1. INTRODUCTION
1.1. Aim and objectives
The European Association of Urology (EAU) Guidelines on Penile Cancer provides up-to-date information on the diagnosis and management of penile squamous cell carcinoma (SCC).
It must be emphasised that clinical guidelines present the best evidence available to the experts but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions - also taking personal values and preferences/individual circumstances of patients into account. Guidelines are not mandates and do not purport to be a legal standard of care.
1.2. Panel composition
The EAU Penile Cancer Guidelines Panel consists of an international multi-disciplinary group of clinicians, including a pathologist and an oncologist. Members of this panel have been selected based on their expertise and to represent the professionals treating patients suspected of having penile cancer. All experts involved in the production of this document have submitted potential conflict of interest statements, which can be viewed on the EAU website Uroweb: http://uroweb.org/guideline/penile-cancer/.
1.3. Available publications
A quick reference document (Pocket guidelines) is available, both in print and as an app for iOS and Android devices. These are abridged versions which may require consultation together with the full text version. Several scientific publications are available, the most recent dating back to 2014 [1], as are a number of translations of all versions of the Penile Cancer Guidelines. All documents are available through the EAU website Uroweb: http://uroweb.org/guideline/penile-cancer/.
1.4. Publication history
The EAU Penile Cancer Guidelines were first published in 2000; the current publication presents a limited update of the 2017 print.
1.5. Summary of changes
Key changes for the 2018 print:
Chapter 3 - Epidemiology, aetiology and pathology. New information has been added on the various histological subtypes of penile carcinomas, risk factors and human papilloma virus (HPV) association.
New and changed recommendations can be found in sections:
3.4.8 Guidelines for the pathological assessment of tumour specimens
Recommendations | Strength rating |
The pathological evaluation of penile carcinoma specimens must include an assessment of the human papilloma virus status. | Strong |
The pathological evaluation of penile carcinoma specimens must include a diagnosis of the squamous cell carcinoma subtype. | Strong |
The pathological evaluation of penile carcinoma surgical specimens must include an assessment of surgical margins including the width of the surgical margin. | Strong |
4.2Guidelines on staging and classification
Recommendation | Strength rating |
The pathological evaluation of penile carcinoma specimens must include the pTNM stage and an assessment of tumour grade. | Strong |
5.4 Guidelines for the diagnosis and staging of penile cancer
Recommendations | Strength rating |
Primary tumour | |
Perform a physical examination, record morphology, extent and invasion of penile structures. | Strong |
Obtain a penile Doppler ultrasound or MRI with artificial erection in cases with intended organ-sparing surgery. | Weak |
Inguinal lymph nodes | |
Perform a physical examination of both groins, record the number, laterality and characteristics of inguinal nodes and: If nodes are not palpable, offer invasive lymph node staging in If nodes are palpable, stage with a pelvic computed tomography (CT) or positron emission tomography (PET)/CT. | Strong |
Distant metastases | |
In N+ patients, obtain an abdominopelvic CT scan and chest X-ray/thoracic CT for systemic staging. Alternatively, stage with a PET/CT scan. | Strong |
In patients with systemic disease or with relevant symptoms, obtain a bone scan. | |
6.2.6 Guidelines for treatment strategies for nodal metastases
Regional lymph nodes | Management of regional lymph nodes is | Strength rating |
Radiotherapy Radiotherapy | Not recommended for nodal disease except as a palliative option. | Strong |
> T1G2: invasive lymph node staging by either bilateral modified inguinal lymphadenectomy or dynamic sentinel node biopsy. | Strong | |
Palpable inguinal nodes (cN1/cN2) | Radical inguinal lymphadenectomy. | Strong |
Fixed inguinal lymph nodes (cN3) | Neoadjuvant chemotherapy followed by radical inguinal lymphade-nectomy in responders. | Weak |
Pelvic Lymph nodes | Ipsilateral pelvic lymphadenectomy if two or more inguinal nodes are involved on one side (pN2) or if extracapsular nodal metastasis (pN3) reported | Strong |
Adjuvant chemotherapy | In pN2/pN3 patients after radical lymphadenectomy. | Strong |
Radiotherapy | Not recommended for nodal disease except as a palliative option. | Strong |
6.3.6 Guidelines for chemotherapy
Recommendations | Strength rating |
Offer patients with pN2-3 tumours adjuvant chemotherapy after radical lymphadenectomy (three to four cycles of cisplatin, a taxane and 5-fluorouracil or ifosfamide). | Strong |
Offer palliative chemotherapy to patients with systemic disease. | Weak |
A systematic review (SR) was performed by the Panel on ‘Risks and benefits of adjuvant radiotherapy after inguinal lymphadenectomy in node-positive penile cancer’ [2]. Even though not fully published, the review findings support the information presented in Section 6.2.2.3 Adjuvant treatment.
This review was performed using standard Cochrane SR methodology: http://www.cochranelibrary.com/about/about-cochrane-systematic-reviews.html