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Department of Urology
University of Washington | School of Medicine
Department of Urology

Diseases & Conditions

Penis Cancer

Authors: Paul H. Lange, MD FACS
Last updated: March 31, 2006

Overview

Penis cancer is an extremely rare tumor in North America where it affects less than 1 in 100,00 men and it accounts for 0.4-0.6 of all cancers among men in the United States and Europe. However, the incidence is much higher in Asia, Africa, and South American countries. It often affects older men between the ages of 50 and 80 although a quarter of the cases involve men under the age of 50. It is a cancer that occurs on the shaft or tip of the penis and can be very dangerous, but in most cases can be treated very well.

Symptoms

Penis cancer usually begins as a small lump or ulcer on the glands (head) but gradually enlarges and spreads to the rest of the penis shaft. It may develop into a fungating mass with foul smelling discharge and bleeding in advanced stages. Pain is not a common presenting complaint. Some men are embarrassed by their condition and are reluctant to seek medical help until the disease is advanced and harder to treat. The early signs of penis cancer include: 1) a wart like growth; 2) an open sore that won’t heal; 3) a reddish rash; 4) a persistent foul smelling discharge under the foreskin. Penis cancer first spreads to the lymph nodes in the groin and therefore another symptom might be swelling and/or pain in the groin From there, penis cancer spreads to other lymph nodes in the body and to other organs.

Causes

The cause of penis cancer is unknown but there is a great deal of evidence suggesting that, like cervical cancer, it is related to certain types of Papilloma virus. This virus is very common in human kind even in Western populations and once contacted, persists for a lifetime. Why certain patients with infection of this virus develop cancer while others do not, is now known but factors such as infection and inflammation play a part.

Risk Factors

In addition to human papilloma virus (HPV) infection, other risk factors include cigarette smoking and genital warts (condoloma cumalada). A major risk factor is the lack of circumcision. Almost no one who gets circumcised as an infant develops penis cancer and almost all patients who develop penis cancer are either uncircumcised or had their circumcision past the age of infancy. The reason why penis cancer develops in uncircumcised men is not totally known but it probably has to do with the accumulation of material around the foreskin and/or infection.

Diagnosis

If a lesion specific for cancer is discovered on the penis, it requires a biopsy. This is a procedure where a small piece of tissue is taken from the lesion either with a needle or by a small surgical incision. Usually this can be done under local anesthesia but sometimes it requires a general anesthesia. Once the biopsy is obtained, it is examined by a pathologist under a microscope. Penis cancer is almost always a type of cancer called squamous cell carcinoma. In addition to diagnosing the squamous cell carcinoma, the pathologist determines certain characteristics of the cancer, more specifically, how deep the cancer extends (so called T-stage), and how aggressive it appears under the microscope (so called Grade). Both of these characteristics help the urologist determine what treatment is appropriate. The T stages are as follows: T0 – the cancer has not eaten through the first layer called the lamina propria; TCIS – the cancer is a flat cancer in which the cells are abnormal but there is no tumor growth; T1 – the cancer has spread through the first layer; T2 – the cancer has extended through the second layer called the “corpus” layer; T3 – the cancer is very large and extends into the urethra (the tube in the penis carrying the urine); T4 – the cancer is extremely large and involves other structures around the penis. The grade types are well differentiated, moderately differentiated, and poorly differentiated.

Once a squamous cell cancer is diagnosed, the physician needs to determine if it has spread. This is done initially by physical examination of the inguinal (groin) lymph nodes. These lymph nodes can also be assessed using x-ray approaches. X-rays also help the urologist to determine if the cancer has spread to the lymph nodes in the pelvis or to other organs such as the lungs. Once the diagnosis of cancer and its grade are determined, the urologist must determine the stage. This involves three categories: T (standing for the organ); N, (standing for the lymph nodes); and M (standing for metastasis or distant spread). The T stage has already been described. The N stage can be N0 – no lymph nodes involved; N1 – only a few lymph nodes in the groin involved; N2 –significant lymph nodes involved in the groin; N3 – lymph nodes in the pelvis or beyond involved. The M stage stands for the amount of spread in non-lymph nodes such as the liver or the lung.

Complications

Penis cancer can of course destroy the penis causing ugly foul smelling lesions. It can also impede the passing of urine. Most importantly, it can spread causing pain and eventual death. It first spreads to the groin (inguinal) lymph nodes, and then to the lymph nodes in the pelvis, and then beyond to other lymph nodes and organs.

If removal of cancerous lymph nodes is preformed (called a lymphadenectomy), occasionally this will result in infection of the wound, or later in swelling of the legs that require support hose.

Treatment

Penis cancer is a very serious cancer. However it has a significant chance of cure. Very often excision of the penis lesion is all that is required. Even if there is spread to the lymph nodes, with properly done surgery, many people with spread to the groin lymph nodes can be cured, If the tumor has spread beyond the groin lymph nodes, cure is not likely although there have been some recent amazing successes with combinations of surgery, radiation, and chemotherapy.

Treatment of penis cancer depends on it’s grade and stage and involves the treatment of the penis lesion and the treatment of the lymph modes and/or metastasis. Treatment of the penis involves excising the lesion completely. In rare cases, if the penis cancer is very small and particularly if it is flat, it can be treated with topical chemotherapy ointments rather than excision. Sometimes surgical excision involves only minor surgery such as a circumcision for a small cancer of the foreskin. Other times it requires removal of a part or even all of the penis. Often these penis surgeries can be performed in such a way that a large part of the penis can be preserved and sexual function can be maintained either spontaneously or after some surgical reconstruction.

Once the cancer of the penis is removed, the urologist must then determine what sort of additional treatment is necessary. The first consideration is whether a lymphadenectomy needs to be performed. A lymphadenectomy stands for removal of lymph nodes. In the penis the lymph nodes in the groin sometimes have to be removed either alone or also with the nodes in the pelvis. Whether a lymphadenectomy needs to be performed will depend on the grade and stage of the tumor. In general, if the lesion is small (e.g. T0 or T1) and the grade of the tumor is not high grade, a lymphadenectomy may not be needed. However, if the grade of the tumor is high grade and/or the lesion has extended deeper (e.g. T2 or greater), then an inguinal (groin) lymphadenectomy must be accomplished on both sides. If the lymph nodes in this area are discovered to be positive, then the lymph nodes in the pelvis on both sides must also be removed. If the penis cancer has spread to the lymph nodes in large amounts and/or has spread to distant sites, then chemotherapy should be given either before or after the lymphadenectomy. In the recent decade, great strides have been made in the success of chemotherapy treatment.

Self-care

It is important that all men periodically examine their penis for any lesions. In patients who aren’t circumcised, it is imperative that they periodically retract the foreskin to see if any lesions are present at the head of the penis. If anything looks suspicious, they should immediately contact their primary care physician and if there is any uncertainty they should be seen by a urologist. It is also imperative that if penis cancer is found, that the patient seek out physicians at institutions that have significant experience in this rare cancer.

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