Inguinal lymph node exam is important and more informative than imaging, although exam understages in 10% and overstages in 16%
Care delays seen in 15-50% for more than 1 year, high levels of denial regarding condition
Diagnosis
Perform biopsy to assess depth, vascular invasion, and histologic grade
Biopsy can be separate from definitive surgical treatment
Low-grade lesions make up 70-80% cases
Imaging is not currently indicated due to poor accuracy
If palpable nodal disease, obtain CT A/P to assess for poor prognostic features - central necrosis or irregular nodal border were predictive of 3+ positive LN, ENE, or positive pelvic nodes
Staging Tips
T1a vs T1b: inguinal metastasis (10-18% vs 33-50%)
T2 (78%) vs T3 (53%): disease specific survival (78% vs 53%), inguinal metastasis (33-35% vs 49-53%)
N1 vs N2: disease specific survival (90% vs 60%)
Primary Penile Cancer Treatment Options, Campbell's
Primary Penile Cancer Treatment Algorithm, Campbell's
Penile Cancer Treatments
Surgical removal
Penectomy: consider if > 4cm, grade 3-4, or T2+
Consider organ-sparing treatments if Tis, Ta, or T1 (low grade), margins < 2cm reasonable
Minimally invasive options include glans stripping and Mohs surgery, but may have no additional benefit over other options
Consider topical therapies (imiquimod, 5-FU) for Ta, TiS
Risk of local recurrence: penectomy (0-8%), organ-sparing (2-6%), laser ablation (7%), Mohs surgery (32%)
Palliative resection: may improve short-term QoL but rarely provides cure, survival 21%, 8%, 4% at 1, 2, 3yrs
Nodal Treatments
Recommended for any primary tumor besides Tis, Ta, or T1 (with low grade) - 0-16% +LN rate
25% risk LN metastases if nonpalpable LNs
Delaying ILND by > 12 weeks decreases 5yr survival 64% to 40%
Prognostic factors associated with longterm survival: ≤ 2 LNs +, unilateral disease, no ENE, and no pelvic metastases
Screening FNA: 93% sensitivity and 91% specificity if palpable adenopathy, avoids giving patients 4-6 weeks antibiotics prior to considering surgery
Perform bilateral ILND if unilateral adenopathy, due to presence of bilateral drainage - may not be indicated if delayed adenopathy after primary treatment
Consider PLND if 2+ LN in ILND or ENE
Make incision transverse to minimize risk for skin necrosis
5yr survival: 90-100% for negative ILND, 80% for 1 positive node, 50% for 2+ unilateral nodes, and 10% for bilateral positive nodes, extranodal extension, or positive pelvic nodes
Early mobilization now recommended unless flap used (bedrest 48-72hr)
Continue postoperative antibiotics x1 week or until drains removed (< 50mL/d)
Most appropriate if T1-T2, < 4cm, no/minimal extension beyond coronal sulcus
Most often used if too old/sick for surgical therapy, or locoregionally advanced disease
Option for primary tumors, may require pre-XRT circumcision, salvage surgery remains an option
Results: 5yr local control 55-70%, penile preservation 39-66%
Lower control if T3+, > 4cm, high grade tumors
Brachytherapy (high/low) are options - 5yr local control 77-88% and penile preservation 74-88%, 10yr local control 70-80% and penile preservation 67-70%
Side effects: acute desquamation, meatal stenosis (10-45%), soft-tissue ulceration (0-26%)
Consider inguinal XRT if multiple positive LN or concern for ENE, can consider for multimodal therapy
Chemotherapy
First-line for advanced or metastatic disease, TIP (paclitaxel, ifosfamide, cisplatin) is recommended regimen
Adjuvant chemotherapy decreases relapse rates (16% vs 45%), but toxicity risk is high
Adjuvant indications: 2+ positive nodes, ENE, or pelvic metastases
Can consider cisplatin NAC if LN metastasis present
Follow-Up
If Low Risk (Tis, Ta, T1a): physical exam q3m year 1-2, q4m year 3, q6m year 4, q12m year 5+
If High Risk (T1b+): physical exam q2m year 1-2, q3m year 3, q6m year 4, q12m year 5+
If penile-preserving treatment: q3m year 1-2, q6m year 3
If partial penectomy: q6m year 1-2, q12m year 3
If ILND with pN0: physical exam q4m year 1-2, q6m year 3, q12m year 4+
if ILND with pN1+: physical exam + CT + CXR q3m year 1-2, q4m year 3, q6m year 4, q12m year 5+
References
AUA Core Curriculum
Kutikov, A., P. L. Crispen, and R. G. Uzzo. "Pathophysiology, evaluation, and medical management of adrenal disorders." Campbell-Walsh Urology 12 (2020).
Pettaway, C., J. Crook, and L. Pagliaro. "Tumors of the Penis." Campbell-Walsh Urology 12 (2020).
Sotelo, R., L. Medina, and M. Machado. "Inguinal Node Dissection." Campbell-Walsh Urology 12 (2020).