Localised penile cancer (organ-confined, node-negative)

Penile squamous cell carcinoma begins on the glans, the inner foreskin or the coronal sulcus, in roughly a third to a half of cases driven by HPV (basaloid and warty types, p16 positive) and otherwise by chronic inflammation, lichen sclerosus and phimosis (usual, verrucous and sarcomatoid types, often TP53 mutant). Penile intraepithelial neoplasia (PeIN) is its precursor. The 2023 EAU-ASCO guideline places organ preservation at the centre of care: PeIN and superficial tumours are treated with topical fluorouracil or imiquimod, laser ablation, circumcision or glans resurfacing; T1 and T2 tumours with glansectomy or partial penectomy with a margin of a few millimetres, which oncological series have shown to be safe; and brachytherapy is an alternative for small distal tumours. Total penectomy is kept for large or proximal tumours.

What decides survival is the groin. Palpably normal nodes still hide metastases in about a fifth of patients with tumours of intermediate or high risk (T1 with grade 2 or higher, lymphovascular invasion, or any T2 or worse), so the guideline recommends dynamic sentinel node biopsy for those patients rather than surveillance, and surveillance only for low-risk tumours; if the sentinel node is positive the patient moves into node-positive management. Circumcision and HPV vaccination prevent much of the disease, and the rarity of penile cancer means that referral to a specialised centre, as required in the United Kingdom since 2002, improves organ preservation and survival.