Penile%20cancer Treatment

• Goal is to remove penile cancer completely with negative surgical margins preserving as much of the penis as possible
  
  • Intra-operative frozen sections may confirm negativity of surgical margins

Penile-preserving Techniques

• For tumors which are superficial or confined to the glans, a penile-preserving procedure is recommended, though recurrence rates are higher than radical surgical procedures
  
  • Local recurrence depends on tumor grade & presence of lymphovascular invasion
• As primary treatment approach for localized lesions, penile-preserving techniques appear to have superior cosmetic & functional results
  • Whenever possible, treatment for organ preservation should be offered for better quality of life & sexual function
• Surgical excision can lead to scarring, deformity & function impairment

Circumcision

• Performed prior to considering conservative non-surgical treatments
• Radical circumcision alone may be curative for lesions limited to the prepuce provided that negative surgical margins are confirmed histologically

Wide Local Excision

• Wide local excision with circumcision may be done in patients with Tis, Ta, T1 grade 1-4, or stage I penile cancer limited to the foreskin
  
  • For stage I infiltrating tumors of the glans with or without adjacent skin involvement, treatment depends on size of tumor, extent of infiltration, & degree of tumor destruction of normal tissue & options may include penectomy or microscopically controlled surgery
• A limited excision can be performed on distal, smaller T2 to T3 tumors as long as a tumor-free margin can be obtained

Laser Therapy

• A penile-preserving technique, laser ablation is correlated with a high continuity rate of sexual activity & sexual satisfaction
• May be considered in patients with Tis, Ta, & T1 grade 1-2 penile cancer
• Nd:YAG or CO₂ laser results in excellent cosmetic & functional results in patients with stage 0 penile cancer
• Nd:YAG laser therapy may be done in patients with stage I penile cancer resulting in excellent control with cosmetic appearance & sexual function preservation
• Stage II patients with small lesions may be treated with Nd:YAG laser therapy for penis preservation

Glansectomy

• Complete removal of the glans & prepuce results in the lowest recurrence rate of the treatments for small penile lesions
• Total glansectomy with or without corporeal head resurfacing may be recommended for T2 lesions
• Total glansectomy may be considered for patients with Tis or Ta penile cancer

Partial/Total Glans Resurfacing

• A surgical procedure primarily used for Tis lesions that removes the epithelial & subepithelial layers of the glans to the corpus spongiosum which is followed by skin graft placement
• Offered as a primary treatment for carcinoma in situ or as a secondary treatment when treatment with topical chemotherapy or laser therapy fails
• Determination of long-term disease control requires further follow-up

Mohs Micrographic Surgery

• Successive horizontal layers of tissue are excised followed by microscopic examination of each layer in frozen section
• Used in patients with in situ, T1 grade 1-2, & invasive penile cancer

Cryosurgery

• Used in patients with erythroplasia of Queyrat & verrucous penile carcinoma with good cosmetic results

Penectomy

• Penectomy is disfiguring & may have an impact on the patient’s quality of life, self-esteem, sexual function, & overall mental health
  
  • Must consider the patient’s preference in the choice of treatment with the risks & benefits carefully weighed
  • Counsel patients on the option of penile reconstruction
• Depending on extent & location of the neoplasm, penile amputation can be partial or total
  • Partial penectomy for glanular & distal penile tumors preserves more length with superior cosmetic & functional results; considered the standard approach for high-grade primary tumors of the penis provided a functional penile stump can be preserved & negative margins are achieved
  • Total penectomy is performed on very large tumors that extend down the penile shaft or tumors that cannot be controlled without leaving an adequate penile length for voiding
  • Considered in patients with T1 grade 3-4 & T2 or greater penile cancer
• Most frequent management for stage II penile cancer

Dynamic Sentinel Node Biopsy (DSNB)

• Has a high sentinel node detection rate & sensitivity for lymph node metastases diagnosis in nonpalpable nodes
  
  • The entire lymph node basin should be tumor free if the sentinel nodes are uninvolved
• Indicated treatment in intermediate- or high-risk disease & an alternative to surveillance in low-risk disease when inguinal lymph nodes are nonpalpable at physical examination
• DSNB reduces morbidity associated with prophylactic lymph node dissection in patients with stage T2 & T3 clinically node-negative penile cancer
• Due to the technical challenges related to DSNB, it is recommended that it should be performed in experienced centers
• If DSNB is unavailable, visualized nodes may be diagnosed with ultrasound-guided fine-needle aspiration cytology (FNAC) biopsy or an inguinal lymph node dissection

Lymph Node Dissection

Inguinal Lymph Node Dissection (ILND)

