Penile Cancer

Background

  • Penile cancer is uncommon, but can be a psychologically devastating and potentially life-threatening diagnosis.
  • Most commonly a squamous cell cancer
    • Slow growing, and usually doesn’t interfere with erectile or voiding function
    • Commonly presents late at an invasive/metastatic stage
      • Also part due to sensitive nature of sx
      • Also part due to misrecognition as another diagnosis- commonly infection/benign lesion
        • Biopsy is essential

Aetiology

  • Penile cancer almost never occurs in circumcised patients
    • It is controversial as to whether smegma is carcinogenic or not
    • Phimosis is also a risk factor; as is balanitis (inflammation of the glans)
  • HPV infection is a risk factor
  • Smoking

Pathophysiology

  • Penile cancers usually begin as small lesions on the glans or prepuce. They range from white-grey, irregular exophytic to reddish flat and ulcerated endophytic masses. They gradually grow laterally along the surface and can cover the entire glans and prepuce before invading the corpora and shaft of the penis. The more extensive the lesion, the greater the possibility of local invasion and nodal metastasis. Penile cancers may be papillary and exophytic or flat and ulcerative. Untreated, penile autoamputation can occur.
  • The growth rates of the papillary and ulcerative lesions are similar, but the flat ulcerative lesions tend to metastasize to the lymph nodes earlier and are therefore associated with a lower 5-year survival rate.

Presentation

  • Lesion that has failed to heal
  • Subtle induration/erosion of the skin
  • Other skin changes
    • e.g. a small bump/outgrowth, a papule, pustule, warty growth, reddened area, large growth
  • Because most men with penile cancer are uncircumsised, there may also be phimosis that can mask signs
  • Men may not present until the cancer has eroded the prepuce and has become malodourous due to infection/necrosis.
  • Pain is uncommon
  • Red flags of cancer (weight loss, sweating etc) may or may not be present (more a sign of late disease)

Investigations

  • Bloods
  • Biopsy (of lesions and also of nodes)
  • CT scan

Management

  • Whilst guidelines may be different for different areas:
    • If carcinoma in situ (otherwise known as Erythroplasia of Queyrat)
      • Local excision +/- glans resurfacing
      • Topical treatments
    • T1 disease
      • Impalpable nodes
        • Grade 1 or 2
          • Local excision
          • External beam radiotherapy
          • Sentinal node biopsy where clinically indicated
        • Grade 3
          • Local excision
          • Limited inguinal node dissection or sentinal biopsy
      • Palpable nodes
        • Fine needle aspirate
          • Positive- block dissection
          • Negative- limited dissection
    • T2/3/4 disease
      • Local excision + limited dissection
      • Partial amputation
      • Total amputation
      • NB If 2 or more positive inguinal nodes, surgery may not be appropriate
    • M1 disease
      • Chemotherapy
      • NB Survival of disease is often very poor
        • Palliative care should be considered where appropriate

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