Penile Cancer

Urinary retention or urethral fistula

due to local corporal involvement is a rare presenting sign

Verrucous carcinoma

is an exophytic well-differentiated variant of squamous cell carcinoma that are locally invasive, but rarely metastasize

Carcinoma in Situ

is an intraepithelial malignant process

Mass, ulceration, suppuration or hemorrhage in the inguinal area

maybe due to nodal metastases from a lesion concealed within a phimotic foreskin

Lung, Bone, Liver

most common site of penile cancer metastasis

Squamous cell carcinoma

most tumors of penis demonstrating keratinization, epithelial pearl formation and various degress of mitotic activity diagnosed often late since patients are in denial most of the tyme

Single Agent Chemotherapy

o Cisplatin(DDCP) o Bleomycin o Methotrexate

Bowen Papulosis

occurs in sexually active adults distinguished from Bowen disease by the younger age of affected patients presentation as multiple (rather than solitary) reddish brown papular lesions Although bowenoid papulosis is histologically indistinguishable from Bowen disease and is also related to HPV type 16, it virtually never develops into an invasive carcinoma and in many cases regresses spontaneously.

Histology of Condyloma acuminatum

single or multiple sessile or pedunculated, red papillary excrescences that may be up to several millimeters in diameter The normal orderly maturation of the epithelial cells is preserved;

Cutaneous Benign Lesions

Peary PeniLE Papules Hirsute papillomas Coronal papillae Zoon's balantis

Penile cancer begins with

a small lesion, gradually extending to the entire glans, shaft and corpora maybe papillary and exophytic or flat and ulcerative

Bushke-Lowenstein Tumor

also known as verrucous carcinoma or giant condyloma displaces, invades, and destroys adjacent tissues demonstrates no malignant change on histopathology no metastasis

HPV types 16, 18, 31 and 33

are associated with CIS and invasive carcinomas

Patients with small lesions of low grade and stage (Tis, Ta, T1; grade 1 and grade 2)

are the optimal candidates for organ preservation to maintain sexual quality of life.

Superficial inguinal node dissection

as indicated for high grade, vascular invasion, or invasive histologic pattern

T1

subepithelial connective tissue

Goals of organ preservation

to maintain glanular tissue for sensory purposes when possible and/or to maintain penile length when glans penis preservation is not possible.

Distribution of penile cancer is due to

constant exposure of the glans, coronal sulcus and interior prepuce to irritants (E.g. smegma, HPV infection) within the preputial sac, whereas the shaft is relatively spared.

T2

corpus spongiosum or cavernosum

2 microscopic patterns of penile squamous cell carcinoma

(1) papillary lesions simulate condylomata acuminata and may produce a cauliflower-like fungating mass. (2) Flat lesions appear as areas of epithelial thickening accompanied by graying and fissuring of the mucosal surface. With progression, an ulcerated papule develops

Mandatory before the initiation of any therapy

- Confirmation of the diagnosis of carcinoma of the penis - assessment of the depth of invasion, - presence of vascular invasion, - histologic grade of the lesion by microscopic examination of a biopsy specimen

Organ preservaton

- applicable for early stage tumors - Topical 5FU - Radiation-seldom employed since tumors don't go away immediately - Circumcision and Limited Excision Strategies - indicated for Stages Tis, Ta, T1; Grade 1 and 2 tumors

Partial penectomy

- at least 2 cm margin - provides sufficient remnant to maintain upright voiding

Erythroplasia of Queyrat

Carcinoma in situ of the penis if it involves the glans penis and prepuce or Bowen disease if it involves the penile shaft or the remainder of the genitalia or perineal region

Chemotherapy

Active single agent and combination strategies Experience with chemotherapeutic management is limited because of the rarity of Penile CA Chemotherapy can induce responses in metastatic penile cancer but are generally partial in character and short in duration Disease consolidation with surgery and potentially radiotherapy is required in most cases to achieve disease-free state

Goal of therapy

Cancer eradication with organ-preserving strategies

Primary tumor

Clinical examination o In patients with penile cancer both the primary tumor and the inguinal lymph nodes are readily assessed by palpation Incisional-excisional biopsy of lesion and histologic examination For grade, anatomic structure invaded and presence of vascular invasion

Decreasing incidence of penile cancer

Decrease in incidence maybe related in part to increased attention to personal hygiene, circumcision standards and virus related infections

Critical in treatment planning

Examination of both the penile primary tumor and the inguinal region is critical to treatment planning.

