician rendering primary patient care than are data derived from just a few patients. Table I1 gives an example of the application of this chart that compares the various staging systems. The theoretical patient is a 60-year-old Caucasian male with a lesion on the penis that is 4 cm in diameter. The lesion has invaded the corpora cavernosa, and the groin nodes on the right are positive for tumor but are not fixed to adjacent structures. Examination of Table I1 reveals a completed chart. To get to this point, we started with a blank chart (Table I) and placed a check in each of the appropriate boxes. If the patient had cancer, a check was placed in the box next to item 2. If the corpora cavernosa was involved by the primary lesion, a check was placed next to item 4. When the primary
Nodes
Tumor
11
C
2
1
1s
0
I11
16
Dist. metastases
D
15
Local spread beyond penis; lnfiltrating neighboring structures
N
14
Inoperable
IV
3
13
Fixed
D
D
2b
12
2, 2a
\. .
d
0
N
Bilateral, contains growth
4
3
c
0
8
IV
0
T
3
I11
I1
0
WFW
7
5
3
0
~~
11
44-
d
4-
4
0
SMJ GJH D&M
UICC
Bilateral (palpable)
Contains growth
Palpable
Deep infiltration, including urethra
cm
> 2cm
Involving shaft
Corpora
Superficial or exophytic
Cancer
1
M%W
Penis Cancer Staging Check List (Filled out for Theoretical Patient)
No tumor (no node)
>S
TABLE 11.
0
M
I
4
247
Staging Carcinoma of the Penis
lesion was less than 5 cni but greater than 2 cm in diameter, a check was placed next to item 6. If inguinal nodes were palpable, item 9 was checked. When the palpable nodes contained tumor clinically, item 10 was checked. Next, a wavy.line (to avoid confusion with the horizontal lines of the table) was drawn through each row of the table adjacent to an item that had been checked. It is therefore possible to use the table to determine the stage of this patient’s disease in terms of any of the staging systems that are represented. To do so, one begins at the bottom of the vertical column that corresponds to the staging system of interest. Then if one moves up the column and stops at the first box containing both a wavy line and an alphabetical or numerical stage indicator, that is the clinical stage of the disease of that particular patient in terms of the staging system noted at the top of the column. If we look at variation in the staging present in the case of the theoretical patient represented in Table 11, the value of such a table becomes readily apparent. For example, in the Murrell and Williams (1965) staging system the disease is stage I1 (Tables I1 and 111). In the staging system of Jackson (1966) the disease is stage 111. Hardner et al. (1972) would consider the disease stage C. If the malignancy was a melanoma, DeCosse and McNeer TABLE 111. Abbreviation M&W SMJ GJH D&M WFW
Stages of Disease for Theoretical Patient Staging System Murrell and Williams S. M Jackson G. A. Hardner et al. DeCosse and McNeer Willet F. Whitmore, Jr. UICC
M
Stage of Disease I1 111
C I1 B 2 lb 0
(1969) would consider it stage 11. The staging system by Whitmore (1970) would call this case stage B. And, finally, the TNM (1968) system would find the disease to be stage T2N1b%. Perhaps little else need be said on this subject at this time, except that when dealing with a disease that does not have a standard accepted clinical staging system in use, one must not just state the numerical or alphabetical indicator of a stage. Rather, one must note which staging system is being used and then specify the clinical stage of the disease.
SUMMARY There are six staging systems for carcinoma of the penis in use at the present time. An addition system, whether revised or new, is not needed. A check list type of format can be used to compare the stages of the various systems. Development of the proposed
table for this type of comparison is not difficult. Use of this device will not only facilitate staging carcinoma of the penis in any of the currently used staging systems, but it will readily permit assessment of different therapeutic modalities in terms of the clinical stage of disease treated in each case.
248
Baker and Watson
ACKNOWLEDGMENT This investigation was supported by Clinical Cancer Training Grant CA-08018 from the National Cancer Institute.
