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Penile cancer

Penile cancer
Penile cancer is the cancer that starts when cells in the penis start to grow out of control. Uncontrollable growth of cells will lead to development of a mass called tumor. Tumor can either be benign (enclosed in one area and cannot spread) or malignant (can spread to other parts). Malignant tumor is also called cancer.

About penis
Penis is a part of male reproductive and excretory systems. It is made of three main parts, root, shaft and head.
• Root. Root is the part of the penis that is contained within the pelvis.
• Shaft. It is the main part of the penis. It is made of three chambers of spongy tissues that contain smooth muscles, blood vessels and nerve tissues. Two of these chambers are called corpora cavernosa covers on either side of the upper part of the penis. The other chamber is called corpus spongiosum covers the lower part.
• Head. This is the part of the penis is also called glans. This is part of the penis which is covered by foreskin before circumcision. It is has thin skin containing nerves for sexual stimulation. Head of the penis contains the opening of the urethra (urethral meatus).
As part of male reproductive system, during an erection, nerves signal the blood vessels inside the erectile tissue of the penis to fill with blood. When the blood flow increases, the spongy tissue expands and causes the penis to stiffen and enlarge. This allows the penis to be inserted into the vagina during sexual intercourse. Semen passes into the urethra and out the tip of the penis when a man ejaculates. After ejaculation, blood will flows back into the body making the penis to be soft again.
As part of excretory system, during urination, urine leaves bladder through a tube called urethra which is inside penis and urine will leave the body through an opening called urethral meatus which is in the head of penis.

Types of penile cancer
Knowing types of these cancers helps to know how serious your cancer is and it helps doctors in knowing what treatment type will give better outcome. Types of penile cancer include the following;
• Squamous cell carcinoma. This is type of cancer that starts from flat, scale-like cells called squamous cells. Squamous cell carcinoma can start at any part of the penis but in most cases it originates either in or on the fore skin.
• Basal cell carcinoma. This originate from basal cells located below (under) the squamous cells of the skin. This type of cancer grows slowly and rarely spread to other parts. It’s a type of non-melanoma skin cancer.
• Melanoma. Melanoma of penis start from cells responsible for production of melanin pigments. These cells are called melanocytes. This is a serious type of cancer.
• Adenocarcinoma. Adenocarcinoma is a rare type of cancer to start from penis. It is also called Paget’s disease of penis. It originates from sweat glands of the skin.
• Sarcomas. These starts from supportive and connective tissues in the penis such as blood vessel and smooth muscles.

Risk factors of penile cancer
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. Risk factors of penile cancer include the following;
• Human papilloma virus. There are different types (strains) of this virus. Those different strains influence development of different types of cancers including penile cancer. Human papilloma virus (HPV) is normally passed from one person to another through sex.
• Smegma. This occur to those who are uncircumcised. Smegma is a substance that builds up under the foreskin of the uncircumcised. Smegma results from dead skin cells, bacteria oil from skin. If left uncleaned smegma may increase your chance of developing penile cancer.
• Phimosis. Phimosis is a condition whereby the foreskin of the penis becomes tight and difficult to retract. This condition will cause cleaning under the foreskin to the uncircumcised to be difficult hence this will increase chance of developing penile cancer as smegma will accumulate under the fore skin and influence development of cancer.
• Smoking. Men who smoke are more likely to develop penile cancer than those who don`t smoke. Men who smoke and they have been infected with HPV have even higher risk of developing the disease.
• Age. Penile cancer is common to men older than 45 years. So the risk of developing the disease increase as age increases.
• Some skin treatment. Treatment of psoriasis which is the skin disease by using drugs followed by exposing the patient to the ultraviolet light increase your chance of developing penile cancer.
• HIV infection. Being HIV positive will lead to the acquired immune deficiency syndrome (AIDS) which increase your chance of developing penile cancer. Your risk increases as your body immunity is low hence your body will not be able to fight even benign conditions of the disease.

