Penile Cancer
Publication Date: March 9, 2023
Last Updated: March 30, 2023
Pathology
Summary of Evidence and Guidelines for the Pathological Assessment of Tumour Specimens
Summary of evidence
Incidence of penile cancer varies according to geographical location, race and ethnicity. (, 2a)
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Western developed countries have seen a slight increase in incidence, which may be caused by higher HPV infection rates. (, 2a)
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In analogy to other HPV-associated cancers, HPV status may influence disease-specific survival (DSS) of penile cancer, but more data is needed, underlining the importance of routine assessment of HPV status in all penile cancer patients. (, 2b)
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Recommendations
The pathological evaluation of penile carcinoma specimens must include the pTNM (see page 8: Classification Systems) stage and an assessment of tumour grade. (S, )
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The pathological evaluation of penile carcinoma specimens must include an assessment of p16 by IHC. (S, )
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The pathological evaluation of penile carcinoma specimens should follow the International Collaboration on Cancer Reporting (ICCR) dataset synoptic report. (S, )
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Classification Systems
Cancer Stage Grouping
Summary of Evidence and Guidelines for the Diagnosis and Staging of Penile Cancer
Summary of evidence
For distinguishing T1 from T2 disease, magnetic resonance imaging (MRI) does not outperform clinical staging. (, 2b)
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For predicting corporal invasion (T3 disease), MRI showed a pooled sensitivity and of 80% (95% confidence interval [CI]: 70–87%) and 96% (95% CI: 85–99%), respectively. (, 2b)
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MRI with and without artificial erection showed similar accuracy in local staging. (, 2b)
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Computed tomography (CT), positron emission tomography/computed tomography (PET/CT) and MRI imaging cannot detect micro-metastases and are therefore of limited value in clinically node-negative (cN0) patients in which the aim is to identify small sub-clinical LN metastasis. (, 2a)
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Inguinal ultrasound (US) + fine needle aspiration cytology (FNAC) of sonographically abnormal nodes can reduce the need of dynamic sentinel node biopsy (DSNB) when tumour positive, allowing for earlier therapeutic treatment of node-positive disease. (, 2a)
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For surgical staging of cN0 patients, DSNB has shown a high diagnostic accuracy. (, 2a)
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Sentinel node biopsy has been shown to lower complication rates compared to modified-, superficial-, or video-endoscopic inguinal LND. (, 2b)
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Imaging with flourine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18FDG-PET/CT) in clinically node-positive (cN+) patients showed higher sensitivity/specificity than CT alone in the pre-operative staging of the pelvic LNs and distant metastasis. (, 2b)
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Recommendations
Primary tumour
Perform a detailed physical examination of the penis and external genitalia, recording morphology, size and location of the penile lesion, including extent and invasion of penile (adjacent) structures. (S, )
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Perform MRI of the penis/primary tumour (artificial erection not mandatory) when there is uncertainty regarding corporal invasion and/or the feasibility of (organ-sparing) surgery. If MRI is not available, offer US as alternative option. (W, )
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Obtain a pre-treatment biopsy of the primary lesion when malignancy is not clinically obvious, or when non-surgical treatment of the primary lesion is planned (e.g., topical agents, laser, radiotherapy). (S, )
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Inguinal LNs
Perform a physical examination of both groins. Record the number, laterality and characteristics of any palpable/suspicious inguinal nodes. (S, )
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Clinically node-negative (cN0)
If there are no palpable/suspicious nodes (cN0) at physical examination, offer surgical LN staging to all patients at high risk of having micro-metastatic disease (T1b or higher). (S, )
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In case of T1a G2 disease, also discuss surveillance as an alternative to surgical staging with patients willing to comply with strict follow-up. (W, )
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When surgical staging is indicated, offer DSNB. If DSNB is not available and referral is not feasible, or if preferred by the patient after being well informed, offer inguinal lymph node dissection (ILND) (open or video-endoscopic). (S, )
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If DSNB is planned, perform inguinal US first, with fine needle aspiration cytology (FNAC) of sonographically abnormal LNs. (S, )
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Clinically node-positive (cN+)
If there is a palpable/suspicious node at physical examination (cN+), obtain (image-guided) biopsy to confirm nodal metastasis before initiating treatment. (S, )
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In cN+ patients, stage the pelvis and exclude distant metastases with 18F-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG-PET) CT or CT of the chest and abdomen before initiating treatment. (S, )
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Overview
Title
Penile Cancer
Authoring Organizations
American Society of Clinical Oncology
European Association of Urology