Penile Cancer
Penis
The penis is a rod-shaped external male reproductive organ. It is made up of skin, nerves, smooth muscle, and blood vessels. The penis is categorized into different parts
- Glans: The glans is the tip of the penis that is covered by skin called mucosa.
- Shaft: The main part of the penis is referred to as the shaft and houses the corpus cavernosum and the corpus spongiosum.
- Corpus cavernosum: It is the two cylindrical shaped tissues that run along the sides of the penis.
- Corpus spongiosum: It is the sponge-like tissue that lies in the front part of the penis and ends at the glans.
- Meatus: The opening on the glans of the penis where semen and urine exit the body is called the meatus.
- Urethra: The urethra is a thin tube that is attached to the bladder and its function is to excrete urine and semen to the outside of the body.
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Function of Penis
- This organ facilitates sexual functions in male.
- The penis acts as a conduit for urine to leave the body.
Penile Cancer
Penile Cancer is a rare but aggressive type of Cancer that occurs on the skin of the penis or within the penis. Penile Cancer usually occurs on the foreskin of the penis, however in some cases it can also occur on the shaft of the penis. It deeply affects the person’s self-esteem.
Types of Penile Cancer
- Epidermoid/squamous cell carcinoma. Epidermoid occurs on the foreskin of the penis while squamous cell carcinoma can begin anywhere on the penis. More than 9 out of 10 penile Cancers are squamous cell Cancers making it the most common type.
- Basal cell carcinoma. Basal cells can sometimes become Cancerous. Basal cell carcinoma is a type of non-melanoma skin Cancer. They are slow growing and highly unlikely to spread.
- Melanoma. Melanocytes cells make the melanin that gives skin color. Melanoma starts in melanocytes. This Cancer sometimes occurs on the surface of the penis.
- Sarcoma. Sarcomas develop in the tissues that support and connect the body, such as blood vessels, muscle, and fat. Sarcomas of the penis are extremely rare but they tend to grow more quickly than other types of penile Cancer.
| Type | Occurrence Rate |
| Epidermoid/squamous cell carcinoma | 95% |
| Basal cell carcinoma | 2% |
| Sarcoma | 1% |
Occurrence Rate of Testicular Cancer in India
Penile Cancer is one of the most common genitourinary Cancers encountered in India. The incidence of carcinoma of the penis varies according to circumcision practice, hygienic standard, phimosis, the number of sexual partners, HPV infection, exposure to tobacco products, and other factors. The statistical report of penile Cancer states that it is encountered in 3.32 per 100,000 inhabitants in India.
Detection of penile Cancer at an early stage is aided by the following symptoms:
- Skin changes
- An area of skin becoming thicker and/or changing color
- A lump on the penis
- A reddish, velvety rash
- Small, crusty bumps
- Flat, bluish-brown growths
- Sore on the penis.
- Persistent discharge of fluid with a foul odor beneath the foreskin
- Blood coming from the tip of the penis or from under the foreskin
- Unexplained pain in the shaft or tip of the penis
- Small, crusty bumps beneath the foreskin
- Swollen lymph nodes in the groin
- Irregular swelling at the end of the penis
Risk factors when not taken care of can result in penile Cancer. Some penile Cancer risk factors, like smoking, HPV, circumcision can be controlled, but others like age or family history, can’t be changed. Some of the risk factors are discussed below.
- Human papilloma virus (HPV) infection
The most important risk factor for penile Cancer is infection with HPV virus. Sexual activity with a person who has HPV is the most common way of getting infected. There are different types of HPV, called strains. It is a group of more than 150 related viruses.- Limiting the number of sex partners.
- Using a condom
- Vaccination.
- Not being circumcised
Circumcision means removing all or part of the foreskin. This procedure is most often done in infants but it can also be done later in life.
Men who were circumcised as children have a lower chance of getting penile Cancer than those who were not, but the same protective effect is not seen if the foreskin is removed as an adult.
In men who are not circumcised, the foreskin can sometimes become tight and difficult to retract. This condition is known as phimosis. Penile Cancer is more common in men with phimosis. - Smegma
Smegma is a thick substance that can build up under the foreskin and is caused by dead skin cells, bacteria, and oily secretions from the skin. Smegma may contain small amounts of Cancer-causing substances.
Smegma is more common in men with phimosis. Uncircumcised men should pull back the foreskin and thoroughly wash the penis on a regular basis. - Smoking
Men who smoke are more likely to develop penile Cancer. Smokers who have HPV infections have an even higher risk. - UV light treatment of psoriasis
Men who have a skin disease called psoriasis are sometimes treated with drugs called psoralens, followed by exposing the body to an ultraviolet A (UVA) light source. This is known as PUVA therapy. Men who have had this treatment have been found to have a higher rate of penile Cancer. - Age
The risk of penile Cancer goes up with age. The average age of a man when diagnosed is 68. It is rare in men under the age of 40. - HIV or AIDS
Men with AIDS have a higher risk of penile Cancer. This higher risk seems to be related to their weakened immune system, which is a result of this disease. The prognosis in these patients is reported to be very poor.
