Penile cancer

A persistent ulcer, thickened area, bleeding lesion or change beneath the foreskin should be examined. Infection and inflammatory skin conditions can look similar, so appearance alone cannot diagnose cancer. Biopsy establishes whether the lesion is penile intraepithelial neoplasia (PeIN), invasive squamous carcinoma or another tumor.

Pathology should describe depth, grade, lymphovascular or perineural invasion and margins when tissue has been removed. HPV-associated and HPV-independent squamous cancers are recognized groups; p16 staining helps classify them. HPV status is not a substitute for stage and does not automatically justify reducing treatment.

HPV infection is common and can persist silently for years. A cancer diagnosis cannot establish when an infection occurred or imply recent infidelity. Smoking and chronic inflammatory conditions can also contribute to risk. Prevention and partner concerns deserve factual, nonjudgmental discussion.

The local T category describes which tissues are invaded. T1a and T1b differ by adverse pathology, including grade and lymphovascular or perineural invasion; deeper involvement of the spongiosum or cavernosa changes the category. EAU's current classification reflects UICC TNM 9, with penile categories unchanged from the preceding edition.

Examine both groins. No palpable nodes is called cN0, but occult disease may still exist. Ultrasound-guided sampling can investigate suspicious nodes; CT or PET cannot reliably rule out small deposits in an otherwise normal groin. MRI or ultrasound of the penis can help when local invasion is uncertain.

PeIN is confined to the epithelium and needs a different approach from invasive cancer. Options include circumcision when relevant, topical treatment, laser or excision/resurfacing. Persistent disease after topical therapy needs reassessment, sometimes another biopsy, rather than repeatedly applying the same treatment to possible invasion.

Selected localized invasive cancers can be treated with local excision, partial or complete glans removal with reconstruction, or carefully selected radiotherapy including brachytherapy. The aim is cancer control while preserving as much function as possible. Discuss margin assessment, recurrence risk, changes in sensation and the possibility of later salvage surgery.

Organ preservation requires commitment to follow-up. More extensive cavernosal invasion, a large tumor or some recurrences may require partial or total penectomy. The proposed operation should be explained in terms of what is removed, how urination will work and what reconstruction can realistically achieve.

For low-risk primary pathology, groin surveillance may be appropriate. Higher-risk disease, generally T1b or above, needs discussion of surgical nodal staging even when the examination is normal. Intermediate-risk T1a grade 2 disease requires individualized discussion, including fitness and ability to comply with close follow-up.

Dynamic sentinel-node biopsy maps the first draining nodes and can limit the extent of staging surgery. It should be performed by an experienced team, with further treatment if cancer is found. Where this service is unavailable, referral or an alternative inguinal dissection is discussed; a negative scan alone is not an equivalent replacement.

A palpable groin node can be inflammatory or malignant and usually needs tissue confirmation. Limited, mobile nodal disease is often managed with inguinal lymph-node dissection. The number of involved nodes and extranodal extension help determine whether pelvic surgery or additional treatment is needed.

Fixed bulky groin masses or pelvic nodal disease commonly need multimodal treatment. For fit patients, cisplatin- and taxane-based chemotherapy, such as TIP, may precede surgery; responding or nonprogressing resectable disease is then reassessed for consolidation. Starting with a large debulking operation is not automatically the best route.

Postoperative radiation or chemoradiation may be discussed for high-risk nodal findings. Evidence is less definitive than in common cancers, so the team should explain the expected local-control benefit, skin and lymphatic toxicity, and why that sequence fits the individual case.

For unresectable or distant metastatic disease, platinum-based chemotherapy remains an important option. The choice depends on previous treatment, kidney function, hearing, neuropathy, fitness and whether shrinkage could enable local treatment. Palliative radiation can help control bleeding, pain or a troublesome mass.

The HERCULES phase II study evaluated pembrolizumab plus platinum and fluorouracil in advanced penile squamous cancer. It showed antitumor activity, but was a small, single-arm study without a chemotherapy-only comparison. EPIC has also studied cemiplimab-based approaches. These findings support specialist or trial discussion, not a promise that adding immunotherapy improves survival for every patient.

Some patients qualify through a tumor-agnostic indication rather than a penile-cancer-specific approval. For example, US pembrolizumab covers eligible unresectable or metastatic MSI-H/dMMR tumors, or TMB-high tumors at the specified threshold, after prior-treatment progression with no satisfactory alternatives. Each label and test requirement must be checked. HPV or PD-L1 positivity alone is not the same qualification.

After partial surgery, urinary direction, sensitivity and intercourse may change. After total penectomy, a perineal urinary opening usually means sitting to urinate. Discuss the actual reconstruction plan and likely function before treatment; sexual rehabilitation and psychological support should be offered as part of care.

Groin-node treatment can cause wound problems, fluid collections and genital or leg lymphedema. Early referral for skin care, appropriate compression, exercise and specialist management is preferable to waiting for severe swelling. Fever, spreading redness, rapidly increasing swelling or inability to pass urine needs prompt assessment.

Follow-up checks both the treated penis and the groins; imaging is added according to nodal status and treatment history. Organ-preserving treatment needs careful local examination and prompt biopsy of suspicious changes. Learn what to look for between appointments and who to contact for a new lesion or groin lump.

Bring the biopsy and final pathology, p16/HPV findings if performed, operative and margin reports, groin sampling results, imaging and previous systemic treatment. Ask for separate explanations of the primary-tumor plan and the nodal plan, including why surveillance, sentinel biopsy or dissection is being proposed.

A second opinion is most useful when it can review both cancer control and function before an irreversible operation. It should not postpone assessment of a rapidly growing, bleeding or obstructing lesion.