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Far Eastern University Institute of Nursing

Penile Cancer

Submitted by: Paul Allan P. Cenabre

Submitted to: Prof. Bugna RM,RN

CANCER OF THE PENIS Penile cancer occurs in men older than age 60 and represents about 0.5% of malignancies in men in the United States (Stadler, Vogelzang, Elwell & Jones, 2000). In some countries, however, the incidence is 10% to 12%. Since most penile cancers occur in uncircumcised men, it has been suggested that the etiology of this cancer may be the irritative effect of smegma and poor hygiene. However, the protective effect of circumcision is seen only in males who are circumcised in the neonatal period; circumcision that occurs at puberty or after does not confer the same benefit (Herr et al., 2001). Can cer of the penis appears on the skin of the penis as a painless, wartlike growth or ulcer. Cancer of the penis can involve the glans, the coronal sulcus under the prepuce, the corporal bodies, the urethra, and regional or distant lymph nodes. Bowen s disease is a form of squamous cell carcinoma in situ of the penile shaft. Typically, a man delays seeking treatment for more than a year, probably because of guilt, embarrassment, or ignorance.

Cause is unclear Risk Factors : 1. preexisting dermatoses 2. lack of circumcision 3. environmental exposures 4. human papillomavirus (HPV) - play a major role Different types of cancer can develop in the penis. Epidermoid carcinoma - if the cancer develops in the skin of the penis. Verrucous carcinoma - this can occur on the female and male genitals, skin, mouth, larynx and anus. It looks a lot like a benign genital wart. This low -grade cancer can spread deeply into surrounding tissue, but they rarely spread to other parts of the body.

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Adenocarcinoma - rare type of penile cancer can develop from the sweat glands in the skin of the penis. Melanomas - about 2% of penile cancers develop from pigment -producing skin cells called melanocytes. This cancer is more dangerous because they grow and spread more rapidly. Basal cell penile cancer - these are slow-growing tumors that rarely spread to other parts of the body.

Sarcomas - cancers that develop from the blood vessels, smooth muscle, and other connective tissue cells of the penis.

PATHOPHYSIOLOGY Penile cancers usually begin as small lesions on the glans or prepuce. They range from
white-grey, irregular exophytic to reddish flat and ulcerated endophytic masses. They gradually grow laterally along the surface and can cover the entire glans and prepuce before invading the corpora and shaft of the penis. The more extensive the lesion, the greater the possibility of local invasion and nodal metastasis. Penile cancers may be papillary and exophytic or flat and ulcerative. Untreated, penile autoamputation can occur. The growth rates of the papillary and ulcerative lesions are similar, but the flat ulcerative lesions tend to metastasize to the lymph nodes earlier and are therefore associated with a lower 5-year survival rate. Cancers larger than 5 cm and those involving more than 75% of the shaft are associated with a high prevalence of nodal metastases and a lower survival rate, but a consistent relationship among the size of the cancer, the presence of inguinal node metastases, and survival has not been identified. The Buck fascia, which surrounds the corpora, acts as a temporary barrier. Eventually, the cancer penetrates the Buck fascia and the tunica albuginea, where the cancer has access to the vasculature and from which systemic spread is possible. Metastasis to the femoral and inguinal lymph nodes is the earliest path for tumor dissemination. The lymphatics of the prepuce join with those from the shaft. These drain into the superficial inguinal nodes. Because of lymphatic crossover, cancer cells have access to lymph nodes in both inguinal areas. The lymphatics of the glans follow a different path and join those draining the corpora. A circular band of lymphatics that drains to the superficial nodes is located at the base of the penis and can extend to both the superficial and deep pelvic lymph nodes. The superficial inguinal nodes drain to the deep inguinal nodes, which are beneath the fascia lata. From here, drainage is to the pelvic nodes. Multiple cross connections exist at all levels, permitting bilateral penile lymphatic drainage. Untreated metastatic enlargement of the regional nodes leads to skin necrosis, chronic infection, and, eventually, death from sepsis or hemorrhage secondary to erosion into the femoral vessels. Clinically apparent distant metastases to the lung, liver, bone, or brain are

unusual until late in the disease course, often after the primary disease has been treated. Distant metastases are usually associated with regional node involvement. Microscopically, the tumors vary from well-differentiated keratinizing tumors to solid anaplastic carcinomas with scant keratinization. Most tumors are highly keratinized and are of moderate differentiation. Poorly differentiated carcinomas have variable amounts of spindle cell, giant cell, solid, acantholytic, clear cell, small cell, warty, basaloid, or glandular components. Penile carcinoma follows a relentless and progressive course that proves to be fatal in most untreated patients within 2 years. The typical SCC has a recurrence rate of 28% and lymph node metastases are found in 28-39% depending upon the extent and grade of the tumor. The mortality rate is 20-38% with a 10-year survival rate of 78%. Spontaneous remission has not been reported.

