Penile Cancer

Penile Cancer

 

The University of Chicago Urologic Cancer Program
Urologists at the University of Chicago specialize in the latest surgical techniques to treat penile cancer. In combination with colleagues in Medical Oncology and the Cancer Research Center, we offer a comprehensive and diverse option of therapies.

 

An Overview of Penile Tumors
Diagnosis
Penile cancer is rare in the United States (annual incidence of 1-2 per 100,000 men, which translates into 1400 cases yearly). Squamous cell carcinoma accounts for 95% of penile cancer cases. The highest incidence in the world is in South America, India, and Africa. Penile cancer is most common in uncircumcised and nonwhite populations. Onset is in the fourth and fifth decades of life.

 

The cause of penile cancer appears to be chronic irritation. Predisposing factors include presence the foreskin (uncircumcised men), phimosis (tight opening of the foreskin), and poor hygiene. Phimosis is present in more than 50% of patients with penile cancer. The closed space under the foreskin allows accumulation of smegma and chronic irritation. The risk of penile cancer can be virtually eliminated by neonatal circumcision. Delayed circumcision offers only slight protection against the subsequent development of penile carcinoma. Penile cancer is associated with exposure to ultraviolet [UV] radiation treatment for psoriasis. There is also evidence of a relationship between penile cancer and HPV types 16, 18, and 33. These are commonly found in women with cervical cancer.

 

Penile cancer begins as a small lesion and gradually enlarges to involve the entire penis. It may be flat and cause an ulcer. Alternatively, it may extend away from the penis with the appearance of cauliflower or broccoli. Laboratory studies are usually normal in patients with penile cancer. There is a limited role for radiologic imaging. CT and MRI scans can be helpful in patients with high grade or invasive tumors in whom pelvic or retroperitoneal lymphadenopathy is suspected. A delay in seeking medical attention is very common and can result in progression to advanced local disease. The course of penile cancer is relentless and most untreated patients die within 2 years.

 

Penile cancer metastasizes in a predictable pattern to inguinal lymph nodes followed by drainage into pelvic lymph nodes (and beyond). Metastatic deposits in the regional lymph nodes continue to enlarge if left untreated, causing skin necrosis, infections, and erosion of the femoral vessels. The risk of spread (metastasis) is related to the size of the initial (primary) lesion. Spread is most common to the lymph nodes, especially those in the thigh. The tumor begins as an area of induration (firmness), erythema (redness), warty growth, nodule, or superficial ulceration. Rarely painful, constitutional symptoms (fatigue, fever, etc.) may result from chronic infection in the nodes.

 

At clinical presentation, determination should be made of the lesion’s size, location, and depth of involvement. The scrotum and perineum must be inspected and inguinal areas palpated. Pathologic staging by deep biopsy remains necessary to plan appropriate management. Accurate staging is imperative for guiding treatment recommendations.


If there are suspicious (enlarged and hard) lymph nodes in the groin, antibiotics are often prescribed. If the lymph node enlargement does not disappear, then surgery may be required to remove the lymph nodes (ilioinguinal lymphadenectomy).

 

Management
The goal of treatment is complete removal of the primary lesion with adequate margins. The standard of therapy for the primary lesion is partial or total penectomy (total or partial removal of the penis). Partial penectomy has produced the lowest recurrence rate and is the standard against which all other treatment modalities must be compared. Because of the disfigurement and psychological impact of penile amputation, other treatment options have gained increasing acceptance in the treatment of penile cancer, but must be used within their limitations.

