Penile Cancer
Summary
Penile cancer is a rare malignancy affecting the glans, foreskin, or shaft of the penis. The vast majority (>95%) are squamous cell carcinomas (SCC). Risk factors include HPV infection (types 16/18), phimosis, poor hygiene, smoking, and lack of circumcision. Premalignant conditions include penile intraepithelial neoplasia (PIN), Bowen's disease (SCC in situ), and erythroplasia of Queyrat (PeIN of the glans). Early lesions may be treated with topical therapy or organ-preserving surgery, while advanced disease requires partial or total penectomy and inguinal lymph node management. Prognosis depends on stage and nodal involvement.
Key Facts
- Histology: >95% Squamous Cell Carcinoma
- Risk Factors: HPV (16/18), Phimosis, Poor hygiene, Smoking, Uncircumcised
- Premalignant: PIN, Bowen's, Erythroplasia of Queyrat
- Spread: Lymphatic to inguinal nodes
- Key Investigation: Biopsy; Inguinal node assessment
- Treatment: Topical, Surgery, Lymphadenectomy
Clinical Pearls
"HPV Causes Penile Cancer": HPV (especially 16/18) is present in 40-50% of penile cancers.
"Phimosis Hides Disease": Inability to retract the foreskin may conceal penile cancer. Any suspicious lesion in a phimotic man warrants circumcision and biopsy.
"Inguinal Nodes Are Key": Nodal status is the most important prognostic factor. Sentinel node biopsy has transformed management.
"Circumcision Protects": Neonatal circumcision is protective; Adult circumcision less so.
Incidence
- Rare in developed countries (<1 per 100,000)
- Higher in Africa, South America, Asia (up to 20%)
Demographics
- Peak: 60-70 years
- Rare before 40
Risk Factors
| Factor | Notes |
|---|---|
| HPV (16, 18) | 40-50% of tumours |
| Phimosis | Chronic inflammation |
| Lack of circumcision | Neonatal circumcision protective |
| Poor hygiene | Accumulation of smegma |
| Smoking | Synergistic with HPV |
| Immunosuppression | HIV, Transplant |
| Lichen sclerosus (BXO) | Premalignant |
Carcinogenesis
- HPV-related: High-risk HPV (16/18) → E6/E7 proteins → p53/Rb inactivation
- Non-HPV: Chronic inflammation, Lichen sclerosus, Phimosis
Premalignant Lesions
| Condition | Features |
|---|---|
| Penile Intraepithelial Neoplasia (PeIN) | Carcinoma in situ |
| Bowen's Disease | SCC in situ on shaft skin |
| Erythroplasia of Queyrat | SCC in situ on glans/prepuce (red velvety plaque) |
| Bowenoid Papulosis | Multiple papules; HPV-related; Younger men |
Spread
- Local → Glans → Corpora → Urethra
- Lymphatic → Superficial inguinal → Deep inguinal → Pelvic
- Haematogenous (late)
Symptoms
| Feature | Description |
|---|---|
| Penile lesion | Ulcer, Nodule, Warty mass, Erythema |
| Location | Most common on glans or prepuce |
| Bleeding | |
| Discharge | Foul-smelling |
| Pain | Often late |
Examination
Penile Examination
- Retract foreskin (if possible)
- Inspect glans, coronal sulcus, shaft
- Palpate for induration
Inguinal Nodes
- Bilateral palpation
- Document size, mobility, fixation
Biopsy
- Punch or excisional biopsy of lesion
Staging
| Test | Purpose |
|---|---|
| MRI Pelvis | Local staging; Corpora involvement |
| CT Chest/Abdomen/Pelvis | Distant staging |
| Sentinel Lymph Node Biopsy (SLNB) | For cN0 (clinically node-negative) |
| Fine Needle Aspiration | For palpable nodes |
TNM Staging
- T: Local extent
- N: Nodal involvement (most important for prognosis)
- M: Metastases
Management Approach
┌──────────────────────────────────────────────────────────┐
│ PENILE CANCER MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ PREMALIGNANT / CIS: │
│ • Topical 5-Fluorouracil or Imiquimod │
│ • Laser ablation │
│ • Glans resurfacing │
│ │
│ EARLY INVASIVE (T1-T2, Small): │
│ • Organ-preserving surgery: │
│ - Local excision with margin │
│ - Glansectomy with resurfacing │
│ - Partial penectomy (if larger) │
│ │
│ ADVANCED (T2+, Large): │
│ • Partial or Total Penectomy │
│ • Urethroplasty (for voiding) │
│ • Reconstruction (if feasible) │
│ │
│ LYMPH NODES: │
│ • cN0 (No palpable nodes): │
│ - Sentinel node biopsy (SLNB) for high-risk tumours │
│ - Surveillance for low-risk │
│ • cN+ (Palpable nodes): │
│ - FNA; If positive → Inguinal lymphadenectomy │
│ - Neoadjuvant chemotherapy for bulky nodes │
│ │
│ CHEMOTHERAPY: │
│ • TIP regimen (Paclitaxel, Ifosfamide, Cisplatin) │
│ • Neoadjuvant for bulky nodes; Palliative for M1 │
│ │
│ RADIOTHERAPY: │
│ • Select cases; Brachytherapy for small tumours │
│ │
└──────────────────────────────────────────────────────────┘
Of Disease
- Urethral obstruction
- Metastatic disease
- Disfiguring surgery
Of Treatment
- Penectomy: Urination issues, Sexual/Psychological impact
- Lymphadenectomy: Lymphoedema, Wound complications
By Nodal Status
| Node Status | 5-Year Survival |
|---|---|
| Node negative | 80-90% |
| 1-2 inguinal nodes | 60-70% |
| > inguinal / Pelvic | 20-30% |
Poor Prognostic Factors
- Nodal involvement
- Lymphovascular invasion
- High grade
Key Guidelines
- EAU: Penile Cancer Guidelines
- BAUS: Guidance on Penile Cancer
Key Evidence
Sentinel Node Biopsy
- Reduces need for prophylactic lymphadenectomy
- High negative predictive value
What is Penile Cancer?
Penile cancer is a rare type of cancer that develops on the skin or tissue of the penis, usually on the head (glans) or foreskin.
What Causes It?
- HPV (the virus that causes warts and cervical cancer)
- Not being circumcised (especially if unable to clean under the foreskin)
- Smoking
What Are the Symptoms?
- A lump, sore, or ulcer on the penis that doesn't heal
- Bleeding or discharge
- Changes in colour or texture
How is It Treated?
- Small or early cancers: Creams, laser, or minor surgery
- Larger cancers: Removal of part or all of the penis
- The lymph nodes in the groin may also need treatment
What's the Outlook?
If caught early, most penile cancers can be cured. Seeing a doctor early if you notice any changes is very important.
Primary Guidelines
- European Association of Urology. EAU Guidelines on Penile Cancer. 2023.
Key Studies
- Hakenberg OW, et al. EAU guidelines on penile cancer: 2014 update. Eur Urol. 2015;67(1):142-150. PMID: 25457021