Penile Cancer

The external genital organ, in the man, is called the penis. It comprises of three tubes, namely, the corpus spongiosum & 2 corpora cavernosa. The corpora cavernosa comprises of spongy erectile tissues along with blood vessels and nerves. The corpora spongiosum serves as a protective sheath for the urethra and terminates into the glans penis.

• Phimosis and lack of personal hygiene: Inability to retract the preputial skin is termed as phimosis. The irritative effect of smegma; a by-product of bacterial action on desquamated cells in the preputial sac is responsible for malignant transformation.
• HPV infection: Human Papillomavirus (HPV) is contracted through unprotected sexual activities with more chances of acquiring the infection with increasing number of sexual partners. Some of the strains of this virus especially HPV type 16 & 18 are responsible for most of the penile cancers in these patients.
• HIV infection: The compromised immune system due to HIV and AIDS, makes the body susceptible to all kinds of diseases, including various cancers.
• Use of tobacco products: Smoking as well as use of smokeless tobacco (eg Hans, Gutkha, betel quid etc) increases ones risk of acquiring penile cancer.
• Chronic balanitis: Chronic infection and inflammation of the glans penis is common in immunosuppressed individuals, eg those with diabetes, AIDS, organ transplant patients, and is associated with increased risk of penile cancer.
• Lichen sclerosis: Lichen sclerosis is an uncommon condition that creates patchy, white skin that appears thinner than normal. It usually affects the genital and anal areas and has been implicated to be associated with increased risk of developing penile cancer. /li>

• Squamous cell carcinoma: This is the most common type of cancer and is found in 95% of the cases.
• Basal Cell Carcinoma: These cancers grow slowly and rarely metastasize to other parts of the body.
• Melanoma: The deepest layer of the epidermis consists of melanocytes. Melanocytes are the skin cells that are responsible for producing melanin- a pigment accountable for brown skin colour, which protects us from the UV rays. Malignant transformation of melanocytes is called melanoma. These are aggressive tumors with high chances of lymph nodal and distant metastasis.
• Sarcoma: These arise from connective tissues of penis and are aggressive tumors.

• Non healing ulcer
• Phimosis with swelling developing underneath the glans penis with or without fowl smelling discharge.
• Swellings in groin
• Change in penile skin thickness or colour
• Changes in pre-existing mole on the penile skin

If you are experiencing any of these symptoms, especially over longer periods, you should immediately, consult a doctor.

Once, you see a specialist, the following tests may be carried out:

1. A physical exam:

A through physical examination will be carried out, after taking a detailed history of your symptoms

2. Biopsy:

Biopsy is performed to determine the exact type of penile cancer. Depending on the size of the growth or suspicious area, biopsy can be:

• Incisional Biopsy: For large ulcerative growths or swellings, a small piece is taken after administering local anaesthesia and sent for histopathological reporting.
• Excisional Biopsy: For smaller growths or suspicious areas, the entire area is removed under local anaesthesia.
• Lymph Node FNAC: A small needle is used to aspirate cells from the enlarged lymph nodes in the groin to check for spread of cancer cells.

3. Imaging tests:

• Ultrasound: In case of early cancers, an ultrasound of the abdomen may be asked for to see for any suspicious lymph nodal enlargements in the groin or pelvic region.
• CT scan: In patients with clinically suspicious groin lymph nodes, a CT scan of the chest, abdomen and pelvis may be done to determine spread of cancer into lymph nodes (pelvic, abdominal or mediastinal) or to other organs. This helps to correctly stage the disease; which in turn will help decide the best treatment sequence for a given patient.
• PET CECT scan: A PET CT scan may be suggested in advanced or recurrent cases to rule out spread of cancer to other sites, eg lungs, liver, bone, etc.

The treatment regimen consists of:

The treatment regimen consists of:

1. Surgery:

Surgery involves removal of the primary penile tumor with a margin of normal tissue. This can be achieved by various procedures depending on the size of the penile cancer.

• Moh’s micrographic surgery: In very small tumors, the tumor is removed layer by layer to preserve the maximum penile tissue possible.
• Circumcision: In small tumors affecting the preputial skin (foreskin) only, circumcision alone suffices.
• Glansectomy: Removal of glans for small tumors affecting glans penis is called glansectomy.
• Partial penectomy: For tumors involving distal part of penile shaft, a partial penectomy is performed. The residual penile stump is adequate for passing urine in upright posture as well as for sexual intercourse with his partner.
• Total penectomy with perineal urethrostomy: For bigger tumors, wherein, an adequate penile stump cannot be left behind, a total penectomy with perineal urethrostomy (a new opening for urethra is created in the perineum for passing urine) is performed.
• Groin lymph node dissection: Unilateral or bilateral groin lymph node dissection may be performed for patients with proven or suspicious groin lymph nodal spread.

2. Non-surgical treatment options:

In very old or frail patients who cannot withstand any surgery or in very early cancers, non-surgical options like use of topical agents, crysurgery cryotherapy or laser may be offered.

3. Chemotherapy:

Chemotherapy in the form of injections or tablets may be suggested depending on the stage of disease. It is done in 2 -3 weekly cycles, for a total of 6 cycles. It can also be recommended during radiation treatment; called as concurrent chemo-radiotherapy.

4. Radiotherapy:

Radiotherapy makes the use of high energy rays to target and destroy the cancer cells. Radiation treatment may be used as an alternative to surgery or after surgery as adjuvant treatment.

Preventive measures to stay safe against penile cancer are:

• Neonatal circumcision: i.e. having circumcision in neonatal age group, has been shown to be protective against penile cancer.
• Maintaining proper hygiene especially in the genital areas
• Use of protective barriers during sexual intercourse
• Avoiding multiple sexual relations
• Quits smoking and other tobacco products