Penile cancer treatment may also affect sexual health and fertility. Discussion among patient and doctor about these topics is mandatory before treatment begin. Decision making should always come from a shared discussion among patient and doctor, who should work together to choose treatments that fit the goals of patient care.

Only tertiary care centers offer multidisciplinary and cancer care teams who can offer the standard of care and the best medical and psychological support to patients and their families.

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Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue, called margins, during an operation. It is the most common treatment for all stages of penile cancer. There are many different surgical techniques to remove the cancer which include:

 

Circumcision: Surgery to remove part or all of the foreskin of the penis. It is generally used if the cancer is only on the prepuce.

 

Excision: It is a surgery that removes only the cancer and some normal tissue around it. Sometimes the surgeon may remove a larger area of healthy tissue around the tumor to make sure that no other cancer cells are left behind. Sometimes, a skin graft or flap is needed to cover the area where the tissue was removed.

 

Partial or total penectomy: When the tumor growth inside the penis reaching structures as corpus spongiosum, the urethra or corpora cavernosa, the penis should be partially or completely amputated. Partial penectomy is a better option if the cancerous tissue and a good margin of healthy tissue can be removed while leaving enough length of the penis for the patient to urinate naturally. When partial penectomy is not feasible, radical amputation remains the only alternative. The penis is completely removed with or without the testicles (depending upon the extension of the disease). Urine orifice is usually moved down in the perineum, meaning the patient will urinate in a sitting position.

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Dynamic Sentinel Lymph Node Biopsy: The dynamic sentinel lymph node biopsy is an important procedure in the treatment of penile cancer, but it requires an advanced and specialized hospital center. This procedure involves not only the urologist but also the nuclear medicine physician and the pathologist. It is used when there is suspicion that the cancer has spread to the inguinal lymph nodes, which are the primary sites of penile cancer metastasis, but they are not palpable or visible with other imaging techniques. Before the biopsy, the patient undergoes a nuclear lymphoscintigraphy exam a few hours prior to the procedure. During this phase, the nuclear medicine physician injects a radioactive tracer (usually Technetium-99-labeled albumin nanocolloid, which emits gamma radiation) at the site of the tumor. Subsequently, images are taken to locate the sentinel lymph node in the inguinal area (in both groins), which is then marked with an indelible pen. In the operating room, the urologist uses a probe that detects the gamma radiation from the radioactive tracer (Technetium-99) to accurately identify the sentinel lymph node, which is the first lymph node to receive drainage from the tumor area. This lymph node is then removed for an immediate histological examination by the pathologist. The pathologist will provide the urologist with information on whether the lymph node is involved with penile cancer metastasis. If the sentinel lymph node is negative, the procedure ends. Otherwise, a more extensive lymph node dissection on the same side of the sentinel lymph node may be necessary. The sentinel lymph node biopsy is an important step in determining the stage of the disease and helps in planning the appropriate treatment.

 

Inguinal lymph node dissection: The groin nodes are the first site of metastasis. Inspection is mandatory before surgical treatment. Depending upon the stage and the characteristics of the cancer, biopsy of these lymph nodes may be taken even when there are no signs that the cancer has spread to the lymph nodes. To explore the involvement of inguinal lymph nodes, many techniques can be adopted including random superficial lymph node asportation, or guided lymph node excision, which rely on different techniques that highlights the lymph nodes that firstly received cancer spread from the primary site. When the lymph node involvement is clinically or histologically proven, extended inguinal lymph node dissection is recommended. While removing groin lymph nodes on both sides is common, removing deeper lymph nodes in the pelvis is generally only done if cancer is found in the groin lymph nodes. When inguinal and/or pelvic lymph nodes are removed, there is often severe swelling called lymphedema in the leg on that side of the body. This can cause significant discomfort and infections that often come back.

 

Topical chemotherapy

For small and non-invasive cancers, or “carcinoma in situ,” low doses of chemotherapy can be used on the surface of the skin. Such drugs include fluorouracil or imiquimod. These drugs may cause side effects such as skin irritation and burning sensation. Doses and treatment schedule should be discussed with surgeon or medical oncologist.

 

Systemic chemotherapy

Chemotherapy is usually advocated when the disease is not confined to the penis, but involves the lymph nodes or distant organs. Chemotherapy can be delivered before or after surgery according to different protocols and tumor characteristics. Accordingly, chemotherapy is advised before surgery when the tumor in the penis may be too large to be completely removed or that the cancer has spread to the regional lymph nodes and that removing the lymph nodes by surgery may be difficult. Similarly, if chemotherapy is not advised before surgery, it can be delivered after, when surgical removal of inguinal lymph nodes revealed cancer in multiple nodes. Many chemotherapy regimens have been tested in penile cancer. Most of them carry non-negligible side effects. Thus, the choice of the treatment plan should be taken by an experienced medical oncologist upon patient discussion. Systemic chemotherapy is given directly into the bloodstream to reach cancer cells throughout the body. Chemotherapy for penile cancer is generally given through an intravenous tube placed into a vein using a needle or in a pill/capsule that is swallowed. Systemic drugs commonly adopted for penile cancer treatment include: cisplatin, methotrexate, bleomycin, paclitaxel, docetaxel, gemcitabine, and ifosfamide. The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, mouth sores, hair loss, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished. In addition, chemotherapy can increase the risk of developing other cancers in the future.

 

Radiotherapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. It can be delivered from a machine outside the body (external-beam radiation therapy) or using implants that deliver the radiation inside the tumor (brachytherapy).

The radiation therapy regimen is planned by a radiation oncologist and it usually consists of a specific number of treatments given over a set period of time. The radiotherapy can focus on the primary lesion when surgery is not recommended or to ensure clean margins after resection. Alternatively, the radiation can be directed to the groins or the pelvis to consolidate the effect of surgery and chemotherapy or to reduce the volume of lymph node metastases allowing their excision. Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, bladder and bowel irritation leading in some patients, after many years from treatment, to the onset of several conditions such as hemorrhagic cystitis or proctitis. In addition, radiation therapy can increase the risk of developing other cancers in the future.

 

Chance of recurrence

If the cancer returns after the initial treatment, it is called recurrent cancer. It may come back in the same place (local recurrence), nearby (regional recurrence), or in another place (distant recurrence). The risk of recurrence depends on several factors, including the type of penile cancer and the treatments used on first place. Risk of recurrence can be assessed after initial treatment according to cancer prognostic factors. A validated risk-based score predicting the probability of recurrence at 24 months after treatment in patients with inguinal lymph node metastases is available online here. When recurrence occurs, the multidisciplinary team may discuss about treatment options. These include surgery, radiotherapy or systemic chemotherapy alone or in combinations.