Penile cancer

Carcinoma of the penis
Classification and external resources
Specialty	Oncology
ICD-10	C60
ICD-9-CM	187
DiseasesDB	29392
MedlinePlus	001276
MeSH	D010412

Penile cancer is a malignant growth found on the skin or in the tissues of the penis. Around 95% of penile cancers are squamous cell carcinomas. Other types of penile cancer such as Merkel cell carcinoma, small cell carcinoma, melanoma and other are generally rare.^[1]

Classification

Around 95% of penile cancers are squamous cell carcinomas. They are classified into the following types:

• basaloid (4%)
• warty (6%)
• mixed warty-basaloid (17%)
• verrucous (8%)
• papillary (7%)
• other SCC mixed (7%)
• sarcomatoid carcinomas (1%)
• not otherwise specified (49%)

Other types of carcinomas are rare and may include small cell, Merkel cell, clear cell, sebaceous cell or basal cell tumors. Non-epithelial malignancies such as melanomas and sarcomas are even more rare.^[1]

Staging

Like many malignancies, penile cancer can spread to other parts of the body. It is usually a primary malignancy, the initial place from which a cancer spreads in the body. Much less often it is a secondary malignancy, one in which the cancer has spread to the penis from elsewhere. The staging of penile cancer is determined by the extent of tumor invasion, nodal metastasis, and distant metastasis.^[2]

The T portion of the AJCC TNM staging guidelines are for the primary tumor as follows:^[2]

• TX: Primary tumor cannot be assessed.
• T0: No evidence of primary tumor.
• Tis: Carcinoma in situ.
• Ta: Noninvasive verrucous carcinoma.
• T1a: Tumor invades subepithelial connective tissue without lymph vascular invasion and is not poorly differentiated (i.e., grade 3–4).
• T1b: Tumor invades subepithelial connective tissue with lymph vascular invasion or is poorly differentiated.
• T2: Tumor invades the corpus spongiosum or cavernosum.
• T3: Tumor invades the urethra or prostate.
• T4: Tumor invades other adjacent structures.

Anatomic Stage or Prognostic Groups of penile cancer are as follows:^[2]

• Stage 0—Carcinoma in situ.
• Stage I—The cancer is moderately or well differentiated and only affects the subepithelial connective tissue.
• Stage II—The cancer is poorly differentiated, affects lymphatics, or invades the corpora or urethra.
• Stage IIIa—There is deep invasion into the penis and metastasis in one lymph node.
• Stage IIIb—There is deep invasion into the penis and metastasis into multiple inguinal lymph nodes.
• Stage IV—The cancer has invaded into structures adjacent to the penis, metastasized to pelvic nodes, or distant metastasis is present.

HPV positive tumors

Human papillomavirus prevalence in penile cancers is high at about 40%. HPV16 is the predominant genotype accounting for approximately 63% of HPV-positive tumors. Among warty/basaloid cancers the HPV prevalence is 70–100% while in other types it is around 30%.^[1]

Signs and symptoms

• Redness of the penis^[3]
• Rash on the penis^[3][4]
• Foul smelling discharge from the penis^[3][4]
• Pain in the penis^[3]
• Growth or sore on the penis that doesn't heal within four weeks (may look like a wart, ulcer, or blister), may or may not be painful^[4]
• Bleeding from the penis or from under the foreskin^[4]
• Change in color of the penis^[4]
• Phimosis^[4]

Risk factors

Infections

• HIV infection—HIV-positive men have eight-fold increased risk of developing penile cancer than HIV-negative men.^[5][6]
• Human papillomavirus—HPV is a risk factor in the development of penile cancer.^[7] According to the Center for Disease Control and Prevention (CDC), HPV is responsible for about 800 (about 40%) of 1,570 cases of penile cancer diagnosed annually in the United States.^[8][9] There are more than 120 types of HPV.^[10]
• Genital warts—Genital or perianal warts increase the risk of invasive penile cancer by about 3.7 times if they occurred more than two years before the reference date.^[7] About half of men with penile cancer also have genital warts, which are caused by HPV.^[11]

Hygiene and injury

• Poor hygiene—Poor hygiene can increase a man's risk of penile cancer.^[12][13]
• Smegma—Smegma, a whitish substance that can accumulate beneath the foreskin, is associated with greater risk of penile cancer.^[5][14] The American Cancer Society suggests that smegma may not be carcinogenic, but may increase the risk by causing irritation and inflammation of the penis.^[5]
• Balanitis and penile injury—Inflammation of the foreskin and/or the glans penis (balanitis) is associated with about 3.1 times increased risk of penile cancer.^[7] It is usually caused by poor hygiene, allergic reactions to certain soaps, or an underlying health condition such as reactive arthritis, infection, or diabetes.^[3] Small tears and abrasions of the penis are associated with about 3.9 times increased risk of cancer.
• Phimosis—Phimosis is a medical condition where the foreskin cannot be fully retracted over the glans. It is considered a significant risk factor in the development of penile cancer (odds ratio of 38–65).^[7] Phimosis may also be a symptom of penile cancer.^[4]
• Paraphimosis—Paraphimosis is a medical condition where the foreskin becomes trapped behind the glans. It is considered a risk factor for the development of penile cancer.^[5]
• Circumcision—Some studies show that circumcision during infancy or in childhood may provide partial protection against penile cancer, but this is not the case when performed in adulthood.^[15] It has been suggested that the reduction in risk may be due to reduced risk of phimosis;^[5][15] other possible mechanisms include reduction in risk of smegma and HPV infection.^[5]

