Table of contents
Penile cancer
What's new
Updated 2024 ESMO/EURACAN guidelines for the diagnosis and management of penile cancer.
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of penile cancer are prepared by our editorial team based on guidelines from the European Association of Urology (EAU/ASCO 2024), the European Reference Network on Rare Adult Solid Cancers (EURACAN/ESMO 2024), and the European Society of Medical Oncology (ESMO 2013).
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Classification and risk stratification
Staging: as per ESMO/EURACAN 2024 guidelines, use the 2022 WHO, the UICC 8th edition, or the AJCC 8th edition systems for disease staging.
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use the WHO system for disease grading. B
TNM classification for penile cancer
Tumor classification
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Penile carcinoma in situ (intraepithelial neoplasia)
Ta: Noninvasive localized SCC
T1a. Tumor invasion (for glans: lamina propria; for foreskin: dermis, lamina propria, or dartos fascia; for shaft: connective tissue between epidermis and corpora regardless of location) without lymphovascular invasion or perineural invasion and is not high grade (grade 3 or sarcomatoid)
T1b: Tumor invasion (for glans: lamina propria; for foreskin: dermis, lamina propria, or dartos fascia; for shaft: connective tissue between epidermis and corpora regardless of location) with lymphovascular invasion and/or perineural invasion, or is high grade (grade 3 or sarcomatoid)
T2: Tumor invading into corpus spongiosum (either glans or ventral shaft) with or without urethral invasion
T3: Tumor invading into corpora cavernosum (including tunica albuginea) with or without urethral invasion
T4: Tumor invading into adjacent structures (scrotum, prostate, pubic bone)
Lymph node classification
Nx: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: ≤ 2 unilateral inguinal metastases, no extranodal extension
N2: ≥ 3 unilateral inguinal metastases or bilateral metastases
N3: Extranodal extension of lymph node metastases or pelvic lymph node metastases
Metastasis classification
M0: No distant metastasis
M1: Distant metastasis present
Stage cannot be fully assessed
Diagnostic investigations
Physical examination
As per ASCO/EAU 2024 guidelines:
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.
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Perform a physical examination of both groins. Record the number, laterality, and characteristics of any palpable/suspicious inguinal nodes.
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Diagnostic imaging
Imaging for staging
Diagnostic procedures
Medical management
General principles
As per ASCO/EAU 2024 guidelines:
Offer a balanced and individualized discussion on the benefits and harms of possible treatment options with the goal of shared decision-making.
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Provide penile cancer care as part of an extended multidisciplinary team comprising urologists specializing in penile cancer, specialist nurses, pathologists, uro-radiologists, nuclear medicine specialists, medical and radiation oncologists, lymphedema therapists, psychologists, counselors, palliative care teams for early symptom control, reconstructive surgeons, vascular surgeons, and sex therapists.
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Management of locoregional disease (stages Tis, Ta)
Management of locoregional disease (stages T1-2)
Management of locoregional disease (stage T3)
Management of advanced/metastatic disease
Management of lymph nodes
Management of recurrent disease
Therapeutic procedures
Perioperative care
Perioperative chemoradiotherapy: as per ASCO/EAU 2024 guidelines, offer induction chemotherapy followed by surgery in responders or chemoradiotherapy in patients with unresectable advanced primary lesions or locally advanced disease refusing surgical management.
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Intraoperative frozen section
Patient education
Follow-up and surveillance
Follow-up
As per ASCO/EAU 2024 guidelines:
Obtain clinical assessment for treatment effects after a treatment-free interval and perform a biopsy in case of doubt. Do not repeat topical treatment if it fails.
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Obtain follow-up in patients after penile cancer treatment initially every 3 months for 2 years, then less frequently to assess for recurrent disease and to offer patient support services through the extended multidisciplinary team. Advise self-examination at discharge with easy access back to the clinic, as local recurrence can occur late.
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