It is a complete presentation on carcinoma penis, covering all aspects starting from premalignant lesions to details of squamous cell carcinoma penis including recent NCCN guidelines and steps of penectomy and lymph node dissection

1. CARCINOMA PENIS
Presenter : DR. RAJGURU SIWACH (P.G. Resident)
Moderator: PROF. DR. SHIVANI B. PARUTHY

2. ANATOMY

3. ANATOMY
• Most penile cancers arise from
squamous cell epithelium of the
epidermis and dermis.
• Layers along the shaft are-
1. Skin
2. Dartos fascia
3. Bucks fascia
4. Vessels(dorsal artery and vein)
5. Tunica albuginea
6. Corpus cavernosum

5. LYMPHATIC DRAINAGE
• The lymphatic drainage of the
penis occurs principally to the
inguinal lymph nodes in each
groin.
• Lymphatic drainage has no
predictable laterality of drainage
patterns with cross-over
occurring in 60-85% of cases.

7. PREMALIGNANT CUTANEOUS
LESIONS

8. Carcinoma in situ (Penile Intraepithelial
Neoplasia)
• It is called Erythroplasia of Queyrat (EQ)
if it involves the glans penis and prepuce.
• It is called Bowen disease (BD) if it
involves the penile shaft or the
remainder of the genitalia or perineal
region.
• Progression to invasive carcinoma in men
with BD and EQ may occur in 5% to 33%
of patients, respectively, if it is not
treated.
Bowen disease involving penile
shaft skin.

9. Non–HPV Related Penile Premalignant
Lesions
1.Cutaneous Horn
• The horn resembles that of an animal and
is characterized by overgrowth and
cornification of the epithelium, which
forms a solid protuberance.
• Tumor may evolve into a carcinoma or may
develop as a result of an underlying
carcinoma.
• Careful histologic evaluation of the base
and close follow-up of the excision site are
essential.

10. 2. Male Lichen Sclerosus (Balanitis Xerotica Obliterans)
• Whitish patch on the prepuce or
glans, often involving the meatus.
• The meatus may appear white,
indurated, and edematous.
• Glanular erosions, fissures, and
meatal stenosis may occur.

11. BXO
• Symptoms include pain, dyspareunia, pruritus, painful erections, and
urinary obstruction.
• Associated with development of squamous cell carcinoma.
• Almost never occurs in males circumcised at birth, thus implicating that
closed, moist preputial environment is permissive for the disease.
• Treatment involves clobetasol propionate cream for 2 to 3 months.
• Meatal stenosis may require repeated dilations, corticosteroid injection, or
even formal reconstructive surgery.

12. Virus-Related Penile Lesions
1.Condylomata acuminata
• Soft, papillomatous growths
typically considered benign.
• Also known as genital warts or
venereal warts.
• They have a predilection for the
moist, glabrous areas of the
body and the mucocutaneous
surfaces of the perineal and
genital areas.

13. • Human immunodeficiency virus (HIV) infection may predispose
affected patients to rapid development of squamous carcinoma from
preexisting condyloma infection.
• Subclinical disease may be detected by the application of 5% acetic
acid solution to the penis, followed by inspection with a magnifying
glass.
• Lesions will turn white, and flat lesions often invisible on regular
inspection may be detected.

14. • Treatment options-
(1) Podophyllotoxin 0.5% solution or gel (used historically),
(2) Trichloroacetic acid 35% to 85%,
(3) Cryotherapy with liquid nitrogen,
(4) Electrofulguration,
(5) CO2 laser therapy, and
(6) Imiquimod 5% cream

15. Treatment options-
• Imiquimod cream (5%) has become the topical treatment of choice
for condyloma. Imiquimod is an immune modulator that enhances
natural killer cell activity.
• Intraurethral lesions may be extremely difficult to treat. 5-
Fluorouracil cream applied weekly for 3 weeks has been successful in
eliminating urethral lesions.
• To avoid exposure of the scrotal skin. Use of a scrotal support or zinc
oxide cream may be helpful.

