In!. J. Radiation
Oncology
Bid.
Phys..
1976. Vol.
1. pp. 10694073.
Pergamon
Press.
Printed
in the U.S.A.
CARCINOMA OF THE PENIS? SRIPRAYOONPRASASVINICHAI,M.D., HAROLD SCHNEIDER, B.S. and LUTHER W. BRADY, M.D. Department of Radiation Therapy and Nuclear Medicine, Hahnemann Medical College and Hospital, Philadelphia, PA 19102, U.S.A. The emphasis of this report is on the role of radiation therapy in the management of carcinoma of the penis. The 5 year results are comparable with the results of surgefl-‘O (Tables 1 and 2). Radiation therapy is superior from a cosmetic, functional and psychological point of vbw. Surgery should be reserved exclusively for recurrence of the disease. Treatment of ingufnal regions should be included fn the initial pfan of treatment. Prophylactic nodal treatment is urged strongly for unreliable patients or patients with massive primary lesions. Penis, Penile carcinoma, Radiation therapy.
INTRODUCTION Cancer of the penis is an uncommon disease in the United States; it is diagnosed in 0.3-0.5% of the male population at risk; uncircumcised males have a higher incidence.’ The incidence increases to 15% in countries where circumcision is not practiced. Since this disease occurs primarily in the uncircumcised male population, it may be related to a cultural practice rather than a racial background or genetic origin. Penile carcinoma can be obliterated if proper circumcision is performed at birth, or shortly after birth, or if careful hygiene is practiced.’ Carcinoma of the penis is a radiocurable disease. When administered properly, radiation therapy offers local control of the disease and preservation of penile function. Although it can be controlled locally by surgery in many instances, this is a traumatic, psychological affront to the patient. Because of the rarity of this disease, the number of reportable cases is small. It is difficult to ascertain from the literature, the recommended choice of treatment for the best end result. Hardner and Woodruff, in 1967, recommended penectomy and bilateral inguinal dissection as the treatment of choice.” On the other hand, Table 1 shows that experience among the European centers advocates radiation therapy as the modality of choice.
METHODS AND MATERIALS From January 1960 to December 1974, 15 patients with cancer of the penis were treated and followed until death. No patient was lost to follow up. All cases were staged according to Jackson, 1966.’
tThis paper was supported by PHS Research Grants Nos. l-RIO-CA12252 and 5-RIO-CA12478 from the National Cancer Institute. by PHS Center
Grant No. I-POl-CA14043 from the National Cancer Institute, by the Friends of the Radiation Therapy Center, and by the Alperin Foundation. 1089
Review of the literature shows that cases have been treated over an extended period of time with a multiple array of different radiation techniques and dosages. The dosage that was suggested most frequently was too low to guarantee control of the cancer; this probably is one of the causes for a rather high incidence of local recurrence and/or persistent tumor. The present report deals with 15 patients, staged and treated accordingly at the Hahnemann Medical College and Hospital.
Stage I Stage II Stage III Stage IV
Case
Tumor limited to glans penis and/or prepuce. Tumor extending onto shaft of penis. Tumor with malignant but operable inguinal nodes. Primary tumor extending off shaft of penis and/or cases with inoperable nodes or distant metastasis.
