Most penile cancers are squamous cell carcinomas; they usually occur in uncircumcised men, particularly those with poor local hygiene. Diagnosis is by biopsy. Treatment includes excision.
Penile cancer is rare, with about 2050 cases and 470 deaths in the United States and higher rates in regions such as South America (1). Human papillomavirus (HPV), particularly types 16 and 18, plays a role in etiology. Other risk factors include balanitis, lack of circumcision, sexually transmitted infections (particularly HIV/AIDS and HPV), poor hygiene, and tobacco use. Premalignant lesions include erythroplasia of Queyrat, squamous cell carcinoma in situ (formerly called Bowen disease), and bowenoid papulosis. Erythroplasia of Queyrat (affecting the glans or inner prepuce) and squamous cell carcinoma in situ (affecting the shaft) progress to invasive squamous cell carcinoma in 5 to 10% of patients; bowenoid papulosis does not appear to do so. The 3 lesions have different clinical manifestations and biologic effects but are virtually the same histologically; they may be more appropriately called intraepithelial neoplasia or carcinoma in situ.
General reference
1. Siegel RL, Miller KD, Wagle NS, et al: Cancer statistics, 2023. CA Cancer J Clin 73(1):17-48, 2023. doi: 10.3322/caac.21763
Symptoms and Signs of Penile Cancer
Most squamous cell carcinomas originate on the glans, in the coronal sulcus, or under the foreskin. They usually begin as a small erythematous lesion and may be confined to the skin for a long time. These carcinomas can grow to become fungating and exophytic or ulcerative and infiltrative. The latter type metastasizes more commonly, usually to the superficial and deep inguinofemoral and pelvic nodes. Metastases to distant sites (eg, lungs, liver, bone, brain) are rare until late in the disease.
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Most patients present with a sore that has not healed, subtle induration of the skin, or sometimes a pus-filled or warty growth. The sore may be shallow or deep with rolled edges. Many patients do not notice the cancer or do not report it promptly. Pain is uncommon. Inguinal nodes may be enlarged due to inflammation and secondary infection.
Diagnosis of Penile Cancer
Treatment of Penile Cancer
Usually surgical
Sometimes topical treatment, laser ablation, or radiation therapy
Untreated infiltrative penile cancer progresses, typically causing death within 2 years. Treated early, penile cancer can usually be cured.
Invasive and high-grade lesions require more radical resection. Partial penectomy is appropriate if the tumor can be completely excised with adequate margins, leaving a penile stump that permits urination and sexual function. Total (radical) penectomy is required for large infiltrative lesions. If tumors are high-grade or invade the corpora, bilateral ilioinguinal lymphadenectomy is required. Lymph node status predicts survival, as patients with nodal metastases have significantly worse prognosis. If there is suspicion for bilateral node-positive disease, bulky unilateral lymphadenopathy, or pelvic lymphadenopathy, then chemotherapy prior to lymphadenectomy is advised. The role of radiation therapy has not been established. For advanced, invasive cancer, palliation may include surgery and radiation therapy, but cure is unlikely. Chemotherapy for advanced cancer has had limited success. Targeted and immunotherapy used for head and neck squamous cell cancers may prove useful for penile cancer patients, but no definitive studies support their use in routine clinical practice.
Prevention of Penile Cancer
Measures that may help in prevention include circumcision in early life, long-term hygiene in uncircumcised men, and recommended human papillomavirus (HPV) vaccination in adolescents.
Key Points
Penile cancer is usually squamous or another skin cancer.
Consider penile cancer with any nonhealing sore, induration, or purulent or warty penile growth, particularly in uncircumcised men.
Diagnose penile cancer by biopsy and treat it typically by excision.
Lymph node status is the driver of survival. Appropriate use of lymphadenectomy in intermediate and high-risk patients is an essential component of managing this disease.
