Early-stage, well-differentiated cancers of the penis can be effectively managed with local therapy, and attention should be paid to preservation of penile function and morphology. Primary surgical management is effective but can be associated with considerable psychosexual morbidity. Even partial penectomy can have a profound effect on sexual health and self-image.¹ Suicide or attempted suicide after partial penectomy has been reported.^2,³ EBRT or interstitial RT is an organ-sparing alternative that preserves penile morphology and function without compromising disease control or survival in selected patients. Unfortunately, many urologists do not routinely offer this penis-conserving option.⁴ Quality of life and sexual health after surgery is infrequently studied or reported.⁵ Sexuality and expectations should be discussed with the patient and partner when deciding on primary management. Advanced or poorly differentiated tumors require a multimodality approach.

Etiology And Epidemiology

Carcinoma of the penis is rare, with an estimated incidence of 1 case per 100,000 men in North America and Europe, where it accounts for 0.4% to 0.6% of cancers. Higher incidences are seen in parts of Asia, Africa, and South America, where it represents up to 10% of malignancies in male patients.⁶ The peak incidence is in the sixth decade in developed countries but earlier where the incidence is higher.

Case-control studies have identified important risk factors (odds ratio [OR] >10) to be phimosis, chronic inflammatory conditions such as lichen sclerosis, treatment with psoralens and ultraviolet A photochemotherapy (PUVA), smoking (dose-dependent association), and a history of genital condylomata (threefold to fivefold increase in risk). Neonatal circumcision is associated with a threefold decrease in risk of penile carcinoma. Circumcised men with a history of human papillomavirus (HPV) infection remain at increased risk ⁷; and, in some series, up to 20% of patients have been circumcised neonatally. HPV types 16 and 18 have been identified in about 50% of invasive penile cancers.^8,⁹

Prevention And Early Detection

Infant circumcision is highly effective in prevention of this disease, but it is no longer recommended on these grounds alone. The emphasis is instead on education, the promotion of good hygiene for the normally retractile foreskin, and surgical correction of phimosis. Men should be made aware of the association between certain HPV subtypes, venereal warts,⁷ and cancer, as well as the premalignant nature of conditions such as lichen sclerosis, which may precede the diagnosis of cancer by many years.

Biologic Characteristics And Molecular Biology

The overall incidence of HPV in penile carcinoma is 40% to 45%, as detected by polymerase chain reaction (PCR) amplification of DNA. HPV-16 and HPV-18 are the most frequent subtypes detected.^10,¹¹ The frequency of HPV detection depends on the histopathologic subtype of penile cancer. HPV association is seen in 80% to 100% of basaloid and warty penile cancers but in only approximately 35% of verrucous or squamous cell carcinomas. The difference in prevalence of HPV in these two groups suggests different pathogenesis. HPV presence in a tumor does not appear to confer a worse prognosis.

TP53 positivity is found in 41% to 75% of invasive penile cancers.^12,¹³ In multivariate analysis, TP53 positivity and lymphatic embolization are predictive of lymph node metastases.^12,14

Pathology And Pathways Of Spread

Premalignant lesions are associated with invasive cancers in 20% to 30% of cases. Intraepithelial neoplasia such as bowenoid papulosis, Bowen disease, and erythroplasia of Queryat ¹⁵ are precursor lesions of warty and basaloid penile cancers. Lichen sclerosis (balanitis xerotica obliterans) is associated with non-HPV variants of penile carcinoma.^16,¹⁷ Condylomata, Buschke-Löwenstein disease, Kaposi sarcoma, and leukoplakia are also associated with penile cancer.

The primary tumor most frequently occurs on the glans (48%) or prepuce (25%), with the glans and prepuce involved in 9%, the coronal sulcus in 6%, and the shaft in only 2%. Squamous cell carcinomas represent 95% of invasive cancers of the penis. Most are low-grade tumors. Other histopathologic primary tumor types are malignant melanoma, transitional cell carcinoma, basal cell carcinoma, and sarcoma.

