Penile cancer

from Wikipedia, the free encyclopedia
Classification according to ICD-10
C60.9 Malignant neoplasm: penis, unspecified
C60.0 Malignant neoplasm: Praeputium penis
C60.1 Malignant neoplasm: glans penis
C60.2 Malignant neoplasm: penile shaft
C60.8 Malignant neoplasm: penis, several parts overlapping
ICD-10 online (WHO version 2019)

The penile cancer (coll. "Penile cancer") is a malignant disease ( cancer ) of the penis . It usually only occurs from the age of 60. About 95% of the skin of the glans , the penis foreskin or the mucous membrane of the urethra is degenerate ( squamous cell carcinoma ).

frequency

In the western world, penile carcinoma is a rare tumor that occurs in men at an advanced age. About a decade ago the incidence in Central Europe and the United States was 0.9 per 100,000 men per year, which corresponds to about 600 new cases per year in Germany. In Germany, penile carcinoma only accounts for about 0.4–0.65% of all malignant tumor diseases in men, with most diseases occurring in men over 50 years of age. There are great geographical differences in frequency around the world. In Puerto Rico, for example, about 20% of all male cancers are penile carcinomas. In Israel, which has a high circumcision rate in newborns and good hygiene standards, the incidence of 0.1 per 100,000 men per year is still below the incidence in Germany. There is no causality between this number - cited in the cited article from 1999 without a source (p. 16) - and the circumcision : it has long been discussed that viruses could be the cause of penile carcinoma. If so, then a higher level of sexual fidelity (e.g. among Orthodox Jews ) than in other countries would explain the low incidence. Israeli Jews are more likely than non-Jewish men to marry abroad (and drink less alcohol). Between 1952 and 1981, the average age at marriage for ultra-Orthodox men fell from 27.5 to 21.5 years.

In the past few decades, the incidence of the disease in the western world has decreased even further due to hygienic improvements. As carcinoma is rare overall, current figures are difficult to collect.

Risk factors

The exact cause of penile cancer is not known, but it is almost certain that certain types of human papilloma viruses (HPV 16 & 18) and benign, chronic inflammatory precursor lesions such as lichen sclerosus and lichen planus can develop into squamous cell carcinoma. The carcinomas that develop on the basis of a chronic inflammatory precursor lesion are said to behave significantly more aggressively than those that develop virally. According to the American Cancer Society , infections with the human papillomavirus (HPV) , tobacco consumption , smegma , a psoriasis combination therapy with psoralen and UV light, old age, and AIDS are risk factors. Another etiological factor for the development of penile cancer is poor hygiene. There is some evidence that lichen sclerosus (also known as balanitis xerotica obliterans ) is also a risk factor.

It remains to be seen whether new findings on HPV infection will lead to a reassessment of the causes. Whether vaccination against this virus, which is the main cause of cervical cancer in women , will also reduce the incidence of penile cancer is still being investigated. Daughter tumors form in penile carcinoma mainly along the inguinal lymph nodes.

Symptoms

There are a number of different symptoms, some of which are quite uncharacteristic and can also indicate other diseases. Chronic inflammatory changes occur in the glans and foreskin of the penis. In addition, bleeding on contact with the affected area and swelling of the inguinal lymph nodes can occur. Penile carcinomas are usually not painful and sometimes occur in neglected people who pay little attention to physical symptoms and rarely visit doctors. Therefore, these are often incidental findings at an advanced stage as part of a general examination.

diagnosis

Because the symptoms are sometimes uncertain, it is safest to take a tissue sample from the tumor and the swollen lymph nodes .

Pathology and pathogenesis

Penile malignancies are 95% squamous cell carcinomas . The remaining 5% are melanomas , sarcomas , metastases and other tumors, about which there are almost only case reports due to their rarity. The squamous cell carcinomas of the penis arise half from the non-keratinized epithelium of the glans penis (glans) and half from the inner foreskin sheet . The WHO distinguishes between the following subtypes:

Non HPV Associated Tumors

  • Squamous cell carcinoma, common type: 70–75% of cases, mortality approx. 30%
  • pseudohyperplastic carcinoma
  • pseudoglandular carcinoma: gland-like growth
  • Verrucous carcinoma: 2–3%, grows wart-like - bulging, keratinizing, can become very large, good prognosis
  • Carcinoma cuniculatum: mature-cell, keratinizing carcinoma with slight atypia
  • papillary carcinoma: shaggy surface, less malignant
  • adenosquamous carcinoma: partly glandular, partly squamous-like
  • sarcoma carcinoma: strongly dedifferentiated, resembles a sarcoma, mortality 75%

HPV-associated

HPV types 16, 18, 31, 45, 56 and 65 are most frequently detected. The immunohistochemical detection of p16 is used as a surrogate parameter for HPV.

The correlation between p16 and HPV is so great that p16 detection replaces other more complex procedures.

