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Penile cancer overview

Published: July 07, 2009. Updated: July 29, 2009

 

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Squamous cell carcinoma of the penis is a rare malignancy, accounting for approximately 0.4% to 0.6% of all malignancies among men in the United States.

Risk factors

It is commonest in men in their 60's, and in Asia, Africa and S. America where it can reach rates of 10-20%.

It can be caused by phimosis and poor genital hygiene. Circumcisions in newborns results in almost 100% protection.

It can be associated with HPV e.g. PCR studies have identified a 50% incidence of HPV type 16 (most common type) in invasive SCC, 90% in CIS (most contain E6 - E7 portions).

Psoralens and UV radiation treatment also results in increased risk.

Up to 40% of patients with SCC penis have a history of a pre-existing penile lesion.

  • Cutaneous horn
  • Balanitis Xerotica Oblitarans (lichen sclerosis et atropicus)
  • Leukoplakia
  • Bowenoid papulosis
  • Condyloma acuminatum
  • Karposi's Sarcoma
  • Buscheke-Lowenstein tumour
  • Carcinoma in situ
  • Bowens disease

Clinical picture

The usual presentation is a painless sore or ulcer on the prepuce or glans. Otherwise it can be balanoposthitis and discharge, or rarely lymphadenopathy. Assessment of the primary disease is via a biopsy and local invasion assessment can be assisted by US or MRI.

Staging

The most commonly used staging system is as follows:

Stage I

Stage I penile cancer is cancer limited to the glans and the foreskin, not involving the shaft of the penis or corpora cavernosa.

Stage II

Stage II penile cancer has invaded the corpora cavernosa of the penis but has not spread to lymph nodes on clinical exam.

Stage III

Stage III penile cancer has clinical spread to the regional lymph nodes in the groin. Cure is related to the number and extent of nodes involved.

Stage IV

Stage IV penile cancer is invasive cancer that has caused extensive and inoperable involvement of lymph nodes in the groin and/or distant metastases.

The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification.[1]

TNM definitions

Primary tumor (T)

  • TX: Primary tumor cannot be assessed
  • T0: No evidence of primary tumor
  • Tis: Carcinoma in situ
  • Ta: Noninvasive verrucous carcinoma
  • T1: Tumor invades subepithelial connective tissue
  • T2: Tumor invades corpus spongiosum or cavernosum
  • T3: Tumor invades urethra or prostate
  • T4: Tumor invades other adjacent structures

Regional lymph nodes (N)

  • NX: Regional lymph nodes cannot be assessed
  • N0: No regional lymph node metastasis
  • N1: Metastasis in a single superficial, inguinal lymph node
  • N2: Metastasis in multiple or bilateral superficial inguinal lymph nodes
  • N3: Metastasis in deep inguinal or pelvic lymph node(s), unilateral or bilateral

Distant metastasis (M)

  • MX: Distant metastasis cannot be assessed
  • M0: No distant metastasis
  • M1: Distant metastasis

AJCC stage groupings

Stage 0

  • Tis, N0, M0
  • Ta, N0, M0

Stage I

  • T1, N0, M0

Stage II

  • T1, N1, M0
  • T2, N0, M0
  • T2, N1, M0

Stage III

  • T1, N2, M0
  • T2, N2, M0
  • T3, N0, M0
  • T3, N1, M0
  • T3, N2, M0

Stage IV

  • T4, any N, M0
  • Any T, N3, M0
  • Any T, any N, M1

Treatment

For lesions limited to the foreskin, wide local excision with circumcision may be adequate therapy for control.

For carcinoma in situ of the glans (also referred to as erythroplasia of Queyrat or Bowen's disease of the penis), with or without adjacent skin involvement, therapeutic options include:

  • Local applications of fluorouracil cream.
  • Microscopically controlled surgery.

For infiltrating tumors of the glans, with or without involvement of the adjacent skin, the choice of therapy is dictated by tumor size, extent of infiltration, and degree of tumor destruction of normal tissue. Equivalent therapeutic options include:

  • Penile amputation.
  • Irradiation (external-beam, brachytherapy).
  • Microscopically controlled surgery.

Stage II penile cancer is most frequently managed by penile amputation for local control. Whether the amputation is partial, total, or radical will depend on the extent and location of the neoplasm. Radiation therapy with surgical salvage is an alternative approach.

Inguinal adenopathy in patients with penile cancer is common but may be the result of infection rather than neoplasm. If palpable enlarged lymph nodes exist three or more weeks after removal of the infected primary lesion and a course of antibiotic therapy, bilateral inguinal lymph node dissection should be performed.

In cases of proven regional inguinal lymph node metastasis without evidence of distant spread, bilateral ilioinguinal dissection is the treatment of choice.[1-4] However, since many patients with positive lymph nodes are not cured, clinical trials may be appropriate.

Standard treatment options:

Clinically evident regional lymph node metastasis without evidence of distant spread is an indication for bilateral ilioinguinal lymph node dissection after penile amputation.

Radiation therapy may be considered as an alternative to lymph node dissection in patients who are not surgical candidates.

Postoperative irradiation may decrease incidence of inguinal recurrences.

There is no standard treatment that is curative for patients with stage IV penile cancer. Therapy is directed at palliation, which may be achieved either with surgery or radiation therapy.

Standard treatment options:

Palliative surgery may be considered for control of the local penile lesion and even for the prevention of the necrosis, infection, and hemorrhage which can result from neglected regional adenopathy.

Irradiation may be palliative for the primary tumor, regional adenopathy, and bone metastases.
Treatment options under clinical evaluation:

Clinical trials combining chemotherapy with palliative methods of local control are appropriate for such patients (tested chemotherapeutic drugs with some efficacy include vincristine, cisplatin, methotrexate, and bleomycin). The combination of vincristine, bleomycin, and methotrexate has been effective both as adjuvant and neoadjuvant therapy.


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