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Penile Cancer - Treatment
Last reviewed: 04.07.2025
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[ Surgical treatment of penile cancer
Penile resection or total penectomy is the "gold standard" of surgical treatment for penile cancer. If the lymph nodes are enlarged, as determined during the patient's initial visit, it is necessary to remove not only the primary tumor, but also the lymph nodes in the area of regional metastasis. Lymph node dissection (Duquesne operation) can be performed simultaneously with surgery for the primary tumor, or after the disappearance of inflammatory changes, or after ineffective chemotherapy or radiation therapy, the indications for which are determined based on the stage of the disease. Unfortunately, there are currently no precise recommendations defining the indications for lymph node dissection, as well as the scope and timing of the surgical intervention.
Indications for lymphadenectomy in patients with non-palpable lymph nodes are based on 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 at stage T1G2 requires consideration of the presence of vascular or lymphatic invasion and the nature of tumor growth.
- High risk in patients at stages T2-4 or T1G3 - lymphadenectomy is mandatory.
Considering that in 60% of patients, despite palpable enlargement of regional lymph nodes on only one side, their bilateral metastatic lesion is detected, inguinal lymphadenectomy is always performed on both sides. If there is no lesion of the inguinal nodes, the iliac lymph nodes are not removed prophylactically. To minimize possible complications of the Duquesne operation, a number of authors recommend "modified" lymphadenectomy with preservation of the saphenous vein of the thigh in patients with non-palpable regional lymph nodes. In this case, an urgent histological examination is performed during the operation and, if metastases are detected, the surgical intervention is expanded to a standard volume.
There are recommendations for stage T1G3 to remove only the sentinel lymph node for biopsy. If there are no metastases in it, inguinal lymph node dissection is not performed, and dispensary observation is continued. However, there is information that in some patients, after removal of unchanged lymph nodes, inguinal metastases subsequently appeared, therefore B.P. Matveyev et al. believe that in all cases of inguinal lymphadenectomy, it is necessary to perform the Duquesne operation.
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 at least 2 cm to form a stump that allows the patient to urinate standing up. If it is impossible to create a stump, extirpation of the penis with the formation of a perineal urethrostomy is performed. The relapse-free 5-year survival rate after amputation is 70-80%.
Organ-preserving treatment of penile cancer
Modern oncology capabilities allow for conservative (organ-preserving) treatment of penile cancer, the indication for which is the initial stage of the disease (Ta, Tis-1G1-2). In this case, in the case of a tumor that does not extend beyond the preputial sac, circumcision is performed. In the case of small tumors of the glans penis, conventional electroresection, cryodestruction or laser therapy can be used. In addition, there are organ-preserving surgeries that allow achieving a complete local effect in 100% of cases, but without additional treatment for penile cancer, local recurrence occurs in 32-50% of cases. When combining surgical treatment with radiation and chemotherapy, it is possible to achieve higher rates of relapse-free survival.
It is possible to use radiation or chemotherapy as an independent organ-preserving treatment method for penile cancer, but there are not enough studies reliably confirming the effectiveness of such treatment due to the rarity of the disease. Before starting radiation therapy, all patients must undergo circumcision to prevent complications associated with the possible occurrence of annular fibrosis, edema and infection. Remote and interstitial (brachytherapy) radiation therapy are also used. Local tumor relapses after radiation therapy occur in 8-61% of patients. Preservation of the penis after various types of radiation therapy is possible in 69-71% of cases.
Penile cancer is quite sensitive to chemotherapy. There are isolated reports of the effective use of fluorouracil in precancerous lesions of the penis. The use of cisplatin, bleomycin, and methotrexate allows for an effect in 15-23, 45-50, and 61% of cases, respectively. The most commonly used polychemotherapy regimens are: cisplatin + bleomycin + methotrexate; fluorouracil + cisplatin; cisplatin + bleomycin + vinblastine. In this case, 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 combination with chemotherapy and radiation therapy. 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, 25.8 months after the end of treatment, disease progression resumes. In this case, local recurrence, damage to regional lymph nodes and a combination of both types of relapses occur in 85.4, 12.2 and 2.4% of cases, respectively. As a result, after organ-preserving treatment, amputation of the penis has to be performed at stage Ta in 20.7% of cases, at stage T1 - in 47.2%.
According to a number of researchers, the use of organ-preserving treatment methods does not reduce specific and relapse-free survival, i.e. in patients with penile cancer at stage Tis-1G1-2, it is advisable to begin treatment of penile cancer with an attempt to preserve the organ. Organ-preserving treatment for invasive penile cancer (T2 and higher) is not indicated due to the high frequency of local recurrence.
Currently, the use of radiation therapy of regional metastasis zones for prophylactic purposes is being discussed. Radiation therapy is better tolerated than open surgery, but after it, metastases in the lymph nodes appear in 25% of cases, as in patients who were under observation and did not receive prophylactic treatment, which indicates the ineffectiveness of prophylactic irradiation. The effectiveness of radiation therapy of the lymph nodes of metastasis zones is lower compared to their surgical removal. Thus, 5-year survival after radiation therapy and lymph node dissection was 32 and 45%, respectively. However, in the presence of metastatic lesions of the lymph nodes, adjuvant radiation therapy after surgery increases 5-year survival to 69%.
Chemotherapy for invasive penile cancer has no independent value. It is used in combination therapy with radiation therapy. Chemotherapy is often used in neoadjuvant mode before surgery for immobile inguinal lymph nodes and metastases to the pelvic lymph nodes in order to increase tumor resectability. Chemotherapy can also be used to reduce the volume of amputation and, if possible, to perform organ-preserving treatment. When distant metastases appear, palliative polychemotherapy remains the only treatment method.
Follow-up care after treatment for penile cancer
The European Association of Urology recommends the following frequency of routine 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.
Remote results and prognosis
Remote results depend on the depth of tumor invasion, the presence of metastatic lesions of the lymph nodes, the occurrence of distant metastases - i.e. on 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%, at N1 - 57%, at N2 - 50%, at N3 - 17%. As can be seen from the data provided, 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.