Editing EAU & ASCO: Penile Cancer 2023 (section)

==== Options ====
* '''<span style="color:#ff0000">Non-surgical (4)'''
*# '''<span style="color:#ff0000">Topical therapy (2)'''
*## '''<span style="color:#ff0000">Imiquimod'''
*## '''<span style="color:#ff0000">5-fluorouracil'''
*# '''<span style="color:#ff0000">Laser therapy'''
*# '''<span style="color:#ff0000">Radiation'''
*#* '''<span style="color:#ff0000">Brachytherapy'''
*#* '''<span style="color:#ff0000">External beam radiation'''
* '''<span style="color:#ff0000">Surgical'''
** '''<span style="color:#ff0000">Organ-sparing (3)'''
**# '''<span style="color:#ff0000">Circumcision'''
**# '''<span style="color:#ff0000">Wide local excision'''
**# '''<span style="color:#ff0000">Partial or total glansectomy, with or without reconstruction'''
** '''<span style="color:#ff0000">Amputative (2)''' 
**# '''<span style="color:#ff0000">Partial amputation'''
**# '''<span style="color:#ff0000">Radical amputation'''
*'''<span style="color:#ff0000">Organ-sparing approaches are considered to be the primary treatment method for localised penile cancer</span>''' 
**Generally, penile-preserving surgery preserves superior functional, erectile and cosmetic outcomes compared to partial or total penectomy (amputation)
***Glans sensation and orgasm can be affected in penile-preserving surgery
**'''Patients should be informed about the higher risk of local recurrence with organ-sparing treatments, compared to amputative surgery'''
*No RCTs or observational comparative studies for any of the treatment options for localised penile cancer

===== Non-surgical =====

====== Topical ======
* '''<span style="color:#ff0000">Indications'''
**'''<span style="color:#ff0000">Biopsy-confirmed PeIN'''
*'''Options'''
*#'''Imiquimod'''
*#'''5-fluorouracil'''
*Dosing
** Imiquimod
*** Commonly used 3 times per week for 12 weeks
** 5-fluorouracil
*** No standard protocol exists
*** 5-FU ointment on for 12 hours every 48 hours during a 4 to 6-week treatment course is often recommended
*Adverse events
**Discontinuation of topical agents due to side effects observed in 12% of cases

====== Laser ======
*'''Options'''
** '''Neodymium:Yttrium-Aluminium-Garnet (Nd:YAG''', penetration 4–6 mm, wavelength 1064 nm)
** '''Carbon dioxide (CO2''', penetration < 1 mm, wavelength 10600 nm)
* '''<span style="color:#ff0000"> Indications
** '''<span style="color:#ff0000"> Biopsy-confirmed PeIN, Ta, or T1 lesions

====== Radiation ======
*Efficacy
**5-year recurrence-free survival improved with brachytherapy compared to EBRT (≈80% vs. ≈55%)
*'''<span style="color:#ff0000">Indications
**'''<span style="color:#ff0000">Biopsy-confirmed T1 or T2 lesions

====== Moh’s micrographic surgery ======
*A surgical technique by which tissue is excised and processed with en face histological margins in real time to give a complete circumferential and deep margin
**Aims at maximal organ-preservation by adopting margin-guided excision
*'''Not routinely recommended as data are very limited'''
===== Surgical =====
* '''Pre-operative planning requires taking into consideration the''' 
** '''Size of the mass'''
** '''Involvement of surrounding structures'''
** '''Anticipated skin and soft tissue defects (as well as plastic surgical consultation (as appropriate))'''
* '''<span style="color:#ff0000">Organ-sparing'''
** '''<span style="color:#ff0000">Options (3)'''
**# '''<span style="color:#ff0000">Circumcision'''
**#* '''<span style="color:#ff0000">Standard treatment for foreskin/preputial penile cancer'''
**#* '''<span style="color:#ff0000">Facilitates follow-up in patients treated with topical treatment, laser therapy or brachytherapy, facilitates follow-up examinations'''
**# '''<span style="color:#ff0000">Wide local excision'''
**# '''<span style="color:#ff0000">Partial or total glansectomy, with or without reconstruction'''
**#* '''Glans resurfacing'''
**#** '''Consists of full thickness removal of the glandular epithelium followed by reconstruction with a graft'''
**'''<span style="color:#ff0000">Indications'''
***'''<span style="color:#ff0000">Lesions confined to the glans and prepuce (PeIN, Ta, T1–T2) and patient willing to comply with strict follow-up'''
* '''<span style="color:#ff0000">Amputative surgery (2)'''
*# '''<span style="color:#ff0000">Partial penectomy'''
*#* '''<span style="color:#ff0000">Indications'''
*#*# '''<span style="color:#ff0000">Invasion of the corpora cavernosa (T3)'''
*#*# '''<span style="color:#ff0000">Patient not willing to undergo organ-sparing surgery or not willing to comply with strict follow-up.'''
*#*Efficacy
*#**Risk of local recurrence ≈4–5%
*#'''<span style="color:#ff0000">Total penectomy with perineal urethrostomy'''
*#*'''<span style="color:#ff0000">Indications'''
*#**'''<span style="color:#ff0000">Large invasive tumours not amenable to partial amputation'''
* '''With surgical treatment, negative surgical margins for invasive carcinoma must be obtained.'''
** Width of negative surgical margin (macroscopic margins can indeed be minimal, specifically in smaller and less aggressive lesions)
*** Standard excision must include a margin of clinically normal-appearing skin around the tumour and surrounding erythema. However, for bulky or higher-grade lesions where local recurrence may have an impact on survival, adoption of a wider margin or partial penectomy may be prudent
** Perform intra-operative frozen section analysis of resection margins in cases of doubt on the completeness of resection.
*** Use of intra-operative frozen section assessment not routinely recommended
*** Helpful tool to achieve definitive tumour-free margin in cases of doubt on the radicality of the resection