Other

• Age—Penile cancer is rarely seen in men under the age of 50. About 4 out of 5 men diagnosed with penile cancer are over the age of 55.^[5]
• Lichen sclerosus—Lichen sclerosus is a disease causing white patches on the skin. Lichen sclerosus increases the risk of penile cancer.^[12][16] As the exact cause of lichen sclerosus is unknown, there is no known way to prevent it.^[12]
• Tobacco—Chewing or smoking tobacco increases the risk of penile cancer by 1.5–6 times depending on the duration smoking and daily number of cigarettes.^[1][7][12]
• Ultraviolet light—Men with psoriasis who have been treated using UV light and a drug known as psoralen have an increased risk of penile cancer.^[5][12]

Pathogenesis

Penile cancer arises from precursor lesions, which generally progress from low-grade to high-grade lesions. For HPV related penile cancers this sequence is as follows:^[1]

• A. Squamous hyperplasia;
• B. Low-grade penile intraepithelial neoplasia (PIN);
• C. High-grade PIN (carcinoma in situ—Bowen's disease, Erythroplasia of Queyrat and bowenoid papulosis (BP));
• D. Invasive Carcinoma of the Penis.

However, in some cases non-dysplastic or mildly dysplastic lesions may progress directly into cancer. Examples include flat penile lesions (FPL) and condylomata acuminata.^[1]

In HPV negative cancers the most common precursor lesion is lichen sclerosus (LS).^[1]

Prevention

• HPV vaccines such as Gardasil or Cervarix may reduce the risk of HPV and, consequently, penile cancer.^[1][12]
• The use of condoms is thought to be protective against the HPV associated penile cancer.^[1]
• Good genital hygiene, which involves washing the penis, the scrotum, and the foreskin daily with water, may prevent balanitis and penile cancer. However, soaps with harsh ingredients should be avoided.
• Cessation of smoking may reduce the risk of penile cancer.^[7]
• Circumcision during infancy or in childhood may provide partial protection against penile cancer. Several authors have proposed circumcision as a possible strategy for penile cancer prevention;^[1][12][17] however, the American Cancer Society points to the rarity of the disease and notes that neither the American Academy of Pediatrics nor the Canadian Academy of Pediatrics recommend routine neonatal circumcision.^[5]
• Phimosis can be prevented by practising proper hygiene and by retracting the foreskin on a regular basis.
• Paraphimosis can be prevented by not leaving the foreskin retracted for prolonged periods of time.

Treatment

There are several treatment options for penile cancer, depending on staging. They include surgery, radiation therapy, chemotherapy, and biological therapy. The most common treatment is one of five types of surgery:

• Wide local excision—the tumor and some surrounding healthy tissue are removed
• Microsurgery—surgery performed with a microscope is used to remove the tumor and as little healthy tissue as possible
• Laser surgery—laser light is used to burn or cut away cancerous cells
• Circumcision—cancerous foreskin is removed
• Amputation (penectomy)—a partial or total removal of the penis, and possibly the associated lymph nodes.

Radiation therapy is usually used adjuvantly with surgery to reduce the risk of recurrence. With earlier stages of penile cancer, a combination of topical chemotherapy and less invasive surgery may be used. More advanced stages of penile cancer usually require a combination of surgery, radiation and chemotherapy. In addition to all the above, treatment of the underlying disease like brucellosis, is important to limit disease recurrence.

Prognosis

Prognosis can range considerably for patients, depending where on the scale they have been staged. Generally speaking, the earlier the cancer is diagnosed, the better the prognosis. The overall 5-year survival rate for all stages of penile cancer is about 50%.^[2]

Epidemiology

Penile cancer is a rare cancer in developed nations with annual incidence varying from 0.3 to 1 per 100,000 per year accounting for around 0.4–0.6% of all malignancies.^[1] The annual incidence is approximately 1 in 100,000 men in the United States,^[18] 1 in 250,000 in Australia,^[19] and 0.82 per 100,000 in Denmark.^[20] In the United Kingdom, fewer than 500 men are diagnosed with penile cancer every year.^[11][21]

However, in the developing world penile cancer is much more common. For instance, in Paraguay, Uruguay, Uganda and Brazil the incidence is 4.2, 4.4, 2.8 and 1.5–3.7 per 100,000, respectively.^[1][7] In some South American countries, Africa, and Asia, this cancer type constitutes up to 10% of malignant diseases in men.^[1] The lowest incidence is in Israeli Jews—0.1 per 100,000.

