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Introduction

Penile cancer is rare with only 600 new cases in the UK every year; it is more common in Asia, Africa & South America. If detected early enough, the chances of cure are very high.

Cancer can develop anywhere on the penis but arises most commonly under the foreskin, in men who have not been circumcised, or on the head (glans) of the penis.

The exact cause of penile cancer is unknown, but there are several risk factors:

  • increasing age
  • smoking
  • human papilloma virus (HPV type-16 & 18)
  • uncircumcised men
  • balanitis xerotica obliterans (BXO)


Symptoms of penile cancer

These include:

  • a growth on the penis that does not heal within 4 weeks (it can look like a wart, ulcer or blister, and is not always painful)
  • bleeding from the penis (especially from under the foreskin)
  • penile discharge
  • tight foreskin (phimosis)
  • a rash or change of colour on the glans penis or foreskin
  • a lump in the groin (due to enlarged inguinal lymph nodes)

Tests & investigations

Clinical examination should be performed to assess the size, position and nature of any penile lesions (pictured below). Always check underneath the foreskin, and feel for enlarged inguinal nodes (number, laterality, firmness, mobility, fixation).

  

If there are palpable lymph nodes, a CT scan is usually performed to check for impalpable pelvic lymph nodes and to assess any extra-nodal metastatic disease.

Local tumour staging is best performed using MRI with an artificial erection (induced by prostglandin-E1 injection). This is the most accurate means of defining the level of tumour invasion, and helps in planning the surgical approach.


Initial biopsy of the penile lesion(s)

Histological confirmation of penile cancer is essential before definitive treatment can be planned. A histological diagnosis can be obtained using several approaches, depending on the size & position of the tumour:

  • fine needle aspiration (FNA) - this can also be used to biopsy enlarged lymph nodes
  • incision biopsy - to remove part of the lesion for examination
  • excision biopsy - removal of the entire lesion (often with the foreskin

Approximately 65% of penile cancers are squamous cell carcinomas. The image below shows a squamous carcinoma extending with finger-like projections into the underlying dermis:

Less common types include basaloid carcinoma (10%), wart carcinoma (10%) and verrucous carcinoma (8%). Among the rarer cancers are adenocarcinoma, melanoma and sarcoma.


TNM-staging & histological grading

TNM + Grade     Details of classification
T-Stage
pT0 No evidence of primary tumour
pTis Carcinoma in situ
pTa Non-invasive carcinoma
pT1 Tumour invades sub-epithelial connective tissue
pT2 Tumour invades corpus spongiosum and/or corpora cavernosa
pT3 Tumour invades urethra
pT4 Tumour invades other adjacent structures
N-Stage
N0 No palpable or visibly enlarged inguinal lymph node
N1 Palpable, mobile unilateral inguinal lymph node
N2 Palpable, mobile, multiple unilateral or bilateral inguinal lymph nodes
N3 Fixed inguinal lymph node mass or pelvic lymphadenopathy (unilateral or bilateral)
M-Stage
M0 No distant metastases
M1 Distant metastasis
Histological Grade
(G-Stage)
G1 Well differentiated tumour  
G2 Moderately differentiated tumour  
G3 Poorly differentiated/undifferentiated tumour  

Lymph nodes & penile cancer

Lymph node metastases in penile cancer follow well-defined anatomical pathways:

  • the superficial & deep inguinal nodes are the first regional nodes affected (either unilateral or bilateral)
  • the ipsilateral pelvic nodes (above the inguinal ligament) are the next to be affected; pelvic nodal disease does not occur without inguinal nodal metastasis
  • further spread may then occur outside the regional nodal system of the penis, to para-aortic and para-caval nodes; this is classified as systemic metastatic disease

Definitive treatment of the penile lesion

Because penile cancer is rare, regional referral units tend to manage the patients and perform their definitive treatment. The aims of treatment are complete tumour removal with as much organ preservation as possible.  Options are:

  • medical treatment (superficial, non-invasive carcinoma in situ can be treated using imiquimod or 5-fluorouracil cream)
  • surgery (this may include either sentinel node biopsy or lymph node dissection)
  1. glansectomy & resurfacing
  2. partial penectomy ± glans reconstruction (by skin grafting)
  3. total penectomy & perineal urethrostomy
  • palliation (debulking surgery, radiotherapy)

Download patient information about surgery for penile cancer.


Lymph node treatment

The management of lymph node metastases in penile cancer is slightly contentious and is under constant review.  Treatment options are dependent on the primary tumour stage, the status of palpable lymph nodes and the presence of pelvic nodal disease.  The following table summarises current thinking:

Regional lymph nodes Management
No palpable nodes G1 histology and stage Tis, Ta or T1: simple surveillance
≥ G2 histology and > stage T1: lymph node staging needed
Palpable lymph nodes Radical inguinal lymphadenectomy
Fixed inguinal lymph nodes Neoadjuvant chemotherapy followed by radical inguinal lymphadenectomy
Pelvic lymph nodes Ipsilateral pelvic lymphadenectomy if ≥ 2 inguinal nodes are positive, or if there is extra-capsular extension in the nodal mass

Hakenberg et al. EAU Guidelines on Penile Cancer: 2014 Update. Eur Urol 2015;67:142-50


Follow-up & prognosis

An intensive follow up regime is needed for the first 2 years; thereafter, less detailed follow up is needed for a further 5 years at least. This consists primarily of surveillance for local and nodal disease, since these are the main sites of recurrence.

Overall, nearly 80% of penile cancer patients of all stages can be cured. Partial penectomy, however, has inevitable negative consequences for patient self-esteem and sexual function.

Specialist experience in the management of penile cancer has shown that organ-preserving treatment provides better quality of life with better sexual function, and should be offered to all patients whenever feasible.