Risk Factors
Uncircumcised
Chronic inflammatory conditions
Poor hygeine
Neonatal circumcision is protective; adult circumcision is not
Premalignant Lesions
Erythroplasia of Queryat - a form of carcinoma in situ
Cutaneous horn
Keratotic balanitis (often associated with balanitis)
Leukoplakia
Human Papillomavirus infection (HPV)
Site
Most occur on the glans (either on the foreskin or glans itself). Tumours on the shaft are very rare. They typically begin on the glans and spread proximally. Lymphatic spread occurs to the inguinal nodes, then external iliac nodes. Haematological metastases are rare.
Investigations
Ultrasound is used to evaluate lymph nodes and depth of invasion. MRI is being investigated. Biopsy is used for suspicious lesions but patients may proceed straight to surgical excision for
Management
Management of penile cancer is split between:
- Management of the primary
- Management of the nodes
Management of Primary
Local excision with circumcision leads to recurrence in close to half of patients. Moh's micrographic surgery offers a method of good local control for tumours < 1 cm.
For T1b tumours, wide local excision or radiotherapy are offered.
Surgical management for high grade T1b or T2 lesions is partial penectomy (2 cm margin from macroscopic disease) with reconstruction of the remaining penis to
T3 and T4 lesions require total penectomy, perineal urethrostomy and adjuvant radiotherapy. Some advocate removal of scrotum and testes due to their interference with urination in these patients.
Management of Nodes
More lymph node invovlement significantly impairs survival. The complicating factor in enlarged nodes on examination is that 50% of palpable nodes are due to infection caused by the primary tumour. For this reason, initial treatment with antibiotics and/or fine needle aspiration are warranted.
Inguinal lymphadenectomy is a highly morbid procedure and is avoided if possible (antibiotics, FNA prior to proceeding). If positive nodes are present, an additional 30% of patients will have external iliac node involvement. If these are present then the patient proceeds to a pelvic lymphadenectomy.
Radiotherapy is inferior to lymphadenectomy in terms of local control (25% vs 50%).
Outcome
93% of patients with stage 1 disease survive for 5 years. The 5-year survival rate for stage IV disease is 0.
