1. Department of urology Dr. Matalu Hamis Dr. Mocha George
PENILE MALIGNACY
Department of urology
Dr. Matalu Hamis
Dr. Mocha George

2. Anatomy

3. Penile parts
Root of the penis(radix)-it is the attached part consisting of the bulb of the penis in the middle and the cruz of penis one on either side of bulb . Lies within the superficial perineal pouch.
Body of the penis(corpus)-has two surfaces; dorsal and ventral.
The glans –sits as a cap on corpora cavernosa but is a part of corpora spongiosa.

4. Gross anatomy

6. Vasculature Arterial supply
Blood supply to the skin of the penis is from the left and right superficial external pudendal arteries which arise from femoral artery.
Supply to deep structures is from continuation of the internal pudendal artery which has three branches bulbourethral artery, carvenosal artery, and the dorsal artery.

8. Venous drainage
Penis is drained by 3 venous systems, the superficial, intermediate and deep.
Superficial veins coalesce to form single superficial dorsal vein which drains to superficial pudendal vein then to great saphenous vein
Intermediate veins has circumflex vein which drains to deep dorsal vein.
Deep veins is via the crura and carvenosal veins which drains to internal pudendal veins.

10. Lymphatic drainage
Drains to deep inguinal nodes of the femoral triangle and some to presymphyseal lymph nodes and lateral lymph nodes of the external iliac lymphatics.

11. Penile cancer

12. Introduction
Is a rare type of cancer that most likely to occurs on the glans of penis, or foreskin.
Mostly are primary.
Among 10 most common is scc.
Others include melanoma,adenocarcinoma from Tyson’s gland, bcc.
20 may also occur and are mostly of urological origin.

13. Risk factors/Etiologies
Uncircumcision.
Chronic balanoposthitis,
phimosis.
Sexually transmitted diseases.
Leukoplakia of glans.
Long-standing genital warts.
Paget’s disease of penis (Erythroplasia of Queyrat is persistent rawness of glans penis).

14. Risk factors cont..
Condyloma acuminata (by human papilloma virus),balanitis xerotica obliterans.
HIV infection
HPV - 16.
Age >50yrs.
Smoking cigarette and chewing tobacco
Penile intraepithelial neoplasia
Poor genital hygiene

15. Natural history of the disease
Penile cancers usually begin as small lesions on the glans or prepuce.
Macroscopically may be exophytic or flat, papillary, or ulcerative.
The growths rates of papillary and ulcerative are similar but of exophytic tend to metastasize to lymph node earlier and are therefore associated with a lower five year rate.
If untreated penile autoamputation can occur.

16. Infiltrating type/exophytic occurs in a preexisting leukoplakia
Infiltrating type/exophytic occurs in a preexisting leukoplakia. It often presents as indurated area.
Papilliferous type eventually attains a large size forming a fungating foul smelling lesion which often gets infected.

17. Microscopically tumor ranges from well-differentiated keratinizing tumors to solid anaplastic carcinomas with scant keratinization.
Moderated differentiated tumors are highly keratinized, and poorly differentiated carcinomas have variable amounts of spindle cell, giant cell, solid acantholytic, clear cell, small cell, warty, basaloid or glandular components.

18. Epidemiology
The annual burden of penile cancer has been estimated to be cases worldwide with incidence rates strongly correlating with those cervical cancer.
Incident rate are higher in less developed than in more developed countries, accounting for up to 10% of male cancers in some part of Africa, South America and Asia.
Is rare.
common affect men aged years.

