CARCINOMA PENIS

Dr. R. KANNAN M.S,

Professor of General Surgery,
Govt. Royapettah Hospital,
Kilpauk Medical College,
Chennai.
.

Prevalence and Importance of the disease.

Cancers of the penis are uncommon tumours that are often

devastating for the patient.

Rare in North America and Europe but constitute a substantial health

concern in many African, South American, and Asian countries.

Penile cancer accounts for 0.4-0.6% of all malignancies in the United

States and Europe whereas 20-30% of all cancers diagnosed in men

who live in Asia, Africa, and South America.

Urban India: 0.7-2.3 cases per 100,000 men.

Rural India :3 cases per 100,000 men(>6% of all malignancies)

Some Important Epidemiological Facts.

Most of the cancers are squamous cell carcinomas and originate on

the glans.

Penile cancer is rare in circumcised men, particularly if they were

circumcised as a neonate.

Penile cancer tends to be a disease of older men.

The incidence of penile cancer increases abruptly in men aged 60

years or older and peaks in men aged 80 years.

But it presents in males less than 40 yrs age.

ETIOLOGY

ETIOLOGY
HUMANPAPPILOMA VIRUS: HPV-16 and HPV-18 have been found in one third of
men with penile cancer.

IMMUNOCOMPROMISED STATE: HIV STATUS

UNCIRCUMCISED MALE: Phimosis is present in at least 25-75% of men with this
disease. Penile cancer is almost never observed in individuals who are circumcised in the
neonatal period.

CIGARETTE SMOKING AND TOBACCO: Risk of penile cancer in men who were
smoking at the time of diagnosis was 2.8 times that of men who never smoked

CHRONIC BALANITIS: odds ratio of 23 for carcinoma in situ and 4.6 for invasive cancer

BENIGN LESIONS
&
CARCINOMA IN SITU
IN THE ETIOLOGY OF PENILE CARCINOMA

BENIGN LESIONS
ANGIOMAS
NEUROMAS
LIPOMAS

FIBROMAS
PEARLY PENILE PLAQUES
CORONAL PAPILLAE
ZOON BALANITIS

PREMALIGNANT CONDITIONS
CUTANEOUS HORNS
PSEUDOEPITHELIOMATOUS KERATOTIS BELANITIS
BELANITIS XEROTICA OBLITERANS

GIANT CONDYLOMA

Balanitis Xerotica Obliterans

Varient lichen sclerosis
Middle age uncircumsied
Site-Prepuce, glans,meatus

Symp-pain, pruritis, uri obstrn.

Ass. With sq.cell Ca.,
Tt-Surgical excision

PREMALIGNANT CONDITIONS
Penile Intraepithelial Neoplasms considered to be premalignant.
Only 5-15% of these lesions evolve into invasive squamous cell

carcinoma.

When carcinoma in situ (CIS) occurs on the glans, it is

termed Erythroplasia of Queyrat.

However, when it occurs on the follicle-bearing skin of the shaft, it is

termed Bowens disease.

ERYTHROPLASIA AND BOWENS DISEASE

SIR JAMES PAGET

I SAW PERSISTANT REDNESS OF GLANS LIKE CHRONIC

BALANITIS WHICH PRESENTED LATER WITH CARCINOMA

OF SUBSTANCE OF PENIS

NATURAL HISTORY

NATURAL HISTORY
HALLMARK OF DISEASE IS CONTIGOUS SPREAD.
SPREAD:

PENIS
TO

NODES
TO
DISTANT SITES

SALIENT FEATURES-LOCAL SPREAD

42 % OF CA FROM PRE-EXISTING BENIGN LEISON.
AT PRESENTATION MOST ARE CONFINED TO PENIS THOUGH DELAY

AT DIAGNOSIS.

BUCKS FASIA-NATURAL BARRIER.

URETHERAL & BLADDER INV. RARE.

DELAY
15 TO 50 % OF PATIENTS PRESENT AFTER 1 YEAR OF NOTISING

LEISON.

1. PATIENTS NEGLIGENCE-MOST COMMON REASON.

2.MISSED BY SURGEON DUE TO VARIED MIMICRY TO BENIGN
LEISON.

Salient Features-NODAL SPREAD

NODAL SPREAD STUDIED BY CABANAS(1977 & 1992)
NODE OF CABANA: LOCATED ABOVE AND MEDIAL TO THE JUNCTION OF
SAPHENOUS AND FEMORAL VEIN

1.EARLIEST SITE OF METASTASIS.

