Therapeutic and Surgical Indications for Patients with Penile Cancer in the COVID-19 era

Nelson Canales Casco María Jiménez Carmona Álvaro Juárez Soto About the authors

ABSTRACT

Purpose:

The aim of this work is to review and synthesize the existing evidence and recommendations regarding to the therapeutic and surgical indications as well as monitoring of patients with Penile Cancer in COVID-19 era and to propose an action protocol to facilitate decision-making.

Material and Methods:

A non-systematic review of the literature regarding the management of penile cancer during the COVID-19 pandemic was performed until April 30, 2020. We propose our recommendations based on this evidence.

Results:

Penile cancer is an uncommon but aggressive disease. Prognosis is determined by several characteristics, being the most important the presence of lymph nodes, in which case, treatment should not be delayed. For these reasons, an initial evaluation is mandatory. Priority classifications, based on the oncological outcomes when treatment is delayed, have been made in order to separate deferrable disease from the one that needs high priority treatment. In penile cancer with low risk of progression, surgical treatment can be delayed, but other options must be considered, like topical treatment or laser therapy. In cases with intermediate risk of progression, surgical treatment may be delayed up to three months, but we must consider radiation therapy and brachytherapy as effective options. When feasible, follow-up should by telemonitoring.

Conclusions:

In the COVID 19 era, initial evaluation of the patient is mandatory. Histological diagnosis with local staging is necessary before offering any therapeutic option. In case of superficial non-invasive disease, topical treatment is effective in absence of lymph node involvement. In selected patients, radiotherapy is an organpreserving approach with good results. Non-deferrable surgical treatment must be performed by an experienced surgeon and as an outpatient procedure when possible. When indicated, iLND should not be delayed since it is decisive for patient survival. Follow-up should be by telemonitoring.

Keywords:
Penile Neoplasms; Clinical Protocols; COVID-19 [Supplementary Concept]; Pandemics

INTRODUCTION

Penile cancer is an uncommon pathology, with an overall incidence, in industrialized countries, of around 1/100.000 males in Europe and USA (11. Chaux A, Netto GJ, Rodríguez IM, Barreto JE, Oertell J, Ocampos S, et al. Epidemiologic profile, sexual history, pathologic features, and human papillomavirus status of 103 patients with penile carcinoma. World J Urol. 2013; 31:861-7.). The incidence is affected by race and ethnicity, with the highest incidence in white Hispanics, followed by Alaskans and native American Indians. In other parts of the World, such as South America, South East Asia and parts of Africa, the incidence is much higher (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
). Several risk factors have been identified, such as HVP infections, smoking, phimosis, chronic penile inflammation and multiple sexual partners (33. Backes DM, Kurman RJ, Pimenta JM, Smith JS. Systematic review of human papillomavirus prevalence in invasive penile cancer. Cancer Causes Control. 2009; 20:449-57., 44. Dillner J, von Krogh G, Horenblas S, Meijer CJ. Etiology of squamous cell carcinoma of the penis. Scand J Urol Nephrol Suppl. 2000; 205:189-93.).

Winters et al. made an analysis of the United States national cancer database from 1998 to 2012, describing that the presence of pathological subtype of the disease, perineural and lymphovascular invasion, depth of the invasion and grade in the primary tumor will determine the prognosis (55. Winters BR, Mossanen M, Holt SK, Lin DW, Wright JL. Predictors of Nodal Upstaging in Clinical Node Negative Patients With Penile Carcinoma: A National Cancer Database Analysis. Urology. 2016; 96:29-34.).

When analyzing the social characteristics of the patients, Jimenez Ríos et al. described that low socioeconomic status, poor education and delay in seeking medical attention are related with advanced disease. This analysis was made in Mexico and concluded that a delay of 10 months between the appearance of the first symptoms and the patient seeking for medical attention was related with advanced disease and worse prognosis (66. Miguel Ángel Jiménez-Ríosa, Pablo Ariza-Villarob, Mario Emmanuel Solares-Sánchezb, Pedro Martínez-Cervera, INCan. Factores pronósticos de mortalidad en cáncer de pene. Gaceta Mexicana de Oncología. 2011:10:191-6. Available at. <https://www.elsevier.es/es-revista-gacetamexicana-oncologia-305-articulo-factores-pronosticosmortalidad-cancer-pene-X1665920111278365>.
https://www.elsevier.es/es-revista-gacet...
).

