Treatment/Prognosis

Question 1

How are noninvasive penile cancers treated?

Answer 1

CIS of the penis can be treated with topical 5-FU or imiquimod with good LC and excellent cosmetic outcome. Other methods that are acceptable include laser therapy, circumcision and WLE, complete glansectomy, or Mohs Sg. The most common Tx are topic therapy and organ-sparing excision.

Question 2

What are the Tx options for T1, grade 1–2 Dz?

Answer 2

Limited excision with penile preservation is preferred if feasible. Options include WLE, glansectomy in select cases, Mohs in select cases, laser therapy, or radiotherapy with interstititial brachytherapy (preferred) or EBRT. Circumcision should always precede RT to minimize complications. Higher rates of LF after brachy for lesions >4 cm are reported. (de Crevoisier, IJROBP 2009)

Question 3

What are the Tx options for T1 (high grade) or ≥T2 Dz?

Answer 3

Partial or total penectomy is generally employed. For tumors encompassing <1/2 of the glans, then WLE or glansectomy can be considered. T1 + grade 3 or T2 tumors <4 cm with negative nodes can be treated with brachy, EBRT alone, or EBRT + chemo. Consider prophylactic inguinal nodal RT if using EBRT (NCCN 2018). 10-yr CSS after brachy in T1–2 and select T3 was 84%. (Crook, World J Urol 2009)

Question 4

How are large (>4 cm) or locally advanced primary tumors managed?

Answer 4

For tumors >4 cm or surgically unresectable nodal Dz, circumcision f/b EBRT + chemo is often preferred. Total penectomy or neoadj chemo f/b resection is another option. (Dickstein, BJU Int 2016)

Question 5

What length of corpus cavernosum is required in order for 50% of men to be able to have sexual intercourse?

Answer 5

∼45% of men are able to have adequate sexual intercourse with about 4–6 cm of corpus cavernosum.

Question 6

What residual penile length is required for men to be able to urinate in the standing position?

Answer 6

∼2.5–3 cm of residual penile length is required for men to be able to urinate in the standing position.

Question 7

What is the most important prognostic factor for OS in penile cancer?

Answer 7

Presence and extent of inguinal node mets.

Question 8

What 3 factors are most predictive for inguinal nodal Dz?

Answer 8

Primary tumor stage, tumor grade, and presence of LVI.

Question 9

How should the inguinal nodes be staged in pts WITHOUT palpable adenopathy?

Answer 9

Risk stratified approach based on the primary tumor, tumor grade, and presence of LVI:

Low risk (Tis, Ta, and T1a): Imaging of the pelvis not needed to stage the nodes in these pts.
Intermediate/high risk (T1b, ≥T2): Perform CT abd/pelvis or MRI and chest imaging → dynamic sentinel node biopsy (preferred) or superficial or modified inguinal node dissection. (NCCN 2018)

Question 10

How should suspicious inguinal LNs be evaluated?

Answer 10

Perform FNA. If FNA is positive, perform inguinal dissection. If FNA is negative and pt has low-risk Dz, excisional Bx can be performed. If FNA is negative but pt has higher-risk Dz, can perform a superficial or modified inguinal LND.

Question 11

When should bilat inguinal LND be performed?

Answer 11

Bilat LND is considered the standard-of-care for high-risk cN0 penile tumors or palpable ipsi nodes.

Question 12

What is the management for a single pathologically involved inguinal node?

Answer 12

These pts require a complete inguinal LND.

Question 13

What is the management for ECE or ≥2 pathologically involved inguinal nodes?

Answer 13

Pts with ECE or ≥2 nodes should undergo a complete inguinal and pelvic LND. (Lont, J Urol 2007)

Question 14

How should a large (>4 cm) ipsi, mobile inguinal node be managed?

Answer 14

If confirmed on FNA or excisional Bx, neoadj chemo should be considered prior to inguinal LND.

Question 15

How should unilat fixed inguinal nodes or bilat inguinal nodes be managed?

Answer 15

If confirmed, pts should rcv neoadj chemo f/b inguinal and pelvic LND. Postop RT or chemoRT can be considered. (NCCN 2018)

Question 16

How should positive pelvic LNs be managed?

Answer 16

Nonsurgical candidates should rcv chemoRT. Resectable pts should rcv neoadj chemo f/b bilat inguinal and pelvic LND. Postop RT or chemoRT should be considered but there is limited evidence. (NCCN 2018)

Question 17

How are pts with penile cancers simulated for EBRT?

Answer 17

Simulation for EBRT for penile cancer Tx: supine position and frog-legged, Foley catheter, and penis surrounded with bolus material. If treating pelvic and inguinal nodes, the penis is secured cranially into the pelvic field.

Question 18

In megavoltage EBRT for penile cancer, should bolus be used?

Answer 18

Yes. Bolus should be used in megavoltage EBRT for penile cancer for dose buildup at the surface (usually a wax or plastic cast with the penis suspended above the abdomen or secured against the abdomen if also treating nodes).

Question 19

In EBRT for penile cancer, what is the CTV and what dose is typically prescribed?

Answer 19

In EBRT for penile cancer, the CTV can be the entire penile length depending on size and extent of the primary, and typically goes to 45–50.4 Gy with standard fractionation, with a 10–20 Gy boost to the tumor + 2-cm margin. Inguinal and pelvic nodal volumes (if included) are treated to 45 Gy. Boost gross nodes to 60–70 Gy. Consider prophylactic EBRT to the inguinal nodes in pts who cannot get Sg or decline Sg.

Question 20

What lesions are amenable to brachytherapy?

Answer 20

Penile cancer lesions that can be treated with brachytherapy are typically <4 cm in diameter and have <1 cm of corpora invasion (T1–T2).

Question 21

What data support the use of concurrent CRT in treating penile cancer?

Answer 21

There is no prospective data directly supporting the use of concurrent CRT in treating penile cancer, but extrapolation from cervical cancer and anal cancer data have led to the increasing use of concurrent cisplatin-based CRT.

Question 22

What are the common chemo agents given for penile cancer, for either localized or metastatic Dz?

Answer 22

Cisplatin-based chemo is the standard for penile cancer pts. If given neoadjuvantly, TIP (paclitaxel, ifosfamide, and cisplatin) is a reasonable 1st-line regimen. With RT, cisplatin, 5-FU, or mitomycin-C can be used. For metastatic Dz, TIP or 5-FU/cisplatin are reasonable regimens. Although metastatic penile cancer is chemosensitive, responses are usually brief and incomplete.

Question 23

What are the expected LC rates for pts managed with EBRT or brachytherapy for penile cancers?

Answer 23

LC estimates vary widely, likely depending on pt selection. In a well-selected pt with T1–T3 penile cancer treated with EBRT or brachytherapy, LC (i.e., penile preservation rate) is 80%–90% (5–10 yrs f/u). (Crook JM et al., IJROBP 2005)

Question 24

How does Sg compare to RT as the initial modality in the management of penile cancers?

Answer 24

Retrospective comparisons b/t Sg and RT suggest that Sg is associated with sup initial LC as a primary modality, though these studies suffer from significant selection bias. Overall LC does not appear to differ when allowing for surgical salvage. The benefit of RT is penile preservation. Long-term OS appears similar b/t the 2 modalities.

Question 25

What is the 5-yr cancer-specific survival for penile cancer pts with N0 or N+ Dz?

Answer 25

pN0: 85%–100%

pN1: 79%–85%

pN2: 17%–60%

pN3: 0%–17% (Ficarra, Urology 2010)

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