penile cancer

general info

squamous cell carcinoma of the penile skin and glans.

aged 60 and older

risk factors:

Phimosis: This is the strongest anatomical risk factor: when the foreskin is too tight to be retracted over the glans. It traps fluids, desquamated skin cells, and bacteria, causing lifelong tissue irritation.

Poor Hygiene & Smegma (a thick, white substance called smegma accumulates under the foreskin which leads to leads to chronic balanoposthitis).

Human Papillomavirus (HPV) 16-18

Smoking

TNM

Ta non-invasive cancer

 T1 invade to subepithelial tissue

 T1a no lymphovascular invasion

 T1b dedifferentiated tissue

 T2 invasion to spongiosum or cavernosum

 T3 urethra

 T4 adjacent structures

No no lymph node met

 N1 single inguinal lymph node

 N2 multiple inguinal nodes

 N3 pelvic nodes or extranodal invasion

 Mo no met

 M1 distant met

pathology classification

1. Premalignant Lesions (Benign but High-Risk)

Cutaneous Horn: A hard, cone-shaped growth made of compact keratin that looks like a miniature horn

Bowenoid Papulosis: Appears as multiple small, reddish-brown or velvety bumps on the penile shaft. It is heavily linked to high-risk HPV strains (16 and 18).

Balanitis Xerotica Obliterans (BXO): Also known as penile lichen sclerosus, can cause phimosis

2. Intraepithelial Lesions (Carcinoma In Situ / CIS)

Erythroplasia of Queyrat: This is simply carcinoma in situ when it is located on the glans (head of the penis) or the inner foreskin

Bowen's Disease: on the shaft

Buschke-Löwenstein Tumor: Also known as Giant Condyloma Acuminata. HPV

3. Invasive Penile Cancer Variants

Classic SCC

Basaloid SCC : HPV

Verrucous SCC : form warts , never spreads to lymph node

Sarcomatoid SCC : most aggressive

Adenosquamous SCC

Diagnosis

1. Physical Examination

2. lymph node check : High-Resolution Ultrasound (US), Fine-Needle Aspiration Biopsy (FNAB

The Antibiotic Trial Course: Because ulcerated penile tumors are highly prone to bacterial superinfections, medical guidelines recommend prescribing a 3 to 4-week course of broad-spectrum antibiotics (and completely removing the primary tumor).

• If the nodes shrink or disappear after the antibiotic course, the swelling was inflammatory.

• If the nodes remain large, hard, or grow further, they are treated as cancer.

For permanently palpable nodes, the clinician must document: Diameter & Location, Mobile vs. Fixed, Infiltration & Leg Oedema (Swelling).

3. Searching for Distant Metastasis: CT, only indicated if the inguinal lymph nodes are clinically positive for cancer.

treatment

1. Superficial Tumors:

Topical Chemotherapy ( Imiquimod or 5-Fluorouracil Cream)

Laser Therapy (CO2 or Nd:YAG Laser)

Local Excision & Esthetic Surgery

Radiotherapy

2. Invasive Tumors:

Glansectomy

Partial Penectomy ( tumor extends onto the distal shaft.)

Total Penectomy

3. Advanced Tumors

Total Penectomy & Emasculanisation: removal of the penis, the scrotum, and both testicles.

Perineal Urethrostomy: They create a new, permanent urinary opening in the perineum (the flat area between the scrotum and the anus).

4. Non-Operable Cases: Primary Chemotherapy & Radiotherapy

therapy of regional lymph node metastasis

1. Active Surveillance: for non-palpable lymph nodes (cN0)

2. Surgical Removal: Ilioinguinal Lymphadenectomy: If lymph node involvement is confirmed or highly suspected in higher-risk patients

Inguinal vs. Ilioinguinal

The Detection Probe (Dynamic Sentinel Lymph Node Biopsy - DSNB): For patients with high-risk primary tumors but non-palpable nodes, urologists use a "detection probe." A radioactive tracer and blue dye are injected into the penile tumor site before surgery. A handheld probe then guides the surgeon to find and remove only the very first node that drains the penis (the sentinel node). If it is negative, a full lymphadenectomy can be safely avoided.

Severe Side Effects: lifelong fluid swelling in the legs and scrotum,Skin Flap Necrosis & Wound Breakdown, Lymphocele: Deep pockets of trapped lymphatic fluid that often become infected.

3. Neoadjuvant and Adjuvant Chemotherapy: systemic chemotherapy using a combination of Paclitaxel, Ifosfamide, and Cisplatin (TIP).

Neoadjuvant Chemotherapy (Before Surgery): This is the standard of care for patients who present with bulky or fixed palpable inguinal lymph nodes (Stage cN3).

Adjuvant Chemotherapy (After Surgery): Recommended for patients who went straight to surgery but whose final pathology reports revealed advanced nodal disease

therapy of advanced cases

1. Extended Surgery: Total Penectomy and Emasculation

2. Pelvic Exenteration / Hemipelvectomy

3. Salvage Lymphadenectomy : those that failed to completely disappear after a full course of systemic chemotherapy

4. Systemic Chemotherapy:3 to 4 cycles of Paclitaxel, Ifosfamide, and Cisplatin (TIP)

Neoadjuvant vs. Palliative Intent

Poor Results!

tumors of the scrotal skin

1. Squamous Cell Carcinoma (SCC)

2. Melanoma

management :

1. Surgical Management: Wide Local Excision : 1 to 2 centimeters

2. Adjuvant and Regional Therapy:

If the inguinal lymph nodes are physically felt (palpable), or if a needle biopsy confirms spread, a formal inguinal lymphadenectomy (surgical clearing of the groin nodes) is performed.

Adjuvant Radiotherapy : after surgery

Systemic Adjuvant Therapy: Cisplatin

urethral cancer

A. Superficial Urethral Cancer: ( non-invasive|) :

1. Endoscopic Excision (Transurethral Resection - TURU

2. Adjuvant Topical Instillations: instil medications like BCG (Bacillus Calmette-Guérin) or Mitomycin C directly into the urethra via a catheter

3. Segmental Urethrectomy (Male Anterior Urethra)

B. Invasive Urethral Cancer:

1. Anterior Tumors (Distal Shaft): Treated with a partial penectomy

2. Posterior Tumors (Bulbomembranous / Prostatic Urethra): These are highly aggressive and carry a poor prognosis. They require a radical multi-organ removal called a Radical Cystoprostatectomy and Penectomy, which involves removing the bladder, prostate, and the entire penis.

3. Reconstructive Solutions: Urinary Diversion (Ileal Conduit (urostomy bag),Neobladder out of intestinal tissue.

4. Chemotherapy and Radiotherapy:

Neoadjuvant Chemotherapy (Before Surgery) : Methotrexate, Vinblastine, Adriamycin, Cisplatin

Definitive Radiotherapy