distribution
according
to stages
is
1070
Radiation Oncology 0 Biology 0 Physics
November-December
Table 1.Cancer of the penis-radiation
Treatment
Norwegian Radium Hospital’ Stage I Updated Report* Hammersmith Hospital” Manchester Hospital’ Royal Marsden Hospital’ Radiumhemmet4 Total
No. of patients
No. patients alive without disease after 5 years
%
36 46 28 59 44 6
32 29 22 39 24 4
89 63 80 66 54 66
219
1.50
68
Table 2. Cancer of the penis-surgical
Stage
therapy 5 year survival rates
No. of patients
center
1976. Vol. I, No. It and No. 12
treatment 5 year survival rates
Alive No. %
CApenis
Dead Other causes
I and II III IV
60 9 3
32 2 0
53 22 0
14 4 3
14 3 0
Totals
72
34
49
21
17
Derrick, 1973.3 outlined below. Of the IS, 10 were Caucasian and 5 were Negroid. The age range was from 33 to 74 years; 3 patients were 30-39 years; 3 were 40-49 years; 2 were 50-59 years; 4 were 50-69 years and 3 were 70-79 years. Most patients presented with a painless mass or ulcer on the penis, with or without draining, discharge or bleeding. All patients had the diagnosis of squamous cell carcinoma. Of these 15 patients, the glans was involved in 10 patients, inguinal nodes in 5, prepuce in 4, shaft in 3 and urethra in 1. In some cases more than one site of the penis was involved. The majority of the patients in our series had surgery as a part of the treatment program (Table 3). Surgical procedures varied from total penectomy? partial penectomy,’ wide excision of the lesion;’ permanent perineal urethrostomy and cystostomy,’ or only biopsy.3 Radiation therapy to the primary was uniform in character. Four of 5 cases were treated on the 6 MV linear accelerator utilizing parallel opposed fields to the whole shaft of
Table 3. Cancer of the penis. Modality of treatment of primary lesion Treatment Surgery Radiation
No. patients 10 5
the penis. A plastic applicator was developed which allows for support and stabilization of the penis during the treatment and serves as the bolus to homogenized radiation dose distribution (Fig. 1). The radiation dose was 6000-6500rad in 7-8 weeks calculated as a tumor dose minimum. Both fields were treated each day, 5 days per week. The total dose was dictated by the resolution of tumor as well as the confluent reaction of surrounding normal tissue. The fifth case was treated by a radium plaque to the primary at another institution and referred to the Hahnemann Medical College and Hospital for treatment of recurrent tumor.
Carcinomaof thepenis 0 S.
PRASASVINICHAI et al.
1071
Fig. 1. Plastic applicator for stabilization and support of the penis during treatment.
A total of 5 pateints presented with inguinal node involvement (Stage III); in 3 of the 5 cases, inguinal nodes were treated by surgery alone. One was irradiated preoperatively. Another was treated by radiation alone. Surgical procedures varied from bilateral radical inguinal node dissection to unilateral inguinal node dissection. In 1 of 3 patients, whose inguinal nodes were treated initially by surgery, recurrent disease appeared in the inguinal region as well as multiple cutaneous and subcutaneous metastases in the scrotal area. He received radiation therapy and chemotherapy to no avail. He died 1 month after recurrence and 9 months after diagnosis. Two patients were treated later when metastatic inguinal nodes were evident. A total of 5 patients were treated by radiation therapy to the inguinal region. Of these 5, 1 was treated on the basis of Stage III disease, 1 on prophylactic basis. 1 by preoperative radiation treatment; 2 were treated when metastasis was evident. Nodes were not treated in 5 cases. When inguinal nodes were treated by radiation on a prophylactic basis, treatment was given with a single anterior portal directed towards each inguinal area. Either a 6 MV photon beam or 11 MeV electrons were used. Wax bolus was placed on the skin when photon beam was used to bring the maximum
dose to the skin. Tumor dose was calculated at 4 or 5 cm depth according to the patient’s measurements. If electrons were used, dosage was calculated at the 80% isodose line. The recommended dose was 5000-6000 rad tumor dose minimum in 6-7 weeks. If inguinal nodes were palpable, treatment was given to both inguinal and pelvic regions. The whole pelvis was. treated through a four field summated technique (anterior and posterior parallel opposing fields and left and right lateral opposing fields), using a 6 MV photon beam. A homogeneous dose of 6000 rad in 6 weeks was delivered to the pelvic volume. Inguinal areas were boosted with single anterior field to each side. The minimum 5boo to 6000 rad tumor dose was given in 6-7 weeks. RESULTS Table 4 summarizes those patients who are free of disease in correlation to treatment and length of survival. The survival period ranged from 5 months to 12 years. Patients whose nodes were not treated as a primary plan (patients 3, 7, 14) have not been followed long enough for evaluation except for patient 15. This patient was treated by radium plaque to the primary in May 1960. Recurrent disease was found and re-treated in November 1960, again with radium plaque only to the primary. In August
1072
Radiation
Oncology
0
Biology 0 Physics
Table 4. Cancer of the penis-patients of disease Patient No.
