Carcinoma Penis

PRAVIN NARKHEDE

• Account for less than 0.5% of cancer in men• Incidence fluctuates widely• 97% are squamous cell carcinoma and resemble like

any SCC in body elsewhere• 3 % is constituted by melanoma, kaposi’ssarcoma,

secondary deposits.

AETIOLOGY

• Phimosis– Accumulation of smegma and irritation and

infection predisposes to development of carcinoma

– Circumcision performed within 1st few days of life confers protection against malignancy

• Balanoposthitis – Chronic or recurrent attacks

• Condyloma acuminata or penilewarts – Human Papilloma Virus– Premalignant

• Leukoplakia of glans penis – Premalignant– Painless greyish-white paint, shows hyperkeratosis

and acanthosis ( thickening of epidermis)• Paget’s disease– Chronic red eczema of glans penis or inside of

prepuce it oozes and crust over it– It is intraepithelial stage of SCC histologicaly similar to

pagets disese of breast– Often escapes detection, diathermy excision is

treatment

• Erthroplasia of Queyrat (Carcinoma in-situ)– Dark red, flat idurated patch over glans or inner

side of prepuce• Bowen’s disease (Carcinoma in-situ)– Only seen in >35 yrs of age– Thickened , opaque plaques with shallow

ulceration and crusting– Form of carcinoma in situ – Prone to involve shaft– Over period of transforms to SCC

• Syphillis and gonorrhoea and implicated as initative factors but not proven

PATHOLOGY

• Lesion usually begin on glans or inner surface of the prepuce near the coronal sulcus

• 1st change is small area of thickening accompained by grey & fissuring of mucosal surface, gradually lekolplakic patch develops which ulcerates when reaches to 1 cm

• Macrscopically 1:- ulcerative form – Large malignant ulcer with necrotic secondarilly infected

floor and ragged, irregular and heaped-up margins– Advanced cases ulcero-invasive disease is seen

2:- papilliferous form– Simulates condyloma and gradually progress to form

cauliflower like fungating mass– As it progress central ulceration develops may

transformed into ulcerative form• Microscopically– Simulates like SCC, demonstrating keratinization, epithelial

pearl formation, and various degrees of mitotic activity

Spread

• Direct spread– Direct spread to body of penis does not take place

before 6 months to 1 year as fascial sheath of corpora cavernosa acts as a barrier

– Once it broken rapid spread occurs to shaft– Pecularily enough urethra is not involved

• Lymphatic spread– Early by embolisation– Prepuce & glans :- superficial inguinal group of

both sides– Some from glans drain directly to deep inguinal

nodes– Involvement of nodes may be due to

inflammatory – Shaft of penis :- iliac group of lymph node– Iliac nodes also involve as efferent from inguinal

nodes

• Blood spread :-– Late & rarely– When growth is anaplastic and virulent– Fewer than 10% occcur in lungs, liver, bones and

brain, prognosis is poor

Clinical Features• History– Middle or old age most common young rare

• Symptoms– Lump or ulcer over penis– Mild irritation & discharge from prepuce– Late cases bloody & foul smelling discharge from

prepuce or growth– Generally painless but superadded infection may

become painful– Generally inguinal node are involved may

inflammatory or metastatic

Investigations• Routine blood examinations– To r/o anaemia, lekuocytosis due to superadded

infections– Some instances hypercalcemia seen which cured after

primary mass excision• Wedge Biposy – Confirmation of the diagnosis and assessment of the

depth of invasion, the presence of vascular invasion, and the histologic grade

– no further radiologic workup is generally needed in patients with early-stage disease and the absence of inguinal adenopathy on examination or other worrisome symptoms

• Ultrasound and gadolinium-enhanced MRI are recommended for high-grade and high-stage lesions suspected of involving the corporal bodies, especially if partial penectomy is contemplated.

• Abdominal and pelvic CT scanning is recommended in obese patients to evaluate the inguinal nodes.

• In patients with known inguinal metastases, CT-guided biopsy of enlarged pelvic nodes

TNM Staging

• Primary tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ Ta Noninvasive verrucous carcinoma T1 Tumor invades subepithelial connective tissue T2 Tumor invades corpus spongiosum or cavernosum T3 Tumor invades urethra or prostate T4 Tumor invades other adjacent structures

• Lymph nodes (N) NX Regional nodes cannot be assessed N0 No regional lymph node metastases N1 Metastasis in a single regional lymph node

Metastases in multiple or bilateral superficial inguinal lymph nodes Metastases in deep inguinal or pelvic lymph nodes; unilateral or bilateral

• Distant metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis

Tretment

• Radiotheray • Surgery

Radiotheray • Indication – small growth T1 & T2– Well differentiated growth limited to glans

• Advantage – Results same as surgery– Avoids operation

• Disadvantage– Bad scarring results in painful erection– Postoperative sterility– Slower rate of regression– Weeks of discomfort

• Contraindication– Big growth– Growth involving shaft– Anaplastic tumour

• Dorsal slit in must for proper radiological exposure

• Methods– Implantation of flexible tantalum wires which

offers total dose of 6000 rads in 5-7 days– Megavoltage X-ray gives 5000-6000 rads in

divided doses over 5-7 days– Surface radiation by radium mold applicator

intermittently or continuous, total dose of 6000 rads in 5-7 days

• Surgery • Indications– Anaplastic growth– Big growth– Infiltration to shaft– Radiotherpy failed methdos of surgery

• Methods– Circumcision, – Conservative local resection, – Laser ablation, and – Mohs micrographic surgery– Partial and Total penectomy.

• Treatment depends on the local extent of the primary neoplasm and the status of the regional lymph nodes

• For treatment of the primary lesion, a 2-cm proximal margin of resection is recommended to avoid local recurrence

• depending on the extent of the primary tumor, resection may include a partial or total penectomy

• Carcinoma in situ (TIS)– also known as erythroplasia of Queyrat– Preputial lesions are adequately treated with

circumcision– Topical 5-FU cream has been used with excellent

cosmetic results for glanular and meatal lesions– combination of carbon dioxide and Nd:YAG lasers has

shown good local tumor control and highly satisfactory cosmetic results on long-term follow-up

– Mohs micrographic surgery has been described as a less-deforming alternative

– Radiation therapy has also been used successfully to eradicate these lesions with minimal morbidity

• Invasive Penile Cancer (T1, T2, T3, and/or N1)– Partial penectomy• Distal penile lesions in which a serviceable penis

for upright micturition and sexual function can be achieved• Patients with recurrence after this treated by

surgical salvage– Total penectomy with excision of both corporal

bodies and creation of a perineal urethrostomy• Extensive lesions approaching the base of the

penis– Most relapses occur within the first 12 to 18

months after penectomy

• Radiation therapy for primary penile cancer should be considered only in a select group of patients: – young patients with small (2- to 4-cm) superficial

lesions of the distal penis who wish to maintain penile integrity,

– patients who refuse surgery, and – patients with inoperable cancer or those

unsuitable for major surgery

• Advanced Penile Cancer (T4, N2/N3, and/or M1)– Large proximal shaft tumors require a total

penectomy with a perineal urethrostomy– extensive, proximal tumors with invasion of

adjacent structures, total emasculation consisting of total penectomy, scrotectomy, and orchiectomy is recommended

– hemipelvectomy or even a hemicorporectomy has been also reported

SURGICAL TREATMENT OF PRIMARY DISEASE

• Management of Regional Lymph Nodes– presence and extent of inguinal lymph node

metastases are the most important prognostic factors in patients with penile cancer