Penile TumourUro-Oncology Unit
Penile tumour is a rare tumour in developed countries, affecting 1/100,000 men in Europe and the USA (in some regions of Spain this incidence is higher). However, in some underdeveloped countries it becomes the most frequently diagnosed tumour in men, as is the case in Uganda.
Epidermoid tumour on the penis (or squamous cell carcinoma) accounts for 95% of cases, but other types of tumours have been described as melanomas, lymphomas, mesenchymal tumours, or metastases from other tumours. It is essential to identify certain precursor lesions of penile cancer: intraepithelial lesions, Bowen’s disease, Paget’s disease, giant condyloma, among others.
The human papillomavirus (HPV) is present in one third of the cases, and is considered one of the main risk factors. The virus is involved in carcinogenesis and interferes with oncogenes and tumour suppressor genes, favouring the development of tumours. The HPV subtypes most commonly associated with penile tumours are HPV 16 and 18.
Other risk factors related to penile tumours are advanced age, phimosis, chronic inflammation (Balanitis xerotica obliterans), condyloma acuminatum (HPV), treatment with psoralen or UVA phototherapy, smoking, living in socio-economically deprived areas, and sexual promiscuity. It is thought that childhood circumcision can decrease the incidence of penile cancer, but this remains a controversial issue nowadays.
- Urologists highly specialised in penile cancer.
- Penis lesions biopsy.
- Penile Doppler ultrasonography.
- Radiodiagnostic service: CT, NMR, and PET.
- Sentinel node.
In the diagnosis of penile cancer, a physical exam is essential. The penis and groin should be examined to identify lesions (number, appearance, location) and discard possible involvement of the corpora cavernosa as well as inguinal lymphadenopathy. In case of doubts about the involvement of corpora cavernosa, a penile Doppler ultrasonography or NMR can be done. Once the lesion has been identified, the anatomopathological diagnosis must be achieved by means of a biopsy or total exeresis, and must state the presence or absence of HPV. The study is complemented by CT, PET or sentinel node identification in selected cases.
- Partial penectomy.
- Complete penectomy.
- Inguinal lymphadenectomy.
- Iliac lymphadenectomy (laparoscopic, open, or robotic).
- Close collaboration with radiotherapy, medical oncology, and dermatology services.
- Andrology and reconstructive surgery unit.
There are several options for the treatment of a penile tumour at an early stage depending on the tumour grade and local spreading.
Topical treatment with imiquimod or 5-fluorouracil (only in cases of carcinoma in situ), CO2 or Nd-YAG laser (associated or not with circumcision), and resurfacing of the glans (complete abrasion of the glans and application of grafts to cover the affected area) for superficial and low-grade tumours.
These techniques aim to remove the tumour while preserving as much of the penis structure as possible: partial glansectomy, total glansectomy, or partial penectomy.
Complete penectomy and perineal urethrostomy. It is performed when the tumour invades the urethra or adjacent organs.
Radiotherapy can be applied in some specific cases provided that lesions are small and do not invade the corpora cavernosa. It can also be used as a mitigation therapy for inoperable tumours.
Treatment of regional nodes
Penile tumours tend to metastasise to the inguinal lymph nodes. If inguinal nodes are palpable or visible in imaging tests, a radical inguinal lymphadenectomy must be made and, depending on the anatomopathological results, a pelvic lymphadenectomy should follow or not. If there are no palpable lymph nodes, or if they are not visible in the imaging tests, it is recommended to make prophylactic lymphadenectomy or biopsies of sentinel node.Monitoring is also possible in the case of superficial and low-grade tumours.
Chemotherapy is used in the most serious cases: to reduce the tumour size before surgery, when the penile tumour affects neighbouring organs, or when the inguinal nodes are large, indurated, and fixed into underlying tissues. It can also be used after surgery in the most adverse cases.
Penile cancer is an aggressive disease that has a 5-year survival rate of 66% if the lymph nodes are not involved and 27% when the nodes are infiltrated by the tumour. Tumour recurrence is frequent and radical surgery is mutilating for patients. Early diagnosis is very important. Besides, adapting the treatment to each case is essential to control the disease while preserving the patient’s quality of life.
It is important to have urologists specialised in the treatment of this tumour and a well-prepared reconstructive surgery unit to offer the patient a comprehensive treatment.