Key Words Competing Interests Article Information Penile cancer, cancer staging, circumcision None declared. Received on September 22, 2021 Accepted on December 30, 2021 This article has been peer reviewed. Soc Int Urol J. 2022;3(2):102–107 DOI: 10.48083/OIKH5959 102 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited. © 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada. BRIEF COMMUNICATION The Relationship of Circumcision With Clinical Tumor Staging of Penile Cancer Marco Bandini,1 Philippe E. Spiess,2 Yao Zhu,3 Antonio A. Ornellas,4 Benjamin A. Ayres,5 Oliver W. Hakenberg,6 Friederike Haidl,7 Filippo Pederzoli,1 Giuseppe Basile,1 Alberto Briganti,1 Francesco Montorsi,1 Juan Chipollini,2 Mounsif Azizi,2 Gert De Meerleer,8 Oscar R. Brouwer,9 Maarten Albersen,8 Andrea Necchi,10 Peter A. S. Johnstone2 1 San Raffaele Hospital and Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy 2 Moffitt Cancer Center and Research Institute, Tampa, United States 3 Fudan University Shanghai Cancer Center, Shanghai, China 4 Hospital Mário Kröeff and Brazilian Cancer Institute, Rio de Janeiro, Brazil 5 St George’s University Hospitals, NHS Foundation Trust, London, United Kingdom 6 University Hospital Rostock, Rostock, Germany 7 Universitätsklinikum Köln, Köln, Germany 8 University Hospitals Leuven, Leuven, Belgium 9 The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands 10 Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy Abstract In this report, we look at the relationship between prior circumcision and presenting stage of penile cancer. We performed an analysis of an international, multicenter database of 1254 penile cancer patients diagnosed from 1980 to 2019 in the United States, Europe, Brazil, and China, and analyzed the relationship between circumcision and presenting T and N stage. A total of 710 patients met the inclusion criteria and were statistically analyzed. We found that uncircumcised men with locally advanced tumors (T3–T4) had significantly higher risk of lymph node metastasis compared with circumcised men. The genital microbiome is the only shared human microbiome[1]. Since circumcised men harbor different bacterial communities than uncircumcised men[2], we hypothesized that circumcised men may present with a different penile squamous cell carcinoma (PSCC) disease burden than uncircumcised men. Were this the case, it could manifest as a difference in either the T or N stage of the subsequent disease. To our knowledge, no prior study has discussed the relationship of prior circumcision with the presenting tumor stage. In order to do so, we performed a retrospective cohort study. Large clinical datasets of patients with PSCC are uncommon given the rarity of the disease[3]. We have collaborated on an international, multicenter retrospective database of 1254 penile cancer patients diagnosed from 1980 to 2019 in the United States, Europe, Brazil, and China. Previous publications from our group have discussed correlates of chemotherapy and lymph node dissection use by participating institutions[4–6], and association between human papillomavirus (HPV) infection and radiosensitivity[7]. For this report, we analyzed the relation between circumcision and presenting T and N stage. Patients treated with circumcision during the surgery of the primary lesion or those without data on time of circumcision were excluded. http://SIUJ.org mailto:Peter.Johnstone%40%20Moffitt.org?subject=SIUJ For this analysis, 710 patients met the inclusion criteria (Figure 1). Patient characteristics are summarized in Table 1. Descriptive statistics included frequencies and proportions for categorical variables. Medians