Presentation and Evaluation of Patients with Advanced Penile Cancer

Patients with advanced disease present with a host of constitutional symptoms. They may be cachectic, lethargic, and anemic particularly if an ulcerating inguinal mass has been bleeding intermittently. The performance status of these patients will determine the extent to which they will tolerate a multimodality approach to the management of their disease. Another feature of advanced disease is the development of hypercalcemia in the absence of osseous metastases. This has been reported in previous studies and is thought to arise as a result of the secretion of a parathyroid hormone protein analogue resulting in a paraneoplastic hypercalcemia due to osteoclastic bone resorption.4,5 The

Department of Urology, University College London Hospital, London, UK

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

DOI 10.1007/978-1-84882-879-7_7, © Springer-Verlag London Limited 2012

development of hypercalcemia can result in patients becoming dehydrated, lethargic, confused, and very weak. Often the hypercalcemia is overlooked particularly when there is no evidence of bone metastases. The patients are then deemed to have a poor performance status making them unsuitable for any palliative surgery. Therefore monitoring the serum calcium and treating hypercalcemia with a combination of intravenous fluids and bisphosphonates may improve the patient's performance status prior to undergoing palliative chemotherapy/radiotherapy. The presence of infection and malnutrition is also associated with a leucocytosis and hypoalbuminemia.

The nature of penile cancer combined with the pattern of disease dissemination means that patients with a delayed presentation often have unsightly fungating inguinal disease together with impaired urinary and anorectal function. The majority of these patients will have some functional impairment in voiding as the primary tumor obstructs the penile urethra. These patients may present with urinary retention but commonly dribbling incontinence is the main feature. More proximal involvement of the membranous urethra and prostate will cause urinary incontinence.

Cross-sectional imaging using CT or MRI allows an accurate assessment of the extent of the disease as distant lymph node involvement or lung metastases are common. For patients with suspected recurrent lymph node involvement, a PET scan is also helpful.

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