Lesions sporadically associated with SCC of the penis
Cutaneous horn of the penis
Bowenoid papulosis of the penis
Balanitis xerotica obliterans (lichen sclerosus et atrophicus)
Lesions at high risk of developing SCC of the penis (up to one-third transform to invasive SCC)
Penile intraepithelial neoplasia (carcinoma in situ): erythroplasia of Queyrat and Bowen’s disease
Table 16.2
Squamous cell carcinoma
Types of SCC |
Classic |
Basaloid |
Verrucous and its varieties |
Warty (condylomatous) carcinoma |
Verrucous carcinoma |
Papillary carcinoma |
Hybrid verrucous carcinoma |
Mixed carcinomas (warty basaloid and adenobasaloid carcinoma) |
Sarcomatoid |
Adenosquamous |
Growth patterns of SCC |
Superficial spread |
Nodular or vertical-phase growth |
Verrucous |
16.9 Signs and Symptoms
In most cases, the very first sign of penile cancer is a superficial asymptomatic modification of the skin of the penis represented by a colour change or a tissue thickening that can start everywhere on the penis, although the most frequent localisations are represented by the penile glans and foreskin.
Sometimes the lesion can present as an ulcer (sore) or a lump on the penis or can appear as a reddish, velvety rash, small crusty bumps or flat growths that are bluish brown. In some cases a secretion, sometimes with a bad smell, can be found; this can represent the first sign in the case of a patient with phimosis where the foreskin is not retractable.
In case the tumour spreads to the lymph nodes, patients can feel tumescence at the level of the inguinal area (American Joint Committee on Cancer 2010).
16.10 Diagnosis
The most important diagnostic step is represented by medical history and physical examination that can suggest the presence of a penile cancer, although specific procedures (biopsy and imaging tests) are needed to confirm the diagnosis (Pizzocaro et al. 2010).
Physical examination of a patient with penile cancer includes careful evaluation of the primary lesion. The following aspects should always be carefully evaluated:
Diameter of the penile lesion or suspicious areas
Location of lesion on the penis
Number of lesions
Morphology of lesion: papillary, nodular, ulcerous or flat
Relationship of lesion to other structures, e.g. sub-mucosa, tunica albuginea and urethra
Corpus spongiosum and corpus cavernosum
Colour and boundaries of lesion
Penis length
16.10.1 Biopsy Procedures
A biopsy is needed to make an accurate diagnosis of cancer, when a suspicious lesion of the penis is present. An incisional biopsy foresees the removal of a small piece of tissue, usually from a large lesion. An excisional biopsy is performed when the entire lesion (usually small) is removed. In the case of patients presenting palpable enlarged lymph nodes, a fine-needle aspiration (FNA) can be performed (Saisorn et al. 2006; Kroon et al. 2005).
There is no need for biopsy if there is no doubt about the diagnosis and/or treatment of the lymph nodes is postponed after treatment of the primary tumour and/or after histological examination of the sentinel node(s).
16.10.2 Imaging Tests
Imaging tests can be used to perform a local staging of the penile lesion or a distant staging of the original tumour. The most used tests for local staging are ultra-sonography (US) or magnetic resonance imaging (MRI) with prostaglandin E1 intra-cavernous injection (Solsona et al. 2001; Kayes et al. 2007).
Imaging techniques (e.g. CT and MRI) are widely used, but they are only useful for staging patients with centrimetrical or lymph node metastases >1 cm. So far, no current imaging modality can identify microscopic invasion.
An assessment of distant metastases should be performed in patients with positive inguinal nodes. Positron emission tomography/CT is reliable for identification of pelvic and distant metastases in patients with positive inguinal nodes (Graafland et al. 2009).
16.11 Tumour Staging
The new 2009 TNM classification for penile cancer includes a change for the T1 category (Table 16.3). This classification needs a further update for the definition of the T2 category. Two recent publications have shown that the prognosis for corpus spongiosum invasion is much better than for corpora cavernosa invasion (Sobin et al. 2009; Rees et al. 2008; Leijte et al. 2008a) (Table 16.4).