Prevention of penile cancer
In order to prevent something you need first to know what causes it. Since there is no known cause of penile cancer, the only way to prevent the disease is through reducing exposure to the known risk factors. This include taking the following measures;
• Lifestyle. Since you already know the risk factors of the disease, then living a healthy life style will reduce the risk of developing penile cancer. This include through avoiding smoking and reducing unsafe sexual practices that could put you at risk of HPV infection.
• Circumcision. Circumcision will reduce your risk of developing penile cancer. Circumcision will reduce the risk of developing penile cancer through smegma and phimosis.
• Personal hygiene. The uncircumcised will reduce the risk of developing the disease through careful regular cleaning under the foreskin. This will help to remove any smegma that would build up.

Early detection and screening
Early detection of cancer is very crucial as it improve prognosis (treatment outcome) of the disease. Early detection of some cancer cases has been greatly contributed by the process called screening.
Screening is the process of running some tests to someone with no signs and symptoms of a certain disease with the intention of testing for presence or absence of that disease. Unfortunately, there are no widely recommended screening tests for penile cancers.
Although there are no recommended screening tests for penile cancers, most cases of penile cancer are detected while they are still at an early stage. This is because, most cases of penile cancer start from the skin of the penis, so it is easy for men to notice that there is something abnormal that has developed to their penis and report for medical checkup. But this is not always the case as some men do not go to hospital as soon as they notice any abnormal change to their penis which may lead to disease to develop to more advanced stage. For those cases that start under the foreskin, it may take time for some men who don`t do regular cleanliness under the foreskin.

Signs and symptoms of penile cancer
Men with penile cancer may experience some of the following signs and symptoms. Sometimes those signs and symptoms may be caused by other medical conditions other than penile cancer, so the only way you can find out is through seeing your doctor for more checkup as soon as you start seeing (experiencing) any abnormalities to your penis (body).
• Thickening of skin of the penis
• Ulcers (sores) at any part of penis. Normally under the foreskin or on glans.
• A lump on the penis
• Smelly discharge under the foreskin.
• Swollen lymph nodes in groin region
• Swelling at the end of the penis
• Blood coming from tip of the penis or under the foreskin

Diagnosis of penile cancer
cancer diagnosis
Medical diagnosis simply means identification of nature of an illness by elimination of the symptoms. Normally people don`t go to hospital knowing they have cancer but during diagnostic procedures is when doctors detect the disease.
Following suspicion of the disease, doctors normally run combination of tests to determine whether there are cancerous cells in the body or not and if there are cancer cells, how far have they spread. Along with thorough medical history and physical examination, doctors normally use combination of the following tests to diagnose cancer.

Laboratory tests
Laboratory tests are important in ruling out other conditions and confirming diagnosis. For cancer diagnosis laboratory tests normally include blood tests, urine tests, tumor markers and other body fluids tests.
• Blood tests. Blood tests help to reveal level of different substances in the blood which will help doctors to know if there is anything wrong in the body. From blood tests doctors can see complete blood count which indicates number, size and maturity of blood cells. Also from the blood tests doctors can analyze if kidney and liver are working properly.
• Urine tests. Urine tests (urinalysis) involve laboratory examination of urine to check presence of blood, proteins, and other substances such as drugs. For instance blood in the urine may be an indication of benign condition, infection or other health problem.
• Tumor markers. These are biomarkers (proteins) that can be produced by both cancer cells and normal body cells in response to cancer. Tumor markers are released into the blood or urine. Although studies are still conducted to determine role of these markers in diagnosing cancer because sometimes people with benign condition will have elevated level of these proteins. Also not all tumors have their markers and some markers are not specific to one type of tumor.
• Other body fluids. Despite being rarely used, sometimes body fluids can be tested in the lab during diagnosis of cancer. For instance the use of cerebral spinal fluid (CSF) and pleural fluid. CSF is used in diagnosis of brain tumors while pleural fluid for lung cancer.

