Penile Cancer

Cancer of the Penis
Penile Cancer

The penis is a male reproductive organ. A caner of the penis is known as penile cancer. Penile cancer usually happens in elderly males. It can start in any part of the penis but is more common under the skin at the head of the penis.

According to Globocan 2018 report, there were 9938 cancers of the in India, making up nearly 1% of all cancers diagnosed.

The most common type of penile cancer is a squamous cell carcinoma. Other types include papillary carcinoma, basaloid carcinoma, verrucous carcinoma and rarely sarcoma like carcinoma.

The risk factors for Penile include those that are listed below.

Age

Penile cancer is more common in those aged more than 50, typically more than 70 years of age.

HPV Infection

HPV is human papilloma virus which is an infection that is transmitted by sexual contact. This infection does not cause any symptoms and those people who have had an HPV infection at some point in their lifetime have an increased risk of developing penile cancer.

Reduced Immunity

People who have a reduced level of immunity due to medications after organ transplantation or infections such as HIV and AIDS have an increased risk of getting a penile cancer.

Others

People who are unmarried and those who have not had a circumcision are at a higher risk of getting a penile cancer. People with a medical condition called Psoriasis who have Psoralen or UVA treatment are also at increased risk of penile cancer.

Cancer of the penis can produce symptoms which can alert the patient about the condition These include

Lump or ulcer

A hard lump, an ulcer or a sore may develop on the penis. This may be seen on the skin or under the skin of the penis. This lump may or may not be painful and increase in size over time.

Bleeding or discharge

Bleeding from the penis or from under the foreskin may be a symptom of a cancer on the penis. A foul smelling discharge may also be noted by some patients with this condition.

Unable to move the foreskin

Being unable to move the foreskin freely over the penis as before could be a sign of a cancer on the penis.

Other symptoms

Other symptoms related to cancer of the penis seen in patients with advanced cancer include swelling or lump in one or both groin regions, tiredness, leg swelling, weight loss and loss of appetite.

When a cancer in the penis is suspected, the following tests are done to confirm the diagnosis and stage the disease.

Biopsy

A biopsy of the lump or growth seen on the penis is done to confirm a diagnosis of cancer. At the same time, if there are any suspicious lymph nodes in the groins, a needle aspiration (FNAC) is done on these nodes to look for spread of the cancer.

CT scan

A CT scan of the chest abdomen and pelvis is done to look for spread of the cancer and to stage it. The scan looks for the spread to cancer into other parts of the body.

MRI Scan

An MRI scan is done to look for suspected cancer and enlarged lymph nodes and to stage the cancer. Usually either a CT scan or an MRI scan is enough for staging but occasionally both are needed in some situations.

PET CT scan

A PET CT scan is done instead of a CT scan to stage the cancer. PET-CT scan may be more sensitive in locating areas of spread of cancer outside the penis.

Sentinel node Biopsy

Sentinel node is first node or nodes that the cancer can spread to. If there is no cancer in the sentinel node, then the chance of there being cancer in other lymph nodes further afield is small.

A sentinel node is usually found in the groin after injection of a small dose of radioactive substance or a blue dye into the area around the tumour in the penis. This dye is taken up by the first lymph node/s that the dye spreads to. These substances help the surgeon to locate the nodes at surgery.

The sentinel node biopsy is done at the same time or before surgery.

These removed nodes are then examined under the microscope for cancer cells. If there are no cancer cells, there is no further need for surgery to remove the nodes. However, if cancer cells are found, then the surgeon may decide to remove all other lymph nodes in the area.

Penile cancer is given a stage according to the TNM or number staging system.
The stage of a cancer is a term used to describe the size and location of the cancer in the body.
Knowing the stage of the cancer helps the doctors to decide on the most appropriate treatment. Penile cancer is staged based on the TNM staging system or the number system.
Staging with either system is based on the extent of the tumour in the penis, the spread of the cancer into the lymph nodes, and spread of cancer into other parts of the body. TNM stands for tumour, node and metastases.T stands for tumour. N stands for nodes and spread of cancer into nodes. M stands for metastases and spread of cancer to distant sites in the body.