• Detects microscopic metastases without a pelvic dissection in patients with nonpalpable inguinal nodes
  
  • Provides more information than a biopsy; however, the procedure has a higher complication rate than DSNB
• Indicated in high-risk disease & is an alternative procedure to DSNB in intermediate-risk patients for treatment & staging of the inguinal region
  • ILND is also done if positive nodes are found on DSNB
• ILND is the standard treatment of metastases to inguinal lymph nodes & like DSNB is warranted in patients with nonpalpable inguinal lymph nodes if the following high-risk features for nodal metastasis are noted in the primary penile tumor: >50% poorly differentiated, ≥T1G3 or ≥T2 any grade, or presence of lymphovascular invasion
• Bilateral lymph node dissection is performed in patients with high-risk features but with nonpalpable lymph nodes as laterality of inguinal nodal metastasis cannot be predicted based on the location of the tumor on the penis
  
  • It is also performed in immediate ILND for high-risk primary tumors or because of palpable nodes as 30% of patients with unilateral palpable node will have contralateral positive nodes that are unpalpable
• A percutaneous biopsy is currently favored over the traditional 6-weeks antibiotic course in differentiating reactive lymph nodes from metastatic disease in patients with palpable nodes; however, a bilateral ILND should be done if ≥3 weeks after completing antibiotic therapy & removing infected primary lesion, enlarged lymph nodes are palpated as it is likely to be a metastatic lymph node disease
• Modified inguinal lymph node dissection involves removal of the nodes within the fossa ovalis by skeletonizing the femoral vessels
  •  Has demonstrated a reduction in complications & is performed in patients with nonpalpable inguinal nodes on PE but with a primary tumor that increases their risk for inguinal metastasis

Pelvic Lymph Node Dissection (PLND)

• Approximately 20-30% of positive inguinal lymph nodes will also have cancer in the pelvic lymph nodes & its presence is associated with <10% 5-year survival rate
• Recommended in patients with ≥2 positive inguinal nodes & in the clinical context of high-grade cancer in the inguinal lymph node pathologic specimen

Nonpalpable Inguinal Lymph Nodes

Low-risk Disease (Tis, TaG1-2 or T1G1)

• Patients may undergo surveillance if they are compliant with follow-up recommendations as occult micrometastases in inguinal lymph node is <17%
• Inguinal node staging by DSNB should be offered to patients unable to continue with surveillance

Intermediate- (T1G2) or High-risk Disease (≥T2 or any G3 or G4)

• Patients in this group should undergo DSNB or a superficial or modified ILND for treatment
• After DSNB or ILND, further therapy may include the following:
  
  • Posttreatment surveillance for patients with negative inguinal nodes
  • Complete inguinal dissection for patients with 1 involved inguinal node
  • Inguinal & pelvic node dissection for patients with >2 involved inguinal nodes

Palpable Inguinal Lymph Nodes

• A percutaneous fine-needle aspiration (FNA) biopsy can diagnose lymph node metastases in palpable nodes
  
  • Procedure is omitted for high-risk tumors to prevent delay of initiating inguinal lymph node dissection (ILND)
• A repeat biopsy or node excision may be done if FNA is negative but nodes are clinically suspicious
  •  If results are negative on excisional biopsy, offer surveillance
  •  If positive, patient should undergo ILND
•  Positive FNA findings in unilateral, mobile inguinal node indicate immediate ILND
  •  Patients should also undergo a staging ILND on the opposite side as it is common to have bilateral inguinal drainage from the primary tumor
  •  A 0-1 positive node finding without extranodal cancer extension on ILND warrants surveillance
  •  ≥2 positive nodes or presence of extranodal extension requires pelvic lymph node dissection
•  Positive FNA findings in multiple or bilateral inguinal lymph nodes (mobile or fixed) require neoadjuvant chemotherapy followed by ILND & pelvic lymph node dissection (PLND) as patient possibly has stage N2 metastatic disease & is at risk of failing treatment with surgery alone

Enlarged Pelvic Lymph Nodes

• A computed tomography (CT), computed tomography/positron emission tomography (CT/PET), or magnetic resonance imaging (MRI) may be done if with positive FNA to detect adverse nodal features, eg ≥3 positive nodes, extranodal extension or pelvic metastases
  
  • A bulky (≥4 cm nodal size) but resectable pelvic lymphadenopathy should be given neoadjuvant chemotherapy followed by consolidation surgery if disease responds or is stable; chemotherapy with radiation therapy for local control or participation in a clinical trial if disease progresses or is unresectable
  • If patient is not a candidate for surgery, radiation therapy with concurrent chemotherapy followed by surveillance can be given for enlarged pelvic lymphadenopathy