Penile cancer is a rare form of cancer, representing less than 1% of cancers in men in the United States. It typically originates in the skin cells of the penis, most commonly as squamous cell carcinoma. Prompt treatment is important due to the potential for spread. Treatment plans are individualized, considering each patient’s specific cancer.
Surgical Treatment Options
Surgery is the primary approach for treating penile cancer, with the specific technique depending on the cancer’s size, stage, depth, and location. The goal is to remove all cancerous tissue while preserving as much healthy penile tissue and function as possible. For small, early-stage cancers, especially those on the foreskin, a circumcision may be sufficient. If confined to this area, this procedure can often be curative.
Wide local excision is another option for small, early-stage lesions, involving removal of the tumor with a margin of healthy tissue. The margin size varies by tumor grade and type, aiming to reduce recurrence risk. Mohs micrographic surgery is a specialized technique where surgeons remove and examine thin tissue layers under a microscope until no cancer cells remain. This preserves surrounding healthy tissue and can lead to improved cosmetic and functional outcomes.
When cancer is confined to the head of the penis (glans), a glansectomy may remove part or all of the glans. Reconstruction using skin grafts may maintain function. If the tumor has grown deeper or is larger, a partial penectomy may be necessary, removing the head and a portion of the penile shaft. Surgeons aim to leave enough shaft for urination while standing and to preserve some sexual function.
For extensive or deeply grown cancer, a total penectomy might be required, removing the entire penis, including its roots. A new opening for urine drainage is then created in the perineum. Penile cancer can spread to lymph nodes, particularly those in the groin. A sentinel lymph node biopsy (SLNB) is a minimally invasive procedure that identifies the first lymph nodes where cancer cells are likely to spread. This involves injecting a tracer near the tumor to visualize and remove sentinel nodes for examination; if these nodes are clear, extensive lymph node dissection can often be avoided, reducing potential side effects.
If cancer is found in sentinel nodes or enlarged lymph nodes, an inguinal lymph node dissection (ILND) may remove groin lymph nodes. This can be a modified (less extensive) or radical dissection, depending on spread. If cancer has spread to pelvic lymph nodes, a pelvic lymph node dissection (PLND) may also be necessary. This surgery removes affected nodes in the pelvic region and can be done concurrently with or after ILND.
Radiation Therapy Approaches
Radiation therapy uses high-energy rays or particles to target and destroy cancer cells. This approach can be a primary treatment for penile cancer, especially for smaller, early-stage tumors, or used with other therapies. It may also be an option for those who prefer to avoid surgery or cannot undergo it.
External Beam Radiation Therapy (EBRT) delivers radiation from a machine outside the body, directing beams to the tumor and surrounding tissues. This treatment is typically administered daily, five days a week, over four to six weeks. EBRT can treat primary tumors, shrink lymph nodes before surgery, or reduce recurrence risk after surgery. Recent advancements include techniques using a water bath for precise dose distribution and minimal exposure to healthy tissues.
Brachytherapy, also known as internal radiation, involves placing radioactive sources directly into or very close to the tumor. This delivers a high radiation dose directly to the cancer, sparing surrounding healthy tissue. It is often considered for small, early-stage tumors (generally under 4 cm) as an organ-sparing treatment. Brachytherapy is usually administered over several days, requiring a hospital stay while radioactive sources remain in place. Both EBRT and brachytherapy aim to preserve penile morphology and function; however, potential side effects include skin irritation, urethral inflammation, and, less commonly, soft tissue necrosis or urethral narrowing.
Systemic Drug Therapies
Systemic drug therapies involve medications that travel throughout the body to target cancer cells. These treatments destroy cancer cells, slow tumor growth, shrink tumors before surgery, or eliminate remaining cancer cells after other treatments.
Topical chemotherapy, applied directly to the skin, is used for very early-stage or superficial lesions, such as carcinoma in situ. 5-fluorouracil (5-FU) is a common topical chemotherapy drug inhibiting cell growth in the skin’s top layers. This localized treatment minimizes systemic side effects, though treated skin may become red and sensitive.
Systemic chemotherapy involves intravenous administration of anticancer drugs throughout the body. This approach is typically reserved for advanced penile cancers, such as those spread to lymph nodes or distant organs. Common chemotherapy drug combinations include cisplatin with 5-fluorouracil, or regimens like paclitaxel, ifosfamide, and cisplatin (TIP). Chemotherapy cycles usually last three to four weeks, followed by a rest period.
Immunotherapy harnesses the body’s immune system to fight cancer. Immune checkpoint inhibitors (e.g., pembrolizumab, nivolumab, cemiplimab) block proteins cancer cells use to evade immune detection, allowing the immune system to attack them. Immunotherapy is primarily used for advanced or recurrent penile cancer, especially in patients with PD-L1 expression. Response rates vary, but these therapies offer a promising option, especially for those unable to tolerate conventional chemotherapy.
How Treatment Decisions Are Made
Penile cancer treatment decisions involve careful consideration of several factors to create a personalized plan. The most important factor is the cancer’s stage, describing the tumor’s size, depth of invasion, and spread to lymph nodes or distant parts of the body. Penile cancer staging often uses the TNM (Tumor, Node, Metastasis) system, with stages 0 to IV. Early-stage cancers may be treated with organ-preserving methods, while advanced stages often require more extensive interventions.
The tumor’s grade, which indicates how abnormal cancer cells look under a microscope and their growth rate, also influences treatment choices. Higher-grade tumors tend to be more aggressive and may require more intensive treatment. The patient’s overall health, age, and co-existing medical conditions are also considered, as these can affect tolerance to different therapies. For instance, a patient with significant heart conditions might not be a candidate for certain systemic chemotherapies.
Patient preferences play a significant role, especially regarding quality of life, such as organ preservation. A multidisciplinary team (urologists, radiation oncologists, medical oncologists, pathologists) collaborates to review all relevant information. This team approach ensures all aspects of the patient’s condition and treatment options are thoroughly evaluated, leading to a comprehensive and tailored strategy.
Life After Treatment and Follow-up
After completing primary treatment for penile cancer, ongoing care monitors for recurrence and manages potential long-term side effects. Regular follow-up appointments are essential, often including physical exams and imaging tests. Frequency and type of appointments depend on the initial cancer stage and treatments received.
Managing long-term side effects is an important aspect of post-treatment care. Depending on the treatment, individuals may experience changes in urinary or sexual function, lymphedema (swelling from lymph fluid buildup), or skin changes. Healthcare providers offer strategies and interventions to alleviate these issues and improve comfort.
Rehabilitation and supportive care services help individuals adjust to life after cancer treatment. This includes psychological support for emotional challenges and sexual health counseling to navigate changes in intimacy and sexual function. Open communication with the healthcare team addresses concerns and ensures comprehensive care throughout recovery.