Stage
1 2 3 6 7 13 14 15
III III I II I III I I
Initial treatment Primary Nodes
: S&R S R S R R
S S -R&S -R ---
alive free
Survival
(months) 31 81 8 7 10 5 17 144
S = Surgery; R = Radiation Therapy; -- = No treatment to regional nodes.
1961, this same patient developed another recurrence necessitating partial penectomy. Bilateral inguinal node dissection was performed at this time. All nodes were negative for metastasis. A total of 6 patients expired with disease (Table 5). In all but one the primary was treated by surgery. In 2 cases, inguinal nodes were treated as part of primary program, 1 by surgery and 1 by radiotherapy. All patients died within 2 years, except for patient 9, who lived for 3 years, when an inguinal node metastasis developed. The patient was treated by an incomplete surgical dissection and post-operative radiotherapy; 4 months later, metastases to the chest wall and right axilla developed. He was treated with 5-fluorouracil and expired in October 1%8, 4.25 years after diagnosis. All patients who died with disease in this Table
5. Cancer
No. 5 ; 10 11 12
Stage II I I I III II
of the penis-patients with disease Initial treatment Primary Nodes S S
R __
; S R
1: S --
S = Surgery; R = Radiation Therapy: -- = No treatment to regional nodes.
expired
Survival (months) 14 16 51 15 9 9
November-December 1976, Vol. 1. No. II and No. 12
series, expired either with local persistent disease (cutaneous or inguinal lymph node metastasis). None of these cases had documented lung or liver metastasis. There were no significant complications from radiation treatment (phimosis, ulceration, stricture, etc.). One patient was killed in an accident, without recurrent cancer 8.25 years after diagnosis. DISCUSSION Squamous cell carcinoma is the most common cell type for carcinoma of the penis and is a radiocurable disease. Radiation therapy, administered with attention to the primary and the pathways of excursion of lymph nodes, is documented as the preferred treatment for this disease. Utilizing supervoltage external photon beam techniques to the primary lesion, a minimum tumor dose of 6000 rad in 6-7 weeks is required to eradicate the local disease. Most of the lesions will have deep lymphatic involvement; brachytherapy will not provide treatment technique homogeneity of the dosage and may give rise to “hot” or “cold” spots leading to necrosis or recurrent disease. With the radiation technique used to treat the Hahnemann patients, there have been no significant complications or side effects. Because of the superior cosmetic, functional and psychological results from radiation treatment, emphasis should be on this program in the management of this disease. On the basis of accumulated data, surgery should be reserved for recurrent tumors.” Radiation therapy failure does not diminish the patient’s opportunity for cure, since surgery can be performed at that time without serious complication. There is no statistical increase in the chance for spread of the disease if radiation is utilized at the onset, since the incidence of spread usually is delayed. It is strongly emphasized that the patient’s prognosis is not jeopardized, if radiation treatment fails.‘.’ Staging laparotomy or lymphangiogram to evaluate pelvic and periaortic nodes should be considered seriously in all patients with penile cancer since recent data show a significant
Carcinomaof thepenis 0 S. PRASASVINICHN et nl.
