Cancer of the Penis

A 38-year-old man presented with a fleshy lesion beneath the tip of his penis. He had discovered it about 18 months before the initial evaluation. A second similar lesion resembling a “cauliflower” had appeared several weeks after the first. Both lesions had grown and had begun to bleed during intercourse.

The patient had been circumcised in infancy and underwent a meatotomy for correction of hypospadias. He denied any history of sexually transmitted diseases.

The lesions measured 2.8 and 0.8 cm and had a verrucous appearance. No bleeding, excoriation, or lymphadenopathy (A and B) were noted. The remainder of the physical examination was unremarkable.

The patient was referred to a urologist. A biopsy of a penile lesion confirmed the diagnosis of carcinoma of the squamous cell type.

Fewer than 1% of malignancies that affect men in the western hemisphere are penile cancers¹; the vast majority of those that do occur (over 95%) are squamous cell carcinomas.² Their cause remains unclear; some investigators suggest an association with the human papillomavirus (HPV) type 16.³ Two recent studies found that late circumcision, multiple sex partners, a history of HPV infection, and smoking are epidemiologic risk factors.^3,4

Squamous cell carcinoma of the penis usually appears as a fleshy growth with an area of erythema. In another patient, a squamous cell carcinoma of the penis manifested as a verrucoid red plaque on the proximal shaft (C). As the lesion enlarges, an itching or burning sensation can evolve into pain, and a nodule or mass that often becomes verrucous may develop along with a foul-smelling discharge. With neoplastic extension, bleeding, fistulization, and lymphagenous dissemination can occur. Enlarged inguinal lymph nodes may be a clue to the diagnosis.

Ultrasonography or MRI can help delineate the degree of disease infiltration. CT scans of the abdomen and pelvis can help detect pelvic lymphatic involvement. A chest film and a bone scan may be required to determine the extent of malignancy.⁵

The Table outlines the staging of penile carcinoma, which can influence treatment choice. The staging system is not correlated with prognosis; the single best prognostic indicator of survival is the degree of lymph node involvement.^6,7

Local excision and circumcision are appropriate for patients with lesions smaller than 2 cm, which are usually less invasive. About 90% of such patients remain alive at 5 years. Penectomy and urethrostomy are performed on those whose lesion is at least 2 cm and who have no nodal involvement. The 5-year survival for these patients is between 80% and 90%.

Radiation therapy and chemotherapy have limited success in patients with advanced disease. Chemotherapeutic agents include cisplatin, bleomycin, methotrexate, vincristine, and 5-fluorouracil. Despite treatment, fewer than 50% of patients with involved lymph nodes survive for 5 years.⁸

This patient underwent a radical penectomy immediately after the disease was confirmed. Postoperative care and emotional support and guidance were given. The patient died 6 weeks after surgery.

REFERENCES:1. Krieg R, Hoffman R. Current management of unusual genitourinary cancers, 1: penile cancer. Oncology. 1999;13:1347-1352.
2. Micali G, Innocenzi D, Nasca MR, et al. Squamous cell carcinoma of the penis. J Am Acad Dermatol. 1996;35:432-451.
3. Holly EA, Palefsky JM. Factors related to risk of penile cancer: new evidence from a study in the Pacific Northwest. J Natl Cancer Inst. 1993;85:2-4.
4. Cubilla AL. Carcinoma of the penis. Mod Pathol. 1995;8:116-118.
5. Kanik AB, Lee J, Wax F, Bhawan J. Penile verrucous carcinoma in a 37-year-old circumcised man. J Am Acad Dermatol. 1997;37:329-331.
6. Burgers JK, Badalament RA, Drago JR. Penile cancer: clinical presentation, diagnosis, and staging. Urol Clin North Am. 1992;19:247-256.
7. Connell CF, Berger NA. Management of advanced squamous cell carcinoma of the penis. Urol Clin North Am. 1994;21:745-756.
8. Eisenberger MA. Chemotherapy for carcinomas of the penis and urethra. Urol Clin North Am. 1992;19:333-338.
9. Penis. In: American Joint Committee on Cancer. AJCC Cancer Staging Manual. 5th ed. Philadelphia: Lippincott-Raven; 1997:215-217.