Penile carcinoma 153

D: Penile malignancy, most commonly squamous cell carcinoma of the penile skin.

A: Chronic irritation is main risk factor. Human papilloma virus also implicated.

A/R: Condyloma acuminata (e.g. warts, human papilloma virus), chronic infection ^^ of the foreskin (balanitis), smoking. Balanitis xerotica obliterans (a form of lichen sclerosus, a chronic inflammatory condition of the glans or foreskin), erythroplasia of Queyrat (a form of carcinoma in situ of the glans skin), Bowen's disease (intraepithelial carcinoma of the penile shaft).

E: Rare, most commonly seen in elderly men (50-70 years), < 0.5% of adult male ^^ cancers.

H: The patient may report a slowly enlarging lesion, often painless leading to delay in seeking medical attention, there may be associated bleeding or rl icrhar/io discharge.

Most often occurs on the glans penis or inner surface of the foreskin, early as a painless red lesion, later as an exophytic papilliferous or nodular growth or ulcer, often with secondary infection causing a discharge or offensive smell. Inguinal lymphadenopathy is present in up to 50% but often due to the associated infection or inflammation with only 30-60% of these having evidence of tumour spread.

These are squamous cell carcinomas, with three histological grades G1, G2 and G3.

Stage I: Localised to the glans or foreskin. Stage II: Involvement of the corpora. Stage III: Spread to inguinal nodes. Stage IV: Distant metastases.

Avariant is giant condyloma of Buschke-Lowenstein that spreads locally with a characteristic sharply defined deep margin.

Biopsy: Punch or excisional biopsy to establish diagnosis (differential: condylomata acuminata, syphilitic chancre or rarely chancroid). Imaging: CT or MRI scanning for evidence of spread.

Prevention: Circumcision at a young age, good hygiene, appropriate treatment of erythroplasia of Queyrat (5-fluorouracil cream or local laser photocoagulation).

Surgical: For stage I and II, partial amputation with 2 cm proximal disease-free margins. In more advanced cases, total penectomy with formation of a perineal urethrostomy.

Inguinal nodes: Palpable nodes should be treated with antibiotics after treatment of the initial lesion as they may be a reactive response to infection. If persistent, bilateral ilioinguinal block dissection is performed, and if involved, this may still be curative. Prophylactic dissection of impalpable nodes has not been associated with " survival although superficial node dissection is used for staging.

Radiotherapy: Local radiotherapy may be used for early stage disease if the tumour is not large, invasive or involving the urethra, or as part of combined modality therapy for palliation of advanced stage disease. Chemotherapy: Usually restricted to cases of systemic spread, agents such as cisplatin and bleomycin are used, although often with only partial responses.

Psychological morbidity of penectomy.

From inguinal node dissection: Lymphoedema, wound breakdown.

5-year survival rate is 80% (stage I), 50% (nodal involvement) and 0% (metastases).

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