REFERENCES Ackerman, L. V., and del Regato, J . A. (Eds.) (1970). Penis. In “Cancer: Diagnosis, Treatment, and Prognosis.” 4th ed. St. Louis: C. V. Mosby Co., pp 682-690. Beggs, J.H., and Spratt, J . S . ,Jr. (1964). Epidermoid carcinoma of the penis. J . Urol. 91:166-172. Bracken, R. B., and Diokno, A. C. (1974). Melanoma of the penis and the urethra: two case reports and review of the literature. J . Urol. 111:198-200. Committee on TNM Classification (1968). “TNM Classification of Malignant Tumours.” International Union Against Cancer, Geneva. pp. 70-71. DeCosse, J . J., and McNeer, G. (1969). Superficial melanoma: a clinical study. Arch. Surg. 99:531-534. DeKernion, J. B., Tynberg, P., PeIsky, L., and Fegen, J . P. (1973). Carcinoma of the penis. Cancer 32: 1256-1262. Derrick, F. C., Jr., Lynch, K. M., Jr., Kretkowski, R. C.,land Yarbrough, W. J. (1973). Epidermoid carcinoma of the penis: computer analysis of 87 cases. J . Urol. 110:303-305. Duncan, W., and Jackson, S. M. (1972). The treatment of early cancer of the penis with megavoltage X rays. Clin. Radiol. 23~246-248. Hardner, G. J . , Bhanalaph, T., Murphy, G. P., Albert, D. J., and Moore, R. H. (1972). Carcinoma of the penis: analysis of therapy in 100 consecutive cases. J. Urol. 108:428-430. Hueser, J. N., and Pugh, R. P. (1969). Erythroplasia of Queyrat treated with topical 5-Fluorouracil. J. Urol. 102:595-597. Jackson, S. M. (1966). The treatment of carcinoma of the penis. Brit. J. Surg. 53:33-35. Murrell, D. S., and Williams, J. L. (1965). Radiotherapy in the treatment of carcinoma of the penis. Brit. J . Urol. 37:211-222. Prout, G. R., Jr. (1973). The penis. In “Cancer Medicine.” J. F. Holland and E. Frei, 111 (Eds.) Philadelphia: Lea and Febiger, pp 1694-1696. Watson, F. R., and Glass, R. L. (1972). Breast cancer staging systems. J. Surg. Oncol. 4: 369-375. Whitmore, W. F., Jr. (1970). Tumors of the penis, urethra, scrotum, and testis. In “Urology.” M. F. Campbell and J. H. Harrison (Eds.), vol. 11, 3rd ed. Philadelphia: W. B. Saunders Co., pp 1190-1229.
Carcinoma of the Penis .......................................................................... .......................................................................... BURTON H. BAKER, M.D.,* and FRANK R. WATSON, Ph.D.** Presently there are six clinical staging systems in use for carcinoma of the penis. We propose a method which compares these systems by means of a check list type of format. With the aid of this device, any penile carcinoma can readily be staged in terms of all six systems. Advantages of multiple system staging include comparing series of patients which have been discussed only in terms of a single staging system and selecting the appropriate therapeutic modality in terms of the stage of disease.
......................................................................................... ......................................................................................... KEY WORDS: staging systems, carcinoma, penis
Carcinoma of the penis comprises less than 1% of the malignancies in the male in the United States (DeKernion et al., 1973), but it is significantly more common in Asia and Africa (Ackerman and del Regato, 1970). In the past ten years, only a few large series of cases have appeared in the world literature (Beggs and Spratt, 1964; Murrell and Williams, 1965; Jackson, 1966; Duncan and Jackson, 1972; Hardner et al., 1972; DeKernion et al., 1973; Derrick et al., 1973). As has been previously noted, there are a number of different opinions regarding the treatment of such lesions (Murrell and Williams, 1965). Many authors discuss the staging of the disease (Murrell and Williams, 1965; Jackson, 1966; Whitmore, 1970; Duncan and Jackson, 1972; and Hardner et al., 1972), and some base the selection of the therapeutic modality on the stage of the disease (Hueser and Pugh, 1969; Duncan and Jackson, 1972). Yet, there is no uniform staging system for malignancies of the penis. A similar problem was noted by one of the authors in dealing with breast cancer. In that case there were eight breast cancer staging systems in current use (Watson and Glass, 1972). Currently, for carcinoma of the penis, there are six staging systems in use. One system is specifically for use in staging cases of malignant melanoma of the penis (Bracken and Diokno, 1974), and the staging is the same as that used for melanoma in other areas of the body (DeCosse and McNeer, 1969). The remainder of the staging systems are for “carcinoma of the penis.” Table I lists the six staging systems and compares the descriptive terminology used *Staff Surgeon, Department of Surgery, Ellis Fischel State Cancer Hospital, Columbia, Missouri 65201 **Chairman, Department of Biomathematics, Cancer Research Center, Columbia, Missouri 65201 Address all correspondence and reprint requests to: Burton H. Baker, M.D.
243
@ 1975 Alan R Liss, Inc., 150 Fifth Avenue, New York, N.Y. 10011
Nodes
Tumor
TABLE 1.