Diagnostic imaging
Diagnostic imagings involve tests that create pictures of inside the body that help the doctor to see if there is tumor or not. There are several imaging tests used in cancer diagnosis depending on the type and location of cancer suspected. These imaging tests include;
• Computed tomography (CT) scan. CT scan machine is a donut-shaped scanner that uses x-rays to create series of pictures of body organs from different angles. This machine is linked to a computer where those series of pictures taken will be combined to create a 3D- image of inside the body. During the scanning process patient will lie still on the table which will slide into the scanner. In order to get a clear image, sometimes the doctor will inject the patient with a contrast material before scanning. From the images the doctor will be able to differentiate between healthy and unhealthy tissues.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses powerful magnet and radio waves to take series of pictures of body organs and create a 3D image in a computer linked to a machine. Just like in CT, during MRI procedure the patient will lie on a table that will slide into a long round chamber. Also during this procedure the doctor may inject the patient with a contrast material for clear image view.
• X-ray. This is an imaging technique that is uses low dose of radiation to create pictures of inside your body. Technician will position the patient and direct the x-ray beam to the intended part of the body.
• Ultrasound. Ultrasound is a diagnostic imaging procedure that uses high energy sound waves to produce images of organs inside the body. During the examination, a patient will lie on the table while the technician will slowly move a device called transducer on the skin over the part of the body that is being examined.
• PET scan. Positron emission tomography (PET) scan is an imaging test that uses radioactive glucose to create 3-D images of areas inside the body. Radioactive glucose is used for this test because cancer cells tend to absorb more glucose than normal body cells, so the scan will show which areas of the body has more glucose than others. Before the scan, doctor will inject the patient with tracer called radioactive glucose then during imaging the patient will be asked to lie on the table that will be moving back and forth through the scanner.
• Bone scan. Bone scan is used to examine bones. When it comes to cancer, bone scan is used for diagnosis of bone cancer or cancer that has metastasized into the bones. Before the test, patient will be injected with small amount of radioactive material that tends to collect more on abnormal parts of the bones. Then pictures that will be taken by a scan will indicate the distribution of those radioactive materials in the bones throughout the body.

Biopsy
Biopsy is a diagnostic procedure that involves removing a tissue sample from the body and examines it under microscope in the laboratory. Examination in the laboratory is normally done by a pathologist who will check if the cells in the tissue are cancerous or not. In most cancer cases, biopsy is considered to be the confirmatory test. Depending on the location and type of cancer, biopsy can be obtained in different ways. Some of them include;
• Using needle. By using a thin needle, doctors can draw same tissue or fluid for examination under microscope. This method can be used to draw some fluid (spinal tap), bone marrow (bone marrow aspiration), blood or small amount of tumor from the suspected organ such as liver and breast (fine needle aspiration).
• Surgery. Abnormal tissue samples are obtained while the doctor is performing the surgery. Tissues are then sent to the lab for examination during the surgery. If the surgeon removes just a portion of abnormal area, it is called incisional biopsy while when the entire tumor (abnormal site) is removed it is called excisional biopsy.
• Using endoscope. Endoscope is a thin, lighted tube with a camera (focusing telescope) at the end. It is used for viewing inside the body through natural openings like mouth and anus. During an examination if the doctor sees any abnormal tissue, then endoscope can also be used to take sample for that tissue. There are different kinds of endoscopy exams depending on the site of the body being examined. Some of the exams include colonoscopy (for rectum and colon), bronchoscopy (for trachea, bronchi and lungs) and esophagogastroduodenoscopy EGD (for esophagus, stomach and duodenum)
In addition to physical examination, diagnosis of penile cancer normally involves the use of biopsy, CT Scan, MRI Scan, and lymph node examination. Lymph nodes around the groin region will be examined to check if tumor has spread to the lymph nodes. Lymph node examination may be done through;
• Removing a sample of lymph nodes. During this operation the surgeon removes a sample of lymph nodes from one or both groins. They remove the nodes through a small cut in each groin. • Sentinel lymph node biopsy (SLNB). SLNB checks the smallest possible number of lymph nodes in the groin to see if they contain cancer cells. The sentinel node is the first node that lymph fluid from the penis drains to. This means it is the node most likely to contain any cancer cells.