Although there is no proven way to completely prevent penile Cancer, a few precautions may be able to lower your risk.
Here are a few ways to lower the risk of penile Cancer.
- Circumcision. Circumcision may provide some protection from penile Cancer because removing the foreskin helps keep the area clean. Epidermoid/squamous cell carcinoma of the penis almost never occurs in men who are circumcised. Circumcision in childhood/adolescence is found to be protective against invasive penile Cancer.
- Personal hygiene. Men who carefully and completely clean under the foreskin on a regular basis can lower their risk of developing penile Cancer.
- Lifestyle factors. Not smoking and avoiding sexual practices that could lead to an HPV or HIV/AIDS infection can help lower your risk of penile Cancer.
Penile Cancer originates in the shaft of the penis and with each passing stage the spread of Cancer goes on increasing. The most common sites of penile Cancer metastasis are the inguinal and iliac region, as lymph fluid carries the Cancer cells from the groin into the inguinal lymph nodes. These lymph fluid further drains into the pelvic
lymph nodes, thus spreading the Cancer cells from inguinal lymph nodes to pelvic lymph nodes.
The grade of penile Cancer is used to understand the stage of Cancer. Low grade Cancers usually grow very slowly. High grade Cancers tend to grow more quickly.
Grade x means the grade can’t be assessed.
Grade 1 (low grade) Cancer cells looks very much like normal cells.
Grade 2 Cancer cells look a bit like normal cells.
Grade 3–4 (high grade) Cancer cells look very abnormal and not like normal cells.
Penile Cancer can be staged as:
Stage 0: The Cancer growth is limited to the surface layer of skin. It has not spread to lymph nodes or distant parts of the body (Tis or Ta; N0, M0).
Stage I: A low-grade Cancer that has grown just below the surface layer of skin. It has not spread to lymph nodes or distant parts of the body (T1a, N0, M0).
Stage II: The Cancer is invasive and is high grade. It might have grown into blood or lymph vessels and/or into the internal chambers of the penis and/or the urethra. It has not yet spread to lymph nodes or distant parts of the body (T1b, T2, or T3; N0, M0).
Stage IIIa: The tumor has grown up to the penis and urethra and has spread to 1 groin lymph node, but it has not spread to distant parts of the body (T1, T2, or T3; N1, M0).
Stage IIIb: The tumor has spread to the penis and urethra, and to more than 1 groin lymph node. It has not spread to pelvic lymph nodes or distant parts of the body (T1, T2, or T3; N2, M0).
Stage IV:
- The Cancer has grown into nearby tissues such as the pubic bone, the scrotum, or the prostate (T4, any N, any M).
- The Cancer has spread to 1 or more lymph nodes in the groin, and it has grown from that lymph node into the surrounding tissue in the groin (any T, N3, M0).
- The Cancer has spread to at least 1 lymph node in the pelvis (any T, N3, M0) and/or to distant lymph nodes outside the pelvis or to other parts of the body (any T, any N, M1).
Survival rates indicate an average outcome of large number of people who had the disease, but they cannot precisely predict the expectancy of any particular case. Multiple factors may affect a person’s outlook.
| Stages | 5 year Survival Rate |
| Stage I | 85% |
| Stage II | 85% |
| Stage III and IV | 59% |
| Last Satge | 11% |
As almost all Penile Cancers start in the skin of penis which is very sensitive, so they are often noticed early in the course of the disease. Also the symptoms of penile Cancer start appearing from the early stages facilitating an early detection. Though at times these symptoms can be caused by other faculties as well, consulting a doctor is highly recommended.
Here are a few diagnostic tests/ procedures that can be followed to detect the presence of the disease.
Biopsy: A biopsy is the removal of a small amount of tissue for examination under a microscope. If Cancerous cells are seen in a tissue sample, then the biopsy is called positive for Cancer. If no Cancer is found, then the biopsy is called benign or negative for Cancer.
The following types of biopsies may be used for penile Cancer:
- A punch biopsy or elliptical excision. In punch biopsy, a sharp round surgical tool is used to remove a circular piece of tissue. In an elliptical excision, a scalpel is used to cut out a piece of tissue.
- A fine needle aspiration: In this procedure, the skin is usually made numb with a topical medication that blocks the sensation of pain. Then, a medication is injected into the area near the tumor to prevent pain in tissues beneath the skin. Then a thin needle is inserted into the tumor and some cells and fluid are removed. The procedure may be repeated 2 or 3 times to collect samples from different areas of the tumor.
- A sentinel lymph node biopsy: In early stages, one cannot feel the lymph nodes, so the lymph nodes are removed and examined under a microscope. This procedure is done to find out if Cancer cells have spread to lymph nodes near the penis. In more advanced stages, a lump in the groin can be felt as the inguinal lymph nodes get bigger.