On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic (77. Gabrielson AT, Kohn TP, Clifton MM. COVID-19 and the Urology Match: Perspectives and a Call to Action. J Urol. 2020: Online ahead of print.). This has led to dramatically changes on medical and surgical priorities. Postponement for all outpatient and elective activities to save facilities and resources for urgent cases and COVID-19 patients have been adopted by most hospitals in the affected countries. We know that cancer patients are characterized by their higher susceptibility to infectious diseases compared to general population with 3.5 folds increased risk of COVID-19 related serious events (88. Puliatti S, Eissa A, Eissa R, Amato M, Mazzone E, Dell’Oglio P, et al. COVID-19 and urology: a comprehensive review of the literature. BJU Int. 2020;125:E7-E14.). Therefore, the choice of urgent and emergent surgeries that should still occur will depend on the capacity and demand, but also must be counterbalanced by the effects of delaying surgeries (99. Stensland KD, Morgan TM, Moinzadeh A, Lee CT, Briganti A, Catto JWF, et al. Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic. Eur Urol. 2020; 77:663-6.). As COVID-19 continues to spread, governments have imposed increasingly aggressive measures that have demonstrated benefits in reducing the spread of the virus minimizing the impact that cases have on local health care systems (77. Gabrielson AT, Kohn TP, Clifton MM. COVID-19 and the Urology Match: Perspectives and a Call to Action. J Urol. 2020: Online ahead of print.). This is generating a rapid and tragic health emergency worldwide, due to the need to provide assistance to an overwhelming number of infected patients and, at the same time, treat all the non-deferrable oncological and benign conditions (1010. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. [published online ahead of print, 2020 Mar 23]).

Liang W et al. in a nationwide analysis of cancer patients with COVID-19 infection proposed that intentional postponing of adjuvant chemotherapy or elective surgery for stable cancer should be considered in endemic areas (1111. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020; 21:335-7.).

Later, Xia Y et al. reported that these findings can't be generalizable due to the small sample analyzed, the heterogeneity on the type of cancers, the great difference in the course of the disease and the different treatment strategies. (1212. Xia Y, Jin R, Zhao J, Li W, Shen H. Risk of COVID-19 for patients with cancer. Lancet Oncol. 2020; 21:e180.) Uncareful delay of onco-urologic surgeries may have an impact on short-term progression and/or mortality (88. Puliatti S, Eissa A, Eissa R, Amato M, Mazzone E, Dell’Oglio P, et al. COVID-19 and urology: a comprehensive review of the literature. BJU Int. 2020;125:E7-E14.).

Knowing that penile cancer is an uncommon, but yet aggressive disease, there is a need to have easy to follow strategies and protocols for early diagnosis, adequate treatment and follow up during COVID-19 pandemic.

MATERIAL AND METHODS

A non-systematic review of the available literature on the management of penile cancer during the COVID-19 pandemic was performed. We navigated through Pubmed, Cochrane library, the American Urology Confederation (CAU) library of COVID-19, we reviewed the European Urology Association (EUA) Rapid Reaction Group recommendations, the British Association of Urological Surgeons (BAUS) recommendations, the National Comprehensive Cancer Network (NCCN) guidelines and the American Urology Association (AUA) COVID-19 library in search of literature available in English and Spanish until April 30, 2020.

We described and analyzed the different protocols and recommendations proposed by different authors and scientific organizations, and based on this evidence and our experience, we created an action protocol for early and safe diagnosis, adequate treatment and follow up of patients with penile cancer during COVID-19 pandemic.

RESULTS

COVID-19 pandemic has led to dramatically changes on medical and surgical priorities. Postponement for all outpatient and elective activities to save facilities and resources for urgent cases and COVID-19 patients have been adopted by most hospitals in the affected countries (88. Puliatti S, Eissa A, Eissa R, Amato M, Mazzone E, Dell’Oglio P, et al. COVID-19 and urology: a comprehensive review of the literature. BJU Int. 2020;125:E7-E14.). This is a problem that is affecting health services worldwide.

Naspro and Da Pozzo stated that the real challenge in this time, is that the health service in Italy is currently unable to easily deal with other conditions except treatment of COVID-19. Urologists manage patients with oncological diseases and surgical priorities, as well as non-oncological conditions that can affect quality of life. Regional guidelines require that any patient requiring oncological surgery must be treated within 30 days from diagnosis. Departments struggle to meet this deadline normally, now it's even harder (1313. Naspro R, Da Pozzo LF. Urology in the time of corona. Nat Rev Urol. 2020; 17:251-3.).

