318 CHAPTER 6 Urological neoplasia

Squamous cell carcinoma of the penis: clinical management

Presentation

A hard, painless lump on the glans penis is the most common presentation. About 15–50% of patients delay presentation for >1 year because of embarrassment, personal neglect, fear, or ignorance. A bloody discharge may be confused with hematuria. Rarely, a groin mass or urinary retention are presenting symptoms.

Examination reveals a solid, non-tender mass or ulcer beneath or involving the foreskin. There is usually evidence of local infection. In more advanced disease, the prepuce, glans, shaft, scrotum, and even perineum are replaced by tumor.

The inguinal lymph nodes are examined. They may be enlarged, fixed, or even ulcerate overlying skin.

Investigations

A biopsy is indicated. Chest radiology, pelvic CT scan, serum calcium, and liver function tests are usually obtained.

Treatment

The management of penile cancer should take place in regional or supraregional centers that can provide multidisciplinary surgical and oncological expertise.

Primary tumor

The first-line treatment of penile cancer, regardless of the inguinal node status, is surgery (see Box 6.7 for 5-year survival rates).

Circumcision is appropriate for preputial lesions, but local recurrence is observed in 22–50%.

Penis-preserving wide excision of glanular lesions with skin graft glanular reconstruction may be suitable for smaller G1–2 Ta–1 tumors, giving good cosmetic and functional results.

Alternatives to surgery include laser or cryoablation, radiotherapy or brachytherapy, photodynamic therapy, or topical 5-fluorouracil. Mohs cutaneous surgery has been used with mixed results.

For G3T1 and more advanced tumors, partial or total penile amputation is required, depending on the extent of the tumor. Partial amputation is preferable, provided a 2 cm margin of palpably normal shaft can be obtained. The patient must be prepared for poor cosmetic and functional results: inability to have sexual intercourse and need to sit to void urine. Local recurrence occurs in 10% if the excision margin is positive.

Total amputation involves excision of the scrotum and its contents, with formation of a perineal urethrostomy. The most common complication is urethral meatal stenosis.

Radiotherapy remains an alternative, but disadvantages include radioresistance, leading to reported recurrence rates of 30–60%; and tissue necrosis and damage leading to urethral stricture, fistula, and pain. Patients with M1 disease are offered palliative surgery.

SQUAMOUS CELL CARCINOMA OF THE PENIS 319

Lymphadenopathy

Six weeks of broad-spectrum antimicrobials (e.g., Augmentin or cephalosporin) are given after the primary tumor has been removed. Nodes become clinically nonpalpable in 50% of patients, who may then be followed up.

For those with persistent inguinal lymphadenopathy, in the absence of demonstrable pelvic or metastatic disease, bilateral inguinal lymphadenectomy should be considered, since 5-year survival is 80%. Even if lymphadenopathy is unilateral, >50% will have contralateral metastases. However, this is major surgery with a high morbidity, including lymphedema, thromboembolism, wound breakdown, and flap complications, so it is not suitable for elderly or unfit men.

Fine needle aspiration cytology is not recommended since a negative result will not alter treatment.

Radiotherapy and chemotherapy

Radiotherapy and chemotherapy are alternative or adjuvant treatments for metastatic nodal disease in unfit, elderly, or inoperable patients; 5-year survival is 25%. There is not a standard chemotherapy. Rarely, potential active agents include 5-FU, bleomycin, methotrexate, and cisplatin.

Rarely, lymphadenopathy ulcerates the skin, may encase the femoral vessels, and invade the deeper musculature. In these circumstances, collaboration with plastic and vascular surgeons is necessary if surgery is considered appropriate.

Prophylactic lymphadenectomy

This is currently practiced in the United States for tumors exhibiting vascular invasion, are high grade, or stages T2–4. It is argued that the risk of metastatic disease with palpably normal groins is >20% and delayed lymphadenectomy could reduce the chance of cure. From 20% to 30% of patients with inguinal metastases will also have pelvic node involvement.

Lymph node sampling (either sentinel node biopsy or modified inguinal dissection) may be offered for patients with palpably normal inguinal nodes and T2 or above lesion to avoid the morbidity of formal inguinal lymphadenectomy.

Distant metastatic disease

This is treated using single-agent systemic chemotherapy: cisplatin, bleomycin, or methotrexate. Responses are partial and short-lived in 20–60% of patients. Experience with combination chemotherapy is increasing.

Box 6.7 5-year survival

320 CHAPTER 6 Urological neoplasia

Carcinoma of the scrotum

Originally described in Victorian chimney sweeps, by Percival Pott, it was the first cancer to be associated with an occupation. A rare disease in men <50 years of age, chronic exposure of the scrotal skin to soot, tar, or oil is the cause.

A squamous cell carcinoma, it presents as a painless lump or ulcer, often purulent, on the anterior or posterior (therefore not obvious if the patient is lying or sitting) scrotal wall. Inguinal lymphadenopathy may suggest metastasis or reaction to infection.

Treatment of a mass or ulcer on the scrotum is wide local excision with a 2 cm margin of skin and dartos. Antimicrobials are administered for 6 weeks if there is lymphadenopathy, then the groin areas are re-evaluated.

Inguinal lymphadenectomy, with adjuvant chemotherapy, is considered if lymphadenopathy persists. Supraclavicular lymphadenopathy, hematogenous visceral, and bony metastasis are rare and carry a poor prognosis.

TUMORS OF THE TESTICULAR ADNEXA 321

Tumors of the testicular adnexa

Epithelial tumors arising from the epididymis and paratesticular tissues are rare; they are mostly of mesenchymal origin.

Adenomatoid tumors

These small, solid tumors arise in the epididymis or on the surface of the tunica albuginea. They usually present without change for several years. There are benign vacuolated epithelial and stromal cells.

The origin is unknown. Treatment is local excision.

Cystadenoma of the epididymis

This is a benign epithelial hyperplasia that occurs in young adults. It is often asymptomatic. One-third of cases are bilateral and associated with VHL syndrome.

Mesothelioma

This presents as a firm, painless, scrotal mass associated with hydrocele, which gradually enlarges. It occurs in any age group, with 15% being metastatic to inguinal nodes.

It is treated with orchiectomy and follow-up.

Paratesticular tumors

Rhabdomyosarcoma

A scrotal mass presents in the first or second decade in the spermatic cord and compresses the testis and epididymis. Lymphatic spread is to the para-aortic nodes.

Treatment is multimodal radical orchiectomy with radiotherapy and chemotherapy, with 5-year survival of 75%.

Leiomyoma/sarcoma

This presents as a scrotal mass at age 40–70 years in the spermatic cord. 30% of cases are malignant, 70% are benign; there is hematogenous distant spread.

Treatment is wide excision or radical orchiectomy.

Liposarcoma

This is a spermatic cord tumor. Radical orchiectomy with high ligation of spermatic cord, similar to surgical management of testicular tumors, is the treatment. Wide local excision may be required to ensure complete tumor removal.

Radiation therapy may be required in cases of incomplete resection leaving residual tumor or extensive local disease.