TUMORS OF THE PENIS

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.

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.

CARCINOMA IN SITU

BOWEN DISEASE• squamous cell carcinoma in situ typically involving the

penile shaft. • The lesion appears as a red plaque with encrustationsERYTHROPLASIA 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.

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

TNM Classification of Tumorsof the Penis*

T—Primary tumorTX: Cannot be assessedT0: No evidence of primary tumorTis: Carcinoma in situTa: Noninvasive verrucous carcinomaT1: Invades subepithelial connective

tissueT2: Invades corpus spongiosum or

cavernosumT3: Invades urethra or prostateT4: Invades other adjacent structures

N—Regional lymph nodesNX: Cannot be assessedN0: No regional lymph node metastasisN1: Metastasis in single superficial

inguinal nodeN2: Metastasis in multiple or bilateral

superficial inguinal nodesN3: Metastasis in deep inguinal or

pelvic nodes

M—Distant metastasisMX: Cannot be assessedM0: No distant metastasisM1: Distant metastasis present

*Reference: Smith’s General Urology 17th edition. Pg.384. Table 23–3.

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.

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.

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

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

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.

Management of Penile Carcinoma

*Reference: Smith’s General Urology 17th edition. Pg.386. Figure 23–4

TUMORS OF THE SCROTUM

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

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.

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.