Pulliati et al.(88. Puliatti S, Eissa A, Eissa R, Amato M, Mazzone E, Dell’Oglio P, et al. COVID-19 and urology: a comprehensive review of the literature. BJU Int. 2020;125:E7-E14.) in a review of the literature available of COVID-19 and Urology, quotes the work of Liang et al. (1111. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020; 21:335-7.), who stated that cancer patients are characterized by their higher susceptibility to infectious disease compared to general population with 3.5 folds increased risk of COVID-19 related serious events in the form of intensive care admission, requirement for mechanical ventilation, or death due to their immune compromised state related to the nature of their malignancy and the anti-cancer management (chemotherapy, radiotherapy, or surgery). This paper recommends to delay all elective cancer surgeries or adjuvant chemotherapy in patients with stable cancer. Wang et al. (1414. Wang H, Zhang L. Risk of COVID-19 for patients with cancer. Lancet Oncol. 2020; 21:e181.) reported that the major risk factor for cancer patients during COVID-19 pandemic is the inability to receive sufficient medical support.

Xia Y et al. (1212. Xia Y, Jin R, Zhao J, Li W, Shen H. Risk of COVID-19 for patients with cancer. Lancet Oncol. 2020; 21:e180.) reported that Liang et al. (1111. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020; 21:335-7.) findings are not generalizable due to the small sample analyzed, the heterogeneity on the type of cancers, differences in their course and the different treatment strategies.

In this same line, Méjean A. et al. as part of the Cancerology Committee of the French Association of Urology (CCAFU) published expert opinion recommendations based on literature review for cancer treatment (1515. Méjean A, Rouprêt M, Rozet F, Bensalah K, Murez T, Game X, et al. Recommandations CCAFU sur la prise en charge des cancers de l'appareil urogénital en période d’épidémie au Coronavirus COVID-19 [Recommendations CCAFU on the management of cancers of the urogenital system during an epidemic with Coronavirus COVID-19]. Prog Urol. 2020; 30:221-31.). They stated that a 3-month delay in diagnose and treatment of penile cancer decreases the possibility of conservative treatment. This 3-month delay seems to have no impact in 5-year overall survival or recurrence free survival. After 6-month delay, survival reduces after 2 years. A 3-month delay in the treatment of lymph nodes, significantly decreases 5-year specific survival (39.5% when compared with 64.1% when there is no delay). This idea reinforces the statement of Xia et al. that we cannot treat all patients and all pathologies as a same (1212. Xia Y, Jin R, Zhao J, Li W, Shen H. Risk of COVID-19 for patients with cancer. Lancet Oncol. 2020; 21:e180.).

We know that prognosis is determined by the pathological subtype of the disease. In this case, the verrucous subtype is considered to demonstrate low malignant potential, while adenosquamous and sarcomatoid variants carry a worse prognosis. The presence of perineural and lymphovascular invasion, depth of the invasion and grade in the primary tumor are also relevant in determining prognosis (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
, 1616. [No Authors]. National Comprehensive Cancer Network. Penile Cancer Available at <http://www.nccn.org/professionals/physician_gls/pdf/penile_blocks.pdf>. (accessed April 27, 2020).
http://www.nccn.org/professionals/physic...
).

This is the reason why, potential new penile cancers require clinical assessment, as stated by the British Association of Urological Surgeons (BAUS) (1717. BAUS -British Association of Urological Surgeons. COVID-19 strategy for the interim management of penile cancerPrepared by the BAUS Sections of Oncology & Andrology. Available at. <https://caunet.org/wp-content/uploads/2020/04/BAUS-Oncology-COVID-19-Penis.pdf>.
https://caunet.org/wp-content/uploads/20...
), in order to determine the most appropriate treatment. It is vital to perform a good physical evaluation of the penile lesion (s) with all its characteristics (diameter, location, number, morphology and involvement of other structures) as well as the presence of suspicious lymph nodes. To complete this initial evaluation, histologic diagnosis with punch, incisional or excisional biopsy is paramount in determining the treatment algorithm (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
, 1616. [No Authors]. National Comprehensive Cancer Network. Penile Cancer Available at <http://www.nccn.org/professionals/physician_gls/pdf/penile_blocks.pdf>. (accessed April 27, 2020).
http://www.nccn.org/professionals/physic...
).