Staging of penile cancer
Staging is a standard way used by cancer care team to explain how far the cancer has grown or spread. Staging also enables the oncology team to decide on the suitable treatment option. In this process of staging doctors normally use systems in order to describe the stage of cancer. For penile cancer, doctors prefer to use TNM staging system (tumor, node and metastasis) to describe stage of the disease.
TNM staging system
TNM system is the combination of three worlds, tumor, node and metastasis.
• Tumor. Tumor explains size (how large is the tumor?) and its location.
• Node. This explain lymph nodes involved
• Metastasis. Metastasis explains how far the cancer has spread
There are five stages of penile cancer under this system (0–IV). More discerption on this TNM system is as follows;
Tumor (T)
TX. Primary tumor cannot be evaluated
T0. There is no evidence of primary tumor.
Tis. Carcinoma in situ. This is non-invasive precancerous growth.
Ta. There is noninvasive verrucous (wart like) carcinoma.
T1. Tumor has invaded subepithelial connective tissues.
• T1a. tumor has not invaded blood or lymph vessels
• T1b. tumor has invaded lymph or blood vessels
T2. Tumor has grown into one of the chambers of the penis
T3. Tumor has invaded urethra.
T4. Tumor has invaded prostate or adjacent structures.
Node (N)
NX. Reginal lymph node involvement cannot be evaluated
N0. No evidence of reginal lymph node involvement.
N1. Tumor has spread to one inguinal lymph node.
N2. Tumor has spread to more than one inguinal lymph nodes
N3. Tumor has spread to the lymph nodes in the pelvis and tumor may have further spread
from these lymph nodes to the surrounding structures.
Metastasis (M)
MX. Distant metastasis cannot be evaluated.
M0. No evidence of distant metastasis.
M1. Tumor has spread to other parts of the body.
Stage grouping of penile cancer • Stage 0 (Tis or Ta; N0, M0): The tumor is noninvasive (found only on the top layer of skin). There is no evidence of lymph node involvement or distant metastasis.
• Stage I (T1a, N0, M0): Tumor has invaded subepithelial connective tissue (just below the skin) but has not invaded any blood or lymph node vessels. These is no evidence of lymph node involvement or distant metastasis.
• Stage II (T1b – T3, N0, M0): Tumor is invasive that may have invaded blood or lymph vessels, tumor may have grown into chambers of the penis also it may have invaded urethra. There is no evidence of lymph node involvement or distant metastasis.
• Stage IIIa (T1 – T3, N1, M0): Tumor has invaded subepithelial tissues (tissues below the skin surface). Tumor may or may not have invaded blood or lymph vessels, chambers of the penis or urethra. Tumor has spread to one inguinal lymph node but there is no distant metastasis.
• Stage IIIb (T1 – T3, N2, M0): Tumor has invaded subepithelial tissues (tissues below the skin surface). Tumor may or may not have invaded blood or lymph vessels, chambers of the penis or urethra. Tumor has spread to more than one inguinal lymph nodes but there is no distant metastasis.
• Stage IV (T4, any N, M0 or Any T, N3, M0 or Any T, any N, M1).
• T4, any N, M0: Tumor has invaded prostate or adjacent structures. Tumor may or may not have spread to groin or any lymph nodes but there is no distant metastasis.
• Any T, N3, M0: Tumor may/may not be invasive that may/may not have invaded blood or lymph vessels, chambers of the penis, urethra, prostate or adjacent organ (any T). Tumor has spread to the lymph nodes in the pelvis and tumor may have further spread from these lymph nodes to the surrounding structures. There is no distant metastasis.
• Any T, any N, M1: Tumor can be of any T and any N but there should be distant metastasis.