2.CONSISTENT PATTERN OF SPREAD TO Pelvic Nodes AFTER Inguinal
Nodes WITHOUT SKIP LEISON.
3.BILATERAL SPREAD CROSS CONNECTON OF LYMPHATICS.

Salient Features METASTATIC SPREAD

EVIDENCE OF DISTANT METASTASIS RARE AT TIME OF

PRESENTATION.

INCIDENCE : 1 10 %
METASTASIS IN ABSENCE OF NODAL INVOLVEMENT RARE.
EVIDENCE OF PELVIC N. AT CT MANDATES SEARCH FOR THEM.

CLINICAL
PRESENTATION

PRESENTATION
SITE
*MC SITE IS GLANS ( 48 %) & PREPUCE(21%).

*RARE IS SHAFT
CORRELATES WITH EXPOSTURE TO HPV & SMEGMA WITHIN P. SAC.

MORPHOLOGY
PATTERN OF PRESENTATION RELATED TO INCIDENCE OF METASTASIS
1.EXOPHYTIC LEISON -42 % NODE INV.

2.ULCERATIVE LEISON-82 % NODAL SPREAD.

SYMPTOMS
PAIN IS NOT A CHARECTERISTIC FEATURE.
1.FOUL SMELLING DISCHARGE
2.HAEMMORAGE.
3.WEIGHT LOSS DUE TO CHRONIC SUPPURATION.
4.HYPERCALCEMIA.

HYPERCALCEMIA
20.9 % OF PATIENTS.
NOT DUE TO BONY METASTASIS.
FUNCTION OF TUMOUR BULK.

PTH LIKE SUBSTANCE.

RELIEVED AFTER OPERATING ON GROWTH & NODE.

DIAGNOSIS

INVESTIGATIONS
1.PRIMARY TUMOUR.
2.REGIONAL NODES.
3.DISTANT METASTASIS.

INVESTIGATIONS- PRIMARY TUMOUR

1.CIRCUMCISION & WEDGE BX.
2.USG.
3.MRI.

MINIMAL INVESTIGATION FOR PRIMARY

WEDGE BX IS MINIMAL INV. SUFFICIENT IN DIAGNOSIS,
*USG & MRI NOT SENSITIVE FOR SMALL LEISON.

*NOT SENSITIVE SPONGIOSUM.

*100 % SENSITIVE CAVERNOSAL

WEDGE BX
1 cm ELLIPTICAL TISSUE REMOVED CENTERING ON MARGIN.

FEATURES NOTED ON BX
1.CONFIRMATION OF DIAGNOSIS.
2.DEPTH OF INVASION.
3.VASCULAR INVASION.
4.GRADING : BRODERS GRADING
4 GRADES.
MOST CA ARE GRADE 1 & 2.

SIGNIFICANCE OF FULL HISTOLOGICAL

CHARACTERIZATION
HELPS IN PREDICTING METASTASIS
1.LOW RISK : Tis , Ta , T1: 1 & 2

10 %
VASCULAR
INVASION
2.HIGH RISK : 50 %

INVESTIGATION FOR ASSESING NODE

FIRST LINE INVESTIGATION.

FOLLOW UP INVESTIGATION.

STUDY COMPARING ROUTINELY USED

MEATHODS
ASSESMENT
MODE

SENSITIVITY

SPECIFICITY

CLINICAL
METHOD

82 %

78 %

CT

36 %

100 %

LYMPHANGIO
GRAPHY

31 %

2 nd LINE INVETIGATION-NODE POSITIVE

1.FNAC

2.NODAL EXCISION BX IF FNAC NEGATIVE.

2nd LINE INVESTIGATION IN HIGH RISK

1.SENTINEL NODE BX.
NOT PRACTICED ROUTINELY BECAUSE OF INSUFFICIENT DATA.

2.SUPERFICIAL NODE DISSECTION:ROUTINELY PRACTISED

ASSESMENT OF METASTASIS
MINIMAL INVESTIGATION ARE

1.CHEST RADIOGRAPH.
2.LIVER FUNCTION TEST.

3.SERUM CALCIUM.
DOSENT FALL AFTER NODE SURGERY IN CASE OF
METASTASIS,
*CT ABDOMEN, CHEST ,BRAIN &BONE SCAN INDICATED
1.PELVIC NODE
2.CLINICAL SUSPICIAN.

MERITS OF SUPERFICIAL NODE

DISSECTION
1.MORE JN FORMATIVE THAN SINGLE GROUP OF NODES.
2.REMOVES ALL POSSIBLE SENTINEL NODES, LEISON NOT MISSED.
3.READILY PERFORMED BY ANY SURGEON.

