indiacancer.org - Penile Cancer

Penile Cancer

		What is the Penis?
		What is Cancer of the Penis?
		How does Penile Cancer present?
		How is Penile Cancer detected?
		What is staging and grading?
		How is Penile Cancer treated?
		What are the side effects of Penile Cancer treatment?
		What is the importance of follow up?

What is the Penis?

The penis is the male organ of reproduction, which is made of skin, muscle and a large number of blood vessels. It has an extensive supply of nerves and is therefore extremely sensitive.

The foreskin or the prepuce of the penis is the skin covering the tip of the penis.

Circumcision is a surgery in which part or all of the foreskin is excised. This is done as a practice in certain religions such as Jews and Muslims.

Side view of a cut section through the Penis & the Testicles with the Prostate and Urinary Bladder on top

	What is cancer of the Penis?

The cancer arises from the skin and the tissues of the penis. Usually, this is a squamous carcinoma, which is made up of flat, scale like cells called squamous cells.

Men who have not been circumcised are at a greater risk of getting cancer of the penis.

How does Penile Cancer present?

	The usual way penile cancer presents (otherwise known as symptoms of penile cancer) is as follows:
		A growth or sore on the penis.
		An abnormal fluid discharge from the opening at the tip of the penis (the meatus).
	The doctor on examination may find a lump or irregularity in the penile shaft. He may also find enlarged lymph nodes in the groin region (the skin crease area at the top of each thigh in the front). Lymph nodes are small bean-shaped organs located in groups in various parts of the body, such as in the neck, the armpits, the groin and inside the abdomen, and the central part of the chest. They act as drainage stations for lymph, a clear transparent fluid which acts as a transporting medium for infection fighting cells as well as cancer cells.

	How is Penile Cancer detected?


	There are several steps to establish in the presence of a penile cancer:
		The doctor takes a history of the patient's symptoms.
		The doctor examines the patient physically, and looks for swellings in the groin.
		If a lesion is present, a biopsy is performed, in which a small piece of the offending area is taken out and is sent for histopathological diagnosis, in which the pathologist visualizes the tissue section under the microscope and tells you conclusively whether it is a cancer or not.

	What is staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome.

Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, IVU, Bone scan or chest X-ray.

Stage 1. Cancer cells only on the surface of the glans penis (the head of the penis) and on the prepuce.

Stage 2. Deeper invasion of the cancer into the penile shaft (spongy tissue inside the penis, arranged in cylinders, which can fill up with blood to produce erections).

Stage 3. Besides the penis, there is spread to the nearby lymph nodes.

Stage 4. Cancer cells found permeating throughout the penis and the lymph nodes of the region, and there may be spread to distant parts of the body.

Recurrent penile cancer. That disease which has come back, either in the same locus or in a different one after primary treatment has been completed.

	How is Penile Cancer treated?

	A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an urologist, an oncosurgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add on. Treatment strategies. The bastion of penile cancer treatment is surgery. Various surgical procedures maybe employed:
		Just the cancer, along with a margin of healthy tissue is taken out. (Wide local excision).
		Microsurgery. Just the cancer, along with a minimal margin of healthy tissue is taken out The margins are checked during the procedure under a microscope for adequacy.
		Removal or amputation of part or the whole of the penis is known as partial or total penectomy. This is still the commonest surgery performed for cancer of the penis.
		During the primary procedure, lymph nodes in the groin may also be removed. This is known as groin node dissection.
		Laser (Light Amplification by Stimulated Emission of Radiation) is a state of the art technique in which a very intense, thin beam of light is used to vaporize the offending tissues. The advantage of laser is that it causes very little post operative scarring and is very exact, not damaging surrounding tissues.
	The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the penis is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. Penile cancer treatment also employs another form of treatment called biological therapy. Biological therapy employs Biological Response Modifiers (BRM's), which are substances that use the body's own immune system, either directly or indirectly, to fight cancer or to lessen the side effects of the anti cancer drugs. Some examples of BRM's are interferon-alfa and interleukin-2. For stage I carcinoma of the penis, one of the following options may be entertained: If cancer is just on the prepuce:
		Circumcision.
		Wide local excision.
	If cancer is on the glans penis.
		5 fluorouracil cream (local / topical chemotherapy).
		Microsurgery.
	If the tumor, originating from the glans, has started to invade adjacent parts of the penis:
		Partial penectomy with or without groin node dissection (GND).
		Teletherapy.
		Microsurgery.
		Laser.
	For stage II carcinoma of the penis, one of the following options may be entertained:
		Partial penectomy.
		Total penectomy.
		Radical penectomy (en bloc` removal of the penis with surrounding lymph nodes and relevant tissues)
		Radiation followed by some form of penectomy.
		Laser (still experimental for this stage).
	For stage III carcinoma of the penis, one of the following options may be entertained:
		Partial or total penectomy, with one sided (unilateral) or both sided (bilateral) GND.
		Some form of penectomy followed by irradiation.
		Chemotherapy with or without irradiation.
	For recurrent carcinoma of the penis, one of the following options may be entertained:
		Partial or total penectomy.
		Radiation.
		Chemotherapy.
		Biological therapy.

	What are the side effects of Penile Cancer treatment?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. Surgery in the form of amputation can cause extreme depression in many men, as they feel they have the chief symbol of their 'manhood'. During rehabilitation, it is important for both clinicians and relatives to realize that physical recovery always outpaces emotional recovery and just the removal of the final stitch does not signify the end of the recovery phase. A significant part of the recovery process is for the relatives to be as positive as possible and to get the patient off his emotional crutches as early as possible. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

	What is the importance of follow up?

The importance of follow-up cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.