The lymphatics of the prepuce and the skin of the shaft drain into the superficial inguinal nodes located above the fascia lata. The glans and the deep penile structure drain into the superficial or deep inguinal nodes. Lymphatics thereafter drain into those that accompany the femoral vessels and extend to the external iliac, common iliac, and para-aortic regions. The sentinel nodes are located above and medial to the junction of the inferior epigastric and saphenous veins.

Clinical Manifestations, Patient Evaluation, And Staging

General Approach

Because of the rarity of carcinoma of the penis, reported series often span several decades. Three different staging systems are encountered in a review of the literature of the past two decades ¹⁸^–²⁰ (Table 55-1).

TABLE 55-1 Staging Systems for Carcinoma of the Penis

Stage	Description
Jackson Staging System*
1	Tumor limited to the glans or prepuce
2	Tumor extending into the shaft or corpora but without node involvement
3	Tumor confined to the shaft but with malignant but operable lymph nodes
4	Invasion beyond the shaft with inoperable lymph nodes or distant metastases
TNM (UICC, 1978)†
Tis	Carcinoma in situ
T1	Tumor ≤ 2 cm
T2	Tumor > 2 cm and ≤ 5 cm
T3	Tumor > 5 cm or deep invasion including urethra
T4	Tumor invades adjacent structures
N1	Metastases in unilateral inguinal lymph nodes
N2	Metastases in bilateral inguinal lymph nodes
N3	Fixed inguinal lymph nodes
TNM (UICC, 1987-2002)‡
T1	Tumor in subepithelial connective tissue
T2	Tumor in corpus spongiosum/cavernosum
T3	Tumor in urethra/prostate
T4	Tumor in other adjacent structures
N1	Tumor in one superficial inguinal lymph node
N2	Tumor in multiple/bilateral superficial inguinal lymph nodes
N3	Tumor in deep inguinal or pelvic lymph nodes

UICC, International Union Against Cancer (Union Internationale Contre le Cancer).

* From Jackson S: The treatment of carcinoma of the penis, Br J Surg 53:33-35, 1966.

† From Harmer M: Penis (ICD-0187). In TNM Classification of Malignant Tumours, ed 3, Berlin, 1978, Springer-Verlag, pp 126-128.

‡ From Hermanek PS, Sobin LH: Penis (ICD-0187). In Hermanek PS, Sobin LH, editors: TNM Classification of Malignant Tumours, ed 4, Berlin, 1987, Springer-Verlag, pp 130-132.

Clinical staging of carcinoma of the penis is very subjective, and it may be difficult to distinguish T1 (i.e., invasion of subepithelial connective tissue) from T2 (i.e., invasion of corpus spongiosum or cavernosum). For this reason, techniques that treat less than the full thickness of the penis must be restricted to very carefully selected cases. MRI may be helpful in cases that are difficult to stage clinically, with a positive predictive value for invasion of the corpora cavernosa of 75% (6 of 8 patients).²¹ When combined with artificial erection, MRI-guided staging showed good agreement with ultimate pathologic stage.^22,²³ Any patient who presents with phimosis and chronic discharge, bleeding, balanitis, or swelling in the region of the coronal sulcus or glans under an unretractable foreskin should have a dorsal slit of the foreskin to allow inspection of the glans and should preferably have a full circumcision. Any suspicious lesions should be sampled. Figure 55-1 shows the diagnostic algorithm for a clinically node-negative patient.

Figure 55-1 Diagnostic algorithm for penile cancer: a clinically node-negative patient. CT, computed tomography; MR, magnetic resonance.