incidence of positive studies. Management of the patients with positive studies would be quite different from those with negative studies. If periaortic nodes are positive, treatment should be palliative since inguinal node dissection would be fruitless. If pelvic nodes are positive, radiation therapy is the treatment program to be followed with treatment being directed to the primary and pelvic nodes by photon beam and to the inguinal nodes by electron beam or a combination of electron and photon beams. But, if pelvic and periaortic nodes are negative, prophylactic inguinal node treatment is encouraged on unreliable patients or when the primary lesion is massive.” However, management of histologically positive lymph nodes must be individualized. It may be surgery or radiation therapy alone, or a combination of the two modalities.” Carcinoma of the penis is a curable disease, if managed properly. However, if death or recurrence occurs, it will occur within 2 years after the initial treatment. The literature correlates well with our series3 All patients (except Case 9) whose inguinal nodes were not treated initially returned within 2 years for treatment of metastatic inguinal nodes. This group of patients did not respond well to
whether surgical or radiation treatment, therapy. These patients expired within 1 year after the diagnosis of metastatic inguinal nodes was established.
1073
Patients who develop recurrent or metastatic inguinal nodes after initial treatment programs for the primary problem do not appear to be salvageable. On the other hand, patients who develop recurrence of the primary itself are salvageable. Therefore, on the basis of our experience and the data in the literature, it is strongly recommended that inguinal nodal treatment be included in the initial treatment plan.
RECOMMENDED TREATMENT PROGRAM Stage I and II. Megavoltage radiation treatment to the whole shaft of the penis with parallel opposing fields using the above mentioned applicator. The tumor dose should be homogeneous with a tumor dose minimum of 6000-7OOOrad in 6-7 weeks. Prophylactic treatment should be given to both inguinal regions utilizing single anterior portals to each area. Tumor dose should be calculated to 4 or 5cm depth, delivering 4000-5000 rad minimum in 5 weeks using megavoltage photon energy or electron beam. Stage III. Treatment to the primary should be given as above. Inguinal nodes may be treated by surgery or radiation therapy. Pelvic node treatment should be given routinely. Stage IV. Only palliative treatment is recommended. Chemotherapy may be considered.
REFERENCES 1. Alexander, L.L., Medina, A., Benninghaff, D.L., Camiel, M.R.: Cancer of the penis. radiation therapy or surgery. J. Natn Med. Assoc. &l(6): 533-536, Nov. 1972. 2. Dagher, R.. Selzer, M.L. Lapides, J.: Carcinema of the penis and anticircumcision crusade. J. Ural. 110: 79-80, July 1973. 3. Derrick, F.C., Lynch, K.M., Kretkowski, R.C., Yanbrough, W.J.: Epidermoid carcinoma of the penis-computer analysis of 87 cases. J. Ural.
7. 8.
9. 10.
110: 303-305, 1973. 4. Eckstrom, T.. Edsmur, F.: Cancer of the penis. Acta. Clin. Scandinou. 115: 25-45, 1958.
5. Englestad, R.B.: Treatment of cancer of penis at Norwegian Radium Hospital. Am. J. Roentgenol. 60: 801-806, 1948. 6. Hardner, G.J., Woodruff. M.W.: Operation
11. 12.
management of carcinoma of penis. J. Ural. 98: 487-492, 1967. Jackson, S.M.: Treatment of carcinoma of penis. Br. J. Surg. 53: 33-35, 1%6. Kundsen, OS., Brennhood, 1.0.: Radiotherapy in treatment of primary tumor in penile cancer. Acta. Clinic. Scandinov. 133: 69-71, 1%7. Lederman, M.: Radiotherapy of cancer of penis. Br. J. Ural. 25: 224-232. 1953. Newaishy, G.A., Deeley, T.J.: Radiotherapy in treatment of carcinoma of penis. Br. J. Radiol. 41: 519-521, 1968. Uehling, D.T.: Staging laparotomy for carcinoma of penis. J. Ural. 110: 213-215,Aug. 1973. Vaeth, J.M., Green, J.P., Lowey, R.O.: Radiation therapy of carcinoma of the penis. Am. J. Roentgenol. 108(l); 130-135, 1970.