Table 16.3
TNM staging
Clinical classification | |
|---|---|
T – Primary tumour | |
TX | Primary tumour cannot be assessed |
T0 | No evidence of primary tumour |
Tis | Carcinoma in situ |
Ta | Non-invasive verrucous carcinoma, not associated with destructive invasion |
T1 | Tumour invades subepithelial connective tissue |
T1a | Tumour invades subepithelial connective tissue without lymphovascular invasion and is not poorly differentiated or undifferentiated (T1G3–T1G4) |
T1b | Tumour invades subepithelial connective tissue with lymphovascular invasion or is poorly differentiated or undifferentiated (T1G3–T1G4) |
T2 | Tumour invades corpus spongiosum/corpora cavernosa |
T3 | Tumour invades urethra |
T4 | Tumour invades other adjacent structures |
N – Regional lymph nodes | |
NX | Regional lymph nodes cannot be assessed |
N0 | No palpable or visibly enlarged inguinal lymph node |
N1 | Palpable mobile unilateral inguinal lymph node |
N2 | Palpable mobile multiple or bilateral inguinal lymph nodes |
N3 | Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or bilateral |
M – Distant metastasis | |
M0 | No distant metastasis |
M1 | Distant metastasis |
Pathological classification | |
The pT categories correspond to the T categories. The pN categories are based upon biopsy or surgical excision | |
pN – Regional lymph nodes | |
pNX | Regional lymph nodes cannot be assessed |
pN0 | No regional lymph node metastasis |
pN1 | Intranodal metastasis in a single inguinal lymph node |
pN2 | Metastasis in multiple or bilateral inguinal lymph nodes |
pN3 | Metastasis in pelvic lymph node(s), unilateral or bilateral or extranodal extension of regional lymph node metastasis |
pM – Distant metastasis | |
pM0 | No distant metastasis |
pM1 | Distant metastasis |
G – Histopathological grading | |
GX | Grade of differentiation cannot be assessed |
G1 | Well differentiated |
G2 | Moderately differentiated |
G3–G4 | Poorly differentiated/undifferentiated |
Table 16.4
Staging categories
Stage | TNM | Definition |
|---|---|---|
0 | Tis | The cancer has not grown into tissue below the top layers of skin and has not spread to lymph nodes or distant sites |
Ta, N0, M0 | ||
I | T1a, N0, M0 | The cancer has grown into tissue just below the superficial layer of skin but has not grown into blood or lymph vessels. It is a grade 1 or 2. It has not spread to lymph nodes or distant sites |
II | T1b, N0, M0 | The cancer has grown into tissue just below the superficial layer of skin and is either high grade or has grown into blood or lymph vessels. It has not spread to lymph nodes or distant sites |
T2, N0, M0 | The cancer has grown into one of the internal chambers of the penis (the corpus spongiosum or corpora cavernosa). The cancer has not spread to lymph nodes or distant sites | |
T3, N0, M0 | The cancer has grown into the urethra. It has not spread to lymph nodes or distant sites | |
IIIa | T1 to T3, N1, M0 | The cancer has grown into tissue below the superficial layer of skin (T1). It may also have grown into the corpus spongiosum, the corpus cavernosum or the urethra (T2 or T3). The cancer has spread to a single groin lymph node (N1). It has not spread to distant sites |
IIIb | T1 to T3, N2, M0 | The cancer has grown into the tissues of the penis and may have grown into the corpus spongiosum, the corpus cavernosum or the urethra (T1 to T3). It has spread to 2 or more groin lymph nodes. It has not spread to distant sites |
IV | T4, any N, M0 | The cancer has grown into the prostate or other nearby structures. It may or may not have spread to groin lymph nodes. It has not spread to distant sites |
Any T, N3, M0 | The cancer has spread to lymph nodes in the pelvis OR the cancer spread in the groin lymph nodes has grown through the lymph nodes’ outer covering and into the surrounding tissue. The cancer has not spread to distant sites | |
Any T, any N, M1 | The cancer has spread to distant sites |
16.12 Survival Rates for Penile Cancer
Because penile cancer is not common, it is hard to find accurate survival rates based on the TNM stage of the cancer. The numbers below come from the National Cancer Institute’s SEER database, looking at more than 1,000 men diagnosed with penile cancer between 1988 and 2001.
For cancers that are still confined to the penis (like stage I and II), the 5-year relative survival rate is around 85 %.
If the cancer has spread to nearby tissues or lymph nodes (like stage III and some stage IV), the 5-year relative survival rate is around 59 %.
If the cancer has spread to distant parts of the body, the 5-year relative survival rate is about 11 % (Howlader et al. 2011).
16.13 Treatment
After the cancer is diagnosed and staged, a cancer care team should discuss different treatment options with the patient also taking into account several factors:
The type and stage of the cancer
Overall patient’s physical health
Patient’s preferences about treatments and their side effects
The main treatment options that can be used to treat penile cancers are:
Surgery
Radiation therapy
Chemotherapy
Surgery is the main method of treatment for nearly all penile cancers, but sometimes radiation therapy may be used, either instead of or in addition to surgery. Chemotherapy is usually indicated in the case of meta-static disease.
16.13.1 Surgery for Penile Cancer
Surgery is the most common treatment for all stages of penile cancer. If the cancer is detected early, the tumour can often be treated without having to remove part of the penis (conservative surgery) (Minhas et al. 2005).
If the cancer is detected at a more advanced stage, part or all of the penis might have to be removed with the tumour.
Patients with cancers that have invaded deep within the penis (stage T2 or higher) usually need to have some nearby lymph nodes removed as well to check for cancer spread.
Instead of removing all of the groin lymph nodes to look for cancer, in some cases it is possible to perform a sentinel lymph node biopsy.
Based on the extension of the penile lesion, various operations can be performed.
16.13.1.1 Circumcision
This operation consists in the removal of the foreskin and some nearby skin and can represent a valid option only for patients with small lesion of the foreskin that are early diagnosed.
In rare cases, circumcision is also performed to remove the foreskin before radiation therapy to the penis, in order to avoid subsequent local side effects.
16.13.1.2 Simple Excision
This operation is indicated for larger but still confined tumours and foresees the removal of the lesion itself along with some surrounding normal tissues.
Based on the extension of the lesion, the residual skin can then be simply stitched back together or can require a skin graft to cover the defect.
16.13.2 Mohs Surgery (Microscopically Controlled Surgery)
In the case of pre-cancerous lesions or early-diagnosed cancers (stage I), this highly sophisticated technique can be applied to spare as more healthy tissues as possible but still performing an oncologically safe procedure.
By using the Mohs technique, the surgeon removes a layer of the skin that the tumour may have invaded and then checks the sample under a microscope right away. If it contains cancer, another layer is removed and examined. This process is repeated until the skin samples are found to be free of cancer cells (Shindel et al. 2007).
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