2 Tumors of the penis less than 1% of cancers among males The one etiologic factor most commonly associated with penile carcinoma is poor hygieneThe disease is virtually unheard of in males circumcised near birth.
3 Tumors of the penisOne theory postulates that smegma accumulation under the phimotic foreskin results in chronic inflammation leading to carcinoma.A viral cause has also been suggested as a result of the association of this tumor with cervical carcinoma.
4 CARCINOMA IN SITU BOWEN DISEASE squamous cell carcinoma in situ typically involving the penile shaft.The lesion appears as a red plaque with encrustationsERYTHROPLASIA OF QUEYRATa velvety, red lesion with ulcerationsinvolve the glansMicroscopic examination shows typical, hyperplastic cells in a disordered array with vacuolated cytoplasm and mitotic figures.
5 INVASIVE CARCINOMA OF THE PENIS Squamous cell carcinomacomposes most penile cancers.most commonly originates on the glansOther common sites: prepuce and shaftThe appearance may be papillary or ulcerative.Verrucous carcinomaa variant of squamous cell carcinoma composing 5–16% of penile carcinomaspapillary in appearancehave a well-demarcated deep margin unlike the infiltrating margin of the typical squamous cell carcinoma on histology
6 TNM Classification of Tumors of the Penis* T—Primary tumorTX: Cannot be assessedT0: No evidence of primary tumorTis: Carcinoma in situTa: Noninvasive verrucous carcinomaT1: Invades subepithelial connective tissueT2: Invades corpus spongiosum or cavernosumT3: Invades urethra or prostateT4: Invades other adjacent structuresN—Regional lymph nodesNX: Cannot be assessedN0: No regional lymph node metastasisN1: Metastasis in single superficial inguinal nodeN2: Metastasis in multiple or bilateral superficial inguinal nodesN3: Metastasis in deep inguinal or pelvic nodesTumor StagingThe staging system used most commonly in the United States was proposed by Jackson (1966), as follows:In stage I, the tumor is confined to the glans or prepuce.Stage II involves the penile shaft.Stage III has operable inguinal node metastasis.In stage IV, the tumor extends beyond the penile shaft, with inoperable inguinal or distant metastases.The TNM classification of the American Joint Committee (1996) is given in Table 23–3.M—Distant metastasisMX: Cannot be assessedM0: No distant metastasisM1: Distant metastasis present*Reference: Smith’s General Urology 17th edition. Pg.384. Table 23–3.
7 Clinical Findings SIGNS SYMPTOMSmay appear as an area of induration or erythema,an ulceration, a small nodule, or an exophytic growthPhimosis may obscure the lesion and result in a delay in seeking medical attentionpain, discharge, irritative voiding symptoms, and bleedingSIGNSLesions are typically confined to the penis at presentationmore than 50% of patients present with enlarged inguinal nodes.
8 Clinical Findings LABORATORY FINDINGS Laboratory evaluation is typically normalAnemia and leukocytosis may be present in patients with long-standing disease or extensive local infection.Hypercalcemia in the absence of osseous metastases appears to correlate with volume of disease.IMAGINGMetastatic workup should include CXR, bone scan, and CT scan of the abdomen and pelvis.
9 Treatment PRIMARY LESION Biopsy of the primary lesion - to establish the diagnosis of malignancyCarcinoma in situtreated conservatively in reliable patientsFluorouracil cream application or neodymium:YAG laser treatment
10 Treatment Invasive penile carcinoma Goal of treatment: complete excision with adequate marginsFor lesions involving the prepuce: simple circumcisionFor lesions involving the glans or distal shaft: partial penectomy with a 2-cm margin to decrease local recurrenceMohs micrographic surgery and local excisions directed at penile preservationFor lesions involving the proximal shaft or when partial penectomy results in a penile stump of insufficient length for sexual function or directing the urinary stream: total penectomy with perineal urethrostomy
11 Treatment: Lymph Nodes Enlarged node commonly due to inflammationShould undergo treatment of the primary lesion followed by a 4- to 6-week course of oral broad-spectrum antibioticssequential bilateral ilioinguinal node dissectionsFor persistent adenopathy following antibiotic treatmentobservation in low-stage primary tumors (Tis, T1)For Resolved lymphadenopathy with antibioticssentinel node biopsy or a modified (limited) dissectionIf lymphadenopathy resolves in higher-stage tumors, more limited lymph node samplings should be consideredbilateral ilioinguinal node dissectionIf positive nodes are encounteredunilateral ilioinguinal node dissectionPatients who initially have clinically negative nodes but in whom clinically palpable nodes later developchemotherapy (cisplatin and 5-fluorouracil)Patients who have inoperable disease and bulky inguinal metastasesRegional radiotherapyFor palliation by delaying ulceration and infectious complications and alleviating pain.
12 Management of Penile Carcinoma *Reference: Smith’s General Urology 17th edition. Pg.386. Figure 23–4
14 Tumors of the Scrotum Tumors of the scrotal skin are rare. The most common benign lesion is a sebaceous cystMost common malignant tumor of the scrotum is Squamous cell carcinomaRare cases: melanoma, basal cell carcinoma, and Kaposi sarcomaEtiology of SCC of the Scrotum: poor hygiene and chronic inflammation
15 Tumors of the Scrotum: Management BiopsyWide excision with a 2-cm margin should be performed for malignant tumorsSurrounding subcutaneous tissue should be excised with the primary tumorPrimary closure using the redundant scrotal skin is usually possible.The management of inguinal nodes should be similar to that of penile cancer.
16 Tumors of the Scrotum: Prognosis Prognosis correlates with the presence or absence of nodal involvement. In the presence of inguinal node metastasis, the 5-year survival rate is approximately 25% There are virtually no survivors if iliac nodes are involved.