Penile cancer is a rare malignancy that primarily affects the skin or tissues of the penis. The majority of these tumors are squamous cell carcinoma, originating in the flat cells of the skin. Treatment is highly specialized, focusing on complete tumor removal while preserving the organ’s function and appearance whenever possible. The approach depends heavily on how early the cancer is detected and the extent of its spread.
Determining Treatment Through Staging
Treatment decisions are guided by the cancer’s stage, which describes how far the disease has progressed. Physicians use the TNM staging system to classify the cancer. “T” defines the size and depth of the primary tumor, “N” indicates spread to nearby lymph nodes (such as those in the groin), and “M” signifies the presence or absence of distant metastasis.
Staging involves diagnostic tests like biopsies and medical imaging and is performed before treatment selection. Determining the exact stage separates localized, superficial disease from more invasive cancer. The stage ensures the chosen therapeutic strategy is appropriately aggressive to cure the disease while minimizing side effects.
Organ-Sparing Approaches for Early Cancer
When penile cancer is diagnosed at an early stage, such as carcinoma in situ or a superficial tumor, the primary goal is to remove the cancer while preserving the maximum amount of penile tissue. Organ-sparing techniques are favored for small, low-grade lesions that have not invaded deeply. Non-surgical options include topical chemotherapy, such as the cream 5-fluorouracil (5-FU), applied directly to the skin to destroy cancerous cells.
Another minimally invasive technique is laser ablation, which uses high-energy light beams to vaporize tumor tissue. Surgeons may employ a carbon dioxide laser for very superficial lesions or an Nd:YAG laser for slightly deeper penetration. For tumors involving the foreskin, a simple circumcision may be curative by removing all cancerous tissue with the excised skin.
Surgical organ-sparing procedures are available for early invasive tumors. Wide local excision involves removing the tumor along with a small, clear margin of healthy surrounding tissue to ensure all cancer cells are gone. Mohs micrographic surgery is a precise method where thin layers of tissue are removed and examined immediately until no cancer cells are detected at the margins. For a tumor confined to the head of the penis, a glansectomy (surgical removal of the glans) is performed, often followed by reconstruction using a skin graft to maintain function and appearance.
Surgical Resection and Reconstruction
For higher-stage tumors or those that have invaded the deeper erectile bodies, more extensive surgery is required to achieve a clear margin and prevent recurrence. A partial penectomy involves removing the tip or a portion of the penile shaft. The surgeon aims to leave a stump long enough to allow for standing urination and preserve some sexual function. The extent of the resection balances oncologic safety and functional preservation.
If the tumor is located near the base or has extensively invaded the organ, a total penectomy may be required to remove all cancerous tissue. This procedure removes the entire penis, and the remaining urethra is rerouted to an opening between the scrotum and the anus, called a perineal urethrostomy. Patients are then required to sit to urinate.
Following a total penectomy, complex reconstructive surgery, known as phalloplasty, can create a new penile structure using tissue flaps. While a neo-phallus may not restore natural erectile function, it can improve body image and allow for sexual penetration with an implanted prosthesis. Reconstruction following either partial or total penectomy often utilizes skin grafts to cover the surgical defect, ensuring proper healing.
Managing Advanced and Metastatic Disease
When penile cancer has spread beyond the primary site, especially to the lymph nodes, treatment shifts to address systemic disease. The status of the lymph nodes in the groin is the most important prognostic factor. Management typically begins with a sentinel lymph node biopsy, where dye is injected near the tumor to identify the first draining lymph node.
If the sentinel node is negative, a full lymph node removal (inguinal lymphadenectomy) can often be avoided, reducing the risk of leg swelling. If the nodes are positive, a complete inguinal lymphadenectomy is performed to remove all lymph nodes in the groin area. Patients with bulky or numerous positive lymph nodes may first receive neoadjuvant chemotherapy, typically a cisplatin-based regimen, to shrink the tumors before surgery.
For widespread or unresectable disease, systemic chemotherapy is the standard treatment, designed to control symptoms and slow progression. External beam radiation therapy (EBRT) can be used as a primary alternative to surgery for some localized tumors, or it may manage localized pain and symptoms in advanced cases. Ongoing research into targeted therapies and immunotherapy offers new avenues for treatment for metastatic penile cancer.