IV
IV
D
111
D
D
C
4
16
I1
Dist. metastases
c
15
IV
Local spread beyond penis; infiltrating neighboring structures
I11
14
~
2, 2a
lb
Inoperable
B
3
I1
13
c
Fixed
111
1, l a
2b
I1
3
12
8
Deep infiltration, including urethra
3
2
1
1s
0
Bilateral, contains growth
I
> 5 cm
A
0
N
11
6
> 2 cm
I1
I
0
T
Bilateral (palpable)
5
Involving shaft
B
A
0
WFW
10
4
Corpora
I
0
GJH D&D
Contains growth
3
Superficial or exophytic
I
0
SMJ
9
2
Cancer
0
M&W
UICC
Palpable
1
No tumor (no node)
Penis Cancer Staging Check List
I
0
M
24 5
Staging Carcinoma of the Penis
for each stage of the disease, Murrell and Williams introduced their staging system in 1965. It refers to the various stages with the Roman numerals I-IV, as does the staging system of Jackson (1966). However, the descriptive terminology used varies sufficiently to create stages with the same numerical designation that do not correspond clinically. The staging system of Whitmore (1970) and that used by Prout (1973) are almost identical, and both use the letter designations A, B, C, and D. Hardner and colleagues (1972) use the same designations as Whitmore and Prout but descriptive phrases vary and discrepancies arise in three stages. The sixth staging system is the TNM system developed by the International Union Against Cancer (UICC~=Union International Contre le Cancer) in 1968. Table I has been set up in order to establish the various relationships that exist between the six staging systems currently in use. The left hand column contains the descriptive terminology that has been used in each system. The terms were combined only when there was no question as to the usage in the staging systems. Disseminated melanoma is considered a stage of the disease that is comparable to distant metastases, although the term distant metastases has not been clarified to the point of enabling one to determine whether or not it includes nodal involvement of other than the regional nodes. Numerous other problems exist in the various staging systems. The importance of each problem will vary with the frequency of use of that category of a staging system. The TNM system utilizes more divisions and categories than the others; yet problems still exist. One such problem is that the TNM staging does not differentiate between the bilateral multiple node and bilateral multiple nodes where one contains a growth and the other does not. This may be more confused when both nodes contain a growth. Perhaps enlarging the system still further with a stage 2ab is necessary. Another problem that this system has is apparent when one looks at the regional node category N. Here the subdivisions a and b are used in spite of the fact that stage 1 corresponds exactly to stage la, and stage 2 corresponds exactly to stage 2a. Condensation of the list of items to be evaluated was generally avoided. In three instances terms were considered to be synonymous. “Primary tumor extending off the shaft of the penis” (Jackson) was accepted as equivalent to “infiltration of neighboring structures” (Whitmore; TNM). “Lesion superficial on the glans or foreskin” (Hardner et al.) was accepted as comparable to “tumor localized to the penis and without demonstrable node metastases” (Murrell and Williams). And finally, “preinvasive carcinoma, so called carcinoma in situ” (TNM) was taken to mean “lesion superficial on the glans or foreskin,” as suggested by Jackson. The distinct advantage of using a chart that compares the various staging systems becomes readily apparent when one wants to evaluate the results of the various therapeutic modalities used in cases of carcinoma of the penis. Since carcinoma of the penis is not a common disease, pooling of data greatly facilitates the dissemination of data gathered from large series of patients. Such data are more valuable to the physician rendering primary patient care than are data derived from just a few patients. Table I1 gives an example of the application of this chart that compares the various staging systems. The theoretical patient is a 60-year-old Caucasian male with a lesion on the penis that is 4 cm in diameter. The lesion has invaded the corpora cavernosa, and the groin nodes on the right are positive for tumor but are not fixed to adjacent structures. Examination of Table I1 reveals a completed chart. To get to this point, we started with a blank chart (Table I) and placed a check in each of the appropriate boxes. If the patient had cancer, a check was placed in the box next to item 2. If the corpora cavernosa was involved by the primary lesion, a check was placed next to item 4. When the primary
Nodes
Tumor
11
C
2
1
1s
0
I11
16
Dist. metastases
D
15
Local spread beyond penis; lnfiltrating neighboring structures
N
14
Inoperable
IV
3
13
Fixed
D
D
2b
12
2, 2a
\. .
d
0
N
Bilateral, contains growth
4
3
c
0
8
IV
0
T
3
I11
I1
0
WFW
7
5
3
0
~~
11
44-
d
4-
4
0
SMJ GJH D&M
UICC
Bilateral (palpable)
Contains growth
Palpable
Deep infiltration, including urethra
cm
> 2cm
Involving shaft
Corpora
Superficial or exophytic
Cancer
1
M%W
Penis Cancer Staging Check List (Filled out for Theoretical Patient)
No tumor (no node)
>S
TABLE 11.