Once histological diagnosis has been made, standard treatment for superficial non-invasive lesions; Tis or Ta should be with penis-preserving techniques including topical treatments, laser therapy, Mohs surgery and conservative penile surgery. In T1G1-2 disease, careful consideration should be given for penile-preserving techniques if the patient is reliable in terms of complications with close follow-up. This includes wide local excision, glansectomy in selected cases, Mohs surgery, laser therapy and radiation therapy. In T1G3 or ≥T2 extensive surgery, RT and in some cases, brachytherapy may be feasible (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
, 1616. [No Authors]. National Comprehensive Cancer Network. Penile Cancer Available at <http://www.nccn.org/professionals/physician_gls/pdf/penile_blocks.pdf>. (accessed April 27, 2020).
http://www.nccn.org/professionals/physic...
).

The presence and extent of regional inguinal lymph node metastases have been identified as the single most important prognostic indicator in determining long-term survival (1616. [No Authors]. National Comprehensive Cancer Network. Penile Cancer Available at <http://www.nccn.org/professionals/physician_gls/pdf/penile_blocks.pdf>. (accessed April 27, 2020).
http://www.nccn.org/professionals/physic...
).

During COVID-19 pandemic, there's a need to create easy to follow recommendations and protocols that are adapted to the actual health situation in order to guarantee a safety environment for the patient and medical staff. That's why different associations, expert groups and authors are doing great efforts to review available data and provide adapted strategies.

There's a need to classify oncological diseases in groups according to their clinical stage, and state priorities for treatment.

The European Urology Association (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
), through the guidelines office, proposed a rapid reaction group (GORRG) on 19th March 2020, to facilitate the development of adapted guidelines to deal with a range of situations and priorities. Levels of prioritization were established taking in count the impact of delay on primary outcomes, possibility of alternative methods that could replace the standard procedure with less operating room requirements, presence of co-morbidities and/or increased risk of complications among others. Low priority was used to classify diseases that were very unlikely to cause clinical harm if postponed 6 months. Intermediate priority for diseases that can cause clinical harm if postponed 3-4 months even though it's unlikely. High priority when disease can cause clinical harm if postponed more than 6 weeks, and emergency for life threatening situations. A similar classification was made by Ficarra V. et al. who distinguished urological procedures to treat cancer in four categories: a) Non deferrable, b) Semi-non-deferrable, c) Deferrable, d) Replaceable by another treatment (1010. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. [published online ahead of print, 2020 Mar 23]).

Goldman et al. from Cleveland Clinic urology department made a tier system from 0-4 to help prioritize surgical procedures. In this classification they used five priority tiers, where 0 is considered an emergency, and 4 a non-essential surgery that can be delayed for long time. Penile cancer is listed a priority 1 in this tier classification. This classification was based on the available data regarding risk of progression but mostly from expert opinion (1818. Goldman HB, Haber GP. Recommendations for Tiered Stratification of Urological Surgery Urgency in the COVID-19 Era. J Urol. 2020. Epub ahead of).

In this case we made our classification (Table-1) based on the classification system proposed by Ficarra V. et al. which is similar as the proposed by the EUA (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
), because it allows us to stratify one same disease in a different category depending on its clinical stage. The time of delay in deferrable disease will be 6 months and in semi non-deferrable 3 months (1010. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. [published online ahead of print, 2020 Mar 23]).

Table 1
Treatment priority classification for Penile Cance during COVID-19 pandemic

The presence of inguinal lymph nodes will automatically classify the disease as non-deferrable. In semi-deferrable disease, the possibility to access priority medical assistance or telemonitoring should be available. During this time, the patient must perform self-examination and in case of noticing palpable inguinal lymph nodes, medical attention should be a priority.

In this case, in order to complete diagnosis, chest, abdomen and pelvic CT scan should be performed (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
, 1616. [No Authors]. National Comprehensive Cancer Network. Penile Cancer Available at <http://www.nccn.org/professionals/physician_gls/pdf/penile_blocks.pdf>. (accessed April 27, 2020).
http://www.nccn.org/professionals/physic...
, 1919. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. Epub ahead of print.).

In a literature review made by Wallis C. et al. they describe that patients who receive early inguinal lymphadenectomy; with median time to surgery of 1.7 months, range 0-6 months, had significantly lower five-year cancer specific mortality than those who underwent delayed intervention (2020. Wallis CJD, Novara G, Marandino L, Bex A, Kamat AM, Karnes RJ, et al. Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic. Eur Urol. 2020: S0302-2838;30331-6.).

In deferrable disease, when other treatment options are available, they must be offered.