16. 2. Buschke-Löwenstein Tumor (Giant Condyloma
Acuminatum)
• It differs from condyloma acuminatum
in that condylomata, regardless of
size, always remain superficial and
never invade adjacent tissue.
• Buschke-Löwenstein tumor displaces,
invades, and destroys adjacent
structures by compression.
• Aside from unrestrained local growth,
it does not metastasize.

17. 3.Kaposi Sarcoma
• Kaposi sarcoma, first described in 1972, is a tumor of the
reticuloendothelial system
• It appears as a cutaneous neovascular lesion, a raised, painful,
bleeding papule or ulcer with bluish discoloration
• Kaposi sarcoma is now subcategorized as follows:
• (1) Classic Kaposi sarcoma
• (2) Immunosuppressive treatment–related Kaposi sarcoma
• (3) African Kaposi sarcoma
• (4) Epidemic or HIV-related Kaposi sarcoma

18. • Nonepidemic Kaposi sarcoma- Localized surgical excision/partial
penectomy.
• In the immunosuppressed patient, it often regresses with the
discontinuation of immunosuppressive therapy.
• In the patient with AIDS, partial or total penectomy may be necessary.
• Radiation therapy and the neodymium:yttriumaluminum-garnet
(Nd:YAG) laser is used to alleviate distal urethral obstruction.

19. SQUAMOUS CELL CARCINOMA

20. SQUAMOUS CELL CARCINOMA
• Penile carcinoma accounts for 0.4% to 0.6% of all malignant
neoplasms among men in the United States and Europe;
• It may represent up to 10% of malignant neoplasms in men in some
Asian, African, and South American countries.
• Penile cancer is a disease of older men, with an abrupt increase in
incidence in the sixth decade of life.

21. SQUAMOUS CELL CARCINOMA
• The incidence of carcinoma of the penis varies according to
circumcision practice, hygienic standards, phimosis, number of sexual
partners, HPV infection and exposure to tobacco products.
• Thus far, there is no evidence to link penile cancer with factors such
as occupation, other venereal diseases (gonorrhea, syphilis, and
herpes), marijuana use, or alcohol intake.

22. Risk factors
• The chronic irritative effects of smegma, a byproduct of bacterial
action on desquamated cells that are within the preputial sac, have
been proposed as a causative agent.
• Incidence of HPV infection directly correlated with the number of
lifetime sexual partners, which was also related to risk of penile
cancer.
• All forms of tobacco products, including cigarettes and chewing
tobacco, were significantly and independently related to the
incidence of penile cancer.

23. Risk factors (cntd.)
• Penile trauma is another risk factor for penile cancer.
• There is odds ratio of 18:1 for the development of penile cancer for
those men reporting a penile injury within 2 years of the onset of the
disease.
• Lichen sclerosus (balanitis xerotica obliterans) is also a risk factor for
the development of penile cancer.

24. Prevention
• Routine neonatal circumcision as a preventive strategy for penile
cancer.
• Good hygiene
• Avoidance of HPV infection.
• Avoidance of tobacco products.

25. Prevention
• Prophylactic HPV vaccines-
• Cervarix, the quadrivalent HPV 16/18/6/11 vaccine.
• Gardasil, 9 HPV 16/18/6/11/31/33/45/52/58 vaccine.
• They have efficacy in preventing HPV infection among HPV-negative young
women and men
• Adult circumcision appears to offer little or no protection from
subsequent development of the disease.

26. Clinical Presentation
• Penile lesion- ranges from a subtle induration or small papule,
pustule, warty growth, to large exophytic lesion.
• Penile tumors occur most commonly on the glans (48%) and
prepuce (21%).
• Urinary retention or urethral fistula from local corporeal
involvement is a rare presenting sign.
• Rarely, a mass, ulceration or hemorrhage in the inguinal area may
be caused by nodal metastases from a lesion concealed within a
phimotic foreskin.

27. • Occasionally, blood loss may occur from the penile lesion.
• Weakness, weight loss, fatigue, and systemic malaise may occur
secondary to chronic suppuration.
• Pain does not develop in proportion to the extent of the local
destructive process and usually is not a presenting complaint.

28. DELAY IN DIAGNOSIS
• Delay seeking medical attention- because of embarrassment, guilt,
fear, ignorance, and personal neglect.
• Delay on the part of the physician- patients have been given
prolonged courses of antibiotics or topical antifungal preparations
before being referred for biopsy.
• Earlier diagnosis and treatment should improve outcome.

