Penile cancer is rare, with about 2200 cases and 460 deaths in the United States and higher rates in regions such as South America. Human papillomavirus Human Papillomavirus (HPV) Infection Human papillomavirus (HPV) infects epithelial cells. Most of the > 100 subtypes infect cutaneous epithelium and cause skin warts; some types infect mucosal epithelium and cause anogenital warts... read more (HPV), particularly types 16 and 18, plays a role in etiology. Other risk factors include balanitis Balanitis, Posthitis, and Balanoposthitis Balanitis is inflammation of the glans penis, posthitis is inflammation of the prepuce, and balanoposthitis is inflammation of both. Inflammation of the head of the penis has both infectious... read more , lack of circumcision, sexually transmitted infections (particularly HIV/AIDS Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more and HPV), poor hygiene, and tobacco use. Premalignant lesions include erythroplasia of Queyrat, Bowen disease Bowen Disease Bowen disease is a superficial squamous cell carcinoma in situ. Diagnosis is by biopsy. Treatment depends on the tumor’s characteristics and may involve curettage and electrodesiccation, surgical... read more , 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.
Symptoms and Signs of Penile Cancer
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 can grow to become 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.
Diagnosis of Penile Cancer
If cancer is suspected, biopsy (punch, incisional, or excisional) is required; if possible, tissue under the lesion should be sampled. CT Computed Tomography Imaging tests are often used to evaluate patients with renal and urologic disorders. Abdominal x-rays without radiopaque contrast agents may be done to check for positioning of ureteral stents... read more or MRI Magnetic Resonance Imaging Imaging tests are often used to evaluate patients with renal and urologic disorders. Abdominal x-rays without radiopaque contrast agents may be done to check for positioning of ureteral stents... read more helps in staging localized cancer, checking for invasion of the corpora, and evaluating lymph nodes.
Treatment of Penile Cancer
Untreated infiltrative 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. Radiation therapy (brachytherapy or external beam radiation therapy) can be considered, either as monotherapy or in conjunction with surgery and chemotherapy. 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 (radical) 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, bulky unilateral lymphadenopathy, or pelvic lymphadenopathy, then 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.
Prevention of Penile Cancer
Measures that may help in prevention include circumcision in early life, long-term hygiene in uncircumcised men, and recommended human papillomavirus (HPV) vaccination in adolescents.
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.