First pioneered by Dr. Frederic Mohs for penile cancer in 1992, MMS offers the benefit of oncologic control while also preserving cosmetic and functional outcomes.2 By meticulously dissecting away diseased tissue and confirming negative margins microscopically in real-time, a Mohs surgeon can remove penile lesions that would typically have been managed with disfiguring surgeries such as partial and total penectomies. MMS has a strong foothold in the dermatologic literature and is the gold standard in managing squamous cell carcinoma (SCC) of other sensitive areas such as the face.3 Despite its efficacy in these other fields, MMS is not well recognized in the urologic literature and indications for its use are unclear. Thus far, guidelines for penile cancer have been published by The European Society of Medical Oncology (ESMO), The European Association of Urology (EAU), and the NCCN. The American Urologic Association has yet to publish guidelines for penile cancer. Among these guideline organizations, indications for MMS are conflicting. ESMO does not include MMS as a modality for organ-sparing approaches.4 The EAU suggests that small localized T1 and T2 lesions can be managed with MMS.5 The NCCN guidelines for penile cancer and SCC are discordant, with MMS being indicated for any male genital squamous cell carcinoma regardless of AJCC stage in the SCC guidelines; however, only in select cases in the penile cancer guidelines.2,3 All these factors make it challenging for the urologist to assess who is an appropriate candidate for MMS and likely contribute to its overall underutilization.
MMS has become the treatment of choice for penile cancer at UNC Health through the work of an interdisciplinary team of urologic oncologists, reconstructive urologists, dermatologists, and Mohs surgeons. Our study serves as the initial review of 10 years of patient data (2010-2020), specifically evaluating local recurrence rates, disease progression, and complications of treatment.6 Utilizing the updated 2017 AJCC TNM staging, 43 patient outcomes were analyzed, and overall local recurrence was found to be minimal at 2%. Local recurrence rates at 1, 3, and 5 years for Ta, Tis, and T1 patients were 0%. Local recurrence rates for T2 patients were 14% at 1 year. Complications were found in 5 patients, all Clavien-Dindo grade III or lower. These findings suggest that MMS provides effective local control for Ta, Tis, and T1 penile cancer with an acceptable rate of complications.
As more men are treated with MMS at UNC Health and follow-up continues to grow, we hope to expand our understanding of this treatment modality. Ideally, a randomized control trial would be conducted comparing MMS to traditional total/partial penectomy; however, clinical equipoise may be challenging. More likely, as our technique continues to improve and more patients are treated, updated long-term oncologic outcomes such as local recurrence, disease progression, and overall- and disease-specific survival will continue to inform the treatment options of penile cancer.
Furthermore, there remains the need better understand the functional outcomes of these men in domains such as sexual dysfunction, urinary function, and overall quality of life—an aspect of penile cancer care that is frequently overlooked.7
Our study serves as an important update to the literature and suggests that MMS provides effective local control for Ta, Tis, and T1 penile cancers regardless of grade.6 We hope these findings increase the urologic community’s awareness of MMS for penile cancer and encourage other programs to establish multidisciplinary teams to treat this rare disease. Furthermore, given that these findings represent 10 years of patient outcomes, we hope future guidelines consider these data and include MMS as an option for penile cancer.
Written by: Nicolas E. Alcalá MD,1 Katy L. Reines MD,2 Bradley Merritt MD,3 Bradley D. Figler MD,2 Marc A. Bjurlin DO, MSc2,4
- Department of Urology, Medstar Georgetown University
- Department of Urology, University of North Carolina
- Department of Dermatology, University of North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina
- NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Penile Cancer. Version 2.2021 - August 16, 2021
- Mohs FE, Snow SN, Larson PO. Mohs micrographic surgery for penile tumors. Urol Clin North Am. 1992;19(2):291–304
- NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Squamous Cell Skin Cancer. Version 2.2021 - August 16, 2021.
- Van Poppel H, Watkin NA, Osanto S, et al. Penile cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 2013;24 Suppl 6:vi115-24.
- Hakenberg OW, Compérat EM, Minhas S, et al. EAU guidelines on penile cancer: 2014 update. Eur. Urol. 2015;67(1):142–150.
- Alcalá, N. E., Reines, K. L., Merritt, B., Figler, B. D., & Bjurlin, M. A. (2022, September). Mohs microsurgery for localized penile carcinoma: 10 year retrospective review of local recurrence rates and surgical complications. In Urologic Oncology: Seminars and Original Investigations. Elsevier.
- Maddineni, S. B., Lau, M. M., & Sangar, V. K. (2009). Identifying the needs of penile cancer sufferers: a systematic review of the quality of life, psychosexual and psychosocial literature in penile cancer. BMC urology, 9(1), 1-6.