4.NOT ASSOCIATED WITH LONG LEARNING CURVE.

STAGING

STAGING
1.

JACKSONS (1966 )

2.

REVISED AJCC TNM STAGING (1997)

JACKSONS STAGING
NOT PRACTISED-LESS ELOBORATE
A.

TUMOR CONFINED TO GLANS/PREPUSE

B.

EXTENSION TO SHAFT

C.

OPERABLE INGUINAL NODES

D.

1.IN OPERABLE NODES

2.ADJACENT STS INV.

3.METASTASIS

MERITS OF REVISED AJCC STAGING

1.ANATOMICALY MORE ELOBORATE.
2.HISTOLOGY INCORPORATED.
3.PELVIC NODE STATUS INCORPORATED.
SIZE OF TUMOR & MORPHOLOGY NOT INVOLVED IN STAGING.

MANAGEMENT

Locoregional treatment of CARCINOMA

PENIS

Squamous

Non squamous malignancies

TREATMENT OF

- PRIMARY

- REGIONAL DISEASE
OPTIONS

Surgical

Chemotherapy

Radiotherapy

Combined

Prognostic factors in squamous

penile cancer
Presence and extent of metastasis to inguinal

region

Primary :

Tumor grade ,
gross appearance ,
morphologic/microscopic patterns
tumor histology
corporal invasion
invasion vascular / lymphatic / urethral

Pathologic criteria
For long term survival (80% 5 yr survival) with attempted curative
surgical resection
Minimal nodal disease upto

2 nodes

Unilateral involvement
No evidence for extranodal

extension

Absent pelvic nodal metastasis

SURGICAL MANAGEMENT OF
PRIMARY
LASER THERAPY
MOHS MICROGRAPHIC SURGERY
PARTIAL PENECTOMY
TOTAL PENECTOMY

LASER THERAPY
Destroys lesion with preservation of normal structure and
function
Forms :
CO2 , Nd:YAG , Argon , KTP

Indications :
Premalignant lesions (bowens,EOQ,BP) ,
CIS,some stage Ta & T1
Higher local recurrence rates
in invasive tumors

MOHS MICROGRAPHIC SURGERY (MMS)

Involves sequencial local excision of primary tumor in thin
horizontal layers with histologic tracking of residual neoplastic
elements
Allows retention of function & anatomic integrity without
compromising local control rates
100

% cure rates for lesions < 1cm , CIS

50 % cure

rates for lesions >3cm

Local failure rate 8 %

Prognostic

factors -

Complications

meatal stenosis , disfig. of glans

CONTRAINDICATED

IN - LARGER , HIGHER STAGE

PARTIAL PENECTOMY
Division of penis atleast 2 cm proximal to the gross
tumor extent
AIM :
To obtain an adequate margin (2 cm)
Preserve sufficient penile length for a directable
urinary stream
TOTAL PENECTOMY
With perineal urethrostomy
Indicated in lesions whose size or location precludes
adequate excision with a functional remnant by partial
penectomy

 Youngs Operation:
Partial amputation of penis with bilateral ilioinguinal lymphnode

block dissection

Sir Piersey Gold Operation:

Total amputation of penis with total scrotectomy and orchedectomy

and perineal urethrostomy. (Emasculation)

TREATMENT OF REGIONAL DISEASE

Penile cancer exhibits an

orderly locoregional pattern of progression

with distant metastasis occuring late ,
preceded by regional lymphadenopathy
EXPECTANT MANAGEMENT
watchful waiting strategies
Ca in situ (Tis)
Verrucous ca. (Ta)
Stage T1 grade 1-2

INGUINAL PROCEDURES
Fine needle aspiration biopsy(FNAC)
Node biopsy
Sentinal lymphnode

biopsy(SLNB)

Extended Sentinal lymphnode

dissection (ESLND)

Intra operative lymph node mapping (IOLM)

Superficial dissection
Modified

complete dissection

Ileo inguinal dissection

unilateral / bilateral

ILEOINGUINAL NODAL DISSECTION

Superficial dissection

Removal of nodes supl to fascia lata

Complete inguinal / ileoinguinal dissection

After 6 week interval after tmt of primary

reduction of any inflammatory componant of adenopathy
minimises wound suppuration

Bilateral / unilateral

Potencial therapeutic value in resectable metastatic adenopathy

Goals :

Eradicate all obvious cancer

Provide coverage for exposed vasculature

Provide rapid wound healing

Incisions

Vertical incision

Sapheno-femoral junction

Iliac vessels

Pelvic lymphadenectomy
Serve

as an effective staging tool(prognostic)

