Penile Carcinoma
~Introduction
Penile carcinoma is a rare but aggressive malignant tumor arising from the tissues of the penis. It accounts for less than 1% of cancers in men in developed countries but has a higher incidence in developing nations, including parts of Asia, Africa, and South America. Despite its rarity, penile carcinoma carries significant morbidity and mortality due to delayed diagnosis, social stigma, and lack of awareness. Early detection and proper management are crucial for improving survival and preserving quality of life.
Most cases of penile carcinoma originate from the squamous epithelium, making squamous cell carcinoma (SCC) the most common histological type. The disease predominantly affects older men, usually between 50 and 70 years of age, although it can occasionally occur in younger individuals.
~Epidemiology
Incidence varies geographically
Rare in Western countries (0.1–1 per 100,000 men)
Higher incidence in India, Brazil, Africa, and Southeast Asia
More common in uncircumcised men
Higher prevalence in low socioeconomic groups
~Risk Factors
Several risk factors contribute to the development of penile carcinoma:
1. Lack of Circumcision
Uncircumcised men have a significantly higher risk due to accumulation of smegma, chronic inflammation, and poor hygiene.
2. Poor Genital Hygiene
Chronic irritation and inflammation of the penile epithelium predispose to malignant transformation.
3. Human Papillomavirus (HPV) Infection
HPV types 16 and 18 are strongly associated
Present in approximately 30–50% of penile cancers
Oncogenic HPV leads to cellular dysplasia and malignancy
4. Phimosis
Inability to retract the foreskin results in poor hygiene and chronic inflammation.
5. Smoking
Tobacco carcinogens cause DNA damage and increase cancer risk.
6. Chronic Inflammatory Conditions
Lichen sclerosus (balanitis xerotica obliterans)
Chronic balanitis
7. Multiple Sexual Partners
Increases risk of HPV infection.
~Precancerous Lesions of Penis
Certain premalignant conditions can progress to invasive carcinoma:
Penile Intraepithelial Neoplasia (PeIN)
Carcinoma in situ
Bowen’s Disease
On shaft of penis
Erythroplasia of Queyrat
On glans penis
Leukoplakia
White plaques with malignant potential
Giant Condyloma (Buschke–Lowenstein tumor)
~Pathology
Gross Appearance
Penile carcinoma may present as:
Ulcerative lesion
Exophytic (cauliflower-like) growth
Indurated plaque or nodule
Foul-smelling discharge
Bleeding on touch
Common sites of involvement:
Glans penis (most common)
Prepuce
Coronal sulcus
Shaft (rare)
Histological Types
1. Squamous Cell Carcinoma (95%)
Subtypes include:
Usual type
Verrucous carcinoma (low-grade, slow growing)
Basaloid carcinoma (aggressive)
Warty carcinoma
Sarcomatoid carcinoma
2. Rare Types
Adenocarcinoma
Melanoma
Basal cell carcinoma
Lymphoma
Sarcoma
Microscopic Features (SCC)
Dysplastic squamous epithelium
Keratin pearl formation
Increased mitotic activity
Invasion into underlying stroma
Lymphovascular invasion in advanced disease
~Clinical Features
Early Symptoms
Painless lump or ulcer on penis
Red or white lesion on glans
Mild discharge
Local irritation or itching
Advanced Symptoms
Pain
Bleeding
Foul-smelling discharge
Difficulty in urination
Inguinal lymph node enlargement
Weight loss and fatigue in metastatic disease
~Spread of Penile Carcinoma
1. Local Spread
Invasion into corpora cavernosa and corpus spongiosum
2. Lymphatic Spread
Superficial inguinal lymph nodes (first)
Deep inguinal nodes
Pelvic lymph nodes
3. Hematogenous Spread
Rare
Lungs, liver, bones in advanced stages
~Staging (TNM Classification)
T – Primary Tumor
Tis: Carcinoma in situ
T1: Tumor invades subepithelial connective tissue
T2: Invades corpus spongiosum or cavernosum
T3: Invades urethra or prostate
T4: Invades adjacent structures
N – Lymph Nodes
N0: No nodal metastasis
N1–N3: Increasing lymph node involvement
M – Distant Metastasis
M0: No metastasis
M1: Distant metastasis present
~Diagnosis
1. Clinical Examination
Inspection and palpation of penile lesion
Assessment of inguinal lymph nodes
2. Biopsy (Gold Standard)
Incisional or punch biopsy
Confirms histological diagnosis
3. Imaging
Ultrasound for local extent
MRI for penile tissue invasion
CT scan for lymph node and distant spread
PET-CT in advanced cases
4. HPV Testing
Helpful for prognostic and research purposes
~Differential Diagnosis
Benign penile ulcer
Syphilitic chancre
Genital herpes
Condyloma acuminata
Peyronie’s disease
~Treatment
Management depends on stage, tumor size, lymph node involvement, and patient preference.
1. Treatment of Early-Stage Disease
Conservative Treatments
Topical chemotherapy (5-Fluorouracil)
Imiquimod cream
Laser ablation
Cryotherapy
Mohs micrographic surgery
Organ-Preserving Surgery
Wide local excision
Partial glansectomy
2. Treatment of Invasive Disease
Surgical Management
Partial penectomy
Total penectomy (advanced cases)
Perineal urethrostomy after total penectomy
Lymph Node Management
Sentinel lymph node biopsy
Inguinal lymph node dissection
3. Radiotherapy
External beam radiotherapy
Brachytherapy
Useful in early disease or patients unfit for surgery
4. Chemotherapy
Used in advanced or metastatic disease:
Cisplatin-based regimens
Combination chemotherapy (TIP: paclitaxel, ifosfamide, cisplatin)
5. Targeted and Immunotherapy
Emerging role
HPV-related tumors show better response
~Prognosis
Prognosis depends mainly on:
Tumor stage
Lymph node involvement
Histological grade
Survival Rates
Localized disease: 70–90%
Regional lymph node involvement: 30–50%
Distant metastasis: Poor prognosis
Early diagnosis significantly improves survival and penile preservation.
~Prevention
Primary Prevention
Neonatal circumcision
Proper genital hygiene
Safe sexual practices
HPV vaccination (effective against oncogenic strains)
Secondary Prevention
Early detection of precancerous lesions
Regular medical examination
Prompt biopsy of suspicious lesions
~Psychosocial Impact
Penile carcinoma causes:
Psychological distress
Sexual dysfunction
Body image issues
Social stigma
Multidisciplinary care including psychological support and counseling is essential.
~Conclusion
Penile carcinoma is a rare but potentially fatal malignancy that predominantly affects older, uncircumcised men. Squamous cell carcinoma is the most common histological type, strongly associated with HPV infection, poor hygiene, and chronic inflammation. Early diagnosis through biopsy and appropriate staging is vital for effective management. Treatment ranges from conservative therapies in early stages to radical surgery and chemotherapy in advanced disease. Preventive strategies such as circumcision, hygiene, HPV vaccination, and public awareness play a crucial role in reducing disease burden. With early intervention and modern therapeutic approaches, survival rates and quality of life can be significantly improved.
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