Contemporary management of patients with penile cancer and lymph node metastasis

Penile cancer is a rare disease that causes considerable physical and psychological patient morbidity, especially at advanced stages. Patients with low-stage nodal metastasis can achieve durable survival with surgery alone, but those with extensive locoregional metastasis have overall low survival. Contemporary management strategies for lymph node involvement in penile cancer aim to minimize the morbidity associated with traditional radical inguinal lymphadenectomy through appropriate risk stratification while optimizing oncological outcomes. Modified (or superficial) inguinal lymph node dissection and dynamic sentinel lymph node biopsy are diagnostic modalities that have been recommended in patients with high-risk primary penile tumours and nonpalpable inguinal lymph nodes. In addition, advances in minimally invasive and robot-assisted lymphadenectomy techniques are being investigated in patients with penile cancer and might further decrease lymphadenectomy-related adverse effects. The management of patients with advanced disease has evolved to include multimodal treatment with systemic chemotherapy before surgical intervention and can include adjuvant chemotherapy after pelvic lymphadenectomy. The role of radiotherapy in the neoadjuvant or adjuvant setting remains largely unclear, owing to a lack of high-level evidence of possible benefits. New targeted therapies have shown efficacy in squamous cell carcinomas of other sites and might also prove effective in patients with penile cancer.