29. Biopsy
• It is gold standard for the confirmation of the diagnosis of carcinoma
of the penis.
• HPE- keratinization, epithelial pearl formation, and various degrees of
mitotic activity.
• Pathologic description of anatomic structures invaded (i.e., stage),
the grade, and the status of vascular and perineural invasion provide
important information to assess the risk of metastasis.

30. Radiological Imaging
• Soft-tissue detail of penile tumors is best imaged by MRI.
• Penile MRI in combination with artificial erection provide accurate
staging information.
• Physical examination of the inguinal region is used for evaluation of
the lymph node metastasis in the nonobese patient.
• CT or MRI can be useful in evaluating the inguinal region of obese
patients and in those who have had prior inguinal surgery.
• PET/CT is useful among patients with clinically palpable inguinal
lymph nodes to define the presence of pelvic or distant metastasis.

31. TNM staging

32. TNM STAGING

35. Prognosis
• Stage of the disease at the time of diagnosis helps predict the
prognosis of the disease
STAGE OF DISEASE 5 YEAR SURVIVAL RATE
STAGE I or II 85% after surgical management
Stage III 59%
STAGE IV 11%

36. Management
1. Management of the primary penile tumour
2. Inguinal lymph nodes
a. Non-palpable
b. Palpable
3. Metastatic disease
a. Chemotherapy
b. Radiation therapy
4. Surveillance strategies

37. SURGICAL MANAGEMENT
• Organ preservation
• Goal of treatment is to preserve glans sensation and penile shaft length.
• Patients with penile primary tumors exhibiting favorable histologic features (stages
Tis, Ta, T1; grade 1 and grade 2 tumors)
• Should be considered to be at a higher risk for local recurrence and require longer-
term follow-up.
• A 2-cm margin may not be necessary for small tumors of lower grade in the presence
of a negative frozen section.
• Penile amputation

41. • Mohs surgery- It involves sequential excision of tissue layers with
concurrent microscopic examination of the undersurface of each layer
to ensure negative margins.
• Glans resurfacing- Subdermal dissection of the skin and subepithelial
connective tissue off the underlying corpus spongiosus is performed.

42. Partial penectomy

43. Total penectomy

45. TREATMENT OF THE INGUINAL NODES
• The presence and extent of inguinal metastases determine
survival in penile cancer.
• For treatment of inguinal lymph nodes, patients can be divided
into-
• Low risk patients (Tis, Ta, T1a)
• High risk patients (T1b- T4)
• Nonpalpable lymph nodes
• Palpable lymph nodes

47. High risk patients- non palpable inguinal L.N.
• High risk criteria for inguinal lymph node metastases include-
• Clinical stage T2 or greater
• Greater than 50% poorly differentiated(high grade) tumour
• Presence of lympho-vascular invasion
• Treatment approach-
• Bilateral superficial inguinal lymph node dissection(SILND) +/- deep ILND if
any lymph nodes are identified on the SILND.
• Bilateral DSNB (less common)

48. High risk patients- palpable inguinal L.N.
POSITIVE IPSILATERAL INGUINAL L.N. (T1b- T4)
• Follow positive algorithm
(i) Ipsilateral inguinal L.N. (superficial + deep) dissection
(ii)Pelvic node dissection
(iii) Contralateral superficial inguinal dissection(frozen section analysis)

50. • A pelvic lymph node dissection (PLND) should be considered in
patients with-
1. Two or more inguinal lymph nodes with metastases
2. Presence of inguinal lymph node metastasis > 3 cm
3. Presence of inguinal extranodal extension
• A bilateral, rather than unilateral pelvic lymph node dissection should
be contemplated if 4 or more inguinal lymph nodes harbour
metastatic disease.
• PLND serves as an effective staging tool for identifying patients with
pelvic metastases in whom adjunctive therapy should be considered.