Lymph Node Assessment: The N0 Patient

Management of the patient with clinically negative groins remains controversial. Although the gold standard treatment for invasive penile cancer has been amputation and bilateral groin dissection,¹² many RT series have advocated a “wait and see” policy, with no systematic staging investigations such as CT or fine-needle aspiration cytology.^3,²⁴^–²⁷ Because only about 20% of clinically negative nodes have micrometastases, staging lymph node dissection is not warranted for all patients. Furthermore, inguinal node dissection may be complicated in one third of cases by infection, skin flap necrosis, deep vein thrombosis, or severe leg edema.^28,29,30

Nodal status is, however, the strongest predictive factor for OS.^3,^31,³² Lymph node dissection may be curative for men with microscopic regional spread. Several surgical series have identified that therapeutic node dissection confers an inferior survival compared with prophylactic node dissection.³³ McDougal³⁴ found a 5-year survival after inguinal node dissection of 92% for clinically N0 patients, compared with 33% for those with clinically involved nodes. Modified inguinal lymphadenectomy, sparing the saphenous vein and limiting the dissection laterally, distally, and proximally, may reduce morbidity.²⁸

Stage and histopathologic factors should be used to identify patients at high risk for microscopic regional spread to selectively offer surgical staging of lymph nodes. Grade is predictive for regional failure, which occurs with 30% of well-differentiated and 81% of moderately to poorly differentiated tumors.²⁹ T stage and lymphovascular invasion are also predictive for nodal relapse.³¹ McDougal³⁴ reported that patients with clinically negative nodes but with poorly differentiated cancers or invasion of the corpora had a 78% rate of node positivity after inguinal dissection, compared with 4% for moderately or well-differentiated tumors and no invasion of the corpora.

The difficulty with applying this information to decision making in RT is that the primary tumor is not available for complete histopathologic examination. Invasion of the corpora may be underappreciated clinically. Diagnostic biopsies are often superficial and unreliable in determining the depth of invasion, the presence of lymphovascular invasion, or the ultimate tumor grade.³⁵ However, if the biopsy shows the presence of lymphovascular invasion or moderate to poor differentiation, surgical assessment of regional lymph nodes is warranted.³⁶ The specificity and sensitivity of CT are not sufficiently reliable for staging,³⁷ although ultrasound-guided fine-needle aspiration cytology is a valuable tool to evaluate suspicious inguinal nodes.³⁸

Dynamic sentinel lymph node mapping using a gamma probe after intradermal injection of technetium-99m around the primary tumor is becoming more widely available in the detection of early lymph node involvement.³⁷ False-negative rates have fallen to 2% to 11% in the recent literature.^39,40,41,42 The use of single proton emission computed tomography may decrease the risk of false-negative results from tumor blockage and rerouting of lymphatics,⁴³ but superficial inguinal lymph node dissection remains the gold standard.

In summary, for patients with clinically negative nodes and a favorable primary tumor (Tis, Ta G1 to G2, T1 G1), observation of the inguinal regions is appropriate. For G2 to G3 or T2 disease, either a staging modified inguinal lymph node dissection or dynamic sentinel lymph node biopsy is recommended.⁴⁴

Primary Therapy

Surgery

Circumcision is the first step in all cases. Small tumors that are limited to the prepuce can be treated by circumcision alone. Penis-conserving surgical techniques such as laser or Mohs surgery may be suitable for selected tumors. Mohs surgery ⁴⁵ for carcinoma in situ or very superficial tumors involves excision of tissue in successive layers with complete microscopic scanning of each horizontally cut layer to identify any tumor outgrowths that may extend beyond the visible or palpable lesion. Successive layers are removed until margins are histologically clear.

Laser surgery using carbon dioxide or neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers has been reported to provide a superior functional and cosmetic result compared with standard surgical techniques for selected premalignant and malignant lesions.46,47,48,49 Most tumors appropriate for this modality are Tis or T1, the recurrence rate being unacceptable for T2 disease.⁴⁶ Windahl and Andersson⁴⁷ reported a 19% local recurrence rate for 67 patients, although 50% of failures could be re-treated with laser. Extended, careful follow-up is required because only 57% of local recurrences occur within the first 2 years, 30% between 6 and 10 years, and 15% after 10 years. Whether these late failures represent true local recurrences or new primary tumors is unknown.

