Medical expert of the article
New publications
Penile cancer: treatment
Last reviewed: 23.04.2024
All iLive content is medically reviewed or fact checked to ensure as much factual accuracy as possible.
We have strict sourcing guidelines and only link to reputable media sites, academic research institutions and, whenever possible, medically peer reviewed studies. Note that the numbers in parentheses ([1], [2], etc.) are clickable links to these studies.
If you feel that any of our content is inaccurate, out-of-date, or otherwise questionable, please select it and press Ctrl + Enter.
[Operative treatment of penile cancer
Resection of the penis or total penectomy serve as the "gold standard" of the operative treatment of penile cancer. With an increase in lymph nodes, determined by the primary treatment of the patient, it is necessary to remove not only the primary tumor, but also the lymph nodes of the zone of regional metastasis. Lymphadenectomy (Duquin's operation) can be performed simultaneously with surgery for the primary tumor, and after the disappearance of inflammatory changes, and after ineffective chemotherapy or radiation therapy, the indications to which are established based on the stage of the disease. Unfortunately, at present there are no precise recommendations defining the indications for lymphadenectomy, as well as the amount and time of the operative intervention.
Indications for lymphadenectomy in patients with non-palpable lymph nodes are justified by the degree of risk of regional metastasis.
- Low risk in patients at stages Tis.a G1-2 or T1G1 - observation is possible.
- Intermediate risk in patients in the T1G2 stage should take into account the presence of vascular or lymphatic invasion, the nature of tumor growth.
- A high degree of risk in patients in stages T2-4 or T1GZ - lymphadenectomy is mandatory.
Considering that 60% of patients, despite palpable regional lymph node enlargement only on one side, find their bilateral metastatic lesion, inguinal lymphadenectomy is always performed on both sides. If there are no lesions of the inguinal nodes, the iliac lymph nodes are not preventively removed. To minimize possible complications of Duquesne's operation, a number of authors recommend a "modified" lymphadenectomy with patients with non-palpable regional lymph nodes preserving the subcutaneous vein of the thigh. At the same time during the operation, an urgent histological examination is carried out and in the case of detection of metastases, surgical intervention is expanded to a standard volume.
There are recommendations for the T1G3 stage to remove only the sentinel lymph node for biopsy. If there are no metastases in it, inguinal lymphadenectomy is not performed, but follow-up care is continued. However, there are reports that in some patients, after removal of unchanged lymph nodes, inguinal metastases subsequently appeared, and therefore BP. Matveev et al. Believe that in all cases with inguinal lymphadenectomy it is necessary to perform Duke's operation.
The amputation of the penis is indicated for tumors of the head and distal part of the body, when it is possible to retreat from the edge of the tumor for at least 2 cm to form a stump allowing the patient to urinate while standing. If the stump is impossible to create, perform the extirpation of the penis with the formation of the perineal urethrostomy. Disease-free 5-year survival after amputation is 70-80%.
Organosokraneuschee treatment of penile cancer
Modern possibilities of oncology allow conducting a conservative (organ-preserving) treatment of penile cancer, which is indicated by the initial stage of the disease (Ta, Tis-1G1-2). In this case, in the case of a tumor that does not go beyond the preputial sac, circumcision is performed. With small tumors of the glans penis, it is possible to use conventional electroresection, cryodestruction or laser therapy. In addition, there are organ-preserving surgeries that make it possible to achieve full local effect in 100% of cases, but without additional treatment of penile cancer, local recurrence occurs in 32-50% of cases. With a combination of surgical treatment with radiation and chemotherapy, it is possible to achieve higher rates of disease-free survival.
It is possible to use radiotherapy or chemotherapy as an independent organ-preserving treatment for penile cancer, but studies that reliably confirm the effectiveness of such treatment, due to the rarity of the disease, are not enough. Before beginning radiation therapy, all patients need to perform circumcision to prevent complications associated with the possible occurrence of ring-shaped fibrosis, edema and infection. They also apply remote and interstitial (brachytherapy) radiation therapy. Local tumor recurrence after radiotherapy occurs in 8-61% of patients. Preservation of the penis after various types of radiation therapy is possible in 69-71% of cases.
Cancer of the penis is sensitive enough to chemotherapy There are some reports on the effective use of fluorouracil in precancerous lesions of the penis. The use of cisplatin, bleomycin, and methotrexate medications makes it possible to obtain an effect in 15-23, 45-50 and 61% of cases, respectively. More often used schemes of polychemotherapy: cisplatin + bleomycin + methotrexate; fluorouracil + cisplatin; cisplatin + bleomycin + vinblastine. The effect is observed in 85% of patients with local recurrence in 15-17% of cases.
Treatment of penile cancer can be quite effective in the combination of chemo- and radiotherapy. In this case, complete regression of the tumor occurs in the vast majority of cases (up to 75-100%). However, according to the Russian Cancer Research Center, in 53.2% of patients, on average, after 25.8 months after the end of treatment, the progression of the disease resumes. In this case, local recurrence, regional lymph node involvement and a combination of both relapses occur in 85.4.12,2 and 2.4% of cases, respectively. As a result, after an organ-preserving treatment, the amputation of the penis should be performed in the Ta stage in 20.7% of cases, at the stage of T1 - in 47.2%.
According to a number of researchers, the use of organ-preserving treatment methods does not reduce specific and disease-free survival, i.e. In patients with penile cancer in the Tis-1G1-2 stage, treatment of penile cancer should be started with an attempt to preserve the organ. Organ-preserving treatment for invasive cancer of the penis (T2 and more) is not indicated because of the high frequency of local recurrence.
Currently, the use of radiotherapy for zones of regional metastasis is discussed with a preventive purpose. Radiation therapy is easier to tolerate than open surgical intervention, but after it metastases in the lymph nodes appear in 25% of cases, as well as in patients who were under observation and who did not receive preventive treatment, which indicates the ineffectiveness of preventive radiation. The effectiveness of radiation therapy of lymph nodes of metastatic zones is lower in comparison with their operational removal. Thus, 5-year survival after radiation therapy and lymphadenectomy was 32% and 45%, respectively. However, in the presence of metastatic lesions of lymph nodes, radiotherapy in adjuvant mode after surgery increases the 5-year survival rate to 69%.
Chemotherapy for invasive cancer of the penis does not have independent significance. It is used in combined treatment with radiation therapy. The bowl is used chemotherapy in the neoadjuvant regimen before surgical treatment with fixed inguinal lymph nodes and metastases in the pelvic lymph nodes in order to increase the tumor's resectability. It is also possible to use chemotherapy to reduce the volume of amputation and when it is possible to perform an organ-preserving treatment. With the appearance of distant metastases, the only method of treatment remains palliative polychemotherapy.
Dispensary follow-up after treatment of penile cancer
The European Association of Urologists recommends the following frequency of dispensary examinations:
- in the first 2 years - every 2-3 months:
- during the 3rd year - every 4-6 months;
- in subsequent years - every 6-12 months.
Long-term results and forecast
The long-term results depend on the depth of the tumor invasion, the presence of metastatic lesions of the lymph nodes, the appearance of distant metastases - i.e. From the stage of the oncological process. Thus, the tumor-specific survival rate at T1 is about 94%, at T2 - 59%, at T3 - 54%. At N0, the survival rate is 93%, with N1 - 57%, with N2 - 50%, with N3 - 17%. As can be seen from the data presented, the most unfavorable prognostic sign of penile cancer is the presence of regional metastases. Therefore, to achieve good results, the main efforts should be aimed at early detection and treatment of penile cancer.