2. Premalignant cutaneous lesions
• Cutaneous horn.
• Pseudoepitheliomatous micaceous and keratotic
balanitis.
• Balanitis xerotica obliterans.
• Leukoplakia.
• Erythroplasia of Queyrat.
• Bowen's disease.
• Buschke Lowenstein tumour: also known as
verrucous carcinoma or giant condyloma
acuminatum
3. Precancerous conditions of the penis have the potential
to develop into penile cancer
• The most common precancerous conditions of the
penis are:
• Penile intraepithelial neoplasia (pein): Penile
intraepithelial neoplasia (PeIN) is the most common
precancerous condition of the penis. PeIN is a general
term used to describe precancerous conditions of the
penis that may develop into invasive squamous cell
carcinoma (SCC) if not treated.
• Balanitis xerotica obliterans (BXO): Balanitis xerotica
obliterans (BXO) is an inflammatory condition of skin
that affects the foreskin and the glans (glans penis or
head) of the penis. It may also be called penile lichen
sclerosus.
4. • Buschke-Lowenstein tumour: Buschke-Lowenstein
tumour is most commonly found on the glans (glans
penis or head) of the penis. It has been suggested that
Buschke-Lowenstein tumour is a low-grade cancer
related to verrucous carcinoma of the penis. It is a slow-
growing tumour that may grow as big as 15 cm.
• Bowenoid papulosis: Bowenoid papulosis has an
extremely low chance of developing into cancer. It affects
younger men more often than older men.
The following risk factor may increase a man’s chance of
developing bowenoid papulosis: HPV infection
• Leukoplakia: Leukoplakia has the potential to become
squamous cell carcinoma (SCC).
5. Classification of penile cancer
• Squamous cell carcinoma (SCC) is the most
common penile cancer
• Kaposi's sarcoma
• Basal cell carcinoma,
• Melanoma, sarcoma,
• Paget's disease.
• Metastases are occasionally seen from bladder,
prostate, rectum, and other primary sites.
6. Incidence and aetiology of SCC:
• Penile cancer is rare, representing 1% of male
cancers.
• The incidence appears to be decreasing, most
occurring in elderly men
7. Risk factors for SCC:
• Age: penile cancer incidence rises during the 6th
decade and peaks in the 8th decade. It is unusual <40
years, but has been reported in children.
• Premalignant lesions: 42% of patients with penile SCC
are reported to have had a pre-existing penile lesion.
• A prepuce (foreskin): penile cancer is rare in men
circumcised at a young age. It is virtually non-existent
in Israel. It is thought that chronic irritation with
smegma and inflammation (balanitis) is contributory.
• Human papilloma virus (HPV) wart infection,
especially with types 16, 18, and 21.
• Smoking and tobacco products.
8. Pathology and staging of penile SCC:
• SCC starts as a slow-growing papillary, flat or
ulcerative lesion on the glans (48%), prepuce
(21%), glans and prepuce (9%), coronal sulcus (6%),
or shaft (2%) preceded by carcinoma in situ.
• The remainder are indeterminate.
• It grows locally beneath the foreskin before
invading the corpora cavernosa, urethra, and,
eventually, the perineum, pelvis, and prostate.
• Metastasis is initially to the superficial then deep
inguinal and, subsequently, iliac and obturator
lymph nodes.
9. • Skin necrosis, ulceration, and infection of the
inguinal lymph nodes may lead to sepsis or
haemorrhage from the femoral vessels.
• Blood-borne metastasis to lungs and liver is rare.
• Histologically, SCC exhibits keratinization,
epithelial pearl formation, and mitoses.
• Grading is low (75%), intermediate (15%), or
high (10%); grading correlates with prognosis, as
does the presence of vascular invasion.
10. Presentation
• A hard, painless lump on the glans penis is the
most common presentation.
• A bloody discharge may be confused with
haematuria.
• Rarely, a groin mass or urinary retention are
presenting symptoms.
• Examination reveals a solid non-tender mass or
ulcer beneath or involving the foreskin.
11. • There is usually evidence of local infection.
• In more advanced disease, prepuce, glans,
shaft, scrotum, and even perineum are
replaced by tumour.
• The inguinal lymph nodes are examined.
They may be enlarged, fixed, or even ulcerate
overlying skin.
12. Investigations
• A biopsy is indicated
• Chest radiology
• Pelvic CT scan
• Serum calcium
• Liver function tests
13. Treatment
The primary tumour:
• The first-line treatment of penile cancer, regardless of the inguinal
node status, is surgery.
• Circumcision is appropriate for preputial lesions, but local recurrence
observed in.
• Penis-preserving wide excision of glanular lesions with skin graft
glanular reconstruction may be suitable for smaller tumours, giving
good cosmetic and functional results.
• Alternatives to surgery include laser or cryoablation, radiotherapy or
brachytherapy, photodynamic therapy, or topical 5-fluorouracil.
• For more advanced tumours, partial or total penile amputation is
required, depending on the extent of the tumour. Partial amputation
is preferable, provided a 2cm margin of palpably normal shaft can be
obtained.
• Local recurrence occurs in 10%, if the excision margin is positive.
14. • Total amputation involves excision of the
scrotum and its contents, with formation of a
perineal urethrostomy. The most common
complication is urethral meatal stenosis.
• Radiotherapy remains an alternative, but
disadvantages include radio-resistance,
leading to reported recurrence rates of 30-
60%; tissue necrosis and damage leading to
urethral stricture, fistula, and pain.
15. Lymphadenopathy:
• Six weeks of broad-spectrum antimicrobials are
given after the primary tumour has been
removed. Nodes become clinically insignificant in
50% of patients, who may then be followed-up.
• For those with persistent inguinal
lymphadenopathy, in the absence of
demonstrable pelvic or metastatic disease,
bilateral inguinal lymphadenectomy should be
considered.
16. • Radiotherapy and chemotherapy are alternative or
adjuvant treatments for metastatic nodal disease in
unfit, elderly, or inoperable patients.
• Prophylactic lymphadenectomy is currently practised
for tumours exhibiting vascular invasion, high grade,
or stages T2-4.
• Distant metastatic disease is treated using single-
agent systemic chemotherapy: cisplatin, bleomycin,
or methotrexate.
• Experience with combination chemotherapy is
increasing.
