Karen Randhawa and Hussain Alnajjar Penile cancer is a rare disease (<1 per 100 000 men) that constitutes 0.2% of all male malignancies with the most common age of presentation in the sixth decade. Early diagnosis is key as the disease can result in devastating disfigurement and a five‐year survival rate of approximately 50%.It can be cured in over 80% of cases if diagnosed early and hence the need for thorough assessment and prompt treatment. There is clear evidence that centralisation of penile cancer care in the UK has led to improved outcomes; as a result, a number of other countries have followed the UK model. Over 95% are subtypes of squamous cell carcinoma most commonly arising from the inner prepuce or glans penis. Presence of a phimotic foreskin/chronic inflammation. Phimosis is strongly associated with invasive penile cancer. Penile cancer is rarely seen in populations where neonatal or childhood circumcision is routinely performed. The protective effect is probably due to a decreased risk of human papilloma virus (HPV) infection in addition to reduced risk of phimosis and chronic inflammation. Human papilloma virus: HPV types 16 and 18 are associated with approximately 45–80% of penile cancers. HPV DNA has been identified in 70–100% of intra‐epithelial neoplasia and in 30–40% of invasive penile cancer. Lichen sclerosus: The incidence of lichen sclerosus is relatively high in penile cancer but is not associated with adverse histopathological features, including penile intraepithelial neoplasia (PeIN). Smoking/tobacco use: The risk of penile cancer is increased fivefold in smokers versus non‐smokers. Similarly chewing tobacco is a significant risk factor. Exposure to ultraviolet radiation: Psoriasis patients undergoing psoralen plus ultraviolet A (PUVA) treatment have an increased penile cancer incidence of 286 times compared to the general population. Patients treated for psoriasis with immunosuppressive drugs also appear to have an increased risk of developing penile cancer. Human immunodeficiency viruses (HIV) infection: There is reported to be an eightfold increased risk of penile cancer in patients with HIV. Multiple sexual partners/early age of first intercourse: Evidence suggests that there is a three‐ to fivefold increased risk of penile cancer associated with multiple sexual partners. Other epidemiological risk factors are low socioeconomic status and a low level of education. Pre‐malignant lesions and benign penile dermatoses may present as a rash, small red lesions or raised area on the penis. It is important that clinicians are aware of the need for biopsy and a prompt referral on to a specialist centre where appropriate. Patients may also present with phimosis, making it difficult to visualise the lesion, in addition to penile pain, palpable lesion, problems voiding, foul odour, bleeding, or discharge from the penis. Presentation can also be late, with obvious fungating penile lesions and/or metastatic groin node masses. It is important to assess the overall health of the patient in terms of co‐morbidities including past medical and surgical history. Ask specific questions relating to: General examination should be performed to assess the overall health of the patient. If it is possible to retract the foreskin, perform a visual examination of the glans assessing the size, location, and morphology of any glans lesions (exophytic or ulcerative). Proximity to the meatus should also be assessed. Palpation of the lesion, glans penis, and penile shaft should be performed to assess for corporal involvement. Assess foreskin for lichen sclerosis, warts, scarring, change in colour, or any evidence of pre‐malignant disease. Palpate both groins for any palpable lymph nodes. If palpable lymph nodes identified – document number, laterality and whether fixed or mobile. Oedema of the penis, scrotum, and/or legs may occur. In practice, for suspected inflammatory penile lesions, early biopsy is required to confirm diagnosis and exclude carcinoma, if there a is lack of early and adequate response to appropriate medical therapy. For suspicious raised lesions and obvious cancers, immediate biopsy can both confirm malignancy and offer information on cancer subtype, grade, and stage to guide further investigation and management. The procedure may be carried out under local anaesthetic penile block or general anaesthetic and may require a dorsal slit to visualise the lesion fully prior to biopsy. Lesions inside the meatus may be difficult to biopsy endoscopically and may therefore require a meatotomy to expose the lesion before performing a biopsy. In any event, this can normally be achieved as an ambulatory procedure. Although a punch biopsy may be sufficient for superficial lesions, an excisional biopsy deep enough to properly assess the degree of invasion and stage is preferable. It is also helpful to include normal adjacent tissue to allow examination of the interface between normal tissue and tumour.
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Penile Cancer: Diagnosis and Management in the Outpatient Clinic
Pathology
Risk Factors
Presentation
History
Examination
Primary Lesion (May Be Hidden Under Phimosis)
Lymph Nodes
Investigation
Role of Penile Biopsy
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