Penile cancer is a rare malignancy, and treatment depends heavily on the disease’s stage and grade. Because of the potential impact on urinary and sexual function, the treatment strategy is highly individualized for each patient. A multidisciplinary team, including urologists, oncologists, and radiation oncologists, collaborates to determine the most effective plan. The goal is always to completely remove the cancer while maximizing the preservation of the penis’s function and appearance when possible.
Localized Treatments for Early-Stage Disease
For cancers that are small, superficial, or confined to the uppermost layer of the skin (carcinoma in situ), the primary goal is to eliminate the malignancy while preserving the organ. These organ-preserving approaches are a priority for patients with early-stage, low-grade tumors.
Topical chemotherapy, such as 5-fluorouracil (5-FU) cream, involves applying a drug directly onto the affected skin. This localized application targets only surface-level cancer cells because the drug does not penetrate deeply. Another topical agent, imiquimod, works by stimulating the body’s immune system to attack and destroy the cancer cells in the treated area.
Laser ablation uses a focused beam of light (often from a CO2 or Nd:YAG laser) to vaporize cancerous tissue. This technique is useful for small lesions on the glans or foreskin and leaves a shallow wound that heals over time. For slightly more invasive, but still localized, disease, a wide local excision removes the tumor along with a small margin of healthy tissue. Mohs micrographic surgery is a precise alternative where thin layers of tissue are removed and immediately examined microscopically until no cancer cells remain.
Definitive Surgical Approaches and Reconstruction
When cancer has invaded deeper tissues or is too extensive for localized treatments, surgical removal of part or all of the penis (penectomy) becomes necessary. The extent of the surgery is determined by the size and depth of the tumor, with the surgeon aiming to achieve a clear margin of tissue around the cancer.
Partial penectomy involves removing the end of the penis and is the preferred method when the tumor is located toward the tip, allowing the patient to retain enough of the shaft to urinate while standing. The tumor is excised with a margin that varies depending on the cancer’s grade and type. If the tumor is large, deeply penetrating, or located at the base of the organ, a total penectomy is required.
Following a total penectomy, the surgeon reroutes the urethra to an opening between the scrotum and the anus (perineal urethrostomy), which allows for seated urination. After either type of penectomy, reconstructive surgery is often performed to restore function and appearance. Techniques range from simple skin grafting to complex procedures like phalloplasty, which uses tissue flaps from other parts of the body to create a new penis.
Managing Regional Spread and Advanced Cancer
Penile cancer frequently spreads first to the inguinal lymph nodes. Managing this regional spread is a necessary step in treatment and often requires surgical removal of these nodes (lymphadenectomy). For patients without visibly enlarged lymph nodes, a sentinel lymph node biopsy may be performed to identify and test the first nodes that drain the cancer site, avoiding a full dissection if they are cancer-free.
If cancer cells are confirmed in the lymph nodes, a full inguinal lymph node dissection is performed, and sometimes a pelvic lymph node dissection is also necessary. Radiation therapy offers an alternative or supplementary approach to managing the primary tumor site and lymph node regions. Techniques include external beam radiation or brachytherapy, which involves placing radioactive sources directly into the tissue. However, radiation can lead to complications such as tissue damage and urethral issues, sometimes requiring subsequent surgery.
For cancer that has spread to distant organs (metastatic disease), systemic chemotherapy is the primary treatment. Chemotherapy drugs, often cisplatin-based combinations, are administered to kill cancer cells throughout the body. These agents can also be used before surgery (neoadjuvant therapy) to shrink a large tumor, or after surgery to eliminate any remaining cancer cells. Newer options, such as immunotherapy and targeted therapies, are being explored for advanced or recurrent disease, offering potential for durable responses in some patients.
Post-Treatment Surveillance and Adjustment
Following active treatment, a structured surveillance plan monitors for any sign of cancer recurrence. The risk of recurrence is highest within the first few years, mandating frequent check-ups. For the first two years, follow-up visits are typically scheduled every three to six months, shifting to every six to twelve months for the next three years.
These appointments usually involve a physical examination of the penis and groin area, along with imaging tests such as ultrasound, CT, or PET scans to check for spread to the lymph nodes or distant sites. Long-term care also focuses on helping patients adjust to the physical and psychological changes resulting from treatment. Patients often require support to address concerns regarding urinary function, sexual health, and body image.