Download carcinoma of the penis - Bugando Medical Centre

PENILE MALIGNACY
Department of urology
Dr. Matalu Hamis
Dr. Mocha George
Anatomy
Penile parts
• Root of the penis(radix)-it is the attached part
consisting of the bulb of the penis in the
middle and the cruz of penis one on either
side of bulb . Lies within the superficial
perineal pouch.
• Body of the penis(corpus)-has two surfaces;
dorsal and ventral.
• The glans –sits as a cap on corpora cavernosa
but is a part of corpora spongiosa.
Gross anatomy
Vasculature
• Arterial supply
Blood supply to the skin of the penis is from the
left and right superficial external pudendal
arteries which arise from femoral artery.
Supply to deep structures is from continuation
of the internal pudendal artery which has
three branches bulbourethral artery,
carvenosal artery, and the dorsal artery.
• Venous drainage
Penis is drained by 3 venous systems, the
superficial, intermediate and deep.
Superficial veins coalesce to form single superficial
dorsal vein which drains to superficial pudendal
vein then to great saphenous vein
Intermediate veins has circumflex vein which drains
to deep dorsal vein.
Deep veins is via the crura and carvenosal veins
which drains to internal pudendal veins.
• Lymphatic drainage
Drains to deep inguinal nodes of the femoral
triangle and some to presymphyseal lymph
nodes and lateral lymph nodes of the external
iliac lymphatics.
Penile cancer
Introduction
•Is a rare type of cancer that most likely to occurs on
the glans of penis, or foreskin.
•Mostly are primary.
•Among 10 most common is scc.
•Others include melanoma,adenocarcinoma from
Tyson’s gland, bcc.
•20 may also occur and are mostly of urological origin.
Risk factors/Etiologies
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Uncircumcision.
Chronic balanoposthitis,
phimosis.
Sexually transmitted diseases.
Leukoplakia of glans.
Long-standing genital warts.
Paget’s disease of penis (Erythroplasia of
Queyrat is persistent rawness of glans penis).
Risk factors cont..
• Condyloma acuminata (by human papilloma
virus),balanitis xerotica obliterans.
• HIV infection
• HPV - 16.
• Age >50yrs.
• Smoking cigarette and chewing tobacco
• Penile intraepithelial neoplasia
• Poor genital hygiene
Natural history of the disease
• Penile cancers usually begin as small lesions
on the glans or prepuce.
• Macroscopically may be exophytic or flat,
papillary, or ulcerative.
• The growths rates of papillary and ulcerative
are similar but of exophytic tend to
metastasize to lymph node earlier and are
therefore associated with a lower five year
rate.
• If untreated penile autoamputation can occur.
• Infiltrating type/exophytic occurs in a
preexisting leukoplakia. It often presents as
indurated area.
• Papilliferous type eventually attains a large
size forming a fungating foul smelling lesion
which often gets infected.
• Microscopically tumor ranges from welldifferentiated keratinizing tumors to solid
anaplastic carcinomas with scant keratinization.
• Moderated differentiated tumors are highly
keratinized, and poorly differentiated carcinomas
have variable amounts of spindle cell, giant cell,
solid acantholytic, clear cell, small cell, warty,
basaloid or glandular components.
Epidemiology
• The annual burden of penile cancer has been
estimated to be 22000 cases worldwide with
incidence rates strongly correlating with those
cervical cancer.
• Incident rate are higher in less developed than
in more developed countries, accounting for
up to 10% of male cancers in some part of
Africa, South America and Asia.
• Is rare.
• common affect men aged 50-70 years.
Staging of penile cancer
Jackson’s staging of carcinoma penis-The commonest
method.
 Stage I
Tumour involving only glans/prepuce/both. 90% five year
survival
 Stage II
Tumour extending into body of penis. 70% five year
survival.
