Cancer of the penis - A review of 50 patients
We reviewed the management of 50 patients with cancer of the penis treated between November 1983 and April 1995 at Tygerberg Hospital. The mean patient age was 54 years. The race of the patient was mixed in 40, white in 8 and black in 2 cases. Serological tests were positive for syphilis in 8/18 (44%), and for human immunodeficiency virus (HIV) in 2/11 patients (18%) who were tested. Only 1 patient had been circumcised (at puberty). Penectomy was performed in 45 patients - partial amputation in 29 cases and radical penectomy in 20 (in 4 of these after previous partial penectomy with positive margins). Complications of penectomy occurred in 9 patients (20%). The histology of the primary lesion was squamous carcinoma in 46, verrucous carcinoma in 3 and melanoma in 1 patient. Differentiation of the tumour was good in 24, moderate in 15 and poor in 8; the grade was not recorded in 3 cases. The pathological T stage was Tis in 1 patient, T1 in 5, T2 in 24, T3 in 17 and T4 in 3 cases. Inguinal lymphadenectomy was performed in 34 patients at a median interval of 72 days after penectomy. Complications after lymphadenectomy occurred in 26 of the 34 patients (76%), but a second operation was required in only 5 cases (15%). In patients without clinically palpable inguinal nodes, cancer was present in 2/8 (25%) specimens. In patients with clinically palpable inguinal nodes, metastases were present in 16/29 (55%) - in 4/16 (25%) of nodes clinically thought to be infective, and in 12/13 (92%) of nodes considered to be malignant. Lymph node metastases were present in 0/2 patients with T1, in 5/19 (26%) with 72, in 12/15 (80%) with T3 and in 3/3 (100%) with T4 tumours. At a mean follow-up of 22 months in 39 patients 62% were alive without evidence of disease, 23% were alive with carcinoma and 15% were dead. Death and recurrence or metastases were significantly more common in patients with T3 - 4 compared with T1 - 2 tumours, and in those with N1 - 3 compared to N0 disease, but tumour grade had no significant effect on outcome. Death and recurrence or metastases were also more common in cases where the surgical margin at penectomy was involved with tumour. In conclusion, our patients presented at a relatively young age with locally advanced tumours and a high incidence of inguinal lymph node metastases. In patients with locally advanced tumours we recommend ablative surgery with bilateral inguinal lymphadenectomy 6 - 8 weeks after penectomy. We avoid pelvic lymph node dissection, since this does not improve the prognosis, while increasing the risk of complications, especially lower limb oedema.