Penis

What is penile cancer?

Penile cancer is a rare tumor that, although it can affect young men, is most commonly diagnosed in individuals over 50 years old. In Brazil, this type of tumor represents 2% of all cancers affecting men.

According to research conducted by the Brazilian Society of Urology (SBU), although there is a large number of penile cancer treatments concentrated in the state of São Paulo, most patients come from the North and Northeast regions of the country.

According to the National Cancer Institute (INCA), more than half of patients with penile cancer take more than a year to seek medical assistance after the appearance of initial lesions.

Subtypes of penile cancer

In early stages, malignant cells are located in the superficial layers of the organ. This type of tumor, known as squamous cell carcinoma, accounts for 95% of cases and has high cure rates. Most of these tumors grow slowly and are found on the foreskin or on the glans. If diagnosed in the early stages, the chance of cure is very high. Over time, it can spread to the groin and abdomen.

The other types of penile cancer are:

• Verrucous carcinoma – a rare form of squamous cell carcinoma. Verrucous carcinoma, also known as Buschke-Lowenstein tumor, resembles a benign genital wart. It can spread to adjacent tissues but rarely spreads to other organs;
• Carcinoma in situ – considered the early stage of squamous cell carcinoma of the penis. At this stage, cancerous cells are found only on the skin’s surface. Carcinoma in situ of the glans is sometimes called erythroplasia of Queyrat. When diagnosed on the body of the penis or other parts of the genital organs, it is called Bowen’s disease;
• Melanoma – a type of skin cancer that begins in the melanocytes, cells responsible for skin pigmentation. These tumors tend to grow and spread rapidly and are more aggressive than other types of skin cancer. Only a small percentage of penile cancers are melanomas.
• Basal cell carcinoma – another type of skin cancer that can develop on the penis, representing a small percentage of cases. This type of tumor grows slowly and rarely spreads to other parts of the body.
• Adenocarcinoma (Penile Paget’s disease) – a very rare type of penile cancer that develops from the sweat glands of the skin of the penis, which can be difficult to distinguish from carcinoma in situ.
• Sarcoma – a small percentage of penile tumors develop from the blood vessels, muscles, or other connective tissue cells of the penis and are called sarcomas.

Symptoms and signs of penile cancer

The most common clinical manifestation of penile cancer is a persistent sore or ulcer, located on the glans, foreskin, or body of the penis. The presence of one of these signs, associated with a white discharge (smegma), may be indicative of the disease. Another sign is the presence of inguinal lymph nodes (swollen lymph nodes in the groin).

More specifically, the symptoms of penile cancer are:

• Changes in the skin – one of the most common symptoms of penile cancer. In addition to possible changes in color and thickness, some reddish and velvety tissue or brown lesions may appear;
• Secretion – in some cases, the sores may have constant white and strongly odorous secretions;
• Swollen lymph nodes – nodules or swelling in the groin area can also occur in patients with penile cancer; and
• Difficulty in healing – the presence of a reddish wound that does not heal is another indication. This is a type of pre-cancerous lesion called erythroplasia of Queyrat.

Note: Not all the symptoms above indicate a malignant tumor in the penis. There are warts or spots in the region that are benign changes, usually located on the skin covering the head or on the head of the penis.

Diagnosis of penile cancer

The chances of curing the neoplasm are much higher when diagnosed at an early stage. All changes in the penis, such as lesions or spots, should be evaluated by a doctor. Even after the clinical examination, the diagnosis is only confirmed after other tests and biopsies.

Biopsy is performed by removing a fragment of the affected area, which undergoes laboratory analysis. There are several types of biopsies, including:

• Incisional biopsy – indicated for larger lesions that have deepened into the skin. The area is anesthetized, and the doctor removes only a piece of tissue;
• Excisional biopsy – for lesions up to 1 cm, with general anesthesia and removal of the entire lesion; and
• Fine-needle aspiration biopsy (FNAB) – a needle attached to a syringe is used to aspirate a sample of the tumor and send material for analysis.

Imaging exams are also important in the evaluation process of the tumor, helping to determine the extent of the disease. These include:

• Magnetic resonance imaging – electromagnetic waves are used for imaging and allow determining the size, location of the cancer, and the possible presence of metastases;
• Computed tomography – some tomography exams are performed in two stages: without and with contrast. Contrast administration into the vein should be performed when seeking details, making the diagnosis more precise; and
• Ultrasound – determines the depth of the tumor in the penis and also identifies any involvement of the lymph nodes in the groin.

Treatment for penile cancer

The choice of treatment is individualized and depends on factors such as the extent and location of the tumor, and involvement of the inguinal lymph nodes. Surgery, radiation therapy, and chemotherapy are options for combating the disease, either used individually or in combination. The stage at which the disease is discovered also influences the decision.

Surgical intervention is the most common approach, and there are several types of surgery that can be used to treat penile cancer, depending on the location, stage, and type of neoplasm:

• Circumcision – technique used when the tumor is located in the foreskin. The foreskin and surrounding skin are removed. It may be indicated before radiotherapy treatment;
• Simple excision – the procedure, similar to a biopsy, involves removing the tumor along with a margin of normal tissue around it. The goal is to prevent any cancerous cells from remaining at the site;
• Mohs surgery – in this type of procedure, the layer of skin that the tumor may have invaded is removed and analyzed. If the disease is confirmed, a new layer is removed and examined. The process of removing layers is repeated until the skin samples are free of cancer cells;
• Laser resection – a beam of light vaporizes the cancer cells, being useful in cases of more superficial cancers, such as squamous cell carcinoma and basal cell carcinoma;
• Cryosurgery – freezing cancer cells with liquid nitrogen. It is effective in treating verrucous penile cancer and carcinoma in situ of the glans;
• Penectomy – partial or total removal of the penis. It is the most efficient way to treat a cancer that has developed within the organ; and
• Lymphadenectomy – surgery of the lymph nodes, which occurs when the tumor has deepened significantly. The procedure prevents the spread of the disease.

Topical treatment is possible. Imiquimod is a cream medication that stimulates the body’s immune system and should be applied to the skin. Occasionally, it is used in the treatment of carcinoma in situ of the penis.

And chemotherapy can also be used. Because it is a systemic treatment, it affects not only cancer cells but also healthy cells in the body. There are two types of chemotherapy for the treatment of penile cancer:

• Topical chemotherapy – the medication, in the form of a cream, is applied directly to the skin. Since it acts on cancer cells located on the surface of the dermis, it is more commonly used in pre-cancerous conditions or for early-stage carcinoma; and
• Systemic chemotherapy – administered orally or intravenously, is indicated for tumors that have spread to the lymph nodes or other organs. When combined with surgery, systemic chemotherapy is used before the procedure to reduce the size of tumors.

Prevention of penile cancer

Correct hygiene of the penis is the best way to prevent cancer in the organ. Daily cleaning should be done with water and soap, especially after sexual intercourse and masturbation. Other practices also help in the prevention of this type of tumor:

• Foreskin surgery – a simple, quick operation that does not require hospitalization. Also called circumcision, foreskin surgery is usually performed in childhood. As the most important aspect of prevention is hygiene habits, circumcised men have some advantage in organ cleanliness;
• Condom – the use of a condom reduces the risk of sexually transmitted diseases, such as HPV virus, and the incidence of penile cancer;
• Self-examination – it is important for men to identify lesions early or any changes in skin color and immediately seek a doctor.