TNM Staging

T Stage

T1 Tumour involves areas just below the skin
T2 Tumour involves corpus spongiosum which is the soft erectile tissue in the penis and may or may not involve the urethra
T3 Tumour has involved corpora cavernosum and may or may involve the urethra
T4 Tumour grows into nearby organs such as prostate gland, scrotum or pubic bone.

N Stage

N0 There is no involvement of lymph nodes
N1 There is cancer spread into one lymph node of the groin(inguinal)
N2 There is spread into many lymph nodes in the groin
N3 There is spread of cancer into the lymph nodes of the pelvis or into surrounding tissues from the lymph node

M Stage

M0 There is no spread of cancer into other organs or tissues
M1 There is spread of cancer to areas outside the pelvis

Number staging

Stage 1 T1 N0 M0
Stage 2 T1b N0 M0
T2 N0 M0
T3 N0 M0
Stage 3a T1-3 N1 M0
Stage 3b T1-3 N2 M0
Stage r4 T4 any N M0
Any T N3 M0
Any T any N M1

The treatment options for penile cancers include surgery to remove the tumour, radiotherapy and chemotherapy. Which treatment to select will depend on the location and stage of cancer at the time of diagnosis and the fitness of the patient.

Surgery

Surgery is one of the main treatments to control this type of cancer. The type of surgery done will depend on the location and extent of the cancer on the penis. The aim of any surgery will be to remove the cancer along with a margin of normal penis around it. Removing a normal margin around it will ensure completeness of the operation. The different types of operation are

Glansectomy

This is an operation where the glans penis (head of the penis) is removed. This operation is done if the cancer is present at the front end of the penis. Once the glans is removed, a part of the skin or muscle is removed from elsewhere in the body and put in place of the glans to give a shape again to the penis.

Penectomy

Penectomy is removal of the penis. This can be a partial penectomy where a part of the penis is removed or a total penectomy, where the entire penis is removed. Which type of penectomy is done depends on how far back into the penis the tumour extends to and the extent of the cancer. If the cancer is present at the back of the penis, a total penectomy is done. Patients who have a partial penectomy will still be able to pass urine while standing and those with a total penectomy will have the urethra connected to the anus to be able to pass urine through the anus. The function of holding and controlling urine will continue to work.

Reconstruction

Some surgeons perform a reconstruction of the penis after surgery using muscle and skin from other parts of the body. Following reconstruction, it may be possible for the patient to pass urine as before surgery.

Lymph node removal

If there is suspicion of lymph node involvement, an FNAC is done to look for presence of cancer in the lymph nodes. If there is evidence of cancer in the lymph nodes of the groin, a lymph node dissection or removal is done where all the lymph nodes in the area are removed. This can be on one or both groins. If a sentinel node biopsy is performed, then the lymph nodes on the side of positive sentinel nodes are removed.

Radiotherapy

Radiotherapy as a treatment in cancer of the penis is used in different situations. It can be used to treat the cancer instead of surgery in patients who cannot have surgery due to reduced fitness or other reasons. Radiotherapy can be used to treat the lymph nodes of the groin after surgery on the penis instead of lymph node dissection. It may also be used to treat cancer that has spread to the lymph nodes in the pelvis. When given it is used as a daily treatment for up to 6 weeks in duration.

Chemotherapy

Chemotherapy is used in penile cancer in patients who have advanced disease. Chemotherapy using a combination of drugs such as Taxanes, Cisplatin and Ifosfamide may be used prior to surgery to reduce the amount of disease. It may also be used after surgery in patients with advanced disease to reduce the risk of recurrence. In patients who have metastatic disease or disease that has come back after initial treatment, chemotherapy is used to control the disease.