Treatment of penile cancer
Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps. After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.
Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.
In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials.
If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time
Treatment options of penile cancer In cancer care, different types of doctors and other health care professionals often work together to create patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For penile cancer treatment, multidisciplinary team may include surgeon, medical oncologist, radiation oncologist, urologist, oncology nurses, dietitian, social workers and palliative care team. Depending on the stage of the disease, treatment options for penile cancer include the following;
Surgery
Surgery is the treatment option of cancer that involve removing the tumor through an operation. This procedure is carried out by a specialized doctor known as surgeon. Depending on stage of the disease and patient`s choice, surgery for penile cancer can be done in the following ways;
• Simple excision. In this option, the surgeon removes the affected part of the penis and the surrounding healthy tissues.
• Mohs surgery. This is microscopically controlled surgery. During surgery the surgeon will remove the tumor and small piece of heathy tissues at the edge of the tumor. These small pieces of tissues will be viewed under microscope to check if they are cancer free or not. Surgery to remove surrounding tissues will continue until surgeon reach cancer free tissues. This is for tumors on the skin surfaces of the penis.
• Circumcision. This is an option used when tumor is only on the foreskin of the penis whereby the surgeon will remove the foreskin.
• Penectomy. This is an option that involve removing part or all of the penis. This option is used when tumor has grown deep into the penis. If tumor is located at the head of the penis, then the surgeon will perform partial penectomy which will leave some part of the shaft to enable urination process. But if tumor has spread to the large part of the shaft, then total penectomy will be performed. During total penectomy, the surgeon will remove all of the penis and create a new opening for urination between scrotum and anus. This is called perineal urethrostomy, which will require urination to be performed in sitting position.
• Lymphadenectomy. This is a surgery that involve removing the lymph nodes. This will involve removing groin lymph nodes and/or pelvic lymph nodes.

Side effects of surgery
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Side effects of surgery for penile cancer will generally depend on the type of surgery performed and extent of surgery. Some of the common side effects of surgery include the following;
• Reaction from anesthesia.
• Risk of infection as a result of lymphadenectomy
• Swelling of legs as a result of lymphadenectomy
• Bleeding
• Pain.

Chemotherapy
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Chemotherapy is the drugs (ant cancer drugs) to destroy or kill cancer cells. Chemotherapy is given by a specialized doctor known as medical oncologist. For penile cancer, there are two types of chemotherapy;
• Topical chemotherapy
• Systemic chemotherapy

Topical chemotherapy
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Topical chemotherapy is the type of chemotherapy used for those tumors on the skin and not those that are deep inside the penis. In this option, ant-cancer drug is applied directly on the skin and not as pill or injection. The most preferred drug for these cases is 5-fluorouracil (5-FU) which is applied daily as cream.
Systemic chemotherapy
Systemic chemotherapy is the type of chemotherapy whereby drugs are given as pill or injection (intravenously). This is an option used when dealing with those tumors that has grown deep inside the penis. This is also an option for those cases at advanced stage.

Side effects of chemotherapy
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Side effects of chemotherapy depends on the dose and type of drug used. Most of these side effects are for systemic chemotherapy. Some side effects normally go away after few days or weeks, but if the effects become too severe, there are medications to relieve them. Some of the possible side effects include the following;
• Hair loss
• Diarrhea
• Nausea and/or vomiting
• Risk of infection as a result of low white blood cells
• Feeling tired due to low red blood cells
• Easily bruised and/or bleeding due to low platelets
• Mouth sores

Radiation therapy
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Radiation therapy is the treatment option that uses high energy x-rays or other radiation particles to destroy cancer cells. This treatment option is performed by a specialized doctor known as radiation oncologist. For treatment of penile cancer, radiation therapy can be given in two ways.
• External beam radiation therapy
• Brachytherapy

External beam radiation therapy
External beam therapy is a form of radiotherapy, whereby radiation is directed to the tumor from the source (machine) outside the body.

Brachytherapy
This form of radiotherapy involve placing radiation source into the tumor or placing it near the tumor (right next to the tumor). Brachytherapy can be given in two ways;
• Interstitial brachytherapy. Hollow needles are placed into the penis, then platelets of radioactive material are put into the needles so as to deliver radiation to the tumor.
• Plesiobrachytherapy. In this, a radioactive source is placed right next to the tumor. Plastic cylinder is placed around the penis then another cylinder with radioactive source is placed on top of it.

Side effects of radiation therapy
Possible side effects of radiation therapy, normally go away soon after completion of treatment. Your treatment team will be there to help you with the medications to relieve some of the side effects if they become too severe. Some of the possible side effects include the following;
• Fatigue
• Nausea
• Diarrhea
• Narrowing of urethra due to scar tissues that will result into urination problems
• Skin reaction at the site where radiation pass through (external beam radiotherapy)

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