Tumors of the penis are rare, comprising less than 1% of cancers in males. Poor hygiene is a major risk factor. Precancerous conditions include carcinoma in situ and erythroplasia of Queyrat. Invasive squamous cell carcinoma is most common, usually originating on the glans or prepuce. Treatment depends on the size and extent of invasion but may include circumcision, partial or total penectomy, and lymph node dissection. Outcomes are best when the cancer is localized; lymph node involvement significantly worsens prognosis. Squamous cell carcinoma is also the most frequent malignant tumor of the scrotum, treated with wide local excision and lymph node management similar to penile cancer.

1. TUMORS OF THE PENIS

2. Tumors of the penis
• less than 1% of cancers among males
• The one etiologic factor most commonly
associated with penile carcinoma is poor
hygiene
• The disease is virtually unheard of in males
circumcised near birth.

3. Tumors of the penis
• One theory postulates that smegma
accumulation under the phimotic foreskin
results in chronic inflammation leading to
carcinoma.
• A viral cause has also been suggested as a
result of the association of this tumor with
cervical carcinoma.

4. CARCINOMA IN SITU
BOWEN DISEASE
• squamous cell carcinoma in situ typically involving the
penile shaft.
• The lesion appears as a red plaque with encrustations
ERYTHROPLASIA OF QUEYRAT
• a velvety, red lesion with ulcerations
• involve the glans
• Microscopic examination shows typical, hyperplastic
cells in a disordered array with vacuolated cytoplasm
and mitotic figures.

5. INVASIVE CARCINOMA OF THE PENIS
Squamous cell carcinoma
• composes most penile cancers.
• most commonly originates on the glans
• Other common sites: prepuce and shaft
• The appearance may be papillary or ulcerative.
Verrucous carcinoma
• a variant of squamous cell carcinoma composing 5–16% of
penile carcinomas
• papillary in appearance
• have a well-demarcated deep margin unlike the infiltrating
margin of the typical squamous cell carcinoma on histology

6. TNM Classification of Tumors
of the Penis*
T—Primary tumor
TX: Cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
Ta: Noninvasive verrucous carcinoma
T1: Invades subepithelial connective
tissue
T2: Invades corpus spongiosum or
cavernosum
T3: Invades urethra or prostate
T4: Invades other adjacent structures
N—Regional lymph nodes
NX: Cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in single superficial
inguinal node
N2: Metastasis in multiple or bilateral
superficial inguinal nodes
N3: Metastasis in deep inguinal or
pelvic nodes
M—Distant metastasis
MX: Cannot be assessed
M0: No distant metastasis
M1: Distant metastasis present
*Reference: Smith’s General Urology 17th edition. Pg.384. Table 23–3.

7. Clinical Findings
SYMPTOMS
• may appear as an area of
induration or erythema,
• an ulceration, a small
nodule, or an exophytic
growth
• Phimosis may obscure the
lesion and result in a delay
in seeking medical attention
• pain, discharge, irritative
voiding symptoms, and
bleeding
SIGNS
• Lesions are typically
confined to the penis at
presentation
• more than 50% of
patients present with
enlarged inguinal
nodes.

8. Clinical Findings
LABORATORY FINDINGS
• Laboratory evaluation is
typically normal
• Anemia and leukocytosis
may be present in
patients with long-
standing disease or
extensive local infection.
• Hypercalcemia in the
absence of osseous
metastases appears to
correlate with volume of
disease.
IMAGING
• Metastatic workup should
include CXR, bone scan,
and CT scan of the
abdomen and pelvis.

9. Treatment
PRIMARY LESION
• Biopsy of the primary lesion - to establish the
diagnosis of malignancy
CARCINOMA IN SITU
• treated conservatively in reliable patients
• Fluorouracil cream application or
neodymium:YAG laser treatment

10. Treatment
INVASIVE PENILE CARCINOMA
• Goal of treatment: complete excision with adequate
margins
• For lesions involving the prepuce: simple circumcision
• For lesions involving the glans or distal shaft: partial
penectomy with a 2-cm margin to decrease local
recurrence
– Mohs micrographic surgery and local excisions directed at penile
preservation
• For lesions involving the proximal shaft or when partial
penectomy results in a penile stump of insufficient length
for sexual function or directing the urinary stream: total
penectomy with perineal urethrostomy

11. Treatment: Lymph Nodes
• Enlarged node commonly due to inflammation
• Should undergo treatment of the primary lesion followed by a 4- to 6-week course of
oral broad-spectrum antibiotics
• sequential bilateral ilioinguinal node dissections
– For persistent adenopathy following antibiotic treatment
• observation in low-stage primary tumors (Tis, T1)
– For Resolved lymphadenopathy with antibiotics
• sentinel node biopsy or a modified (limited) dissection
– If lymphadenopathy resolves in higher-stage tumors, more limited lymph node
samplings should be considered
• bilateral ilioinguinal node dissection
– If positive nodes are encountered
• unilateral ilioinguinal node dissection
– Patients who initially have clinically negative nodes but in whom clinically palpable
nodes later develop
• chemotherapy (cisplatin and 5-fluorouracil)
– Patients who have inoperable disease and bulky inguinal metastases
• Regional radiotherapy
– For palliation by delaying ulceration and infectious complications and alleviating
pain.

12. Management of Penile Carcinoma
*Reference: Smith’s General Urology 17th edition. Pg.386. Figure 23–4

13. TUMORS OF THE SCROTUM

14. Tumors of the Scrotum
• Tumors of the scrotal skin are rare.
• The most common benign lesion is a sebaceous cyst
• Most common malignant tumor of the scrotum is
Squamous cell carcinoma
• Rare cases: melanoma, basal cell carcinoma, and
Kaposi sarcoma
• Etiology of SCC of the Scrotum: poor hygiene and
chronic inflammation

15. Tumors of the Scrotum: Management
• Biopsy
• Wide excision with a 2-cm margin should be
performed for malignant tumors
• Surrounding subcutaneous tissue should be
excised with the primary tumor
• Primary closure using the redundant scrotal skin
is usually possible.
• The management of inguinal nodes should be
similar to that of penile cancer.

16. Tumors of the Scrotum: Prognosis
Prognosis correlates with the presence or
absence of nodal involvement.
In the presence of inguinal node metastasis, the
5-year survival rate is approximately 25%
There are virtually no survivors if iliac nodes are
involved.