Selected cases, especially those involving only skin, can be treated by wide excision, but local wedge excision is associated with a high recurrence rate. Glansectomy and reconstruction with a split-thickness skin graft preserves a greater length of penile shaft than traditional partial penectomy.50,51 Total or partial penectomy is indicated for larger or more invasive tumors. Traditionally, an adequate resection margin is considered to be 2 cm, but closer margins of 10 mm or less may be acceptable if tumor-free on frozen section.⁵² Partial penectomy is possible when the tumor involves the glans or the distal shaft, and the penile remnant will allow the patient to direct the urinary stream. Total amputation is indicated for larger or proximal tumors and requires a perineal urethrostomy.

Radiation Therapy

Radical RT in the form of brachytherapy or EBRT is effective in achieving local control in a high percentage of patients (Table 55-2). Often, series span several decades, during which time treatment techniques and dose prescriptions evolve. Staging systems have also undergone significant modifications (see Table 55-1).

TABLE 55-2 Summary of Literature Results for Brachytherapy and External Beam Radiation Therapy

Interstitial brachytherapy yields a 5-year local tumor control rate of 77% to 87%, with penile preservation rates at 5 years ranging from 72% to 88%. For EBRT, local control rates are less favorable, 41% to 70% at 5 years. The increased need for surgical salvage decreases penile preservation rates to 36% to 66%. Careful extended follow-up is recommended because local failures can occur several years after treatment. Crook and colleagues ⁵³ found that although five of eight local failures in a series of 67 men occurred in the first 2 years, the remaining three occurred at 4.5, 7, and 8 years. Similarly, Mazeron and associates²⁵ reported that 18% of local failures occurred between years 5 and 8, and de Crevoisier and colleagues⁵⁴ reported that 20% of the local failures occurred after 8 years. This late recurrence pattern is strikingly similar to that seen after penile-conserving laser treatment⁴⁷ and necessitates careful long-term follow-up because the majority can be successfully salvaged.

Surgery for Salvage

Surgery for salvage is successful in more than 80% of failures.24,55 Local excision is rarely appropriate, with procedures equally divided between total and partial penectomy^24,26,27,55 (Table 55-3). The choice depends on penile length and the proportion of the shaft irradiated by the primary treatment. The localized nature of brachytherapy should result in less radical salvage operations.

TABLE 55-3 Type of Salvage Surgery for Local Recurrence or Necrosis after External Beam Radiation Therapy or Brachytherapy

Patient Selection for Radiation Therapy

Several prognostic factors have been identified for penile preservation. For EBRT, a total dose of less than 60 Gy, a protracted treatment time of more than 45 days, and a daily fraction size of less than 2 Gy are all associated with an increased risk of local failure.2,55

For brachytherapy, the volume of tumor and depth of invasion are predictive of local control. The ideal tumor for brachytherapy should be less than 4 cm in its maximum diameter, with less than 1 cm of invasion.3,25,26,56 Local failure rates of 50% to 60% for tumors larger than 4 cm in diameter have been reported, compared with 14% to 30% for those less than 4 cm. Use of more than six brachytherapy needles and tumor volumes greater than 8 mL are also associated with an increased risk of failure.^3,^24,²⁶ Crook and colleagues⁵⁷ found that wider needle spacing was associated with a decreased risk of failure (p = .006). Wider spacing results in a wider lateral margin, ensuring more generous margins around the tumor (Fig. 55-2).

Figure 55-2 Schematic of Paris system of dosimetry for two-plane interstitial implants. Dimensions of treatment isodose can be predicted from length and spacing of radioactive sources.

Reprinted with permission from Crook J, Jezioranski J, Cygler JE: Penile brachytherapy. Technical aspects and postimplant issues, Brachytherapy 9:151-158, 2010.

Histopathology does not appear to be a factor in local control. Most penile cancers are well-differentiated squamous cell carcinomas. A more favorable outcome for verrucous cancers has been reported, but most series do not specify this pathology subtype. Moderate to poor differentiation influences OS and the risk of nodal involvement ⁵⁸ but does not preclude a penile-conserving approach.