19. Staging of penile cancer
Jackson’s staging of carcinoma penis-The commonest method.
Stage I
Tumour involving only glans/prepuce/both. 90% five year survival
Stage II
Tumour extending into body of penis. 70% five year survival.
Stage III
Tumour having mobile inguinal nodes. 50%
Stage IV
Tumour spreading to adjacent structures/fixed nodes. 5%

20. TNM TX Primary tumour cannot be assessed TO
No evidence of primary tumour
Tis
Carcinoma in situ Ta
Non invasiive carcinoma T1
Tumour invades sub epithelial tissue
T1a without lymphovascular invasion and is not
poorly differentiated or undifferentiated
T1b with either of the above T2
Tumour invades corpus spongiosum and/or corpora cavernosa T3
Tumour invades urethra T4
Tumour invades other adjacent structures

21. N
Regional lymph nodes Nx
Regional lymph nodes cannot be assessed No
No palpable or visibly enlarged inguinal lymph node N1
Palpable mobile unilateral inguinal lymph node N2
Palpable mobile multiple unilateral or bilateral inguinal lymph nodes N3
Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or bilateral M
Distant metastasis Mo
No distant metastasis M1

22. Spread of the cancer Lymphatics
It spreads to the horizontal group of inguinal lymph nodes which become nodular and hard. Lymph nodes on both sides can get involved. Later, external iliac group are involved (above and on medial aspect of the inguinal ligament).
Once inguinal lymph nodes are fixed, it causes severe excruciating pain and lymphoedema. Fixed lymphnode status indicates the advancement of the disease. It may erode into the femoral vessels causing torrential haemorrhage and death. Fungation can occur.
From glans, it also spreads to Cloquet lymph node which is located in femoral canal.
Carcinoma from shaft of penis can spread directly to the external iliac lymph nodes.
It spreads proximally to the body of penis causing induration.

23. Urethral meatus may get involved causing alteration in urinary stream
Urethral meatus may get involved causing alteration in urinary stream. It is a locoregional malignant disease.
Blood spread is rare.

24. Histopathological grading
GX level of differentiation can not be assessed.
G1 well differentiated.
G2 Moderate differentiated.
G3 Poorly differentiated/undifferentiated.

25. Diagnosis Clinically History & physical exam.
Mostly are obvious clinically except those hidden by phimosis.
A painless lesion on the glans penis/inner aspect of prepuce skin.
Papillary vs ulcerative.
Penile discharge
Dysuria
50% palpable inguinal lymph nodes at presentation.. Inflammatory vs malignant.

26. Investigations Punch or excisional biopsy confirms the diagnosis.
Role of imaging in staging…
Uss
MRI
CT scan
PET/CT

27. TREATMENT
The aim is complete removal of the tumor with organ preservation as much as possible.
Depends on the stage.
Modalities include:
Surgery
Chemotherapy
Radiotherapy

28. Stage
Modality of rx
CIS
Topical chemotherapy eg imiquimod or 5FU
Glans resurfacing
Ta/T1a
Penile preserving modalities
Radical circumcision, glansectomy, laser therapy, moh’s surgery.
radiotherapy
T1b /T2
Glansectomy +/- resurfacing of the corporeal heads T3
Partial or total penectomy with perineal uresthrostomy.
Radiotherapy T4
Total penectomy
Neoadjuvant chemotherapy

29. NOTE; that for the early stages modality of treatment should depend on the;
Size, site relative to the meatal opening, histology, stage.
No significant differences in terms of long term recurrence rate among the different modalities.
Cancer free margin of 10mm is considered oncologically safe.

30. Complication and prognosis
From treatment.
Psychological.

31. Prevention Circumcision- neonatal. HPV vaccination. Hygiene.
Early management of premalignant conditions.
Early refferal

32. Summary Its rare. Circumcision main risk factor.
Mostly involves the glans penis or the inner aspect of the prepuce.
SCC is the most common.
Left untreated-auto amputation.
Treatment multimodality.
Prognosis
Prevention

33. Refferences Lippincotts and william Atlas of anatomy
Baileys and love 25th edition
Short practice of surgery
SRB’s manual of surgery 3rd edition
Smith general urology 17th edition
Guidelines on Penile Cancer O.W. Hakenberg (chair), E. Compérat, S. Minhas, A. Necchi, C. Protzel, N. Watkin © European

34. Ten-year surgical experiences with penile cancer at a tertiary care hospital in northwestern Tanzania: a retrospective study of 236 patients Phillipo L Chalya1*, Peter F Rambau2, Nestory Masalu3 and Samson Simbila4