Méjean A. et al. (1515. Méjean A, Rouprêt M, Rozet F, Bensalah K, Murez T, Game X, et al. Recommandations CCAFU sur la prise en charge des cancers de l'appareil urogénital en période d’épidémie au Coronavirus COVID-19 [Recommendations CCAFU on the management of cancers of the urogenital system during an epidemic with Coronavirus COVID-19]. Prog Urol. 2020; 30:221-31.) proposed that when all therapeutic options are available and low risk disease is being treated; Tis (PeIN), topical treatment should be the first option. In case of conservative treatment failure, if strict supervision is available (this may be done by telemonitoring), reasonable delay on surgery may be an option, and, when invasive disease; <T1G2 or verrucous cancer, with low risk of lymph node affection, a delay on surgery must be discussed with the need of lymph node evaluation. Alchiede Simonato et al. (1919. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. Epub ahead of print.) made a simplification of the diagnostic therapeutic algorithms based on the EUA guidelines and the experience gained in Italy during this crisis. They proposed that, when indicated, penectomy with inguinal lymph node dissection must not be delayed. We understand that this refers to patients with ≥T1G3, or any N+. This was also stated by Puliati et al. (88. Puliatti S, Eissa A, Eissa R, Amato M, Mazzone E, Dell’Oglio P, et al. COVID-19 and urology: a comprehensive review of the literature. BJU Int. 2020;125:E7-E14.).

Following the same line, Stensland et al. (99. Stensland KD, Morgan TM, Moinzadeh A, Lee CT, Briganti A, Catto JWF, et al. Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic. Eur Urol. 2020; 77:663-6.), suggested a triage for surgical cancer treatments, where they recommend to not delay treatment of possible clinically invasive penile cancer or obstructive cancers. Prevention of lymph node metastases is vital to spare significant patient morbidity.

They emphasized the importance of performing surgery as an outpatient procedure when feasible.

In order to facilitate decision-making for treating penile cancer during COVID Era, we created a recommendation flowchart (Figure-1).

Figure 1
Decision-making recommendations for Penile Cancer during COVID-19 era.

Simonato A. et al. (1919. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. Epub ahead of print.), the EUA protocol created by the GORRG (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
) and the BAUS recommendations (1717. BAUS -British Association of Urological Surgeons. COVID-19 strategy for the interim management of penile cancerPrepared by the BAUS Sections of Oncology & Andrology. Available at. <https://caunet.org/wp-content/uploads/2020/04/BAUS-Oncology-COVID-19-Penis.pdf>.
https://caunet.org/wp-content/uploads/20...
) all coincide that follow-up should be by remote monitoring.

DISCUSSION

We made a review of the literature available at the moment, for the diagnosis, treatment and follow-up of penile cancer during COVID-19 pandemic. Despite the lack of information at this point, several authors and scientific organizations are moving quickly to make different protocols and guides of recommendations to facilitate decision--making in urological cancer disease during the COVID-19 pandemic.

Based on the characteristics of penile cancer; epidemiological, histological and clinical behavior, we know we are dealing with an uncommon but aggressive disease, with high mortality when diagnosis and treatment are delayed. During COVID-19 pandemic hospitals worldwide have been forced to make changes in order to save facilities and resources for urgent cases. This has led to postponement of outpatient and elective activities.

As more information appears, protocols are being adapted. Liang et al. (1111. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020; 21:335-7.) recommended to delay all elective cancer surgeries or adjuvant chemo-therapy in patients with stable cancer. This was based on the premise that oncological patients have higher susceptibility to infectious diseases. It's well known that evolution, treatment response and prognosis vary between different cancer diseases, so we must treat each one individually, as reported by Xia et al. (1212. Xia Y, Jin R, Zhao J, Li W, Shen H. Risk of COVID-19 for patients with cancer. Lancet Oncol. 2020; 21:e180.) and Wang et al. (1414. Wang H, Zhang L. Risk of COVID-19 for patients with cancer. Lancet Oncol. 2020; 21:e181.).

