EAU & ASCO: Penile Cancer 2023

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See Original Guidelines

Background

  • Penile cancer negatively impacts quality of life through
    • Physical and emotional changes
    • Feelings of mutilation
    • Loss of masculinity
    • Voiding and sexual dysfunction, which in turn can result in relationship breakdowns and withdrawal from society
    • Lymphedema

Epidemiology

  • Uncommon in industrialized countries
  • More common in South America, Southeast Asia, and parts of Africa
  • Race
    • Highest incidence in white Hispanics, followed by Alaskans and Native American Indians, African Americans, white non-Hispanics.
  • Increasing incidence in Western/developed countries most likely due to higher infection rates of HPV

Pathophysiology

Risk factors

  • Human papilloma virus (HPV)
    • Most important risk factor
    • Most frequent HPV genotypes: HPV16 followed by HPV6
    • Risk of penile cancer is increased in patients with condyloma acuminata
    • Female sexual partners of patients with penile cancer have not been found to have an increased incidence of cervical cancer
    • No general recommendation (except in a few countries) for HPV vaccination in males because of the different HPV-associated risk patterns in penile- and cervical cancer
      • Since up to 50% of invasive penile carcinomas and 80% of preneoplastic lesions are HPV-associated, HPV vaccination is encouraged
  • Phimosis
    • Strongly associated with invasive penile cancer, due to associated chronic infections
    • Smegma is not a carcinogen
    • Neonatal circumcision reduces the incidence of penile cancer, but does not reduce the risk of Penile Intraepithelial Neoplasia
  • Chronic penile inflammation
  • Lichen sclerosus
  • Ultraviolet A phototherapy
  • Cigarette smoking
  • Low level of education
  • Low socio-economic status

Pathology

  • >95% of penile cancers are squamous cell carcinomas (SCCs)
  • Other malignant lesions of the penis
    • Melanoma
    • Mesenchymal tumors
    • Lymphomas
    • Metastases
      • Penile metastases are frequently of prostatic, urinary bladder or colorectal origin
    • Sarcoma

Penile Squamous Cell Carcinoma

  • Usually arises from the epithelium of the inner prepuce or the glans
  • Subtypes
    • HPV-independent
      • Usual
      • Pseudohyperplastic
      • Pseudoglandular
      • Verrucous
      • Caniculatum
      • Papillary
      • Sarcomatoid (Most aggressive and worse prognosis)
      • Mixed
    • HPV-associated
      • Basaloid (most common among HPV-associated penile carcinomas)
      • Warty
      • Clear cell
      • Lymphoepithelioma-like
      • Mixed
  • Penile intraepithelial neoplasia is considered the precursor lesion of penile SCC
    • Clinical terms such as ‘Erythroplasia of Queyrat, Bowenoid papulosis and Bowen’s disease’ are discouraged
    • Penile intraepithelial neoplasia is also classified as HPV-independent and HPV-associated

Diagnosis and Evaluation

Management

Prognosis

  • Overall 5-year survival: 67%
    • Localized disease: 81%
    • Distant metastasis: 18%

References