Penis Cancer/Carcinoma (Penile Cancer)

Penile cancer is usually a squamous cell carcinoma (SCC), and they usually arise from the epithelium layer of the foreskin or the body of the penis.

Penile cancer is rare in the developed world and are more common in less developed areas of the world. It is typically a disease of older men, with the mean age of diagnosis being 60 years. However, it can also be seen in men less than 40 years.

The penis consists of the skin, connective tissue, the erectile bodies and the urethra.

• Men who experience phimosis, when the foreskin is too tight to be pulled back over the head of the penis, are associated with a 11 to 16-fold risk of penile cancer due to associated chronic infection.
• Men who experience lichen sclerosis, also known as chronic inflammatory skin disorder.
• Penile cancer is more common in areas of the world that have a high prevalence of human papillomavirus (HPV) infection.
• Men with multiple sexual partners and early age of first intercourse. are associated with a 3 to 5 fold increased risk of penile cancer.
• Cigarette smokers are associated with a 5 fold increased risk of penile cancer compare to non-smokers.

Penile cancer usually presents as a mass or ulcer on the penis. It is usually painless and there may be bleeding or discharge associated with it. Penile tumours can occur anywhere on the penis, but most are found on the glans (48 percent) and on the foreskin (21percent).

Physical examination

At the initial assessment, your urologist will perform a physical examination including a palpation of the penis to assess the extent of local invasion. Penile cancer is usually a noticeable lesion on the penis but sometimes it can be hidden under a phimosis.

The examination should also include a palpation of both groins to assess the likelihood of lymph node involvement. When penile cancer advances, it usually first involves the lymph nodes in the groin, before spreading to the lymph nodes of the pelvis.

Biopsy

A biopsy is the main test used to differentiate between benign or malignant penile lesions. A small sample of tissue is removed for examination under the microscope. This test can be performed under local anaesthesia. 

Imaging

Imaging by ultrasound or magnetic resonance imaging (MRI) can help to assess the extent of invasion of the penile cancer. If no enlarged lymph nodes were palpated in the groins, an ultrasound of the groin region may be arranged to evaluate for abnormal lymph nodes. If suspicious lymph nodes were palpated in the groins, a computed tomography (CT) scan can be arranged to evaluate the extent of disease, looking for any spread of disease to distant sites in the chest, abdomen or pelvis.

Treatment strategy depends on the size of the tumour, the extent it has invaded, whether it has spread (metastasised), and whether the risk of recurrence is low or high.

In general, for early stage of penile cancer, men with a low risk of recurrence are candidates for organ preservation treatment; whereas those with a high risk of recurrence will require penile resection.

For advanced penile cancer, such as when the tumour is very large or if there is involvement of lymph nodes, treatment will likely include chemotherapy and other modes of therapy in combination with surgery.

Penile resection

Invasive disease requires partial or total amputation of the penis. Removal of lymph nodes in the groin is usually done in the same setting.

Chemotherapy before and/or after surgery is often recommended if lymph nodes in the groin or pelvis are involved.

Partial amputation

A partial amputation may be suitable for invasive tumours located at glans, where resection of the tumour will still allow sufficient penile length for passing urine while standing.

Total amputation

A total penile amputation would involve removal of the glans penis and most or all of the underlying corporal bodies. This procedure is done if the tumour cannot be safely removed while allowing sufficient penile length to stand and void. This is often necessary for very large tumours that extend down the shaft of the penis.

The urethra would need to be brought out onto the perineum as an opening, to facilitate voiding in a sitting position.

Follow-up after treatment for penile cancer

All men treated for penile cancer require close follow-up for at least 5 years, as they are at risk of both recurrence of disease locally in the penis or groin, or at distant sites elsewhere in the body.

For men who underwent organ-preserving treatments like topical creams or laser treatment, their follow-up may involve repeating biopsy.