Identify chemotherapeutic strategies (adj/neoadj)
Adds to locoregional control
Little additional morbidity to inguinal procedure
Technique

Approaches
Includes distal common iliac,
external iliac,
obturator groups
No added benefit in removal of proximal iliac / para-aortic

IIBD nodes

Modified complete dissection (CATALONA)

DIFFERS FROM STANDARD DISSECTION IN

Shorter skin incision,

Limited node dissection

Saphenous vein preserved,

Transpositon of sartorious eliminated

ADVANTAGES

Provides more information than biopsy ,

removes all potential first echelon nodes,

minimal morbidity,

can be performed by any experienced surgeon

Modified complete dissection (CATALONA)

(Limited therapeutic lymphadenectomy )
INDICATIONS

Clinically neg. nodes ,

minimal or equivocally enlarged nodes

TECHNIQUE

Position,incision,
plane of dissection,
flaps,nodes
Boundaries of dissection :
medial adductor longus ,
lateral - femoral a.
superior- sp.cord ,
inferiorly fossa ovalis

DRESSLERS QUADRANGLE

RADIATION THERAPY of the primary lesion

INDICATIONS
Young pts

with

small(2-4cm),superficial,exophytic,
noninvasive lesions on glans/coronal sulcus (80%success)
Pts refusing

surgery

Pts with inoperable

tumor / distant mets who require local tmt but

desire to retain penis

OPTIONS
5000-5700 rad
External

over 3 weeks

beam,electron beam,radium moulds,

Interstitial

brachytherapy (ra226,iri192,ces137)

RADIATION THERAPY
Disadvantages
SCC is characteristically radioresistant
Cause urethral stricture,fistula,stenosis

penile necrosis,pain,edema

sensory loss,erectile dysfunction

testis damage,secondary neoplasia
Infection decreases therapeutic effect of RT

increases risk of damage , compl.

Post RT scar,fibrosis,ulcer

impossible to differentiate from recurrent lesion

RADIATION THERAPY of inguinal areas

Limitations
Inguinal regions tolerate radiation poorly
Subject to skin maceration and ulceration
Infection reduces effect,exacerbates complications

Perilymphatic fat acts as a barrier

Radiation therapy does not alter the course of the

disease

Indications (may be considered in)

inoperable fixed,ulcerative lesions
As a Palliation,to postpone local complications

CHEMOTHERAPY
Indications
Neoadjuvant therapy in -

stage 3

Adjuvant in extensive inguinal metastasis

pelvic nodes
Palliative in - locally inoperable tumor /

distant metastasis
Can induce responses in metastatic penile cancer
Responses partial , short in duration

CHEMOTHERAPY REGIMES
Drugs useful :

5FU(F),methotrxate(M), vincristine(V),
cis-Platin(P) , bleomycin(B)
REGIMES
VBM

(8-12 weekly courses)

PF

(4 courses at intervals of 3 weeks)

MPB

(every 28 days for 2-4 cycles)

PMB

(every 21 days for 4-6 cycles)

COMBINED THERAPY
AIM
To convert the tumor to a potential resectable lesion in

patients presenting with unresectable disease

Helpful in minimizing disfigurement and functional

loss associated with penile amputative surgery in select

cases

Modalities
Chemo + surgery or radiotherpy
LASER hyperthermia + radiation
Chemo + iv peplomycin
Interferon-alpha + retinoid(etretinate)

RISK BASED MANAGEMENT

Low risk criteria

Tis , Ta ,
T1 Grade1-2 ,no vascular invasion
High risk criteria

T any ,
vascular invasion +/ grade 3
Metastatic disease :

fixed nodal metastasis

nodes > 4 cm -mobile
pelvic nodal metastasis

Low risk patients (Tis,Ta)

Regional lymphatics
(Physical/imaging)
Negative

observe

positive

FNAC

4weeks antibiotics reassess

Negative

Excisional biopsy
Negative
Observe
Positive
Positive

NODE DISSECTION

Low risk patients

(T1-grade2,no vasc. invasion)
Regional lymphatics
(Physical/imaging)
observe

Negative

Negative

Positive

4 weeks antibiotics , reassess

Positive

Follow
high risk algorithm

High risk patients

(any T- grade3/vasc. invasion)
Bilateral negative nodes

Bilateral - supl dissection /

Complete modified dissection
FROZEN SECTION
NEGATIVE

POSITIVE

OBSERVE

Ipsilateral
radical
dissection

High risk patients

(any T- grade3/vasc. invasion)
UNILATERAL POSITIVE NODES < 4 cm , mobile

Ipsilateral radical ,
Contralat supl / modified complete
Dissection
FROZEN SECTION
NEGATIVE