Kaposi Sarcoma

HHV 8 closely linked to HIV malignant, vascular, neoplastic growth characterized by cutaneous nodules

Glans (48%) Prepuce (21%)

Location of penile cancer

Presentation of penile cancer

Relatively subtle indurations or small excrescence to a small papule, pustule, warty growth, or more luxuriant exophytic lesion May appear as a shallow erosion or as a deeply excavated ulcer with elevated or rolled-in edges Phimosis may obscure a lesion and allow a tumor to progress silently Eventually, erosion through the prepuce, foul preputial odor, and discharge with or without bleeding call attention to the disease. May present anywhere on the penis

Non-cutaneous Benign Lesions

Retention cyst Inclusion Cyst Syringomas Neuliemomas

Contemporary Penile Amputation

The "Gold Standard" but with poor sexual quality

Penile Cancer

Tumors of the penis are, on the whole, uncommon. The most frequent neoplasms are carcinomas and a benign epi- thelial tumor, condyloma acuminatum. Benign prolifera- tions of fibroblasts (Peyronie disease) are also worthy of brief mention. 58 % Squamous cell carcinoma 15 % Papillary 10% Basaloid 10% Condylomatous 3% Sarcomatoid

Bowen disease and Bowenoid papulosis

Two distinct lesions display histologic features of CIS in the penis These lesions have a strong association with infection by high-risk HPV, most commonly type 16.

T3

Urethra or prostate

Condyloma acuminatum

Virus types 6, 11, and 42 to 44 are associated with gross condylomata and low-grade dysplasia Types 16, 18, 31, 33, 35 and 39 have a higher association with malignant disease (Smotkin, 1989)

Acanthosis

What dermatologic condition matches the following statement: black velvety plaques on flexor surfaces and intertriginous areas? a branching, villous, papillary connective tissue stroma is covered by epithelium that may have considerable superficial hyperkeratosis and thickening of the underlying epidermis

Give antibiotics 4-6 week

because in penile cancer, there might be secondary infection of inguinal lymph nodes

HPV type 6 and 11

commonly associated with genital warts, but also noted in nonmetastatic verrucous carcinomas

Metastasis is due to

embolization of tumor deposits from the penile tumor through penile lymphatics to the inguinal lymph nodes

HPV 16

frequently seen in primary carcinomas and has also been detected in metastatic lesions

Flat ulcerative tumors

have a tendency for early nodal metastasis and have poorer 5-year survival rates

Lesions > 5cm and those over 75% of the shaft

have an increased incidence of metastases and a decreased survival rate

Hypercalcemia without detectable osseous metastases

have been associated with penile cancer

Bowen Disease

occurs in the genital region of both men and wome usually in those older than age 35 years. In men: tends to involve the skin of the shaft of the penis and the scrotum Bowen disease transforms into infiltrating squamous cell carcinoma in approximately 10% of patients, usually over a span of many years. Grossly: It appears as a solitary, thickened, gray-white, opaque plaque. CAN ASLO manifest on the glans and prepuce as single or multiple shiny red, sometimes velvety plaques Histologically: Histologically the epidermis is hyperproliferative, containing numerous mitoses, some atypical. The cells are markedly dysplastic with large hyperchromatic nuclei and lack of orderly maturation the dermal-epidermal border is sharply delineated by an intact basement membrane.

T4

other adjacent structures

Laser ablation

patients with Tis and small T1 SCCA and patients with manageable T2 tumors who refuse more aggressive surgical treatment

Virus-related dermatologic lesions

penile lesions must be considered in the differential diagnosis of penile carcinoma. - They include: condyloma acuminatum, Buschke-Löwenstein tumor, balanitis xerotica obliterans, infectious lesions (e.g., chancre, chancroid, herpes, lymphopathia venereum, granuloma inguinale, and tuberculosis)

Total Penectomy

penile tumors whose size or location would not allow excision with an adequate surgical margin and preservation of a remnant sufficient for upright voiding

PTH and related substance

produced by both tumor and metastasis that activate osteoclastic bone resorption

Amputation

remains the standard for large or deeply invasive lesions to gain rapid tumor control

Moh's Micrographic surgery

removal of penile cancer by excision of tissue in thin layers cure rate of 81% for tumors on the glans or prepuce Best suited for patients with CIS or small superficially invasive tumors

Koilocytosis

shrunken nucleus like a raisin surrounded by perinuclear halo Cytoplasmic vacuolization of the squamous cells (koilocytosis), characteristic of HPV infection, is noted in these lesions

Etiology of Penile cancer

• Circumcision practice • Hygienic standards • Phimosis • Number of sexual partners • HPV infection (HPV 16, 18, 31 & 33) • Exposure to tobacco

Premalignant Lesions

• Cutaneous horn • Pseudoepitheliomatous micaceous balanitis • Balanitis Xerotica Obliterans (BXO) • Leukoplakia

Radiation

• External Beam Radiation or Brachytherapy • May permit the preservation of penile structure • Indicated in only a few appropriate patients • Patients with inoperable tumor or distant metastases who require local therapy for the primary tumor and who express a desire to retain the penis.