Oncology
Bid.
Phys..
1976. Vol.
1. pp. 10694073.
Pergamon
Press.
Printed
in the U.S.A.
CARCINOMA OF THE PENIS? SRIPRAYOONPRASASVINICHAI,M.D., HAROLD SCHNEIDER, B.S. and LUTHER W. BRADY, M.D. Department of Radiation Therapy and Nuclear Medicine, Hahnemann Medical College and Hospital, Philadelphia, PA 19102, U.S.A. The emphasis of this report is on the role of radiation therapy in the management of carcinoma of the penis. The 5 year results are comparable with the results of surgefl-‘O (Tables 1 and 2). Radiation therapy is superior from a cosmetic, functional and psychological point of vbw. Surgery should be reserved exclusively for recurrence of the disease. Treatment of ingufnal regions should be included fn the initial pfan of treatment. Prophylactic nodal treatment is urged strongly for unreliable patients or patients with massive primary lesions. Penis, Penile carcinoma, Radiation therapy.
INTRODUCTION Cancer of the penis is an uncommon disease in the United States; it is diagnosed in 0.3-0.5% of the male population at risk; uncircumcised males have a higher incidence.’ The incidence increases to 15% in countries where circumcision is not practiced. Since this disease occurs primarily in the uncircumcised male population, it may be related to a cultural practice rather than a racial background or genetic origin. Penile carcinoma can be obliterated if proper circumcision is performed at birth, or shortly after birth, or if careful hygiene is practiced.’ Carcinoma of the penis is a radiocurable disease. When administered properly, radiation therapy offers local control of the disease and preservation of penile function. Although it can be controlled locally by surgery in many instances, this is a traumatic, psychological affront to the patient. Because of the rarity of this disease, the number of reportable cases is small. It is difficult to ascertain from the literature, the recommended choice of treatment for the best end result. Hardner and Woodruff, in 1967, recommended penectomy and bilateral inguinal dissection as the treatment of choice.” On the other hand, Table 1 shows that experience among the European centers advocates radiation therapy as the modality of choice.
METHODS AND MATERIALS From January 1960 to December 1974, 15 patients with cancer of the penis were treated and followed until death. No patient was lost to follow up. All cases were staged according to Jackson, 1966.’
tThis paper was supported by PHS Research Grants Nos. l-RIO-CA12252 and 5-RIO-CA12478 from the National Cancer Institute. by PHS Center
Grant No. I-POl-CA14043 from the National Cancer Institute, by the Friends of the Radiation Therapy Center, and by the Alperin Foundation. 1089
Review of the literature shows that cases have been treated over an extended period of time with a multiple array of different radiation techniques and dosages. The dosage that was suggested most frequently was too low to guarantee control of the cancer; this probably is one of the causes for a rather high incidence of local recurrence and/or persistent tumor. The present report deals with 15 patients, staged and treated accordingly at the Hahnemann Medical College and Hospital.
Stage I Stage II Stage III Stage IV
Case
Tumor limited to glans penis and/or prepuce. Tumor extending onto shaft of penis. Tumor with malignant but operable inguinal nodes. Primary tumor extending off shaft of penis and/or cases with inoperable nodes or distant metastasis.
