test About Medicine OnLine Medicine OnLine Home Page Cancer Libraries DoseCalc Online Oncology News
Cancer Forums Medline Search Cancer Links Glossary



National Cancer Institute

PDQ® bullet Treatment  bullet Health Professionals


Important: This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

Penile cancer


Table of Contents

GENERAL INFORMATION
CELLULAR CLASSIFICATION
STAGE INFORMATION
Stage I
Stage II
Stage III
Stage IV
TREATMENT OPTION OVERVIEW
STAGE I PENILE CANCER
T1, N0, M0
STAGE II PENILE CANCER
T1, N1, M0 or T2, N0, M0 or T2, N1, M0
STAGE III PENILE CANCER
T1, N2, M0 or T2, N2, M0 or T3, N0, M0 or T3, N1, M0 or T3, N2, M0
STAGE IV PENILE CANCER
T4, any N, M0 or Any T, N3, M0 or Any T, any N, M1
RECURRENT PENILE CANCER

GENERAL INFORMATION

When diagnosed early (stages I and II) penile cancer is highly curable. Curability decreases sharply for stages III and IV. Because of the rarity of this cancer in the United States, clinical trials specifically for penile cancer are infrequent. Patients with stage III and IV cancer can be candidates for phase I and II clinical trials testing new drugs, biologicals, or surgical techniques to improve local control and distant metastases.

The selection of treatment is dependent on the size, location, invasiveness, and stage of the tumor.[1,2]

References:

  1. Herr HH, Fuks Z, Scher HI: Cancer of the urethra and penis. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp 1386-1395.

  2. Pilepich MV: Carcinoma of the penis and male urethra. In: Perez CA, Brady LW, Eds.: Principles and Practice of Radiation Oncology. Philadelphia: JB Lippincott, 1987, pp 912-918.


CELLULAR CLASSIFICATION

Virtually all penile carcinomas are of squamous cell origin.


STAGE INFORMATION

The most commonly used staging system is as follows:


Stage I

Stage I penile cancer is cancer limited to the glans and the foreskin, not involving the shaft of the penis or corpora cavernosa.


Stage II

Stage II penile cancer has invaded the corpora cavernosa of the penis but has not spread to lymph nodes on clinical exam.


Stage III

Stage III penile cancer has clinical spread to the regional lymph nodes in the groin. Cure is related to the number and extent of nodes involved.


Stage IV

Stage IV penile cancer is invasive cancer that has caused extensive and inoperable involvement of lymph nodes in the groin and/or distant metastases.



The American Joint Committee on Cancer (AJCC) has designated staging by TNM
classification.[1]

-- TNM definitions --

Primary tumor (T)
  TX:  Primary tumor cannot be assessed
  T0:  No evidence of primary tumor
  Tis:  Carcinoma in situ
    Ta:  Noninvasive verrucous carcinoma
  T1:  Tumor invades subepithelial connective tissue
  T2:  Tumor invades corpus spongiosum or cavernosum
  T3:  Tumor invades urethra or prostate
  T4:  Tumor invades other adjacent structures

Regional lymph nodes (N)
  NX:  Regional lymph nodes cannot be assessed
  N0:  No regional lymph node metastasis
  N1:  Metastasis in a single superficial inguinal lymph node
  N2:  Metastasis in multiple or bilateral superficial inguinal lymph nodes
  N3:  Metastasis in deep inguinal or pelvic lymph node(s), unilateral or
       bilateral 

Distant metastasis (M)
  MX:  Distant metastasis cannot be assessed
  M0:  No distant metastasis
  M1:  Distant metastasis

-- AJCC stage groupings --

--Stage 0--

  Tis, N0, M0
  Ta, N0, M0

--Stage I--

  T1, N0, M0

--Stage II--

  T1, N1, M0
  T2, N0, M0
  T2, N1, M0

--Stage III--

  T1, N2, M0
  T2, N2, M0
  T3, N0, M0
  T3, N1, M0
  T3, N2, M0

--Stage IV--

  T4, Any N, M0
  Any T, N3, M0
  Any T, Any N, M1

References:

  1. Penis. In: American Joint Committee on Cancer: AJCC Cancer Staging Manual. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp 215-217.


TREATMENT OPTION OVERVIEW

The designations in PDQ that treatments are "standard" or "under clinical evaluation" are not to be used as a basis for reimbursement determinations.