Locally Advanced Disease And Palliation

Although a penile-sparing approach may be warranted for a T3 tumor in a younger patient, most locally advanced tumors require partial or total penectomy with a perineal urostomy and bilateral groin dissection.

Node-Positive Disease

Involved nodes should be resected if possible. As in squamous cancers of other sites that drain to the inguinal regions, patients with pathologic findings of multiple positive nodes or extracapsular spread should be offered postoperative RT.^58,⁵⁹ If dissection of deep pelvic nodes is negative, treatment can be limited to the involved groin. A direct anterior electron field of suitable energy to deliver a dose of 45 to 50 Gy over 5 weeks to the depth of the nodes is appropriate. If the status of the pelvic nodes is unknown, they should be included in the treatment volume.

Unresectable nodes are rarely controlled by RT but can be palliated. A combined approach beginning with systemic chemotherapy should be considered if the patient’s general condition permits an aggressive approach. The choice of agents is not well established. Intra-arterial chemotherapy for locally advanced or recurrent penile cancer using cisplatin, methotrexate, and bleomycin (CMB regimen)⁶⁰ or CMB plus 5-fluorouracil and mitomycin C has shown promise.⁶⁰ The Southwest Oncology Group has reported a trial using the CMB regimen in locally advanced or metastatic penile cancer in 40 men, with a response rate of 32.5%.⁶¹ An ongoing trial of neoadjuvant paclitaxel, ifosfamide, and cisplatin at the M.D. Anderson Cancer Center has reported a response rate of 55% in the first 20 patients.⁶² Surgery or RT, or both, can be used after a response to chemotherapy. Concurrent chemoradiation should be evaluated in view of improved local control when compared with either EBRT alone (cervical cancer) or sequential chemoradiation (head and neck cancer) in other disease sites.

Irradiation Techniques AND tolerance

External Beam Irradiation

EBRT has several advantages in that it is widely available, delivers a reliably homogeneous dose, and does not require the specific expertise of brachytherapy. Well-localized carcinoma in situ (Tis) may be treated effectively using 125-kV orthovoltage beams or 9-MeV electrons with suitable bolus, using fractionation schemes commonly employed for skin cancer such as 35 Gy given in 10 fractions over 2 weeks ⁶³; however, most such lesions would be treated by a penile-conserving surgical technique. Most lesions referred for RT will require irradiation to the full thickness of the penis with a full dose to the skin surface. Fraction sizes less than 2 Gy are suboptimal,² and fraction sizes larger than 2 Gy may be associated with increased long-term sequelae.⁶⁴ Doses range from 60 Gy in 25 fractions over 5 weeks to 74 Gy in 37 fractions over 7.5 weeks, avoiding interruptions due to acute reactions (e.g., edema, pain, desquamation). An easily reproducible setup over the 6-week period that is comfortable for the patient despite increasing local reaction and is easily verified by technologists is essential.

Successful application of megavoltage EBRT to treat penile cancer must overcome the technical challenge of positioning the penis in such a way that other tissues will not be exposed to irradiation and counteract the skin-sparing nature of megavoltage x-rays. Several techniques have been developed to accomplish this.

A 10 × 10-cm to 10 × 15-cm wax block can be constructed in two halves with a central cylindrical chamber.^55,⁶³ The patient is positioned supine on the treatment couch, and the penis is supported in a vertical position, encased in the wax block. Tissue-equivalent material must be placed in the distal portion of the cylindrical chamber to maintain full dose to the glans. Parallel-opposed beams of cobalt 60 or 4- to 6-MV photons treat the entire length of the penis (Fig. 55-3A).This technique may become increasingly uncomfortable for the patient as treatment progresses. Penile swelling may require modification of the wax block. Verification of penile position within the wax is impossible, but catheterization throughout the 6 weeks of treatment may prevent the penis from “slumping” inside the wax.

Figure 55-3 A, Patient positioned with Perspex block in place. Block provides full buildup and is transparent for verification of penile position. The blocks are bivalved and can be made in a range of sizes to accommodate penile swelling as treatment progresses. B, Water bath technique. The patient lies prone on Styrofoam slabs such that the penis is suspended in a water bath. Transparent sides on the water bath permit a visual check of penile position.

