Penis


 * **Epidemiolgy:** || Rare in the U.S., one per one hundred thousand each year or less than 1% of male cancers. Circumcision done early in life has been found to protect against penile cancer however if the procedure is done later in life has no effect. This can explain higher incidence in areas of the world where circumcision is not routine. Narrowing of the opening of the prepuce (foreskin) known as phimosis, is common in men that have been diagnosed with cancer of the penis.(3) ||
 * **Etiology:** || Common links to urethral cancer are also links to penile and include chronic inflammation, HPV, and past stricture formation.[1] ||
 * **Signs & Symptoms:** || Some of the signs and symptoms of penile cancer are: [1]
 * HPV infection
 * Lesion
 * Mass
 * Ulceration
 * Irritation
 * Bleeding
 * Pain
 * Discharge ||
 * **Diagnostic Procedures:** || Some of the diagnostic procedures to evaluate staging and extent of cancer (spread) are: [1]
 * Excisional biopsy
 * Physical exam
 * Chest roentgenography
 * CT of abdomen and pelvis
 * Ilioinguinal lymphadenectomy (or needle aspiration) ||
 * **Histology:** || Most penile tumors are well-differentiated squamous cell carcinomas. Other types include transitional cell, adenocarcinoma, and undifferentiated or mixed carcinomas. [2] ||
 * **Lymph node drainage:** || The prostatic urethra has three routes including: external and internal iliac, and presacral nodes. The lymphatic channels of the prepuce and the skin of the shaft drain into the superficial inguinal nodes located above the fascia lata, as well as the deep inguinal nodes. Lymphatic drainage may be considered bilateral. [2] ||
 * **Metastatic spread:** || Nodal metastases are reported in 35% of all patients, and around 50% of those with palpable lymph nodes. Inguinal lymph nodes are the most common site of metastatic spread. [2] ||
 * **Grading:** || There is some controversy as to an accepted grading system for penile tumors. Listed here is a proposed grading system.
 * Grade 1: well-differentiated cells, almost undistinguishable from normal squamous cells except for the presence of minimal basal/parabasal cell atypia.
 * Grade 3: tumors predominantly composed of anaplastic cells.
 * Grade 2: all tumors not fitting into criteria described for grade 1 or 3.

Any proportion of grade 3 was equally associated with a significant risk of nodal metastasis. Any focus of grade 3 should be sufficient to grade the neoplasm as a high-grade tumor.[2] || Staging system by Ray and associates.[2]
 * **Staging:** || General staging.[2] || Stage || Description ||
 * Stage-0 || Carcinoma in situ abnormal cell growth pre-cancerous. ||
 * Stage-1 || Cancer has only affected the glans and/or foreskin. ||
 * Stage-2 || Cancer has spread to the shaft of the penis. ||
 * Stage-3 || Mobile (operable) inguinal lymph nodes ||
 * Stage-4 || Fixed (inoperable) inguinal lymph nodes or distant metastasis. ||
 * Recurrent || Cancer that has returned after treatment. ||
 * Stage || Description ||
 * 0 || Tumor confined to mucosa only ||
 * A || Tumor extension into but not lamina proria ||
 * B || Tumor extension into but not beyond substance of corpus spongiosum or prostate. ||
 * C || Extension into proximal tissues (corpora cavernosa, muscle, fat, skin, fascia) or beyond prostate. ||
 * D1 || Regional metastasis (inguinal and pelvic) lymph. ||
 * D2 || Distance metastasis. ||

AJCC staging (primary tumor)[3]

Radiation therapy: preservation of the phallus, External beam, Iridium 192 mold plesiotherapy, Interstitial implant using iridium 192 wires, Inguinal nodes should be treated as well, Chemoirradiation is often used in advanced-stage lesions A surgical excision is the treatment of choice the distal urethra: penectomy or radiation therapy[5] Brachytherapy: A mold is built in the form of a box or cylinder, sources are placed in the periphery of the device. The Dose typically used is 60-65Gy at the surface, approx. 50Gy at the center of the organ (in 6-7 days). A single or double-plane implants can be used as well 60-70Gy in 5-7 days[5]
 * Stage || Description ||
 * TX || Primary tumor cannot be assed. ||
 * T0 || No evidence of tumor. ||
 * Tis || Carcinoma in situ. ||
 * Ta || Non-invasive carcinoma. ||
 * T1 || Tumor invades subepithelial connective tissue. ||
 * T2 || Tumor invades corpus spongiosum or cavernosum. ||
 * T3 || Tumor invades urethra or prostate. ||
 * T4 || Tumor invades other adjacent structures. ||  ||
 * **Radiation side effects:** || Side effects
 * Erythema
 * Dry or moist desquamation,
 * Swelling of the subcutaneous tissue.
 * Telangiectasia and fibrosis are asymptomatic and are late consequences of radiation.
 * Ulcerations, necrosis of the glands and skin. (rare in occurrence)[3]
 * Lymphedema, if inguinal nodes are treated.[3] ||
 * **Prognosis:** || I f penile cancer has been diagnosed and treated early then the 5 year survival rate is 65%, so it is important to seek medical attention quickyl[5]. Elderly men are the most likely to suffer from this form of cancer[5]. ||
 * **Treatments:** || Local excision, chemosurgery, partial or total penectomy[5]. Lesions of the prepuce: wide circumcision, Lesions on the glans penis: partial penectomy [5]

|| Rectum (severe proctitis,necrosis,fistula,stenosis) 6000 – – 8000 – – Femoral head 5200 – – 6500 – – Spinal cord (20 cm) 4700 (10 cm) 5000 (5 cm) 5000 – (10 cm) 7000 (5 cm) 7000 Small intestine (obstruction,perforation) 4000 – 5000 5500 – 6000 Stomach (ulceration,perforation) 5000 5500 6000 6500 6700 7000 Colon (obstruction,perforation,ulceration) 4500 – 5500 5500 – 6500 || 2. Chao KS, Perez CA, Brady LW. Radiation Oncology: Management Decisions. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 3. Washington CM, Leaver D. //Principles and Practice of Radiation Therapy //.2nd ed. Mosby; 2010 4.Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys. 1991. 5. Kennard, J. Penis Cancer. About.com. February 15, 2006. Available at: []. Accessed on: June 12, 2012. ||
 * **TD 5/5:** || TD 5/5[4]:
 * **References:** || 1. Lenhard RE, Osteen R, Gansler T. The American Cancer Society’s Clinical Oncology. Williston, VT: Blackwell Publishing, Inc; 2001.

Back to Week 4