Different classifications have been made in an attempt to establish levels of prioritization. The EAU guidelines (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
), Ficarra et al. (1010. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. [published online ahead of print, 2020 Mar 23]), Méjean et al. (1515. Méjean A, Rouprêt M, Rozet F, Bensalah K, Murez T, Game X, et al. Recommandations CCAFU sur la prise en charge des cancers de l'appareil urogénital en période d’épidémie au Coronavirus COVID-19 [Recommendations CCAFU on the management of cancers of the urogenital system during an epidemic with Coronavirus COVID-19]. Prog Urol. 2020; 30:221-31.), the BAUS guidelines (1717. BAUS -British Association of Urological Surgeons. COVID-19 strategy for the interim management of penile cancerPrepared by the BAUS Sections of Oncology & Andrology. Available at. <https://caunet.org/wp-content/uploads/2020/04/BAUS-Oncology-COVID-19-Penis.pdf>.
https://caunet.org/wp-content/uploads/20...
) and Goldman et al. (1818. Goldman HB, Haber GP. Recommendations for Tiered Stratification of Urological Surgery Urgency in the COVID-19 Era. J Urol. 2020. Epub ahead of) agree that different cancer diseases can be classified in low priority (deferrable), intermediate priority (semi non-deferrable), high priority (non-deferrable) and emergencies, depending on the probable onco-logical outcome if attention is delayed. In terms of treatment the EAU guidelines (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
), Stensland et al. (99. Stensland KD, Morgan TM, Moinzadeh A, Lee CT, Briganti A, Catto JWF, et al. Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic. Eur Urol. 2020; 77:663-6.), Ficarra V. et al. (1010. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. [published online ahead of print, 2020 Mar 23]), Méjean et al. (1515. Méjean A, Rouprêt M, Rozet F, Bensalah K, Murez T, Game X, et al. Recommandations CCAFU sur la prise en charge des cancers de l'appareil urogénital en période d’épidémie au Coronavirus COVID-19 [Recommendations CCAFU on the management of cancers of the urogenital system during an epidemic with Coronavirus COVID-19]. Prog Urol. 2020; 30:221-31.), the NCCN Guidelines (1616. [No Authors]. National Comprehensive Cancer Network. Penile Cancer Available at <http://www.nccn.org/professionals/physician_gls/pdf/penile_blocks.pdf>. (accessed April 27, 2020).
http://www.nccn.org/professionals/physic...
), Simonato (1919. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. Epub ahead of print.) and Wallis (2020. Wallis CJD, Novara G, Marandino L, Bex A, Kamat AM, Karnes RJ, et al. Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic. Eur Urol. 2020: S0302-2838;30331-6.) all recommend special attention to the presence of inguinal lymph nodes because they will affect prognosis. In case of affection, treatment must not be delayed.

During COVID-19 pandemic, authors agree that, when feasible, follow-up can be done by remote monitoring, phone calls or even by sending pictures (22. EAU Guidelines. Edn. Presented at the EAU Annual Congress Amsterdam, 2020. Available at. < https://uroweb.org/guidelines/how-to-cite-the-eau-guidelines/>.
https://uroweb.org/guidelines/how-to-cit...
, 1717. BAUS -British Association of Urological Surgeons. COVID-19 strategy for the interim management of penile cancerPrepared by the BAUS Sections of Oncology & Andrology. Available at. <https://caunet.org/wp-content/uploads/2020/04/BAUS-Oncology-COVID-19-Penis.pdf>.
https://caunet.org/wp-content/uploads/20...
, 1919. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during COVID-19 pandemic. Minerva Urol Nefrol. 2020. Epub ahead of print.).

CONCLUSIONS

In the COVID era, evaluation of the patient is necessary in order to clinically determine the stage of the disease and proceed to adequate treatment. Appropriate safety measures must be taken to guarantee the safety of the patient and medical staff. Histological diagnosis with local staging must be obtained before offering a therapeutic option. In case of superficial non-invasive disease, topical treatment is effective and should be the first option in absence of lymph node involvement. In selected patients with T1-2 lesions <4cms in diameter, radiotherapy is an organ-preserving approach with good results. It can be given as external radiotherapy combined with brachytherapy boost or as brachytherapy alone.

When surgical treatment can't be delayed, it should be performed by an experienced surgeon, under appropriate safety measures and as an outpatient procedure when feasible. When indicated, LND should not be delayed since it is decisive for patient survival. The follow up should be performed by telemonitoring when possible.

    ABREVIATIONS
  • CAU  American Urology Confederation
  • EAU  European Urology Association
  • GORRG  Guidelines Office Comissioned a Rapid Reaction Group
  • NCCN  National Comprehensive Cancer Network
  • BAUS  British Association of Urological Surgeons

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Publication Dates

  • Publication in this collection
    27 July 2020
  • Date of issue
    July 2020

History

  • Received
    25 Apr 2020
  • Accepted
    10 May 2020
  • Published
    05 June 2020
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