Perspex is a good alternative to wax and provides full buildup to the skin surface while allowing treatment by parallel-opposed beams.² Preconstructed blocks in a range of sizes of the central cylindrical chamber can be sterilized for reuse. Penile swelling can be accommodated easily by choosing the next larger size, and penile position within the transparent block can be easily verified visually.

An alternative approach has been described with the patient positioned prone and the penis suspended in a water bath (see Fig. 55-3B). This approach may not, however, be applicable to all types of body habitus.⁶⁵

Brachytherapy

The penis is well suited to brachytherapy. For centers with appropriate expertise, surface molds or interstitial techniques can be used with good effect. Circumcision should be performed before brachytherapy to ensure complete exposure of the tumor and prevent subsequent phimosis or annular fibrosis of the foreskin.

Molds

Unlike interstitial brachytherapy, a mold is not invasive and does not require anesthesia.⁶⁴ The acute reaction develops after the treatment is finished. A surface dose of 55 to 60 Gy is prescribed, with a central axis dose of 46 to 50 Gy over 84 hours (12 hr/day) and may be delivered using a Perspex tube or silicon monomer.⁶⁴

Interstitial Brachytherapy

There is broad experience with interstitial brachytherapy for T1 or T2 penile carcinoma, with reports from many European countries and from Canada. Implants can be performed with the patient under general or local anesthesia. The Paris system of dosimetry ⁶⁶ is applicable to manually afterloaded implants and remote afterloading pulse-dose-rate systems, although for the latter some optimization can be introduced.

Circumcision should always precede penile brachytherapy. When there is preexisting phimosis, circumcision allows full visualization of the tumor. Often the foreskin is involved as well as the glans, and circumcision may remove a considerable portion of the tumor bulk, simplifying brachytherapy planning. Finally, the foreskin is very prone to necrosis and if it is left in situ during brachytherapy the ensuing very painful ulceration can be slow to heal, be troublesome to manage, and result in a chronically adherent or phimotic foreskin.

Penile brachytherapy is generally performed as a volume implant delivering full-thickness irradiation, although well-selected, very superficial tumors may be treated with a single-plane implant. A video of penile brachytherapy is available on the Expert Consult version of this chapter. For volume implants, two or three parallel planes of sources are inserted, with two or three needles in each plane. Equal intersource and interplane spacing ranges from 12 to 18 mm. The distribution, spacing, and total number of needles depend on tumor size. Planes are usually oriented with the needles passing from the dorsal to the ventral surface of the glans, but a left-to-right orientation may be acceptable depending on tumor location. Visual verification of coverage can be readily accomplished. Needle placement should be planned such that the prescription isodose will cover 10 mm beyond visible or palpable tumor. Care must be taken to adhere to the rules of the Paris system ⁶⁶ and to be aware of the relationship of the treated volume to the needles such that placement ensures that the entire tumor and desired margin are within the high-dose volume (Fig. 55-4). Specific considerations of needle placement for meatal tumors or unilateral tumors have been described.⁵³

Figure 55-4 Interstitial brachytherapy according to the Paris system of dosimetry.⁶⁶ A, Six-needle, two-plane implant. B, Nine-needle, three-plane implant. C, Dose distribution for B. According to the Paris system, dose rate minima in the central plane (61.3 cGy/hr in this case) are the basal dose rate. The prescription isodose is 85% of the basal dose rate (52.1 cGy/hr in this case).

Needle placement requires 30 to 45 minutes in the operating room. Catheterization aids in identification of the urethra so as to avoid transfixing it with implant needles. The 19.5-gauge needles are appropriate for manually afterloaded iridium-192 wire, and 17.5-gauge needles are compatible with a pulse-dose-rate remote afterloader. The needles are stabilized through the duration of treatment with predrilled Plexiglas templates. The prescribed dose is generally 60 Gy at a dose rate of 50 to 60 cGy/hr over 100 to 120 hours (4 to 5 days). No dose rate correction is required for pulse-dose-rate therapy (hourly fractions) compared with continuous low-dose-rate therapy. A Styrofoam collar positioned around the base of the penis proximal to the needles supports the penis, distances the implant from the testes, and minimizes unnecessary irradiation of adjacent tissue. A thin sheet of lead can be inserted into the Styrofoam collar to decrease transmitted dose to the testes if subsequent fertility is an issue.

