Mariela R. Pow-Sang, MD, Victor Benavente, MD, Julio E. Pow-Sang, MD, Carlos Morante, MD, Luis Meza, MD, Mark Baker, MD, and Julio M. Pow-Sang, MD

Disclosures

Cancer Control. 2002;9(4) 

In This Article

Treatment of the Primary Lesion

Small tumors limited to the foreskin can be treated by circumcision with a 2-cm margin of clearance. Circumcision alone, especially with tumors in the proximal foreskin, may be associated with recurrence rates of 32%.[49] These high recurrence rates under-score the need for careful follow-up of patients treated by circumcision alone. Local recurrence, as high as 56%, most commonly occurs after organ-preserving procedures.[50,51]

Mohs micrographic surgery is used for the treatment of selected patients with small, superficial penile cancers.[52] The Mohs technique involves excision of the penile lesion and microscopic examination of the underside of each layer for systematic inspection of serial sections. Two techniques are used for the complete microscopic control of the excision of the cancer: (1) the fixed-tissue technique, in which the tissues are fixed with zinc chloride paste before the excision of the successive layer and (2) the fresh-tissue technique, in which the tissues are excised in the fresh, unfixed state and evaluated by frozen section. A study by Mohs and colleagues[52] reported on 35 patients with squamous cell carcinomas of the penis who were treated by means of micrographic surgery. Eight patients recurred, with 6 developing uncontrolled metastases and 2 with tumor extension along the urethra. The 5-year cure rate and the overall local 5-year cure rate was 74%, and 94%, respectively.

Laser ablation using a neodymium:yttrium-aluminum garnet (Nd:YAG) or carbon dioxide (CO2) laser also has been used in selected patients with small superficial or superficially invasive penile cancers.[53,54,55] Since 1982 the Nd:YAG laser has been used at the Instituto de Enfermedades Neoplasicas in Lima, Peru, as a penis-conserving approach. Horenblas et al[53] reported on 110 patients with penile cancer, using penis-conserving treatment with an Nd:YAG laser in 51 patients (46%) and some form of amputation in 59 patients (54%). Overall, 16 (15%) of the 110 patients had local recurrence. The risk of local recurrence after penis-conserving therapy was significantly related to T category, with 10% local recurrences in stage T1 tumors in contrast to 32% and 100% in stages T2 and T3 tumors, respectively. All of the recurrences in patients with stage T1 tumors were localized, and all were successfully treatment. Of 6 recurrences in the conservatively treated stage T2 disease group, 4 were strictly local. These were all moderately or well-differentiated tumors not exceeding 3.5 cm in diameter. Penile cancers that are more deeply infiltrative or poorly differentiated usually cannot be adequately controlled with laser therapy alone.[53]

Radiation therapy has yielded local control rates similar to surgical resection.[56] Radiation therapy techniques include external-beam irradiation, iridium molds or wires, and interstitial brachytherapy. Using external-beam radiation therapy, Almgard and Edsmyr[57] achieved a control rate of only 50%. For T1-T2 penile carcinoma, an overall local control rate of 74% to 86% was achieved with 192Ir interstitial implants and 80% with brachytherapy.[58]

Carcinomas of the penis involving the glans and the distal shaft are best managed by partial penectomy excising 1.5 to 2 cm of normal tissue proximal to the margin of the tumor. This should leave a 2.5- to 3-cm stump of penis to allow directable micturition in a standing posture, with some coital function as well. Recently, Agrawal et al[59] evaluated the possibility of reducing the margin of clearance at surgery for carcinoma of the penis without causing an increase in the incidence of local tumor recurrence in order to minimize the functional and cosmetic compromise associated with penectomy. Of 64 patients who underwent partial or total penectomy, 20 patients (31%) were grade I, 32 (50%) were grade II, and the remaining 12 (19%) were grade III. The maximum histological extent beyond the clinical lesion was 5 mm for grades I and II tumors and 10 mm for grade III tumors. The authors concluded that a 10-mm clearance is adequate for grade I and II lesions, and 15-mm clearance for grade III tumors, leaving a more acceptable penile stump length.

For bulky T3 or T4 proximal tumors involving the base of the penis, total penectomy with perineal urethrotomy is done. These proximal tumors are often advanced and associated with regional metastatic disease.