The lifetime risk has been estimated as 1 in 1,437 in the United States and 1 in 1,694 in Denmark.^[22]

See also

• Urethral cancer
• Male breast cancer

References

1. Bleeker, M. C. G.; Heideman, D. A. M.; Snijders, P. J. F.; Horenblas, S.; Dillner, J.; Meijer, C. J. L. M. (2008). "Penile cancer: Epidemiology, pathogenesis and prevention". World Journal of Urology. 27 (2): 141–150. doi:10.1007/s00345-008-0302-z. PMID 18607597.
2. "Stage Information for Penile Cancer". National Cancer Institute. Retrieved 3 November 2013.
3. PubMed Health PubMed, Last Reviewed: September 16, 2011
4. Cancer Research UK: Penile Cancer: Symptoms of penile cancer Cancer Research UK
5. The American Cancer Society: Penile Cancer: "What are the risk factors for penile cancer?" The American Cancer Society
6. Bleeker, M. C. G.; Heideman, D. L. A. M.; Snijders, P. J. F.; Horenblas, S.; Meijer, C. J. L. M. (2011). "Epidemiology and Etiology of Penile Cancer". Textbook of Penile Cancer. p. 1. doi:10.1007/978-1-84882-879-7_1. ISBN 978-1-84882-878-0.
7. Pow-Sang, M. R.; Ferreira, U.; Pow-Sang, J. M.; Nardi, A. C.; Destefano, V. (2010). "Epidemiology and Natural History of Penile Cancer". Urology. 76 (2): S2–S6. doi:10.1016/j.urology.2010.03.003. PMID 20691882.
8. National Cancer Institute: Penile Cancer National Institutes of Health
9. http://www.cdc.gov/cancer/hpv/statistics/penile.htm HPV-Associated Penile Cancer Rates by Race and Ethnicity] Center for Disease Control and Prevention
10. Brandel France de Bravo; Maushami DeSoto; Krystle Seu (April 2009). "HPV: Q&A". Cancer Prevention and Treatment Fund. Retrieved August 13, 2013.
11. Cancer Research UK: Penile Cancer: Risks and causes of penile cancer Cancer Research UK
12. Minhas, S.; Manseck, A.; Watya, S.; Hegarty, P. K. (2010). "Penile Cancer—Prevention and Premalignant Conditions". Urology. 76 (2): S24–S35. doi:10.1016/j.urology.2010.04.007. PMID 20691883.
13. Reis AA, Paula LB, Paula AA, Saddi VA, Cruz AD (June 2010). "[Clinico-epidemiological aspects associated with penile cancer]". Cien Saude Colet (in Portuguese). 15 Suppl 1: 1105–11. PMID 20640268.
14. Morris BJ, Gray RH, Castellsague X, et al. (2011). "The Strong Protective Effect of Circumcision against Cancer of the Penis". Adv Urol. 2011: 812368. doi:10.1155/2011/812368. PMC 3113366. PMID 21687572.
15. Larke NL, Thomas SL, dos Santos Silva I, Weiss HA (August 2011). "Male circumcision and penile cancer: a systematic review and meta-analysis". Cancer Causes Control. 22 (8): 1097–110. doi:10.1007/s10552-011-9785-9. PMC 3139859. PMID 21695385.
16. Micali, G.; Nasca, M. R.; Innocenzi, D.; Schwartz, R. A. (2006). "Penile cancer". Journal of the American Academy of Dermatology. 54 (3): 369–391; quiz 391–4. doi:10.1016/j.jaad.2005.05.007. PMID 16488287.
17. de Souza KW, dos Reis PE, Gomes IP, de Carvalho EC (March 2011). "[Prevention strategies for testicular and penile cancer: an integrative review]". Rev Esc Enferm USP (in Portuguese). 45 (1): 277–82. PMID 21445520.
18. The American Cancer Society: Penile Cancer: What is penile cancer? American Cancer Society, Last revised: January 8, 2012
19. The Official Website of the Royal Australasian College of Physicians, Published September 2010
20. Frisch M, Friis S, Kjær SK, Melbye M. Falling Incidence Of Penis Cancer In An Uncircumcised Population (Denmark 1943-90). BMJ: British Medical Journal. 1995;311(7018):1471.
21. The American Cancer Society: Penile Cancer: What are the key statistics about penile cancer American Cancer Society, Last revised: January 18, 2012
22. Cold CJ, Storms MR, Van Howe RS (April 1997). "Carcinoma in situ of the penis in a 76-year-old circumcised man". J Fam Pract. 44 (4): 407–10. PMID 9108839.