Surgical options for advanced penile cancer
Thursday, 19 March 2009- There are a number of treatment options for advanced penile carcinoma but surgery has a primary role in the treatment of difficult cases. Surgery in combination with chemo-radiation therapy can not only improve quality of life but also improve survival in this difficult group of patients, according to Mr. Suks Minhas, consultant uro-andrologist (UK) during a sub-plenary session at the 24thAnnual EAU Congress in Stockholm.
Minhas said early diagnosis and treatment of penile cancer is crucial to preserving cosmesis and function, and therefore reducing psychological morbidity but oncological safety should not be compromised. In this respect, early cancer clearance has a significant impact on survival.
Treatment of advanced penile cancer is a difficult problem. These patients are usually elderly and of poor performance status and therefore treatment options can be limited. Traditionally many of these patients were treated with palliative chemo-radiation. There is however increasing evidence that multi-modal therapy and surgical resection may be a therapeutic option in this difficult group of patients.
Advanced surgical cancers can either be locally advanced, which includes T2, T3 or T4 lesions, or regionally advanced, including N2, N3 or M1 disease. This is in reference to the TNM staging. Surgical principles are, as in any type of reconstructive surgery, that the surgery should be undertaken by a dedicated genital reconstructive surgeon. The surgeon should understand the principles of reconstruction and be familiar with the use of local or free flaps, including full-thickness and split-thickness grafts.
Each case must be discussed in depth at a local MDT, such that an informed decision can be made with the patient discussing all aspects of treatment, including palliative care. In those patients of good performance status who wish to proceed with surgery, surgery can either be performed prior to chemotherapy or, alternatively, surgical debulking can be performed initially.
Minhas opined that radiation therapy should only be used after surgical debulking, as this makes any attempt at surgical consolidation extremely difficult. Localised staging with a gadolinium enhanced MRI scan following intra-cavernosal injection of PGE1 is often useful in staging advanced tumours. In many instances where it is clinically deemed that total amputation may be the only option, following penile MRI scanning, it is often possible to preserve the penis with a variety of reconstructive techniques.
Reconstructive techniques to gain penile length and reconstruct the penis include penile lengthening procedures such as dividing the suspensory ligament and fixing the neophallus to the base of the pubis. Furthermore, a neoglans and shaft can be created by use of full-thickness and split-thickness skin grafts.
In those patients whose tumours are invading the shaft of the penis and are young, or alternatively palliative procedures are being performed, the tunica can be reconstructed using various bio-materials including pelvicol. Again, a neophallus is created using full-thickness and split-thickness skin grafts.
In many instances patients will present with N2/N3 disease. In these cases, tumour bulk within the groin basin may be very large and radical lympadenectomy is undertaken. Wound closure is achieved utilising advancement flaps, sartorius muscle flap transposition and vertical rectus abdominis flaps. Quality of life can be improved in patients undergoing palliative resection and at the same time surgery may be curative in a number of these patients. Those patients with an extensive regional tumour burden with subcutaneous metastases can also be treated in a very similar fashion.