  • Circumcision: 20% percent of lesions are located on the prepuce. If the cancer is small, low grade, noninvasive, involves only the prepuce, is not located near the coronal sulcus, and permits an adequate margin, complete tumor removal can be accomplished with circumcision, although circumcision alone is followed by a 30 -50% recurrence rate. Long term survival approaches 90%. These patients must be followed very closely.
  • Moh’s Microsurgery (MSS): A method of surgically removing skin cancer by removing tissue in thin layers. Zinc chloride paste, a fixative, is applied after application of dichloroacetic acid, a keratolytic agent. Layers of chemically fixed tissue are excised and examined microscopically until cancer free planes are obtained. MSS includes color coding of excised specimens, accurate orientation through creation of tissue maps, and frozen section analysis of excised tissues. The micrographic surgeon is responsible for all steps in the process, including interpretation of frozen sections. Healing is by secondary intention. Best applied for small distal penile lesions less than 1 cm. Following Moh’s surgery, the glans is often misshapen and meatal stenosis is common.
  • Laser: Nd-YAG; acceptable for the rare superficial Tis, Ta, and T1 lesions (survival compares favorably with partial penectomy). Although laser therapy offers the advantage of being organ preserving, the depth of laser penetration and histologic confirmation of tumor destruction can be difficult to determine; deep biopsies are necessary.
  • Penectomy: For lesions near the coronal sulcus or involving the glans and distal shaft of the penis, partial penectomy is necessary. A 2 cm margin proximal to the tumor is desirable, leaving a 3 cm or greater stump. The stump must be adequate for upright urination, a directable urinary stream, and satisfactory sexual function. Negative margins must be confirmed in the operating room. Local recurrence rates are 0-6%.
    Larger lesions, or those in the mid or proximal shaft of the penis, require a radical (total) penectomy. This is also true for those lesions that may be treated with a partial penectomy but will, if performed, result in a stump inadequate for upright urination, a directable urinary stream, and satisfactory sexual function.
  • Radiation Therapy: The sole advantage of radiation therapy is that it preserves penile anatomic structure. The disadvantages are that penile cancers are relatively radioresistant and there is a high rate of complications (fistula, stricture, edema, superficial necrosis, and pain). Approximately 30-50% patients will require subsequent penectomy.
  • Chemotherapy: There is no defined role for chemotherapy, although it may be of help in patients with palpable, bulky, bilateral inguinal adenopathy proved by biopsy who are at high risk for local recurrence and distant metastasis. Chemotherapy prior to lymph node dissection may make surgery technically easier and may improve surgical margins. The most effective chemotherapeutic drugs are cisplatin, bleomycin, and methotrexate.
     

Treatment of penile cancer is often individualized to each patient. Surgeons at the University of Chicago are trained in the most up-to-date and technologically-advanced methods of treating kidney cancers. At you appointment, your surgeon will be glad to discuss all of these treatment options with you.

 

Surgical Treatment Options for Penile Tumors
Surgery is the main treatment for penile cancers.

 

Partial Penectomy

  • This involves removal of the end of the penis. This operation is used for penile tumors that are small and located towards the tip of the penis.
  • A stump of penis is left behind through which the patient urinates and ejaculates.
  • If an inadequate length of stump is left behind, the entire penis is removed (see Radical (Total) Penectomy, below.
  • Patients are followed closely for any sign of recurrence.
  • This operation is rarely used in conjunction with a lymph node dissection.


Radical (Total) Penectomy

  • This involves removal of the entire penis and urethra (the tube through which urine exits the body). This operation is used for penile tumors that are large and located in the middle or at the base of the penis. Also, this operation is used when a partial penectomy is attempted but adequate length is not achieved.
  • The urethra is redirected to the area between the scrotum and rectum (perineal urethrostomy). The patient must sit to urinate and cannot ejaculate. The testes are left in place so reproduction is possible, but only through surgery to harvest sperm from the testes followed by in vitro fertilization.
  • Patients are followed closely for any sign of recurrence.
  • This operation is often used in conjunction with a lymph node dissection.


Ilioinguinal Lymph Node Dissection

  • This involves removal of the lymph nodes in the groin. This operation is used for men with penile cancer who have palpable masses in their groins after taking 6 weeks of antibiotics.
  • Ilioinguinal lymphadenectomy can carry substantial morbidity, such as infection, skin necrosis, wound breakdown, edema, and even a low, but finite, mortality rate.
  • Patients are followed closely for any sign of recurrence.
  • Because the treatment of penile cancer is often individualized to each patient, at your appointment, your surgeon will be glad to discuss all of these treatment options with you