distribution
according
to stages
is
1070
Radiation Oncology 0 Biology 0 Physics
November-December
Table 1.Cancer of the penis-radiation
Treatment
Norwegian Radium Hospital’ Stage I Updated Report* Hammersmith Hospital” Manchester Hospital’ Royal Marsden Hospital’ Radiumhemmet4 Total
No. of patients
No. patients alive without disease after 5 years
%
36 46 28 59 44 6
32 29 22 39 24 4
89 63 80 66 54 66
219
1.50
68
Table 2. Cancer of the penis-surgical
Stage
therapy 5 year survival rates
No. of patients
center
1976. Vol. I, No. It and No. 12
treatment 5 year survival rates
Alive No. %
CApenis
Dead Other causes
I and II III IV
60 9 3
32 2 0
53 22 0
14 4 3
14 3 0
Totals
72
34
49
21
17
Derrick, 1973.3 outlined below. Of the IS, 10 were Caucasian and 5 were Negroid. The age range was from 33 to 74 years; 3 patients were 30-39 years; 3 were 40-49 years; 2 were 50-59 years; 4 were 50-69 years and 3 were 70-79 years. Most patients presented with a painless mass or ulcer on the penis, with or without draining, discharge or bleeding. All patients had the diagnosis of squamous cell carcinoma. Of these 15 patients, the glans was involved in 10 patients, inguinal nodes in 5, prepuce in 4, shaft in 3 and urethra in 1. In some cases more than one site of the penis was involved. The majority of the patients in our series had surgery as a part of the treatment program (Table 3). Surgical procedures varied from total penectomy? partial penectomy,’ wide excision of the lesion;’ permanent perineal urethrostomy and cystostomy,’ or only biopsy.3 Radiation therapy to the primary was uniform in character. Four of 5 cases were treated on the 6 MV linear accelerator utilizing parallel opposed fields to the whole shaft of
Table 3. Cancer of the penis. Modality of treatment of primary lesion Treatment Surgery Radiation
No. patients 10 5
the penis. A plastic applicator was developed which allows for support and stabilization of the penis during the treatment and serves as the bolus to homogenized radiation dose distribution (Fig. 1). The radiation dose was 6000-6500rad in 7-8 weeks calculated as a tumor dose minimum. Both fields were treated each day, 5 days per week. The total dose was dictated by the resolution of tumor as well as the confluent reaction of surrounding normal tissue. The fifth case was treated by a radium plaque to the primary at another institution and referred to the Hahnemann Medical College and Hospital for treatment of recurrent tumor.
Carcinomaof thepenis 0 S.
PRASASVINICHAI et al.
1071
Fig. 1. Plastic applicator for stabilization and support of the penis during treatment.
A total of 5 pateints presented with inguinal node involvement (Stage III); in 3 of the 5 cases, inguinal nodes were treated by surgery alone. One was irradiated preoperatively. Another was treated by radiation alone. Surgical procedures varied from bilateral radical inguinal node dissection to unilateral inguinal node dissection. In 1 of 3 patients, whose inguinal nodes were treated initially by surgery, recurrent disease appeared in the inguinal region as well as multiple cutaneous and subcutaneous metastases in the scrotal area. He received radiation therapy and chemotherapy to no avail. He died 1 month after recurrence and 9 months after diagnosis. Two patients were treated later when metastatic inguinal nodes were evident. A total of 5 patients were treated by radiation therapy to the inguinal region. Of these 5, 1 was treated on the basis of Stage III disease, 1 on prophylactic basis. 1 by preoperative radiation treatment; 2 were treated when metastasis was evident. Nodes were not treated in 5 cases. When inguinal nodes were treated by radiation on a prophylactic basis, treatment was given with a single anterior portal directed towards each inguinal area. Either a 6 MV photon beam or 11 MeV electrons were used. Wax bolus was placed on the skin when photon beam was used to bring the maximum
dose to the skin. Tumor dose was calculated at 4 or 5 cm depth according to the patient’s measurements. If electrons were used, dosage was calculated at the 80% isodose line. The recommended dose was 5000-6000 rad tumor dose minimum in 6-7 weeks. If inguinal nodes were palpable, treatment was given to both inguinal and pelvic regions. The whole pelvis was. treated through a four field summated technique (anterior and posterior parallel opposing fields and left and right lateral opposing fields), using a 6 MV photon beam. A homogeneous dose of 6000 rad in 6 weeks was delivered to the pelvic volume. Inguinal areas were boosted with single anterior field to each side. The minimum 5boo to 6000 rad tumor dose was given in 6-7 weeks. RESULTS Table 4 summarizes those patients who are free of disease in correlation to treatment and length of survival. The survival period ranged from 5 months to 12 years. Patients whose nodes were not treated as a primary plan (patients 3, 7, 14) have not been followed long enough for evaluation except for patient 15. This patient was treated by radium plaque to the primary in May 1960. Recurrent disease was found and re-treated in November 1960, again with radium plaque only to the primary. In August
1072
Radiation
Oncology
0
Biology 0 Physics
Table 4. Cancer of the penis-patients of disease Patient No.
