Conservative surgical treatment of primary tumor
Conservative treatment is strongly recommended, but not at the cost of impairing the prognosis.
- When differentiated/undifferentiated PeIN on the inner fold of the prepuce and the epithelial cells of the glans are healthy, a radical circumcision is recommended.
- When differentiated/undifferentiated PeIN on the glans without evidence of change on the prepuce, a local resection on the glans may be performed, and epithelia on the inner fold of the prepuce can be used for coverage, or epithelia may be transplanted from the mouth/skin.
- This method may also be applied if it is a superficially invading tumor. (Ta and T1/ grade 1 and 2).
- If grade 3, surgical resection may be acceptable treatment for primary tumors T ≤ 1, but only on small tumors in fit patients.
Collaboration with the pathologist is essential for conservative treatment because the surgical margins all around the specimen must be definitely free of cancer.
If there are multiple of the above conditions, YAG laser therapy is an alternative. The downfall is that this causes high morbidity for many weeks (months) after treatment and also uncertainty, since there is no assessment by a pathologist of margins of the specimen (14). If the lesion is premalignant, photodynamic therapy is also an alternative.
Radical surgical treatment of primary tumor
- If the primary tumor invades the corpora spongiosa and/or cavernosa regardless of grade < T3, a partial or total penis amputation must be performed according to the extent of the tumor. There is no consistent consensus on the width of the margins required for the level of amputation. A 2 cm distance (palpable) from the tumor to the level of amputation has been recommended. If grade 1 and grade 2 tumors, 0.5 to 1.0 cm is sufficient.
Recurrence after conservative treatment of the primary tumor
- If there is local recurrence after conservative treatment of the primary tumor, conservative treatment may still be considered, at any rate after primary surgery and YAG laser therapy.
- Regular follow-up is critical after conservative primary surgery for early diagnosis of recurrence.
Spreading of penile cancer occurs primarily lymphatically. There are very good treatment options available intended to cure the disease, even in cases where there are positive inguinal nodes. Spreading to inguinal nodes can be predicted statistically based on the grade and T stage of the primary tumor. This is also used in evaluation of indication of diagnostic procedures in the groin.
If inguinal nodes are palpable, ultrasound-guided biopsy is performed.
Dynamic sentinel node biopsy (DSNB) is performed if nodes are not visible with UL but grade 2-3, T>1. This procedure should be done bilaterally. If positive nodes are found during the procedure, a radical lymphadenectomy is performed in a separate session. DSNB has been shown to be valuable for other cancer types (for example, breast cancer) and the method has been improving for penile cancer for years.
A radical lymphadenectomy is a procedure with significant morbidity and should only be carried out on patients with positive nodes either subsequent to FNAC or DSNB.
Pelvic node surgery can be performed with laprascopic technique and should be done if there is suspicion of metastases on CT or PET scan.