Overview
Definition:
Partial penectomy is the surgical removal of a portion of the penis, typically for localized cancer
Nodal management is a critical component of treatment, focusing on the assessment and management of lymph node involvement (metastasis) to determine prognosis and guide further therapy.
Epidemiology:
Penile cancer is rare in developed countries but more prevalent in certain regions like Africa, South America, and Asia
Incidence increases with age
Squamous cell carcinoma is the most common histology
Nodal status is the most important prognostic factor.
Clinical Significance:
Effective nodal management is paramount in improving survival rates for penile cancer patients
Undertreatment of nodal disease leads to increased recurrence and mortality, while overtreatment can result in significant morbidity
Proper staging and management strategies are crucial for informed clinical decision-making and successful outcomes.
Clinical Presentation
Symptoms:
Painless penile lesion or ulcer
Change in skin color or thickening
Penile discharge or bleeding
Swelling in the groin area (indicating lymphadenopathy)
Difficulty urinating
Pain localized to the penis or groin.
Signs:
Visible or palpable penile mass or ulceration
Enlarged, firm, and often fixed inguinal lymph nodes
Edema of the penis
Phimosis or paraphimosis
Palpable pelvic lymphadenopathy in advanced cases.
Diagnostic Criteria:
Diagnosis is based on a combination of clinical examination, biopsy of the penile lesion, and imaging to assess nodal status
Histological confirmation of squamous cell carcinoma is essential
Staging is performed according to TNM classification.
Diagnostic Approach
History Taking:
Detailed history of penile lesion onset, evolution, and symptoms
Past medical history, including HPV exposure, phimosis, and previous STIs
Smoking and sexual history are relevant
Family history of genitourinary cancers.
Physical Examination:
Thorough examination of the penis, including glans, shaft, and foreskin
Palpation of inguinal lymph nodes for size, consistency, mobility, and tenderness
Examination of the abdomen and pelvis for signs of distant metastasis or pelvic lymphadenopathy
Assessment of urinary stream and meatal patency.
Investigations:
Biopsy of penile lesion for histological diagnosis and grading
Ultrasound of inguinal lymph nodes with fine-needle aspiration cytology (FNAC) if enlarged
CT scan of abdomen and pelvis to assess nodal status and detect distant metastases
MRI of the penis for local staging
Chest X-ray or CT chest for pulmonary metastases
Tumor markers (e.g., SCC antigen) may have limited utility.
Differential Diagnosis:
Benign penile lesions (e.g., condyloma acuminatum, lichen sclerosus, psoriasis)
Sexually transmitted infections (e.g., syphilis, herpes)
Melanoma of the penis
Other cutaneous malignancies
Granulomatous diseases
Inflammatory conditions.
Management
Initial Management:
Biopsy of the primary penile lesion for definitive diagnosis
Radical excision of the primary tumor with adequate margins if indicated by staging
Initial assessment of inguinal nodal status is crucial before definitive lymphadenectomy.
Medical Management:
Adjuvant chemotherapy may be considered for high-risk nodal disease (e.g., multiple positive nodes, extracapsular extension)
Neoadjuvant chemotherapy can be used for unresectable nodal disease
Systemic treatment is generally reserved for metastatic disease.
Surgical Management:
Nodal management is predominantly surgical: 1
Sentinel Lymph Node Biopsy (SLNB): For clinically node-negative (cN0) patients with intermediate-risk primary tumors
2
Dynamic Sentinel Lymph Node Biopsy (DSNLB): Uses a radioactive tracer and gamma probe to identify and excise sentinel nodes
3
Inguinal Lymphadenectomy (ILND): Therapeutic ILND for clinically node-positive (cN+) patients or after positive SLNB
Can be superficial, deep, or modified
4
Pelvic Lymphadenectomy (PLND): Indicated for patients with multiple positive inguinal nodes, extracapsular extension, or positive pelvic nodes on imaging
Performed in conjunction with ILND.
Supportive Care:
Pain management
Wound care to prevent infection and promote healing
Lymphedema management and physiotherapy
Nutritional support
Psychological support for patients and their families
Management of sexual dysfunction.
Complications
Early Complications:
Wound infection
Wound dehiscence
Lymphocele formation
Seroma
Hematoma
Deep vein thrombosis (DVT).
Late Complications:
Chronic lymphedema of the lower extremities and scrotum
Skin necrosis
Chronic pain
Sexual dysfunction (erectile dysfunction, altered sensation).
Prevention Strategies:
Meticulous surgical technique
Appropriate use of drains
Compression stockings and early ambulation to prevent DVT
Careful wound closure
Prophylactic antibiotics
Adherence to physiotherapy protocols for lymphedema.
Prognosis
Factors Affecting Prognosis:
Nodal status (number of positive nodes, extracapsular extension)
Histological grade of the primary tumor
Presence of lymphovascular invasion
Stage of the primary tumor
Response to neoadjuvant chemotherapy if administered.
Outcomes:
Five-year survival rates are excellent (>90%) for node-negative patients
Survival decreases significantly with positive lymph nodes: ~70-80% for one positive node, ~30-50% for multiple positive nodes or extracapsular extension
Distant metastasis portends a poor prognosis.
Follow Up:
Regular clinical examination of the penis and groin
Imaging (ultrasound, CT) to monitor for recurrence or metastasis
Frequency of follow-up depends on stage and nodal status, typically every 3-6 months for the first 2-3 years, then annually
Long-term surveillance is essential.
Key Points
Exam Focus:
Nodal status is the single most important prognostic factor in penile cancer
DSNLB is the preferred method for staging clinically node-negative patients with intermediate-risk disease
Inguinal lymphadenectomy is indicated for clinically positive nodes or after positive SLNB
Pelvic lymphadenectomy is reserved for high-risk inguinal nodal disease.
Clinical Pearls:
Palpable inguinal lymphadenopathy in a patient with penile lesion warrants high suspicion for metastasis
Do not hesitate to perform a biopsy or FNAC on suspicious nodes
Modified inguinal lymphadenectomy can reduce morbidity while maintaining oncological control in selected cases.
Common Mistakes:
Underestimating the significance of even small, non-tender inguinal lymph nodes
Inadequate oncological margins during primary tumor resection
Performing unnecessary pelvic lymphadenectomy in low-risk nodal disease
Delayed referral to a specialized center for management
Inadequate follow-up leading to missed recurrences.