0
M
I
4
247
Staging Carcinoma of the Penis
lesion was less than 5 cni but greater than 2 cm in diameter, a check was placed next to item 6. If inguinal nodes were palpable, item 9 was checked. When the palpable nodes contained tumor clinically, item 10 was checked. Next, a wavy.line (to avoid confusion with the horizontal lines of the table) was drawn through each row of the table adjacent to an item that had been checked. It is therefore possible to use the table to determine the stage of this patient’s disease in terms of any of the staging systems that are represented. To do so, one begins at the bottom of the vertical column that corresponds to the staging system of interest. Then if one moves up the column and stops at the first box containing both a wavy line and an alphabetical or numerical stage indicator, that is the clinical stage of the disease of that particular patient in terms of the staging system noted at the top of the column. If we look at variation in the staging present in the case of the theoretical patient represented in Table 11, the value of such a table becomes readily apparent. For example, in the Murrell and Williams (1965) staging system the disease is stage I1 (Tables I1 and 111). In the staging system of Jackson (1966) the disease is stage 111. Hardner et al. (1972) would consider the disease stage C. If the malignancy was a melanoma, DeCosse and McNeer TABLE 111. Abbreviation M&W SMJ GJH D&M WFW
Stages of Disease for Theoretical Patient Staging System Murrell and Williams S. M Jackson G. A. Hardner et al. DeCosse and McNeer Willet F. Whitmore, Jr. UICC
M
Stage of Disease I1 111
C I1 B 2 lb 0
(1969) would consider it stage 11. The staging system by Whitmore (1970) would call this case stage B. And, finally, the TNM (1968) system would find the disease to be stage T2N1b%. Perhaps little else need be said on this subject at this time, except that when dealing with a disease that does not have a standard accepted clinical staging system in use, one must not just state the numerical or alphabetical indicator of a stage. Rather, one must note which staging system is being used and then specify the clinical stage of the disease.
SUMMARY There are six staging systems for carcinoma of the penis in use at the present time. An addition system, whether revised or new, is not needed. A check list type of format can be used to compare the stages of the various systems. Development of the proposed
table for this type of comparison is not difficult. Use of this device will not only facilitate staging carcinoma of the penis in any of the currently used staging systems, but it will readily permit assessment of different therapeutic modalities in terms of the clinical stage of disease treated in each case.
248
Baker and Watson
ACKNOWLEDGMENT This investigation was supported by Clinical Cancer Training Grant CA-08018 from the National Cancer Institute.
REFERENCES Ackerman, L. V., and del Regato, J . A. (Eds.) (1970). Penis. In “Cancer: Diagnosis, Treatment, and Prognosis.” 4th ed. St. Louis: C. V. Mosby Co., pp 682-690. Beggs, J.H., and Spratt, J . S . ,Jr. (1964). Epidermoid carcinoma of the penis. J . Urol. 91:166-172. Bracken, R. B., and Diokno, A. C. (1974). Melanoma of the penis and the urethra: two case reports and review of the literature. J . Urol. 111:198-200. Committee on TNM Classification (1968). “TNM Classification of Malignant Tumours.” International Union Against Cancer, Geneva. pp. 70-71. DeCosse, J . J., and McNeer, G. (1969). Superficial melanoma: a clinical study. Arch. Surg. 99:531-534. DeKernion, J. B., Tynberg, P., PeIsky, L., and Fegen, J . P. (1973). Carcinoma of the penis. Cancer 32: 1256-1262. Derrick, F. C., Jr., Lynch, K. M., Jr., Kretkowski, R. C.,land Yarbrough, W. J. (1973). Epidermoid carcinoma of the penis: computer analysis of 87 cases. J . Urol. 110:303-305. Duncan, W., and Jackson, S. M. (1972). The treatment of early cancer of the penis with megavoltage X rays. Clin. Radiol. 23~246-248. Hardner, G. J . , Bhanalaph, T., Murphy, G. P., Albert, D. J., and Moore, R. H. (1972). Carcinoma of the penis: analysis of therapy in 100 consecutive cases. J. Urol. 108:428-430. Hueser, J. N., and Pugh, R. P. (1969). Erythroplasia of Queyrat treated with topical 5-Fluorouracil. J. Urol. 102:595-597. Jackson, S. M. (1966). The treatment of carcinoma of the penis. Brit. J. Surg. 53:33-35. Murrell, D. S., and Williams, J. L. (1965). Radiotherapy in the treatment of carcinoma of the penis. Brit. J . Urol. 37:211-222. Prout, G. R., Jr. (1973). The penis. In “Cancer Medicine.” J. F. Holland and E. Frei, 111 (Eds.) Philadelphia: Lea and Febiger, pp 1694-1696. Watson, F. R., and Glass, R. L. (1972). Breast cancer staging systems. J. Surg. Oncol. 4: 369-375. Whitmore, W. F., Jr. (1970). Tumors of the penis, urethra, scrotum, and testis. In “Urology.” M. F. Campbell and J. H. Harrison (Eds.), vol. 11, 3rd ed. Philadelphia: W. B. Saunders Co., pp 1190-1229.