The brachytherapy needles are generally well tolerated. The patient remains catheterized and in bed for the duration of the implant, although with pulse-dose-rate therapy the source cables can be disconnected from the needles to allow the patient to move for brief periods between fractions. Sufficient analgesia is usually provided by acetaminophen, with or without codeine. Leg exercises and prophylactic subcutaneous heparin (5000 U every 12 hours) are recommended. Removal of the needles occurs at the bedside after premedication with a narcotic analgesic.

With the increasing availability of high-dose-rate (HDR) brachytherapy it is very likely that this modality will be applied to penile brachytherapy. At present there is very little evidence on which to base recommendations for fractionation. A recent experience with 10 patients over 8 years using twice-daily fractions of 3 Gy to deliver 54 Gy over 9 days has been reported.⁶⁷ These researchers did not observe any necrosis but very small volume implants were used and the majority were single plane. Limited personal experience suggests that 3.75 Gy × 12 over 6 days for a total dose of 45 Gy may be effective for a two-plane volume implant. CT planning is required with delineation of the gross tumor volume using fine wire. It is recommended to keep the V₁₅₀ less than 20%. Further published experience and longer follow-up is required before any definitive recommendations can be made regarding optimal fractionation for HDR brachytherapy in the management of penile carcinoma.

Tolerance: Acute and Chronic Reactions

Sexual Function

There is no systematic study available in the literature dealing with sexual function after RT for penile cancer. The impact on sexual function often is not assessed. Crook and colleagues ⁵⁸ found that in a series of 49 men treated with brachytherapy, 22 of 27 who were potent at baseline reported satisfactory potency at last follow-up. Delannes and associates²⁷ observed that apart from 1 patient who developed painful erections due to sclerosis, “sexual function did not appear to be altered by the implant.” Sarin and colleagues² provided details for only 14 of the 59 patients, commenting that 12 were normal and 2 had minor impairment. Mazeron and associates²⁵ stated that for noninfiltrating or moderately infiltrating tumors less than 4 cm in diameter, “sexual function remained the same as before treatment.”

If necessary, dose to the testes can be limited by incorporation of a layer of 2 mm of lead into the Styrofoam collar around the penis. Thermoluminescent dosimeter measurements for pulse-dose-rate penile brachytherapy then indicate a total dose to the anterior testis of 55 cGy and 26 cGy to the posterior testis during a 60-Gy treatment course.⁵⁸ No data are available on postbrachytherapy sperm counts.

Other Sequelae

Mottled hypopigmentation or hyperpigmentation, telangiectasia, and mild to moderate focal fibrosis may occur. Some atrophy of the glans in areas of deep tumor infiltration is common.

Treatment Algorithm, Controversies, And Challenges

Penile cancer is a rare but psychologically devastating disease. The functional and sexual implications of treatment should be discussed with patients.

Our preferred treatment algorithm is shown in Figure 55-5. For Tis, T1, and T2 tumors less than 4 cm in diameter, a penile-conserving approach as primary management is warranted. Laser surgery can provide satisfactory cosmesis, function, and local tumor control, especially for Tis or small T1 lesions, with the option of re-treating local recurrences with further laser surgery. The RT of choice is interstitial brachytherapy, which results in penile preservation in 70% of cases at 10 years. If brachytherapy expertise is not available, EBRT can prevent amputation in 50% to 60% of patients. For more locally advanced lesions (T2 >4 cm, T3, ? T4), concurrent chemoradiation should be evaluated. With any penis-conserving approach, protracted follow-up is necessary because local failure can occur many years later and surgical salvage can be curative.