Cancer of the Penis
Summary of Key Points
1. A 64-year-old man has a 2-cm indurated lesion on his penile shaft skin that is suspicious for cancer. Physical exam demonstrates that this lesion is fixed to the underlying corpora cavernosum. After frozen section confirms malignancy, the least invasive technique to be applied should be
2. A 27-year-old circumcised, sexually active man presents with multiple small lesions on his penile shaft. They are erythematous, papular, and scaly. He denies pruritus. He denies history of sexually transmitted disease. Biopsy is performed and the pathologist’s diagnosis is carcinoma in situ. What is the next best step?
3. A 56-year-old man undergoes partial penectomy for high-grade T2 squamous cell carcinoma of the penis. He has undergone a 6-week course of antibiotics and his groin is negative on exam for lymphadenopathy. Dynamic sentinel lymph node biopsy is not available. The next step at this point is:
1. Answer: E. Physical exam is very accurate in staging penile tumors. Fixation to underlying corpora is therefore clinically diagnostic for T2 disease. Unless the tumor is very distal on the glans, the best approach is penile amputation. If physical exam is equivocal, MRI can be performed to determine invasiveness of the lesion. All patients undergoing surgery for penile cancer should be informed of the possibility of invasive disease being discovered and the necessity of penile amputation.
2. Answer: C. Given the age, circumcision status, and location on the penile shaft, the presentation is most consistent with bowenoid papulosis. This lesion is histologically similar to carcinoma in situ, with the differences being primarily subjective. Although felt to be benign, most patients do receive treatment focused toward HPV infection with imiquimod or 5-fluorouracil.
3. Answer: D. Imaging is currently unable to identify patients with inguinal metastasis and clinically negative groins. Neither CT nor ultrasound will be useful in this setting. Although ultrasound-guided biopsy can rule in suspicious nodes for cancer, it is not useful for ruling out metastasis in nonpalpable nodes. Pelvic laparoscopy is indicated when inguinal nodes are fixed in cases where identification of pelvic disease would change management. Although intraoperative findings may require a complete inguinal node dissection, it is reasonable to start with a superficial lymph node dissection as deep nodes are rarely positive when superficial nodes are negative. In a low-risk patient (T1, low-grade disease) negative groins may be observed; however, in high-risk patients such as this one, strong consideration should be given to lymphadenectomy.