Who is at risk: Nearly 2/3 of cases are diagnosed in men older than 65. Researchers believe that infection with the human papillomavirus (HPV) can contribute to the risk of penile cancer. Another risk factor is if the penis is not properly cleaned especially for those men who are not circumcised. Oily secretion from the skin, dead skin cells and bacteria accumulate under the foreskin. The result is a thick, sometimes odorous substance called smegma. Some studies suggest that smegma may contain cancer-causing substances, but recent studies disagree. In parts of Africa and South America, penile cancer accounts for up to 10% of male cancers. Chance of Survival: Data is limited, but the five-year survival rate for all patients diagnosed with this cancer from 1995 to 2000 is 7 5%. The more localized the cancer, the better your odds. Symptoms -A painless ulcer or growth -A reddish, velvety rash, small crusty bumps, or flat, bluish-brown growths; -Persistent, foul discharge beneath the foreskin. -A wart-like growth or lesion -An open sore that won't heal -A reddish rash -Persistent, smelly discharge under the foreskin

DIAGNOSTIC EXAM Biopsy. A biopsy removes a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a diagnosis for certain. Fine needle aspiration . A local anesthetic may be injected into the skin near the nodule prior to the biopsy. The doctor will insert a thinneedle into the nodule and extract (take out) cells and some fluid.The procedure may be repeated two or three times to obtain samplesfrom different areas of the nodule. The report, done by a pathologist,can be positive (for malignant cells), negative, or undetermined. Sentinel lymph node biopsy . It is important to know if cancer cells have spread to other areas. In this technique, the doctor removes oneor a few sentinel lymph nodes, the first node(s) into which the lymphsystem drains, to check for cancer cells. In the case of penile cancer,the sentinel lymph nodes are located just under the skin in the groin.If cancer cells are detected, it means that the disease may havespread to other lymph nodes in the region or beyond through theblood and lymph vessels. X-ray. A picture is taken of areas inside the body to help the doctor identify the presence of a tumor. An x-ray is usually used to examine the lungs for evidence of metastases. This is known as a chest x-ray. Computerized tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-raymachine. A computer then combines these images into a detailed,cross-sectional view that shows abnormalities or tumors. Magnetic resonance imaging (MRI ). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body Medical Management Smaller lesions involving only the skin may be controlled by excision (Herr et al., 2001). Topical chemotherapy with 5 -fluorouracil cream is an option in selected patients. Radiation therapy is used to treat small squamous cell carcinomas of the penis or for palliation in advanced tumors or lymph node metastasis. Partial penectomy (removal of the penis) is preferred to total penectomy if possible; about 40% of patients can then participate in sexual intercourse and stand for urination. The shaft of the penis can still respond to sexual arousal with an erection and has the sensory capacity for orgasm and ejaculation. Total penectomy is indicated when the tumor is not amenable to conservative treatment. After a total penectomy, the

patient may still experience orgasm with stimulation of the perineum and scrotal area. Chemotherapy Chemotherapy (using drugs to kill the cancer cells). It can be onedrug or several drugs used together. It is not commonly used to treatcancer of the penis. Chemotherapy cream may sometimes be used totreat very small, early cancers that are confined to the foreskin andend of the penis (glands). Chemotherapy may also be given astablets or by injection into a vein for more advanced cancer. It may begiven along with surgery or radiotherapy (or both). This treatment isstill experimental and is given as part of research trials (clinical trials).The side effects of chemotherapy are hair loss, nausea, vomiting,diarrhea, lowered blood counts, and an increased risk of infection.

Prevention Circumcision in infancy almost eliminates the possibility of penile cancer because chronic irritation and inflammation of the glans penis predispose to penile tumors (Herr et al., 2001; Pettaway & Dinney, 2001; Schoen et al., 2000). In uncircumcised men, personal hygiene is an important preventive measure.

REFERENCES : -on-Penile-Cancer