and interquartile ranges (IQR) were reported for continuous variables. The statistical significance of differences in medians and proportions between circumcised and uncircumcised men with penile cancer was tested with the Kruskal-Wallis and chi-square tests, respectively. Ana lyses were organized in several steps. First, we explored predictors of inguina l ly mph node metastases (ILNM) among several variables including circumcision, histology (squamous cell versus non- squamous cell), T stage (T< 2 versus T2 versus T3–T4), age at penile cancer diagnosis, use of perioperative chemotherapy, surgical procedure to the primary (total penectomy versus partial penectomy versus no surgery/ local surgical procedures). The choice of the predictors for this multivariable model has been made based on clinical relevance. Second, to assess whether the higher risk of ILNM in locally advanced tumors (T3–T4) was different by circumcision status, we tested an interaction with T stage and circumcision. Third, we depicted the probability of inguinal lymph node metastases for circumcised and uncircumcised men with penile cancer across T sub-stages. FIGURE 1. Inclusion/exclusion criteria and study population 710 patients enrolled in this study cohort 1254 patients with penile cancer 475 patients without circumcision data 779 circumcised and uncircumcised patients with penile cancer 2 patients without available pT and pN stage data 777 patients with available pT and pN stage data 20 patients without type of surgery of the primary data 757 patients received surgery of the primary 47 patients without available follow-up data TABLE 1. Epidemiological, geographical, and disease-specific characteristics of 710 penile cancer patients treated within 9 tertiary referral institutions Variable Overall (n = 710) Circumcised (n = 550) Not circumcised (n = 160) P-value Median age at diagnosis (range) 59 (50–69) 59 (50.2–68.8) 58 (48.8–69) 0.98 Median ILMN (range) 13.3 (4.3–25) 13.3 (4.8–25) 12.5 (0–26.8) 0.89 Geographical areas (%) Europe Brazil United Kingdom United States 388 (54.6) 173 (24.4) 77 (10.8) 72 (10.1) 304 (55.3) 145 (26.4) 66 (12) 35 (6.4) 84 (52.5) 28 (17.5) 11 (6.9) 37 (23.1) < 0.001 HPV infection (%) Yes No NA 371 (52.3) 38 (5.4) 301 (42.4) 284 (51.6) 26 (4.7) 240 (43.6) 87 (54.4) 12 (7.5) 61 (38.1) 0.21 Smoking habit (%) Current or former Never NA 246 (34.6) 166 (23.4) 298 (42) 204 (37.1) 121 (22) 225 (40.9) 42 (26.2) 45 (28.1) 73 (45.6) 0.04 CHT: chemotherapy; ILNM: inguinal lymph node metastasis; LND: lymph node dissection; RT: radiotherapy; SCC: squamous cell carcinoma 103SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 The Relationship of Circumcision With Clinical Tumor Staging of Penile Cancer http://SIUJ.org TABLE 1. Epidemiological, geographical, and disease-specific characteristics of 710 penile cancer patients treated within 9 tertiary referral institutions Variable Overall (n = 710) Circumcised (n = 550) Not circumcised (n = 160) P-value Histology (%) SCC Non-SCC 622 (87.6) 88 (12.4) 477 (86.7) 73 (13.3) 145 (90.6) 15 (9.4) 0.21 pT stage (%) pT<2 pT2 pT3-4 277 (39) 279 (39.3) 154 (21.7) 190 (34.5) 235 (42.7) 125 (22.7) 87 (54.4) 44 (27.5) 29 (18.1) < 0.001 pN stage (%) Nx-N0 N1-N2 N3 230 (32.4) 193 (27.2) 287 (40.4) 182 (33.1) 151 (27.5) 217 (39.5) 48 (30) 42 (26.2) 70 (43.8) 0.60 Inguinal LND (%) Bilateral Unilateral Not performed 479 (67.5) 143 (20.1) 88 (12.4) 364 (66.2) 107 (19.5) 79 (14.4) 115 (71.9) 36 (22.5) 9 (5.6) 0.01 Node metastasis side (%) Negative ILNM Bilateral ILNM Unilateral ILNM ILND not performed NA 112 (15.8) 174 (24.5) 158 (22.3) 21 (3) 245 (34.5) 78 (14.2) 133 (24.2) 120 (21.8) 19 (3.5) 200 (36.4) 34 (21.2) 41 (25.6) 120 (21.8) 2 (1.2) 45 (28.1) 0.1 Type of surgery of the primary penile lesion (%) Total penectomy No surgery/ local procedures Partial penectomy 162 (22.8) 97 (13.7) 451 (63.5) 141 (25.6) 40 (7.3) 369 (67.1) 21 (13.1) 57 (35.6) 82 (51.2) < 0.001 Perioperative CHT (%) No CHT CHT NA 328 (46.2) 258 (36.3) 124 (17.5) 249 (45.3) 193 (35.1) 108 (19.6) 79 (49.4) 65 (40.6) 16 (10) 0.02 Perioperative RT (%) No RT RT NA 509 (71.7) 82 (11.5) 119 (16.8) 388 (70.5) 57 (10.4) 105 (19.1) 121 (75.6) 25 (15.6) 14 (8.8) < 0.01 Pelvic LND (%) No Yes NA 366 (51.5) 264 (37.2) 80 (11.3) 271 (49.3) 207 (37.6) 72 (13.1) 95 (59.4) 57 (35.6) 8 (5) 0.01 CHT: chemotherapy; ILNM: inguinal lymph node metastasis; LND: lymph node dissection; RT: radiotherapy; SCC: squamous cell carcinoma 104 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG BRIEF COMMUNICATION http://SIUJ.org TABLE 2a. Univariable and multivariable analysis testing the risk of ILMN according to several predictors Univariable analysis Multivariable analysis Covariates OR 5% 95% P-value OR 5% 95% P-value Previous circumcision 0.72 0.46 1.14 0.2 0.63 0.36 1.10 0.1 Non-SCC histology 5.19 2.10 17.28 0.002 2.82 1.00 10.17 0.07 pT2 stage (ref T < 2) 1.36 0.87 2.14 0.2 1.82 1.06 3.15 0.03 pT3-T4 stage (ref T < 2) 2.22 1.25 4.14 0.009 2.83 1.42 5.86 0.004 Age at diagnosis 1.01 0.99 1.02 0.4 1.01 0.99 1.03 0.2 Perioperative CHT unknown (ref. no perioperative CHT) 13.62 4.11 84.31 < 0.001 7.36 1.92 48.71 0.01 Perioperative CHT (ref. no perioperative CHT) 9.59 5.40 18.42 < 0.001 10.57 5.88 20.54 < 0.001 Total penectomy versus no surgery/local surgical procedures 0.90 0.46 1.83 0.9 2.42 0.97 6.20 0.06 Total penectomy versus partial penectomy 0.96 0.58 1.56 0.9 1.28 0.71 2.26 0.4 CHT: chemotherapy; OR: odds ratio; SCC: squamous cell carcinoma TABLE 2b. Interaction between circumcision and pT stage for prediction of lymph node invasion adjusted for all the other covariates: histology, age, perioperative CHT, surgical procedure on the primary penile lesion Variable OR 5% 95% P-value Previous circumcision*T2 stage 0.48 0.14 1.61 0.2 Previous circumcision*T3-T4 stage 0.21 0.04 0.92 0.03 105SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 The Relationship of Circumcision With Clinical Tumor Staging of Penile Cancer http://SIUJ.org Uncircumcised patients harbored T< 2 tumors more frequently than did circumcised men (54.4% versus 34.5%; P < 0.001) (Table 1). No statistical difference was found regarding N stage between circumcised and uncircumcised men. Furthermore, circumcision rates differed with smoking and geographic patient variables, and with several treatment variables including extent of surgery and delivery of chemotherapy and radiother- apy. Multivariable analyses showed a clear and expected association between advanced pT stages and higher risk of ILNM, as well as between use of perioperative chemo- therapy and higher risk of ILNM. Conversely, no asso- ciation was found between circumcision and the risk of ILNM. Nevertheless, we found that circumcision, compared with no-circumcision, conferred a lower risk of ILNM (Table 2) in patients with locally advanced tumors (T3–T4). The risk of ILNM according to T stage in circumcised versus uncircumcised penile cancer patients is depicted in Figure 2. Debate continues about the potential role of circum- cision in subsequent development of PSCC[8,9]. To our knowledge, no prior study has discussed the association of prior circumcision with tumor stage at presentation. Our data reveal correlations between circumcision and PSCC staging. First, there is an association of prior circumcision with