Stage
1 2 3 6 7 13 14 15
III III I II I III I I
Initial treatment Primary Nodes
: S&R S R S R R
S S -R&S -R ---
alive free
Survival
(months) 31 81 8 7 10 5 17 144
S = Surgery; R = Radiation Therapy; -- = No treatment to regional nodes.
1961, this same patient developed another recurrence necessitating partial penectomy. Bilateral inguinal node dissection was performed at this time. All nodes were negative for metastasis. A total of 6 patients expired with disease (Table 5). In all but one the primary was treated by surgery. In 2 cases, inguinal nodes were treated as part of primary program, 1 by surgery and 1 by radiotherapy. All patients died within 2 years, except for patient 9, who lived for 3 years, when an inguinal node metastasis developed. The patient was treated by an incomplete surgical dissection and post-operative radiotherapy; 4 months later, metastases to the chest wall and right axilla developed. He was treated with 5-fluorouracil and expired in October 1%8, 4.25 years after diagnosis. All patients who died with disease in this Table
5. Cancer
No. 5 ; 10 11 12
Stage II I I I III II
of the penis-patients with disease Initial treatment Primary Nodes S S
R __
; S R
1: S --
S = Surgery; R = Radiation Therapy: -- = No treatment to regional nodes.
expired
Survival (months) 14 16 51 15 9 9
November-December 1976, Vol. 1. No. II and No. 12
series, expired either with local persistent disease (cutaneous or inguinal lymph node metastasis). None of these cases had documented lung or liver metastasis. There were no significant complications from radiation treatment (phimosis, ulceration, stricture, etc.). One patient was killed in an accident, without recurrent cancer 8.25 years after diagnosis. DISCUSSION Squamous cell carcinoma is the most common cell type for carcinoma of the penis and is a radiocurable disease. Radiation therapy, administered with attention to the primary and the pathways of excursion of lymph nodes, is documented as the preferred treatment for this disease. Utilizing supervoltage external photon beam techniques to the primary lesion, a minimum tumor dose of 6000 rad in 6-7 weeks is required to eradicate the local disease. Most of the lesions will have deep lymphatic involvement; brachytherapy will not provide treatment technique homogeneity of the dosage and may give rise to “hot” or “cold” spots leading to necrosis or recurrent disease. With the radiation technique used to treat the Hahnemann patients, there have been no significant complications or side effects. Because of the superior cosmetic, functional and psychological results from radiation treatment, emphasis should be on this program in the management of this disease. On the basis of accumulated data, surgery should be reserved for recurrent tumors.” Radiation therapy failure does not diminish the patient’s opportunity for cure, since surgery can be performed at that time without serious complication. There is no statistical increase in the chance for spread of the disease if radiation is utilized at the onset, since the incidence of spread usually is delayed. It is strongly emphasized that the patient’s prognosis is not jeopardized, if radiation treatment fails.‘.’ Staging laparotomy or lymphangiogram to evaluate pelvic and periaortic nodes should be considered seriously in all patients with penile cancer since recent data show a significant
Carcinomaof thepenis 0 S. PRASASVINICHN et nl.