STAGE I PENILE CANCER


T1, N0, M0

Stage I penile cancer is curable.[1]

Treatment options:

Standard:

1. Lesions limited to the foreskin:
Wide local excision with circumcision may be adequate therapy for
control.

2. For carcinoma in situ of the glans (also referred to as erythroplasia of Queyrat or Bowen's disease of the penis), with or without adjacent skin involvement, therapeutic options include:
  • local applications of fluorouracil cream
  • microscopically controlled surgery [2]

3. For infiltrating tumors of the glans, with or without involvement of the adjacent skin, the choice of therapy is dictated by tumor size, extent of infiltration, and degree of tumor destruction of normal tissue. Equivalent therapeutic options include:
  • penile amputation [3]
  • irradiation (external-beam, brachytherapy) [4,5]
  • microscopically controlled surgery [2]

Under clinical evaluation:
Nd: YAG laser therapy has offered excellent control/cure with preservation
of cosmetic appearance and sexual function.[6,7] The CO2 laser has been
employed successfully for treatment of carcinoma in situ.[8]

Because of the high incidence of microscopic node metastases, elective adjunctive inguinal dissection of clinically uninvolved (negative) lymph nodes in conjunction with amputation is often used for patients with poorly differentiated tumors. However, lymphadenectomy can carry substantial morbidity, such as infection, skin necrosis, wound breakdown, chronic edema, and even a low, but finite, mortality rate. The impact of prophylactic lymphadenectomy on survival is not known. For these reasons, there are varying opinions on its use.[9-12]

References:

  1. Harty JI, Catalona WJ: Carcinoma of the penis. In: Javadpour N, Ed.: Principles and Management of Urologic Cancer. Baltimore: Williams and Wilkins, 2nd ed., 1983, pp 581-597.

  2. Mohs FE, Snow SN, Messing EM, et al.: Microscopically controlled surgery in the treatment of carcinoma of the penis. Journal of Urology 133(6): 961-966, 1985.

  3. Schellhammer PF, Grabstaldt H: Tumors of the penis. In: Walsh PC, Gittes RF, Perlmutter AD, et al., Eds.: Campbell's Urology. Philadelphia: W.B. Saunders, 5th ed., 1986, pp 1583-1606.

  4. Pilepich MV: Carcinoma of the penis and male urethra. In: Perez CA, Brady LW, Eds.: Principles and Practice of Radiation Oncology. Philadelphia: JB Lippincott, 1987, pp 912-918.

  5. McLean M, Akl AM, Warde P, et al.: The results of primary radiation therapy in the management of squamous cell carcinoma of the penis. International Journal of Radiation Oncology, Biology, Physics 25(4): 623-628, 1993.

  6. Hofstetter A, Frank F: Laser use in urology. In: Dixon JA, Ed.: Surgical Application of Lasers. Chicago: Year Book Medical Publishers, Inc., 1983, pp 146-162.

  7. Horenblas S, van Tinteren H, Delemarre JF, et al.: Squamous cell carcinoma of the penis: II. treatment of the primary tumor. Journal of Urology 147(6): 1533-1538, 1992.

  8. Rosemberg SK, Fuller TA: Carbon dioxide rapid superpulsed laser treatment of erythroplasia of Queyrat. Urology 16(2): 181-182, 1980.

  9. Theodorescu D, Russo P, Zhang ZF, et al.: Outcomes of initial surveillance of invasive squamous cell carcinoma of the penis and negative nodes. Journal of Urology 155(5): 1626-1631, 1996.

  10. Lindegaard JC, Nielsen OS, Lundbeck FA, et al.: A retrospective analysis of 82 cases of cancer of the penis. British Journal of Urology 77(6): 883-890, 1996.

  11. Ornellas AA, Seixas AL, Marota A, et al.: Surgical treatment of invasive squamous cell carcinoma of the penis: retrospective analysis of 350 cases. Journal of Urology 151(5), 1244-1249, 1994.

  12. Young MJ, Reda DJ, Waters WB: Penile carcinoma: a twenty-five-year experience. Urology 38(6): 529-532, 1991.


STAGE II PENILE CANCER


T1, N1, M0 or T2, N0, M0 or T2, N1, M0

Treatment options:

Standard:

Stage II penile cancer is most frequently managed by penile amputation
for local control. Whether the amputation is partial, total, or radical
will depend on the extent and location of the neoplasm. Radiation
therapy with surgical salvage is an alternative approach.[1-4]

Under clinical evaluation:
Nd: YAG laser therapy has been used to preserve the penis in selected
patients with small lesions.[5]

Because of the high incidence of microscopic node metastases, elective adjunctive dissection of clinically uninvolved (negative) lymph nodes in conjunction with amputation is often used for patients with poorly differentiated tumors. However, lymphadenectomy can carry substantial morbidity, such as infection, skin necrosis, wound breakdown, chronic edema, and even a low, but finite, mortality rate. The impact of prophylactic lymphadenectomy on survival is not known. For these reasons, there are variant opinions on its use.[6-9]

References:

  1. Harty JI, Catalona WJ: Carcinoma of the penis. In: Javadpour N, Ed.: Principles and Management of Urologic Cancer. Baltimore: Williams and Wilkins, 2nd ed., 1983, pp 581-597.

