Editing EAU & ASCO: Penile Cancer 2023 (section)

== Diagnosis and Evaluation ==

=== UrologySchool.com Summary ===

==== Recommended ====

* '''<span style="color:#ff0000">History and Physical Exam'''
** '''<span style="color:#ff0000">History'''
*** '''<span style="color:#ff0000">Risk factors for penile cancer'''
** '''<span style="color:#ff0000">Physical exam'''
*** '''<span style="color:#ff0000">Penis'''
*** '''<span style="color:#ff0000">Inguinal lymph nodes'''
* '''<span style="color:#ff0000">Other'''
** '''<span style="color:#ff0000">Penile biopsy'''

==== Optional ====

* '''<span style="color:#ff0000">Imaging'''
** '''<span style="color:#ff0000">Regional'''
*** '''<span style="color:#ff0000">Penile MRI'''
**** '''<span style="color:#ff0000">Indications (2)'''
****# '''<span style="color:#ff0000">Uncertainty if the tumour invades the cavernosal bodies (cT3)'''
****# '''<span style="color:#ff0000">Organ-sparing treatment options (e.g., glansectomy) are considered'''
** '''<span style="color:#ff0000">Distant'''
*** '''<span style="color:#ff0000">18FDG-PET/CT'''
**** '''<span style="color:#ff0000">Indications (1)'''
****# '''<span style="color:#ff0000">Clinically node positive disease'''

=== History and Physical Exam ===

==== History ====

* '''Risk factors for penile cancer (see above)'''

==== Physical exam ====

===== Penis/foreskin =====
* Often presents as raised or ulcerous lesions which can be locally destructive
** '''Can sometimes be hidden under the foreskin/prepuce in case of phimosis'''
** Most PeIN lesions are located on the mucosal surfaces of the glans or prepuce
*** Lichen sclerosus also affects the foreskin/prepuce
* Note the dimensions, anatomic location, and extent of local invasion
* Examine entire penis to identify potential skip lesions
* Assess stretched penile length

===== Inguinal lymph nodes =====
* '''<span style="color:#ff0000">False-negative'''
** '''<span style="color:#ff0000">Reliable physical examination can be challenging in case of obesity and in patients with previous inguinal surgery'''
* '''<span style="color:#ff0000">False-positive'''
** '''<span style="color:#ff0000">Enlarged LNs secondary to infection of the primary tumour (rather than metastasis) can occur'''
*** '''Use of antibiotics with the aim to resolve enlarged nodes may delay further staging and treatment and is not recommended'''
* '''<span style="color:#ff0000">Based on physical examination, patients can be divided into (2)''' 
** '''<span style="color:#ff0000">Those without suspicious nodes at physical examination (clinically node-negative, cN0),'''
** '''<span style="color:#ff0000">Those with suspicious palpable nodes (clinically node-positive, cN+).''' 
*** In case of suspected pathologic LNs at palpation; the number, location, size and whether the node is fixed or mobile, should be noted.

=== Imaging ===

==== Local ====

* '''<span style="color:#ff0000">Not routinely indicated'''
** Physical examination is a reliable method for estimating penile tumour size and clinical T stage
* '''<span style="color:#ff0000">Indications (2)'''
*# '''<span style="color:#ff0000">Uncertainty if the tumour invades the cavernosal bodies (cT3)'''
*# '''<span style="color:#ff0000">Organ-sparing treatment options (e.g., glansectomy) are considered'''
* '''<span style="color:#ff0000">Modalities'''
** '''<span style="color:#ff0000">MRI (preferred)'''
*** '''MRI with and without artificial erection showed similar accuracy in local staging'''
** Penile ultrasound, if MRI not available

==== Regional/Distant ====

* '''<span style="color:#ff0000">Indications (1)'''
*# '''<span style="color:#ff0000">Clinically node-positive patients'''
*'''<span style="color:#ff0000">Modality'''
**'''<span style="color:#ff0000">18FDG-PET/CT'''
***Imaging with 18FDG-PET/CT is likely to be more accurate than CT alone
***CT and MRI have similar sensitivity and specificity for lymph node metastasis

=== Penile biopsy ===
* '''Indications'''
** '''Absolute'''
*** '''When malignancy is not clinically obvious, or when non-surgical treatment of the primary lesion is planned (e.g., topical agents, laser, radiotherapy).'''
** '''Relative'''
*** '''All suspected cases of penile cancer'''
**** '''Even in clinically obvious cases, histological information from a biopsy can facilitate treatment decisions (such as indications for surgical staging).'''
* '''Technique'''
** '''In most cases, acquiring a punch biopsy (e.g., 2–3 mm) under local anaesthesia is sufficient to confirm the diagnosis.'''
** '''in cases where assessment of depth of invasion is necessary, an incisional biopsy which is deep enough to properly assess the degree of invasion and stage is preferable.'''
** Tissue sections determine the accuracy of histological diagnosis. 
*** Small lesions should be fully included
*** Bigger lesions should have at least 3-4 blocks of tumour with the anatomical landmarks
* Second-opinion pathology review is recommended given the rarity of this cancer
* The pathology report must include 
** Surgical procedure
** Anatomical site of the primary tumour
** Size of tumour
** Maximum thickness
** Histological type of SCC
** Grade
** Depth and extent of invasion
** Vascular invasion (venous/lymphatic)
** Perineural invasion
** Surgical margins
** HPV assessment