What's penile cancer?
The penis is a sexual organ that is also part of a man's urinary system. It is an erectile organ made up of different types of tissues (skin, nerves, and blood vessels) and crossed by a channel called the urethra, which serves to empty the bladder of urine (with urination) and emit seminal fluid (with ejaculation).
Inside the penis, there are two chambers called "corpora cavernosa" and another, called "corpus spongiosum," which lines the urethra. The chambers contain an intertwining of blood vessels responsible for erection. In response to signals from the nervous system, the blood concentrates in the corpora cavernosa and the corpus spongiosum, causing the expansion of the tissues through vasodilation and the method of valves that maintain it. After ejaculating, the blood flows back from the penis to the rest of the body, and the penis goes back to how it looks when it is at rest.
All the cells that make up the penis can transform and give rise to a tumour, although this process is not very frequent; penile cancer is, in fact, quite rare.
The expert's advice
How widespread is Penile cancer?
Squamous cell carcinoma of the penis affects approximately 1 in 100,000 males in Western countries. It is almost non-existent in communities where circumcision is practised at birth (common among Jews and in the United States) or before puberty (frequent in Muslim populations). At the same time, it is a little more frequent in developing countries.
In developed countries, the average age at which the disease starts is 60, while in less developed countries, it starts at 50.
The main risk factor is HPV infection (human papillomavirus), which is generally contracted by sexual contact between the genitals, oral cavity, and anal canal. About one-third of people with penile cancer are infected with HPV, a virus already known to be linked to other types of cancer such as that of the cervix, vulva, anus, oral cavity, and throat. A sex life with many partners, the early age of first sexual intercourse, and a history of warts are associated with a 3-5 times greater risk of penile cancer. For this reason, in Italy, vaccination against the papillomavirus is given free of charge to both girls and boys in their twelfth year of age. The practise of neonatal circumcision seems to reduce HPV transmission and, therefore, the incidence of penile cancer in males and cervical cancer in female partners. The appearance of cervical cancer in a woman is not associated with an increase in the incidence of penile cancer in her sexual partner.
Other known risk factors for penile cancer are phimosis, which is the narrowing of the skin of the foreskin (the flap of skin that covers the glans penis, i.e. the head of the penis), which can be congenital or acquired, old age, chronic inflammatory conditions (for example, lichen sclerosis), treatment with ultraviolet rays (sometimes linked to the treatment of psoriasis or other diseases) and smoking. There is no scientific proof that having HIV or full-blown AIDS makes you more likely to get penile cancer.
To reduce the risk of suffering from penile cancer, it is essential to have good hygiene of the genital organs and avoid known risk factors. Therefore, beware of cigarette smoking and sexual practises that increase the risk of contracting HPV infections. There is still no incontrovertible data showing that vaccination against papillomavirus reduces the incidence of penile cancer, but vaccination certainly helps to reduce the circulation of the virus.
If performed early, circumcision, which consists of removing the foreskin, reduces the incidence of penile cancer by 3-5 times, while if performed in adulthood, it has no protective effects. not currently encouraged by scientific societies, choosing to undergo circumcision to prevent penile cancer.
The most common penile cancer is squamous cell carcinoma (95 per cent of cases), which originates from the epidermal lining of the glans penis and the inside of the foreskin. Other cancers follow, such as basal cell carcinoma and melanoma. Cases of sarcoma and other even rarer cancers have been reported.
Typically, one of the first symptoms of penile cancer is a change in the appearance of the skin that changes colour and becomes thinner or thicker in some areas.
Sometimes small ulcerations or nodules form on the penis, which can be more or less painful or completely asymptomatic, and small whitish or reddish superficial plaques on the inner surface of the foreskin or the surface of the glans, sometimes accompanied by the production of an irritating secretion. Swelling in the glans could also indicate the presence of a tumour, while swelling affecting the lymph nodes in the groyne could be a sign that the disease has spread beyond the starting site.
None of these symptoms are sufficient for a specific diagnosis of penile cancer because benign pathologies can cause the same symptoms; always consult your doctor if you have any doubts.
A diagnosis of penile cancer begins with a visit. The doctor collects detailed information about the patient's symptoms and family history and carefully examines the entire genital region to check for signs of the tumour or other pathology. In cases of suspicion, a biopsy is carried out; that is, a small amount of tissue from the penis is taken and analysed under a microscope; this method allows for a specific cancer diagnosis.
If penile cancer is diagnosed, it is essential to determine whether and how far the disease has spread in the body. Tests like magnetic resonance imaging (MRI) of the penis, inguinal ultrasound with possible lymph node needle biopsy, computed tomography (CT), and positron emission tomography (PET) may be needed.
As with many other solid tumours, the so-called TNM staging system is also used for squamous cell carcinoma of the penis. Thanks to this system, it is possible to assign a stage to the tumour, that is, to understand how widespread it is in the body, taking into account the local extension of the disease (T), the involvement of the lymph nodes (N) and the presence of metastases in distant organs (M ). The prognosis for patients whose disease has spread to the lymph nodes is worse for those
Another critical parameter for knowing the tumour is the grade, which measures how much the tumour cells are abnormal compared to the healthy ones. There are four grades to describe penile cancer: the higher the grade (i.e., the more cancer cells appear different than healthy ones), the greater the tendency for the disease to grow and spread to other organs.
Penile cancer is typically treatable when diagnosed in its earliest stages. The choice of the most suitable treatment depends on several factors such as the type, location, and extent of the tumour; the patient's general health conditions; and, in some cases, also the patient's preferences based on the side effects of the therapies.
Surgery is the most widely used treatment for penile cancer in all stages. Several techniques are more or less indicated depending on the characteristics of the neoplasm. In particular, in cases of non-invasive superficial tumours, laser surgery is carried out, which destroys the more superficial cells; if, on the other hand, the cancer is not well localized, circumcision can be used (to remove tumour masses confined to the foreskin), the simple removal of the tumour and a small part of adjacent tissue with a scalpel or Mohs surgery (which involves the removal of a very thin layer of tissue and its analysis; if there are cancer cells, we proceed with the removal of one layer at a time until a completely healthy one is encountered). In the cases described above, we speak of conservative surgery since we tend to preserve the aesthetic and functional characteristics of the penis. In some cases, however, if the tumour has already invaded the organ in-depth, it is necessary to proceed with more radical interventions with the partial removal (with possible reconstruction of the glans) or total removal of the penis. In these cases, surgery also removes the inguinal lymph nodes to find out if the tumour has spread and to get rid of the cancerous cells in those lymph nodes.
Surgical removal of inguinal and sometimes pelvic lymph nodes (lymphadenectomy) is the primary therapeutic strategy for locally advanced forms of the disease, possibly preceded by chemotherapy if the condition is judged beyond the boundaries of operability. Post-operative chemotherapy may be considered for operated patients with a high-risk histological examination, though efficacy data in the literature are limited.
Radiotherapy can be used alone, in the form of rays or tiny radioactive "seeds" placed inside the tumour (brachytherapy), or in combination with surgery to lower the risk of metastasis to other parts of the body. Systemic chemotherapy is the only treatment option, but it is only used for palliative care.