Histologically, most penile cancers (over 90%) are categorized as squamous cell carcinomas.
Typically penile cancer affects elderly uncircumcised men who have experienced decades of poor hygiene, and accumulation of irritant smegma secretions under a nonretractile foreskin.
Cigarette smoking and compromised immunity (as with HIV infection) are other predisposing factors.
It is much less often seen in middle age and even less so in young adults, but when it does it is more likely to be secondary to chronic infection with certain strains of human papilloma wart virus, or secondary to chronic BXO.
Indeed recent research has suggested that up to a third of penile squamous carcinomas develop in association with BXO.
For documentation, research and prognostic assessment, it can be staged in several ways. Researchers now commonly use the TNM anatomical classification, where a numerical value for ‘T’ represents the extent of local anatomical spread of the tumour, a numerical value for ‘N’ represents the extent of any spread to local or regional lymph nodes, and ‘M’ whether or not there is evidence of distant metastasis to other organs of the body.
This anatomical staging may be used in conjuction with a histological grading of the microscopic appearance that ranges from Gx-G4. Some clinicians still use the older and simpler numerical Jackson system where tumour extent ranges from Stage 0 through to Stage IV, the latter representing advanced tumour that has spread to involve pelvic lymph nodes or other parts of the body.
Although encouragingly high cure rates over 80% are possible in the earlier stages, when the tumour is still confined to the penile tissues and not yet metastasized, it is nevertheless a greatly feared disease.
Traditional treatments with either radiotherapy or conventional amputations, whilst often curative, can unfortunately be debilitating, disfiguring or emasculating, and greatly compromise the patient’s quality of life. New approaches to therapy developed in the late 90s have now made possible a greatly improved quality of life without compromising on the cure rate.
We have now abandoned radiotherapy as the first-line treatment, particularly in the younger patient, because whilst it is seen as an organ preserving alternative to amputation, this is at the expense of lower cure rates and the potential for a great deal of long-term misery and morbidity from the effects of the radiation. Radiotherapy is now more commonly used in an ancillary back-up role when primary surgery alone is not sufficient.
This change has come about from the recognition that conventional guidelines for surgical amputation have been overzealous.
Traditionally it has been considered
mandatory to remove at least 2cm of normal tissue beyond the extent of the tumour, resulting in quite extensive amputations that leave behind an unusable stump of penis. With a better understanding of the way that penile cancer behaves, we are recognising that much smaller clearance margins (measured in mm rather than cm) can safely be taken without compromising the chances of cure.
This is now supported by long-term follow-up data from a number of cancer centres, and is changing the way we view the management of this disease.
It means that a much greater length of penis can usually be preserved, and with the application of specialised plastic surgery techniques, a convincing looking pseudo-glans and meatus can be constructed instead of leaving the ugly dysfunctional stump that used to be the norm.
Non-invasive in-situ forms of glans malignancy (Bowens disease and Erthyroplasia of Queyrat) can be effectively managed by glans resurfacing, wherein the unhealthy covering of the glans is dissected off and replaced with a graft of new healthy skin.
When tumour is invasive but confined to the glans, it is no longer necessary to amputate any of the penile shaft. It suffices to remove just the glans cap and fashion a new pseudo-glans from the underlying tissue with the aid of a skin graft.
Even when tumour has spread through the glans to involve part of the shaft, we can now offer much more conservative amputations with immediate reconstruction of a pseudoglans.
Thus many patients who would previously have had to sit down to pass urine and accept loss of their sexual function, can now hope to achieve a much more normal quality of life after conservative surgical removal of their penile cancer.
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