Cancer of the Penis

A 38-year-old man presented with a fleshy lesion beneath the tip of his penis. He had discovered it about 18 months before the initial evaluation. A second similar lesion resembling a “cauliflower” had appeared several weeks after the first. Both lesions had grown and had begun to bleed during intercourse. The patient had been circumcised in infancy and underwent a meatotomy for correction of hypospadias. He denied any history of sexually transmitted diseases. The lesions measured 2.8 and 0.8 cm and had a verrucous appearance. No bleeding, excoriation, or lymphadenopathy (A and B) were noted. The remainder of the physical examination was unremarkable. The patient was referred to a urologist. A biopsy of a penile lesion confirmed the diagnosis of carcinoma of the squamous cell type. Fewer than 1% of malignancies that affect men in the western hemisphere are penile cancers¹; the vast majority of those that do occur (over 95%) are squamous cell carcinomas.² Their cause remains unclear; some investigators suggest an association with the human papillomavirus (HPV) type 16.³ Two recent studies found that late circumcision, multiple sex partners, a history of HPV infection, and smoking are epidemiologic risk factors.^3,4 Squamous cell carcinoma of the penis usually appears as a fleshy growth with an area of erythema. In another patient, a squamous cell carcinoma of the penis manifested as a verrucoid red plaque on the proximal shaft (C). As the lesion enlarges, an itching or burning sensation can evolve into pain, and a nodule or mass that often becomes verrucous may develop along with a foulsmelling discharge. With neoplastic extension, bleeding, fistulization, and lymphagenous dissemination can occur. Enlarged inguinal lymph nodes may be a clue to the diagnosis. Ultrasonography or MRI can help delineate the degree of disease infiltration. CT scans of the abdomen and pelvis can help detect pelvic lymphatic involvement. A chest film and a bone scan may be required to determine the extent of malignancy.⁵ The Table outlines the staging of penile carcinoma, which can influence treatment choice. The staging system is not correlated with prognosis; the single best prognostic indicator of survival is the degree of lymph node involvement.^6,7 Local excision and circumcision are appropriate for patients with lesions smaller than 2 cm, which are usually less invasive. About 90% of such patients remain alive at 5 years. Penectomy and urethrostomy are performed on those whose lesion is at least 2 cm and who have no nodal involvement. The 5-year survival for these patients is between 80% and 90%. Radiation therapy and chemotherapy have limited success in patients with advanced disease. Chemotherapeutic agents include cisplatin(, bleomycin(, methotrexate(, vincristine, and 5-fluorouracil. Despite treatment, fewer than 50% of patients with involved lymph nodes survive for 5 years.⁸ This patient underwent a radical penectomy immediately after the disease was confirmed. Postoperative care and emotional support and guidance were given. The patient died 6 weeks after surgery. (Case and photographs A and B courtesy of Dr Steven N. Glavas; photograph C courtesy of Dr Reynold C. Wong.)