Penile cancer

I have a lump on my penis. Is this cancer?

Penile cancer usually presents as either a lump or a red patch on the penis. Most red patches on the penis are not cancer, but inflammation or a fungal infection. If the red patch is red and weepy, then this maybe Erythroplasia of Queyrat, which is a potential precursor to cancer.

Cancer in situ can look like a recurrent red patch, which does not settle with creams. True penile cancer is usually a nasty lump or ulcer, which has been present for some time. Because it is a potentially embarrassing site, some men present quite late with large lesions.

Penile cancer is very rare. It affects about 1/100,000 men/year. It is much more common in men who have not been circumcised.

What are the symptoms of penile cancer?

Typically, penile cancer will present as a lump or erosive lesion. It can weep and discharge and usually does not settle with creams. Sometimes it can be difficult to see as it can be under a foreskin which is stuck and will not pull back.

penile cancer can vary from a small red patch (this is an example of carcinoma in situ a pre-malignant condition)

to a red angry lump

(in this case an invasive form of cancer)

What causes penile cancer?

Penile cancer is caused by irritation. The two most common causes are HPV (which is a virus) and a foreskin which does not retract. HPV is a virus passed on during sex. Some types of HPV cause genital warts that you can see. Some forms of HPV cause an invisible infection. It is the virus which you cannot see that can lead to penile cancer. It is extremely rare for penile cancer to begin in men who have been circumcised before they became sexually active.

How is penile cancer diagnosed and assessed?

The first step is a biopsy of the lesion. The most common type of penile cancer is scc or squamous cell cancer. This grows from the skin covering the penis. The cancer usually starts at the junction between the head of the penis (glans) and the shaft of the penis. This is called the coronal sulcus.

Here a cancer is just beginning in the coronal sulcus

If the biopsy confirms penile cancer, then additional tests will be carried out to see if there is any evidence of spread of the cancer. This may include an MRI or ultrasound of the penis. A CT scan of the abdomen and sometimes a special x-ray called a PET scan.

Will I need my penis chopped off?

Not usually but unfortunately sometimes this is still necessary. Today we try and preserve as much of the head (glans) and shaft of the penis as possible. What needs to be done and what needs to be removed depends on how big and how deep the cancer goes.

Here we can see the penis after surgery for early penile cancer. The cancer has been removed and a skin graft placed on the end of the penis.

The penis several weeks later looks almost normal

Here the penis has unfortunately been removed for a much more extensive cancer.

I have cancer in my lymph nodes, am I going to die?

Penile cancer is one of the rare cancers where spread of the cancer to lymph nodes can be cured.

Cancer of the penis spreads in a stepwise fashion, form the penis to the inguinal nodes and then onto the pelvic nodes.

Cure is more likely is there are only a few nodes involved, and if these positive nodes are confined to the inguinal nodes. To look for cancer in the lymph nodes a PET scan maybe used.

This pet scan shows a group of lymph nodes in the left groin (bright yellow area) which have cancer in them.

What are the treatment options for penile cancer?

Treatment of penile cancer can be divided into the treatment of the primary lesion, that is the cancer itself on the penis, and the treatment of the lymph nodes. Lymph nodes are where the cancer might have spread to. The primary treatment involves excising or cutting out the cancer. Depending on how aggressive and how far the cancer has spread the lymph nodes may need to be operated on. Sometimes we take a biopsy from the lymph nodes (called a dynamic sentinel node biopsy) and sometimes the lymph nodes are removed.

An x-ray is first taken mapping the nodes and a mark is placed on the skin over the hottest node on the x-ray. Here we have an xray showing a small area of abnormal uptake in the right groin

The penis is then injected with a tiny dose of blue dye, and a gamma probe used to locate the highest area of radiation. The node is then removed and checked for blue dye and radioactivity. This saves the patient having a complete dissection of their lymph nodes.

Will I need chemotherapy?

No. Chemotherapy is only used if a large lymph node is involved. For most penile cancers surgery is the best and only option. If chemotherapy is used, then a regime called TIP is the most effective.

Should I have radiotherapy afterwards?

No. radiotherapy is not used very often for penile cancer. This may change in the future as SCC in other parts of the body is being treated more and more with a combination of chemotherapy and radiotherapy.

Do I always need surgery?

No. if the lesion is very superficial, then a cream maybe all that is needed. This cream is called Imiquimod. Imiquimod turns on the immune cells in your skin to attack and kill the cancer cells.

What happens afterwards?

After surgery, you will have follow-up in the clinic for the next 5 years. Follow-up may include CT scans and clinical examination. It is extremely rare to have a recurrence of penile cancer after 5 years, and we would assume that if no recurrence has occurred by 5 years then you are cured.

A good discussion on sex after penile cancer:

http://www.cancerresearchuk.org/about-cancer/type/penile-cancer/living/your-sex-life-after-penile-cancer

three good general sites with information for patients on penile cancer: review of penile cancer

http://www.macmillan.org.uk/cancerinformation/cancertypes/penis/penilecancer.aspx

http://www.cancerresearchuk.org/about-cancer/type/penile-cancer/

http://www.cancer.org/cancer/penilecancer/detailedguide/index

medical review of treatment of penile cancer

http://www.esmo.org/Guidelines/Genitourinary-Cancers/Penile-Carcinoma

http://uroweb.org/wp-content/uploads/12-Penile-Cancer_LR1.pdf (very comprehensive review of penile cancer).