 Stage III
Tumour having mobile inguinal nodes. 50%
 Stage IV
Tumour spreading to adjacent structures/fixed nodes. 5%
TNM
TX
Primary tumour cannot be assessed
TO
No evidence of primary tumour
Tis
Carcinoma in situ
Ta
Non invasiive carcinoma
T1
Tumour invades sub epithelial tissue
• T1a without lymphovascular invasion and is not
poorly differentiated or undifferentiated
• T1b with either of the above
T2
Tumour invades corpus spongiosum and/or corpora cavernosa
T3
Tumour invades urethra
T4
Tumour invades other adjacent structures
N
Regional lymph nodes
Nx
Regional lymph nodes cannot be assessed
No
No palpable or visibly enlarged inguinal lymph node
N1
Palpable mobile unilateral inguinal lymph node
N2
Palpable mobile multiple unilateral or bilateral inguinal lymph nodes
N3
Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or
bilateral
M
Distant metastasis
Mo
No distant metastasis
M1
Distant metastasis
Spread of the cancer
• Lymphatics
It spreads to the horizontal group of inguinal lymph nodes which
become nodular and hard. Lymph nodes on both sides can get
involved. Later, external iliac group are involved (above and
on medial aspect of the inguinal ligament).
Once inguinal lymph nodes are fixed, it causes severe
excruciating pain and lymphoedema. Fixed lymphnode status
indicates the advancement of the disease. It may erode into
the femoral vessels causing torrential haemorrhage and
death. Fungation can occur.
From glans, it also spreads to Cloquet lymph node which is
located in femoral canal.
Carcinoma from shaft of penis can spread directly to the
external iliac lymph nodes.
It spreads proximally to the body of penis causing induration.
• Urethral meatus may get involved causing
alteration in urinary stream. It is a
locoregional malignant disease.
• Blood spread is rare.
Histopathological grading
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GX level of differentiation can not be assessed.
G1 well differentiated.
G2 Moderate differentiated.
G3 Poorly differentiated/undifferentiated.
Diagnosis
Clinically
History & physical exam.
• Mostly are obvious clinically except those hidden by
phimosis.
• A painless lesion on the glans penis/inner aspect of
prepuce skin.
• Papillary vs ulcerative.
• Penile discharge
• Dysuria
• 50% palpable inguinal lymph nodes at presentation..
Inflammatory vs malignant.
Investigations
• Punch or excisional biopsy confirms the
diagnosis.
Role of imaging in staging…
• Uss
• MRI
• CT scan
• PET/CT
TREATMENT
• The aim is complete removal of the tumor
with organ preservation as much as possible.
• Depends on the stage.
Modalities include:
• Surgery
• Chemotherapy
• Radiotherapy
Stage
Modality of rx
CIS
• Topical chemotherapy eg imiquimod
or 5FU
• Glans resurfacing
Ta/T1a
Penile preserving modalities
• Radical circumcision, glansectomy,
laser therapy, moh’s surgery.
• radiotherapy
T1b /T2
• Glansectomy +/- resurfacing of the
corporeal heads
T3
• Partial or total penectomy with
perineal uresthrostomy.
• Radiotherapy
T4
• Total penectomy
• Neoadjuvant chemotherapy
• NOTE; that for the early stages modality of
treatment should depend on the;
• Size, site relative to the meatal opening,
histology, stage.
• No significant differences in terms of long
term recurrence rate among the different
modalities.
• Cancer free margin of 10mm is considered
oncologically safe.
Complication and prognosis
• From treatment.
• Psychological.
Prevention
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Circumcision- neonatal.
HPV vaccination.
Hygiene.
Early management of premalignant
conditions.
• Early refferal
Summary
• Its rare.
• Circumcision main risk factor.
• Mostly involves the glans penis or the inner
aspect of the prepuce.
• SCC is the most common.
• Left untreated-auto amputation.
• Treatment multimodality.
• Prognosis
• Prevention
Refferences
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Lippincotts and william Atlas of anatomy
Baileys and love 25th edition
Short practice of surgery
SRB’s manual of surgery 3rd edition
Smith general urology 17th edition
Guidelines on Penile Cancer O.W. Hakenberg
(chair), E. Compérat, S. Minhas, A. Necchi, C.
Protzel, N. Watkin © European
• Ten-year surgical experiences with penile
cancer at a tertiary care hospital in
northwestern Tanzania: a retrospective study
of 236 patients Phillipo L Chalya1*, Peter F
Rambau2, Nestory Masalu3 and Samson
Simbila4