Introduction

Penile cancer is a rare disease, in the UK it accounts for <1% of all male malignancies. The incidence of penile cancer in England and Wales is 1.2-1.5 per 100,000 per year.1 This figure is very similar to other Western European and North American countries. However, in parts of Africa, Asia, and South America penile cancer has been reported to account for up to 20% of all male malignancies.2 The presentation of penile SCC can manifest as several different subtypes with varying growth patterns. The penile lesion can be nodular, ulcerative, an erythematous area, or it may present with phimosis which obscures the tumor. Invasive disease is generally straightforward to diagnose, unlike premalignant penile lesions which can be difficult to differentiate from benign genital dermatoses. Previous penile radiotherapy may also make the diagnosis less clear. More importantly, carcinoma in situ (CIS) may coexist with invasive disease and therefore histological diagnosis is mandatory in order to determine the grade and pathological characteristics. The TNM staging system for penile cancer has recently been revised and the grading is by Broder's system, dividing tumors into well, moderate, and poorly differentiated lesions.3

Many guidelines relating to the management of this disease, although controversial are based on small, single institute series which are often retrospective. Consequently, the National Institute for Clinical Excellence (NICE) recommends that patients with penile cancer in the UK should be managed in supraregional centers which treat at least 25 new cases per annum, or cover a population of at least four million.4 The development of such centers has allowed for the implementation of new surgical techniques together with research resources which continues to further our understanding of this uncommon but potentially fatal disease.

Department of Urology, Churchill Hospital, Oxford , Oxfordshire , UK

A. Muneer et al. (eds.), Textbook of Penile Cancer,

DOI 10.1007/978-1-84882-879-7_6, © Springer-Verlag London Limited 2012

Table 6.1 Local recurrences after radical surgery

Author(s)

Operation

Patients no

Local recurrence no (%)

Salvage surgery procedures (no)

Mean follow-up

(months)

Rempelakos et al.6

Partial penectomy

227

0

>120

Total penectomy

75

0

Leijte et al.7

Partial penectomy

214

15(5.1)

6.6

Total penectomy

71

0

Ornellas et al.8

Partial penectomy

522

25 (4)

21 (TP)

11

Total penectomy

98

0

4 (PP)

TP total penectomy, PP partial penectomy

TP total penectomy, PP partial penectomy

Traditionally, radical surgery or radiotherapy have been the mainstay of treatment for penile cancer. Radical surgery undoubtedly provides excellent loco-regional control. It is, however, associated with urinary and sexual dysfunction as well as significant psychological morbidity.5 Radical radiotherapy preserves the penis, but often leaves the patient with a disfigured and dysfunctional organ. In addition, recurrence rates following radiotherapy of up to 40% have been reported, and recurrent disease can be difficult to both clinically detect and subsequently manage.

Penile-preserving techniques have been developed with the aim of providing both oncological control with minimal anatomical and functional disruption. Early diagnosis and accurate staging is essential when such techniques are utilized. In the UK, where only 15-20% of tumors invade the corpus cavernosum at presentation, the vast majority will be able to benefit from penile-preserving therapies. This probably holds true for other Western countries, although in less developed countries patients often present late with advanced disease and therefore penile-preserving techniques are unsuitable. In this chapter we discuss the penile-preserving therapeutic options available for the management of patients with penile cancer based on the grade, stage, and location of the primary lesion.

The management of stage T4, high-grade stage T3, or advanced stage T2 disease using radical surgery is not in question (Table 6.1). However, the requirement for such surgery in less advanced, lower grade disease has been challenged. Several authors have published data disputing the need for continuing to use the conventional 2 cm resection margin. Agrawal and colleagues examined 64 partial and total penectomy specimens, looking for disease extension into healthy tissue. They found that of 52 grade 1 and grade 2 tumors, only seven had positive margins 5 mm from the visible tumor; 25% of grade 3 tumors had microscopic extension up to 10 mm.9 In a further study, Hoffman and coworkers looked at surgical specimens from 14 patients with penile SCC undergoing conventional surgery. At 33 months of follow-up none of these patients had developed local recurrence, including seven patients with resection margins of <10 mm.10 In a larger series, Minhas and colleagues reviewed the resection margins in patients undergoing penile-preserving surgery and reported the local recurrence rates. In this study, 48% had a surgical clearance of <10 mm, while 90% had clearance of <20 mm. Local recurrence rates were

Fig. 6.1 T staging of penile tumors

reported in only 4%, with a mean follow-up time of 26 months. Furthermore, long-term survival does not appear to be compromised by local recurrence, as most cases are still surgically salvageable.11

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