POSITIVE

OBSERVE

IPSILATERAL
RADICAL
DISSECTION

High risk patients

(any T- grade3/vasc. invasion)
BILATERAL POSITIVE MOBILE , > 4 CM
FNAC
NEGATIVE

B/L NEGATIVE
ALGORITHM

POSITIVE

B/L RADICAL
DISSECTION
ADJUVANT
CHEMOTHERAPY

Adjuvant chemo : >2 nodes,pelvic nodes,extra nodal disease

METASTATIC DISEASE

FIXED NODAL METASTASIS

>4CM MOBILE INGUINAL NODES

PELVIC NODAL METASTASIS

COMBINATION
CHEMOTHERAPY
RESPONSE /
STABLE DISEASE

AGGRESSIVE
SURGICAL
RESECTION

PROGRESSIVE
DISEASE

RESECTABLE

UNRESECTABLE

PALLIATIVE
SURGERY

SALVAGE CHEMO
RADIOTHERAPY

RECONSTRUCTIVE PROCEDURES
OF PENIS AFTER PENECTOMY AND EMASCULATION

(after proved to be cancer free)

Anatomy and physiology of erectile tissues are unique and
cannot be reproduced by transfer of other human tissues

Requirements
One stage
Creation

microsurgical procedure

of a competant urethra to achieve normal voiding

Restoration of tactile

& erogenous sensible phallus

Bulk to allow prosthetic

Aesthetic

stiffener implant for vaginal penetration

acceptence by the patient

RECONSTRUCTIVE PROCEDURES
OF PENIS AFTER PENECTOMY AND EMASCULATION
(after proved to be cancer free)

AFTER PARTIAL PENECTOMY

Microvascular Free flap reconstuction

- Radial forearm flap
Upper lateral arm flap

Prosthetic placement

Distal corpora construction Gore-tex vascular graft

Inverted forearm osteocutn. flap with big toe pulp for glans

RECONSTRUCTIVE PROCEDURES
AFTER TOTAL PENECTOMY (neophallus)
Problems :
Insensate,tend to atrophy ,multiple steps

Realistically attainable
Tube within a tube abdominal flap
Direct cutaneous arterialised flaps

Supl perineal arterial flaps

Musculocutaneous flaps - Gracilis,RF,RA
Stretch Gore-tex graft-corporal reconstuction

RECONSTRUCTIVE PROCEDURES
INGUINAL - AFTER NODE DISSECTION

Gracilis musculocutaneous unit

Tensor fascia lata flap (TFL)

Inferiorly based RA musculocutaneous flap

Contralateral Inferior RA muscle flap

Transversely oriented Inferior RA abd flap

Omental flaps with SSG

- excellent neovascularisation
- lymphatic abundance

Eroded femoral A. reconstruct vein patch/Gore-tex

excise and restore continuity

Inguinal reconstruction

NON SQUAMOUS MALIGNANCY

BASAL CELL CA.
Local excision

always curative

Benign(premalignant)

variant

fibroepit. Of Pincus
Excisional biopsy
MELANOMA

Surgery primary mode (prog. Factors,spread)

CT/RT adjunctive/palliative

Stage 1 / 2 adequate excision by penectomy

with en bloc ileo-ing. node dissection

NON SQUAMOUS MALIGNANCY

SARCOMA
Superficial wide local surface excision
Deep total penile amputation
Node dissections not recommended
Local recurrences are common

PAGETS DISEASE
Complete local surface excision of skin & subcut tissues
Radical node dissection if nodes +

SURFACE ADENO-SQUAMOUS CA.

Local excision of primary + limited nodal dissection

NON SQUAMOUS MALIGNANCY

LYMPHORETICULAR MALIGNANCY
Systemic

chemotherapy

Local low dose irradiation

METASTASIS to PENIS
Indicates dissiminated disease
Solitary

localised nodule in distal penis

- Partial amputation
Intractable
RT /CT

pain penectomy / dorsal nerve section

Lymphedema prevention
long term - after surgery
Care of foot
Care of nails

- cut with clippers

Wear comfortable slipper

Aviod areas where needs to go bare foot

Crepe bandage / graduated compression

stockings

Keep the limb elevated while sitting/sleeping

Carry home points

Carcinoma penis is a potentially curable disease

Multimodality tmt with combination chemotherapy

as treatment of choice

Surgery

emerges

is the mainstay of treatment

Radiotherapy

has very minimal role in treatment

Numerous options are developing for

reconstuction of penis

THANK YOU