  2. Schellhammer PF, Spaulding JT: Carcinoma of the penis. In: Paulson DF: Genitourinary Surgery. New York: Churchill Livingston, Vol 2, 1984, pp 629-654.

  3. Johnson DE, Lo RK: Tumors of the penis, urethra, and scrotum. In: deKernion JB, Paulson DF, Eds.: Genitourinary Cancer Management. Philadelphia: Lea and Febiger, 1987, pp 219-258.

  4. McLean M, Akl AM, Warde P, et al.: The results of primary radiation therapy in the management of squamous cell carcinoma of the penis. International Journal of Radiation Oncology, Biology, Physics 25(4): 623-628, 1993.

  5. Horenblas S, van Tinteren H, Delemarre JF, et al.: Squamous cell carcinoma of the penis: II. treatment of the primary tumor. Journal of Urology 147(6): 1533-1538, 1992.

  6. Theodorescu D, Russo P, Zhang ZF, et al.: Outcomes of initial surveillance of invasive squamous cell carcinoma of the penis and negative nodes. Journal of Urology 155(5): 1626-1631, 1996.

  7. Lindegaard JC, Nielsen OS, Lundbeck FA, et al.: A retrospective analysis of 82 cases of cancer of the penis. British Journal of Urology 77(6): 883-890, 1996.

  8. Ornellas AA, Seixas AL, Marota A, et al.: Surgical treatment of invasive squamous cell carcinoma of the penis: retrospective analysis of 350 cases. Journal of Urology 151(5), 1244-1249, 1994.

  9. Young MJ, Reda DJ, Waters WB: Penile carcinoma: a twenty-five-year experience. Urology 38(6): 529-532, 1991.


STAGE III PENILE CANCER


T1, N2, M0 or T2, N2, M0 or T3, N0, M0 or T3, N1, M0 or T3, N2, M0

Inguinal adenopathy in patients with penile cancer is common but may be the result of infection rather than neoplasm. If palpable enlarged lymph nodes exist three or more weeks after removal of the infected primary lesion and a course of antibiotic therapy, bilateral inguinal lymph node dissection should be performed.

In cases of proven regional inguinal lymph node metastasis without evidence of distant spread, bilateral ilioinguinal dissection is the treatment of choice.[1-4] However, since many patients with positive lymph nodes are not cured, clinical trials may be appropriate.

Treatment options:

Standard:

1. Clinically evident regional lymph node metastasis without evidence of distant spread is an indication for bilateral ilioinguinal lymph node dissection after penile amputation.[5]

2. Radiation therapy may be considered as an alternative to lymph node dissection in patients who are not surgical candidates.

3. Postoperative irradiation may decrease incidence of inguinal recurrences.

Under clinical evaluation:
Clinical trials using radiosensitizers or cytotoxic drugs are appropriate.
A combination of vincristine, bleomycin, and methotrexate has been effective
as both neoadjuvant and adjuvant therapy.[6] Cisplatin (100 milligrams per
square meter) as neoadjuvant therapy plus continuous-infusion 5-fluorouracil
has also been shown to be effective.[5] Single-agent cisplatin (50
milligrams per square meter) was tested in large trial and was found to be
ineffective.[7]

Because of the high incidence of microscopic node metastases, adjunctive inguinal dissection of clinically uninvolved (negative) lymph nodes in conjunction with amputation is often used for patients with poorly differentiated tumors. However, lymphadenectomy can carry substantial morbidity, such as infection, skin necrosis, wound breakdown, chronic edema, and even a low, but finite, mortality rate. The impact of prophylactic lymphadenectomy on survival is not known. For these reasons, there are variant opinions on its use.[2,3,8,9]

References:

  1. Harty JI, Catalona WJ: Carcinoma of the penis. In: Javadpour N, Ed.: Principles and Management of Urologic Cancer. Baltimore: Williams and Wilkins, 2nd ed., 1983, pp 581-597.

  2. Theodorescu D, Russo P, Zhang ZF, et al.: Outcomes of initial surveillance of invasive squamous cell carcinoma of the penis and negative nodes. Journal of Urology 155(5): 1626-1631, 1996.

