Penile cancer is rare, with about 2000 cases and 400 deaths in the United States and higher rates in regions such as South America. Human papillomavirus (HPV), particularly types 16 and 18, plays a role in etiology. Premalignant lesions include erythroplasia of Queyrat, Bowen disease, and bowenoid papulosis. Erythroplasia of Queyrat (affecting the glans or inner prepuce) and Bowen disease (affecting the shaft) progress to invasive squamous cell carcinoma in 5 to 10% of patients; bowenoid papulosis does not appear to do so. The 3 lesions have different clinical manifestations and biologic effects but are virtually the same histologically; they may be more appropriately called intraepithelial neoplasia or carcinoma in situ.
Most squamous cell carcinomas originate on the glans, in the coronal sulcus, or under the foreskin. They usually begin as a small erythematous lesion and may be confined to the skin for a long time. These carcinomas may be fungating and exophytic or ulcerative and infiltrative. The latter type metastasizes more commonly, usually to the superficial and deep inguinofemoral and pelvic nodes. Metastases to distant sites (eg, lungs, liver, bone, brain) are rare until late in the disease.
Most patients present with a sore that has not healed, subtle induration of the skin, or sometimes a pus-filled or warty growth. The sore may be shallow or deep with rolled edges. Many patients do not notice the cancer or do not report it promptly. Pain is uncommon. Inguinal nodes may be enlarged due to inflammation and secondary infection.
Untreated penile cancer progresses, typically causing death within 2 years. Treated early, penile cancer can usually be cured.
Topical treatment with 5-fluorourcil or imiquimod and laser ablation are effective for small, superficial lesions. Circumcision is done for lesions of the foreskin. Wide excision is preferred for recurrent lesions or in patients who cannot reliably follow up. Mohs surgery, when available, can be done instead of wide excision.
Invasive and high-grade lesions require more radical resection. Partial penectomy is appropriate if the tumor can be completely excised with adequate margins, leaving a penile stump that permits urination and sexual function. Total penectomy is required for large infiltrative lesions. If tumors are high-grade or invade the corpora, bilateral ilioinguinal lymphadenectomy is required. If there is suspicion for bilateral node–positive disease or bulky unilateral lymphadenopathy, then neoadjuvant chemotherapy prior to lymphadenectomy is advised. The role of radiation therapy has not been established. For advanced, invasive cancer, palliation may include surgery and radiation therapy, but cure is unlikely. Chemotherapy for advanced cancer has had limited success. Targeted and immunotherapy used for head and neck squamous cell cancers may prove useful for penile cancer patients but no definitive studies support their use in routine clinical practice.
Penile cancer is usually squamous or another skin cancer.
Consider penile cancer with any nonhealing sore, induration, or purulent or warty penile growth, particularly in uncircumcised men.
Diagnose penile cancer by biopsy and treat it by excision.
Lymph node status is the driver of survival. Appropriate use of lymphadenectomy in intermediate and high-risk patients is an essential component of managing this disease.