52. SENTINEL LYMPH NODE BIOPSY
• Dynamic Sentinel Node Biopsy (DSNB)-
The goal of DSNB is to define where in the inguinal lymph node field
the sentinel lymph node resides through use of a combination of visual
(vital blue dyes) or gamma emission (hand-held gamma probe)
techniques at the time of surgery.
• The technique involves intradermal injection of a vital blue dye or
technetium-labeled colloid adjacent to the lesion. The dye (or
radioactive tracer) is transported by the afferent lymphatics to a
specific node in the regional nodal basin. This node is designated the
sentinel lymph node.

53. Superficial Inguinal Lymph Node Dissection
(SILND)
• This technique consists of removal of the ILNs that are located above
the fascia lata.
• The rationale is that if the lymph nodes in the superficial
compartment are negative, there should be no involvement of the
deep package.

54. Inguinal lymph node dissection

55. • Incisions for inguinal lymph node dissection

56. Radical inguinal lymph node dissection
• It is done 4-6 weeks after surgical treatment of the primary tumour
• Extent-
• Superiorly- a line drawn from margin of the external ring to the anterior
superior iliac spine.
• Laterally- by a line drawn from the anterior superior iliac spine extending 20
cm inferiorly.
• Medially- by a line drawn from the pubic tubercle 15 cm down the medial
thigh.

58. • Superior and inferior limits of dissection

59. Complications:
• Seroma formation
• Lymphocoele
• Wound infection or necrosis
• Lymphedema
• Flap necrosis

60. RADIOTHERAPY
• Primary radiation therapy has curative potential and may permit
preservation of penile form and function.
• Before radiation therapy, circumcision is necessary to expose the
lesion, and to prevent preputial edema and subsequent phimosis.
• Types-
• External-Beam Radiotherapy
• Brachytherapy

62. • Brachytherapy can provide better local control and penile preservation with
faster dose delivery (4 to 5 days rather than 6-7 weeks) compared with
external beam radiotherapy.
• T1 and T2 tumors smaller than 4 cm with no or minimal extension beyond
the coronal sulcus are appropriate for radiotherapy.
• Unresectable lymph nodes may be rendered operable by neoadjuvant
chemoradiation.
• The two most common late side effects associated with radiotherapy are
meatal stenosis and soft-tissue ulceration.

63. • Neoadjuvant radiation
• Fixed inguinal lymph nodes positive for metastases
• Adjuvant radiation
• After circumcision-
• T1,T2 N0 disease
• EBRT +/- Chemotherapy
• After pelvic lymph node dissection-
• Multiple positive LN
• LN >4cm
• ENE
• B/L pelvic LN

64. CHEMOTHERAPY
• Neoadjuvant chemotherapy with a cisplatin-containing regimen should be
considered for patients with lymph node metastases, as responses in this
setting may facilitate curative resection.
• Surgical consolidation to achieve disease-free status or palliation should be
considered in fit patients with a proven objective response to systemic
chemotherapy.
• Among patients who progress through chemotherapy, surgery is not
recommended.

65. SURVEILLANCE

67. MANAGEMENT OF RECURRENT DISEASE

69. NONSQUAMOUS MALIGNANT NEOPLASMS
• Basal cell carcinoma represents a highly curable variant with a relatively low
metastatic potential.
• Sarcomas are prone to local recurrence; regional and distant metastases are rare.
Superficial lesions can be treated with less radical procedures.
• Melanoma is an aggressive form of cancer but can be cured if diagnosed and
treated with the appropriate surgical procedure at an early stage.
• Penile metastases most often represent spread from a clinically obvious existing
primary tumor. Prognosis is poor, and therapy should be directed toward the
primary tumor site histology and local palliation.

70. • (A) Basal cell carcinoma, (B) Melanoma, (C) Leiomyosarcoma, (D) Paget
disease

71. CONCLUSION
• Penile sparing surgical approaches should be considered for lower
grade/ stage primary penile tumours in favourable anatomic sites.
• Patients exhibiting high risk primary penile tumours should have
their inguinal lymph nodes evaluated to r/o occult disease (even in
absence of palpable adenopathy).

72. CONCLUSION
• Bulky inguinal adenopathy in the context of penile SCC should be
considered for multimodal therapy consisting of upfront systemic
therapy followed by consolidative surgical resection (in patients with
favourable response).
• Locally recurrent inguinal nodal metastases (post ILND) should be
considered for upfront systemic therapy (+/- XRT).

73. Thank you