For penile Cancer, the sentinel lymph nodes are located just under the skin in the groin. If Cancer cells are found in these lymph nodes, it means that the Cancer is more likely to have spread to other nearby lymph nodes or to other parts of the body through the blood and lymph vessels. Even if Cancer cells are not found during a sentinel lymph node biopsy, there is still a chance that the Cancer has spread. - Inguinal (groin) lymph node dissection. Groin is the area between the abdomen and the upper thigh on either side of the body. Dissection of the groin lymph node is the most accurate way to find out whether the Cancer has spread to any lymph nodes near the penis. In this procedure, the lymph nodes near the penis are removed and checked for Cancer.
X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation.
Computed tomography (CT or CAT) scan. A CT scan creates a 3-D picture of the inside of the body using x-rays taken from different angles. A computer then combines these images into a detailed, cross-sectional view that shows abnormalities or tumors. A CT scan can also be used to measure a tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, to produce detailed images of the body. MRI can also be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill to swallow.
If a Cancer is found early, it can often be removed with little or no damage to the penis. But if it is not diagnosed until later, part of or the entire penis may need to be removed to treat the Cancer. It is also more likely to require other, more invasive treatments, and may even be life threatening.
Surgery: Surgery is the removal of the tumor and some surrounding healthy tissue. The types of surgery that may be used for penile Cancer are described below.
- Extended Inguinal lymphadenectomy: It is the effective and preferred surgery for staging and curing inguinal metastasis in penile Cancer. However, in this techniques postoperatory complications such as cutaneous flap necrosis, lymphedema, and vascular lesions may be experienced.
- Laser therapy: Laser therapy is the use of a very powerful beam of light to destroy Cancer cells. Laser therapy may be an option for some men with early-stage penile Cancer, including
- Men with Tis and small T1 squamous cell carcinoma of the penis.
- Men with small T2 tumors who do not wish to have surgery.
- Cryosurgery: Cryosurgery, also called cryotherapy or cryoablation, uses liquid nitrogen to freeze and kill cells.
- Circumcision: Circumcision is generally used if the Cancer is only on the foreskin.
- Excision: An excision is a removal of the tumor and some surrounding healthy tissue using a scalpel or other surgical tool.
- Mohs surgery: This technique is used to remove the Cancer that can be seen on the surface of the penis. A small amount of healthy tissue around the edge is removed to make sure that no Cancer is left behind. This is most often used for small tumors that are only on the surface of the penis.
- Penectomy: This is the surgical removal of part or the entire penis. It is the most common and effective procedure to treat penile Cancer that has grown inside of the penis.
If a penectomy is needed to treat the Cancer effectively, a partial rather than total penectomy is a better option if the Cancerous tissue and a 2 cm margin of healthy tissue can be removed while leaving enough length of the penis for the patient to urinate naturally. When this is not possible, a total penectomy is performed, which is the removal of the entire penis. The surgeon will tunnel the urinary tract underneath the scrotum, requiring the patient to urinate in a sitting position. - Lymph node dissection: This is done even if there are no signs that the Cancer has spread to the lymph nodes. If the groin lymph nodes are larger before surgery, then surgery to remove these lymph nodes is generally more extensive.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to destroy Cancer cells. Radiation therapy is of two types:
External-beam radiation therapy: It is the most common type of radiation treatment and is given from a machine outside the body.
Internal radiation therapy or brachytherapy: It is the radiation treatment given using implants.
Chemotherapy
Chemotherapy is the use of drugs to destroy Cancer cells, usually by stopping the Cancer cells’ ability to grow and divide.
There are 2 types of chemotherapy that may be used for penile Cancer: topical chemotherapy and systemic chemotherapy.
- Topical chemotherapy
For small noninvasive Cancers, or “carcinoma in situ,” lower doses of chemotherapy can be used on the surface of the skin. - Systemic chemotherapy
Systemic chemotherapy gets into the bloodstream to reach Cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
Common systemic drugs for penile Cancer include:
- Bleomycin (Blenoxane)
- Cisplatin (Platinol)
- Docetaxel (Docefrez, Taxotere)
- Gemcitabine (Gemzar)
- Ifosfamide (Ifex)
- Methotrexate (multiple brand names)
- Paclitaxel (Taxol)
Penile Cancer is highly treatable, when the Cancer is diagnosed at early stages. A surgery to remove part or entire penis can be useful to treat penile Cancer even at the later stages.
In case of experiencing any of the mentioned symptoms or having a prior or familial history of testicular Cancer, a physical examination by a doctor is highly recommended.
In most of the cases, men discover the signs and symptoms of penile Cancer and being aware of them aids in suspecting the presence of the disease. Consulting a doctor immediately and going for diagnosis will definitely make things clear.
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