Radiation therapy in the management of the primary penile tumor: an update

Squamous carcinoma of the penis is rare but psychologically devastating and potentially fatal. Radiotherapy offers a penile-conserving treatment option without jeopardizing cure. We have used primary penile brachytherapy as the treatment of choice for T1, T2 and selected T3 patients since 1989 and present updated results for 67 patients. Mean age was 60 years (range 22-93). Stage was T1 in 56%, T2: 33%, T3: 8%, and Tx: 3%. Grade was moderate or poorly differentiated in 48%. In Toronto after-loading pulse dose rate (PDR) brachytherapy (n = 41) was used for all treatments while Ottawa used manually loaded Iridium(192) (n = 26). Two or three parallel planes of needles (median 6) were inserted using pre-drilled lucite templates for guidance and fixation; 60 Gy was delivered over 4-5 days. Median follow-up is 4 years (range 0.2-16.2). At 10 years, actuarial overall survival is 59%, cause specific survival 83.6%. Nine men died of penile cancer and eight of other causes with no evidence of recurrence. Penectomy was required for eight local failures and two necroses, for an actuarial penile preservation rate at 5 years of 88% and 10 years of 67%. The soft tissue necrosis rate is 12% and the urethral stenosis rate 9%. Six of 11 regional failures were salvaged by lymph node dissection +/- external radiation. The other five all had concurrent distant failure and died of disease. Brachytherapy is an effective treatment for T1, T2 and selected T3 SCC of the penis. Close follow-up is mandatory as local failures and many regional failures can be salvaged by surgery.