  3. Lindegaard JC, Nielsen OS, Lundbeck FA, et al.: A retrospective analysis of 82 cases of cancer of the penis. British Journal of Urology 77(6): 883-890, 1996.

  4. Schellhammer PF, Grabstaldt H: Tumors of the penis. In: Walsh PC, Gittes RF, Perlmutter AD, et al., Eds.: Campbell's Urology. Philadelphia: W.B. Saunders, 5th ed., 1986, pp 1583-1606.

  5. Fisher HA, Barada JH, Horton J, et al.: Neoadjuvant therapy with cisplatin and 5-fluorouracil for stage III squamous cell carcinoma of the penis. Journal of Urology 143(4 Suppl): A-653, 352A, 1990.

  6. Pizzocaro G, Piva L: Adjuvant and neoadjuvant vincristine, bleomycin, and methotrexate for inguinal metastases from squamous cell carcinoma of the penis. Acta Oncologica 27(6B): 823-824, 1988.

  7. Gagliano RG, Blumenstein BA, Crawford ED, et al.: Cis-diamminedichloroplatinum in the treatment of advanced epidermoid carcinoma of the penis: a Southwest Oncology Group study. Journal of Urology 141(1): 66-67, 1989.

  8. Ornellas AA, Seixas AL, Marota A, et al.: Surgical treatment of invasive squamous cell carcinoma of the penis: retrospective analysis of 350 cases. Journal of Urology 151(5), 1244-1249, 1994.

  9. Young MJ, Reda DJ, Waters WB: Penile carcinoma: a twenty-five-year experience. Urology 38(6): 529-532, 1991.


STAGE IV PENILE CANCER


T4, any N, M0 or Any T, N3, M0 or Any T, any N, M1

There is no standard treatment which is curative for stage IV penile cancer. Therapy is directed at palliation, which may be achieved either with surgery or radiation therapy.

Treatment options:

1. Palliative surgery may be considered for control of the local penile lesion and even for the prevention of the necrosis, infection, and hemorrhage which can result from neglected regional adenopathy.

2. Irradiation may be palliative for the primary tumor, regional adenopathy, and bone metastases.

Under clinical evaluation:
Clinical trials combining chemotherapy with palliative methods of local
control are appropriate for such patients (tested chemotherapeutic drugs
with some efficacy include vincristine, cisplatin, methotrexate, and
bleomycin). The combination of vincristine, bleomycin, and methotrexate has
been effective both as adjuvant and neoadjuvant therapy.[1]

References:

  1. Pizzocaro G, Piva L: Adjuvant and neoadjuvant vincristine, bleomycin, and methotrexate for inguinal metastases from squamous cell carcinoma of the penis. Acta Oncologica 27(6B): 823-824, 1988.


RECURRENT PENILE CANCER

Locally recurrent disease can be approached by surgery or radiation therapy. Patients who fail irradiation as the initial treatment are often salvaged by penile amputation. Patients with nodal recurrences that are not controllable by local measures are candidates for phase I and II clinical trials testing new biologicals and chemotherapeutic agents.[1-5]

References:

  1. Pizzocaro G, Piva L: Adjuvant and neoadjuvant vincristine, bleomycin, and methotrexate for inguinal metastases from squamous cell carcinoma of the penis. Acta Oncologica 27(6B): 823-824, 1988.

  2. Ahmed T, Sklaroff R, Yagoda A: Sequential trials of methotrexate, cisplatin and bleomycin for penile cancer. Journal of Urology 132(3): 465-468, 1984.

  3. Dexeus FH, Logothetis CJ, Sella A, et al.: Combination chemotherapy with methotrexate, bleomycin and cisplatin for advanced squamous cell carcinoma of the male genital tract. Journal of Urology 146(5): 1284-1287, 1991.

  4. Fisher HA, Barada JH, Horton J, et al.: Neoadjuvant therapy with cisplatin and 5-fluorouracil for stage III squamous cell carcinoma of the penis. Journal of Urology 143(4 Suppl): A-653, 352A, 1990.

  5. Hussein AM, Benedetto P, Sridhar KS: Chemotherapy with cisplatin and 5-fluorouracil for penile and urethral squamous cell carcinomas. Cancer 65(3): 433-438, 1990.

Date Last Modified: 02/1999



Home | 

test About Medicine OnLine Medicine OnLine Home Page Cancer Libraries DoseCalc Online Oncology News
Cancer Forums Medline Search Cancer Links Glossary