incidence of positive studies. Management of the patients with positive studies would be quite different from those with negative studies. If periaortic nodes are positive, treatment should be palliative since inguinal node dissection would be fruitless. If pelvic nodes are positive, radiation therapy is the treatment program to be followed with treatment being directed to the primary and pelvic nodes by photon beam and to the inguinal nodes by electron beam or a combination of electron and photon beams. But, if pelvic and periaortic nodes are negative, prophylactic inguinal node treatment is encouraged on unreliable patients or when the primary lesion is massive.” However, management of histologically positive lymph nodes must be individualized. It may be surgery or radiation therapy alone, or a combination of the two modalities.” Carcinoma of the penis is a curable disease, if managed properly. However, if death or recurrence occurs, it will occur within 2 years after the initial treatment. The literature correlates well with our series3 All patients (except Case 9) whose inguinal nodes were not treated initially returned within 2 years for treatment of metastatic inguinal nodes. This group of patients did not respond well to
whether surgical or radiation treatment, therapy. These patients expired within 1 year after the diagnosis of metastatic inguinal nodes was established.
1073
Patients who develop recurrent or metastatic inguinal nodes after initial treatment programs for the primary problem do not appear to be salvageable. On the other hand, patients who develop recurrence of the primary itself are salvageable. Therefore, on the basis of our experience and the data in the literature, it is strongly recommended that inguinal nodal treatment be included in the initial treatment plan.
RECOMMENDED TREATMENT PROGRAM Stage I and II. Megavoltage radiation treatment to the whole shaft of the penis with parallel opposing fields using the above mentioned applicator. The tumor dose should be homogeneous with a tumor dose minimum of 6000-7OOOrad in 6-7 weeks. Prophylactic treatment should be given to both inguinal regions utilizing single anterior portals to each area. Tumor dose should be calculated to 4 or 5cm depth, delivering 4000-5000 rad minimum in 5 weeks using megavoltage photon energy or electron beam. Stage III. Treatment to the primary should be given as above. Inguinal nodes may be treated by surgery or radiation therapy. Pelvic node treatment should be given routinely. Stage IV. Only palliative treatment is recommended. Chemotherapy may be considered.
REFERENCES 1. Alexander, L.L., Medina, A., Benninghaff, D.L., Camiel, M.R.: Cancer of the penis. radiation therapy or surgery. J. Natn Med. Assoc. &l(6): 533-536, Nov. 1972. 2. Dagher, R.. Selzer, M.L. Lapides, J.: Carcinema of the penis and anticircumcision crusade. J. Ural. 110: 79-80, July 1973. 3. Derrick, F.C., Lynch, K.M., Kretkowski, R.C., Yanbrough, W.J.: Epidermoid carcinoma of the penis-computer analysis of 87 cases. J. Ural.
7. 8.
9. 10.
110: 303-305, 1973. 4. Eckstrom, T.. Edsmur, F.: Cancer of the penis. Acta. Clin. Scandinou. 115: 25-45, 1958.
5. Englestad, R.B.: Treatment of cancer of penis at Norwegian Radium Hospital. Am. J. Roentgenol. 60: 801-806, 1948. 6. Hardner, G.J., Woodruff. M.W.: Operation
11. 12.
management of carcinoma of penis. J. Ural. 98: 487-492, 1967. Jackson, S.M.: Treatment of carcinoma of penis. Br. J. Surg. 53: 33-35, 1%6. Kundsen, OS., Brennhood, 1.0.: Radiotherapy in treatment of primary tumor in penile cancer. Acta. Clinic. Scandinov. 133: 69-71, 1%7. Lederman, M.: Radiotherapy of cancer of penis. Br. J. Ural. 25: 224-232. 1953. Newaishy, G.A., Deeley, T.J.: Radiotherapy in treatment of carcinoma of penis. Br. J. Radiol. 41: 519-521, 1968. Uehling, D.T.: Staging laparotomy for carcinoma of penis. J. Ural. 110: 213-215,Aug. 1973. Vaeth, J.M., Green, J.P., Lowey, R.O.: Radiation therapy of carcinoma of the penis. Am. J. Roentgenol. 108(l); 130-135, 1970.