After 4 to 6 weeks of oral antibiotics following treatment of the primary lesion, the patient is reevaluated for the presence of palpable regional lymphadenopathy. The presence of palpable inguinal lymph nodes at the time of diagnosis may be due to inflammatory reaction or metastatic disease. Only 50% of patients presenting with palpable lymphadenopathy actually have metastatic disease, the remainder having lymph node enlargement secondary to inflammation. The development of new adenopathy during follow-up is more likely due to tumor in 70% of cases.[3]

Despite a negative physical examination, as many as 20% of patients undergoing prophylactic lymphadenectomy will have nodal metastasis.[36,60] In patients with minimal nodal metastases (ie, 1 positive node), the 5-year survival rate is 81% compared with 32% if more than 2 positive nodes are found.[60] Patients with clinically palpable lymphadenopathy and histologically proven inguinal node metastases treated by inguinal lymphadenectomy have a 5-year disease-free survival rate of 20% to 50%.[60]

The morbidity of inguinal lymphadenectomy may be considerable, with a 30% to 50% incidence of severe lymphedema and skin flap necrosis.[3,61,62]

A modification of the standard inguinal lymphadenectomy has been developed by Catalona[63] as another option for patients with clinically negative inguinal lymph nodes. The procedure differs from the standard lymphadenectomy in that the length of the skin incision is reduced, the subcutaneous tissue superficial to Scarpa's fascia is preserved, the dissection is reduced to exclude the regions lateral to the femoral artery and caudal to the fossa ovalis, the saphenous vein is preserved, and transposition of the sartorius muscles is eliminated (Fig 1). In patients with histologically negative inguinal nodes, pelvic lymphadenectomy is not performed. In patients with positive lymph nodes on frozen section, a bilateral iliac lymphadenectomy also is performed.

Figure 1.

Limits of dissection of modified inguinal lymphadenectomy (dashed line) with classical groin dissection (dotted line). Black: superficial inguinal nodes. White: deep inguinal nodes. Gray: external iliac nodes. From Catalona WJ. Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results. J Urol. 1988;140:306-310. Reprinted with permission. http://lww.com

The technique has been associated with less morbidity than the standard lymphadenectomy, and the results are encouraging. Colberg and colleagues[64] reported on 9 patients who underwent modified inguinal lymphadenectomy. Three had histologically positive lymph nodes, and none of the patients with positive or negative nodes had evidence of recurrent disease. All patients were alive with a mean follow-up of 67.5 months (range 13 to 108 months). Early postoperative complications occurred in 2 patients with skin-flap necrosis, in 1 with prolonged lymphatic drainage, and in 1 with a delayed groin lymphocele and cellulitis. In another study, Parra[65] performed a modified inguinal lymphadenectomy on 12 patients. Five patients were identified with nodal metastasis. The sites of inguinal node involvement were localized within the boundaries of the dissection in all patients. No major complications occurred, and no permanent lymphedema or flap necrosis was encountered. Follow-up of 14 to 72 months demonstrated no disease. However, the reliability of this procedure in detecting histological metastases in patients with clinically negative groin nodes has been questioned.[66]

The timing of a lymph node dissection is important, particularly for patients who present with no clinical sign of metastatic disease. Proponents of an early or immediate lymphadenectomy note that patients who do not undergo surgery but are observed often present at a stage where cure is no longer possible.[67,68,69,70] Horenblas and colleagues[61] proposed observation in patients with clinically negative nodes. Patients were followed every 2 months for 3 years, and almost all patients who developed lymph node metastases after treatment of the primary tumor were salvaged by lymph node dissection. Unreliable patients or others who cannot be followed adequately every 2 months are best served by prompt inguinal lymphadenectomy. Solsona et al[40] proposed three risk groups -- low, inter-mediate, and high -- for occult lymph node metastases in patients with penile carcinoma and clinically negative lymph nodes. Low-risk patients had stageT1/grade I tumors. None of these patients developed lymph node metastasis on follow-up. Intermediate risk group were patients with stage T1/grades II-III tumors or stages T2-3/grade I tumors. These patients had a 36.4% incidence of positive lymph nodes on follow-up. High risk group were patients with stages T2-3/grades II-III tumors with an 80% incidence of lymph node involvement on follow-up.

In patients with unilateral nodal recurrence during the follow-up, bilateral lymph node dissection should be done. In these cases, the probability of occult contralateral involvement is 60% to 79% of cases due to crossover lymphatics at the base of the penis.[71,72]

Metastasis to the pelvic nodes in the absence of inguinal node metastasis is a rare event and has not been observed in many modern series.[67,73] In the setting of negative superficial and deep inguinal lymphadenectomies and a negative pelvic computed tomography scan, pelvic lymphadenectomy is not required.

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