presenting T stage on multivariable analysis. Second, there is no association of circumcision with presenting N stage. These findings suggest there may be a difference in local microbiota in uncircumcised compared with circumcised individuals, which might contribute to development of PSCC. Limitations of this analysis include a lack of broad generalizability, since data are lacking from Africa, India, and most of South America, and we consider our coverage of North America and Europe to be subopti- mal. Lack of data on HPV status on these patients is a limitation in terms of understanding its potential etiol- ogy in penile cancer, most notably in non-circumcised men. Specific analysis of large populations with equal access to health care would help clarify the potential role of the genital microbiome in this process. FIGURE 2. Risk of ILNM according to T-stage in circumcised versus uncircumcised penile cancer patients Uncircumcised Circumcised60 T<2 T2 T3–4 70 80 90 T stage Pr ob ab ili ty o f L N in va si on ILNM: inguinal lymph node metastasis 106 SIUJ • Volume 3, Number 2 • March 2022 SIUJ.ORG BRIEF COMMUNICATION http://SIUJ.org References 1. Liu CM, Hungate BA, Tobian AA, Ravel J, Prodger JL, Serwadda D, et al. Penile microbiota and female partner bacterial vaginosis in Rakai, Uganda. mBio.2015;6(3). doi:10.1128/MBI0.00589-15 2. Nelson DE, Dong Q, Van der Pol B, Toh E, Fan B, Katz BP, et al. Bacterial communities of the coronal sulcus and distal urethra of adolescent males. PloS One.2012;7(5):e36298. doi: 10.1371/journal.pone.0036298. Epub 2012 May 11. 3. Bandini M, Zhu Y, Ye D-W, Ornellas AA, Watkin N, Ayres B, et al. Contemporary treatment patterns and outcomes for patients with penile squamous cell carcinoma: identifying management gaps to promote multi-institutional collaboration. Eur Urol Oncol.2021;4(1):121– 123. doi:10.1016/J.EU0.2020.07.007. Epub 2020 Sep 14. 4. Necchi A, Lo Vullo S, Mariani L, Zhu Y, Ye D-W, Ornellas A A, et al. Nomogram-based prediction of overall survival after regional lymph node dissection and the role of perioperative chemotherapy in penile squamous cell carcinoma: retrospective multicenter study. Urol Oncol.2019 Aug;37(8):531.e7–531.e15. doi: 10.1016/j. urolonc.2019.04.003. Epub 2019 May 1. 5. Johnstone PAS, Boulware D, Djajadiningrat R, Ottenhof S, Necchi A, Catanzaro M, et al. Primary penile cancer: the role of adjuvant radiation therapy in the management of extranodal extension in lymph nodes. Eur Urol Focus.2019 Sep;5(5):737–741. doi: 10.1016/j.euf.2018.10.007. Epub 2018 Oct 14. 6. Tang DH, Djajadiningrat R, Diorio G, Chipollini J, Ma Z, Schaible BJ, et al. Adjuvant pelvic radiation is associated with improved survival and decreased disease recurrence in pelvic node-positive penile cancer after lymph node dissection: a multi-institutional study. Urol Oncol.2017;35(10):605.e17– 605.e23. doi:10.1016/J. UROLONC.2017.06.001 7. Bandini M, Ross JS, Zhu Y, Ye D-W, Ornellas AA, Watkin N, et al. Association between human papillomavirus infection and outcome of perioperative nodal radiotherapy for penile carcinoma. Eur Urol Oncol.2021 Oct;4(5):802–810. doi: 10.1016/j.eu0.2020.10.011. Epub 2020 Nov 14. 8. Thomas A, Necchi A, Muneer A, Tobias-Machado M, Tran ATH, Van Rompuy A-S, et al. Penile cancer. Nat Rev Dis Primers.2021;7(1):11. doi:10.1038/S41572-021-00246-5 9. Bandini M, Ahmed M, Basile G, Watkin N, Master V, Zhu Y, et al. A global approach to improving penile cancer care. Nat Rev Urol.2021 Dec 22;1–9. doi: 10.1038/s41585-021-00557-y. 107SIUJ.ORG SIUJ • Volume 3, Number 2 • March 2022 The Relationship of Circumcision With Clinical Tumor Staging of Penile Cancer http://SIUJ.org