  • basal carcinoma: tumor cells resemble basal cells (lowest cell layer of the squamous epithelium)
  • Papillary basal carcinoma: additional shaggy surface
  • warty carcinoma: like verrucous carcinoma, with HPV detection
  • warty basaloid carcinoma
  • clear cell carcinoma: glycogen-containing tumor cells appear clear because the glycogen is usually dissolved during preparation.
  • lymphoepithelioma- like carcinoma: mixed tumor with atypical lymphocytes and epithelioid cells

Stages

The staging is based on the eighth edition of the UICC's TNM classification

T TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Ta Non-invasive verrucous carcinoma
T1 Tumor infiltrates subepithelial connective tissue (sub-forms: T1a: no lymphovascular infiltration, not poorly differentiated / undifferentiated; T1b: with lymphovascular infiltration or poorly differentiated / undifferentiated)
T2 Tumor infiltrates corpus spongiosum with / without invasion of the urethra
T3 Tumor infiltrates the corpus cavernosum with / without invasion of the urethra
T4 Tumor infiltrates other neighboring structures
N NX Regional lymph nodes cannot be assessed
N0 No palpable or visibly enlarged inguinal lymph nodes
N1 A palpable mobile unilateral inguinal lymph node
N2 Multiple or bilateral palpable mobile inguinal lymph nodes
N3 Fixed inguinal bundles of lymph nodes or uni- or bilateral pelvic lymphadenopathy
pN pNX Regional lymph nodes cannot be assessed
pN0 No lymph node metastases
pN1 Metastases in one or two inguinal lymph nodes
pN2 Metastases in more than two unilateral inguinal or bilateral inguinal lymph nodes
M. M0 No distant metastases detected
M1 Distant metastases detected

Regarding the T stage: A carcinoma in situ is a tumor that has not yet broken through the basement membrane of the epithelium and thus cannot form metastases. A verrucous carcinoma has a gross wart-like appearance and is a variant with low malignancy. As the tumor progresses, it first affects the erectile tissue (corpus spongiosum and corpus cavernosum).

To the N stage: penile carcinomas first metastasize to the inguinal lymph nodes . Higher lymph node stations in the small pelvis (pelvic lymphadenopathy) only occur in very advanced tumors. A distinction is made between a clinical lymph node stage before an operation and a postoperative stage at which the microscopic examination of the lymph nodes is already available. Postoperative stages are marked with a small P, for example pN1. If lymph node metastases have grown immovably into the surrounding area, this is a sign of a more advanced tumor disease, hence stage N3.

therapy

In the early stages of penile cancer, radiation therapy , local removal of the tumor, or laser treatment of the affected areas may be indicated. In the advanced stages with lymph node metastases , the affected lymph nodes must be removed and a penile amputation or partial penile amputation is usually necessary.

forecast

If the diagnosis is made early, the chances of recovery are good (70–90% cures). However, many patients do not see a doctor until the tumor is at an advanced stage. At the time of diagnosis, 17–45% of patients have histologically confirmed lymph node metastases. The prognosis depends primarily on the stage, grade, and age of the patient. Relative 5-year survival rates in relation to normal age-related mortality were calculated from the Swedish penile cancer registry. The 5-year survival rate at stage pTis was 97%, pT1 90%, pT2 66% and pT3 55%. The involvement of regional lymph nodes worsened the prognosis: 94% of histologically tumor-free lymph nodes survived five years, but only 46% of lymph node metastases were found. The prognosis of the disease in the presence of distant metastases is poor with a 5-year survival of less than 5%. The influence of the grading, i.e. the extent of the histological degeneration, on the prognosis can also be shown in the Swedish penile cancer registry: With the lowest degeneracy level G1, 96% of the patients survived 5 years, with the highest level G3 only 67%. Old patients had a worse prognosis than young ones. This is possibly due to the fact that older patients more often had far advanced, dragged tumors.

further reading

  • B. Mahlmann, C. Doehn, T. Feyerabend: Radiotherapy of the penile carcinoma. In: Der Urologe A Volume 40, Number 4, pp. 308-312. doi : 10.1007 / s001200170042

Individual evidence

  1. ↑ a b c G. Schoeneich, D. Heimbach, SC Müller: penis carcinoma . In: Journal of Urology and Urogynaecology . Volume 6 (1) (edition for Austria), 1999, pp. 16-27 ( PDF )
  2. ^ Information from the University of Munich
  3. ↑ Journal for Urology and Urogynaecology, page 17 (1999) PDF
  4. ↑ zeit.de November 1, 2012: zeit.de: Nobody lives as long as men in Israel
  5. ^ Gershom Gorenberg: Israel abolishes itself , Campus Verlag 2012, page 172
  6. ↑ [1] ; PDF; 550 kB
  7. ^ ACS :: What Are the Risk Factors for Penile Cancer? . Archived from the original on September 26, 2007. Retrieved December 13, 2007.
  8. ↑ bmj.com Rapid Responses for Rickwood et al., 321 (7264) 792-793 . Retrieved February 26, 2014.
  9. ↑ C. Padevít: diseases of the penis. In: Journal for Urology and Urogynaecology 2013; 20 (1) pp. 7-9 . (PDF; 821 kB)
  10. ↑ Oliver Walther Hakenberg, Desiree Louise Dräger, Andreas Erbersdobler, Carsten Maik Naumann, Klaus-Peter Jünemann: The diagnosis and treatment of penile cancer . In: Deutsches Aerzteblatt Online . September 28, 2018, ISSN  1866-0452 , doi : 10.3238 / arztebl.2018.0646 , PMID 30375327 , PMC 6224543 (free full text) - ( aerzteblatt.de [accessed on July 25, 2019]).
  11. ↑ C. Wittekind (editor): TNM. Classification of malignant tumors. Eighth edition. Wiley-VCH Verlag 2017. ISBN 978-3-527-34280-8
  12. ↑ a b Peter Kirrander, Amir Sherif, Bengt Friedrich, Mats Lambe, Ulf Håkansson: Swedish National Penile Cancer Register: incidence, tumor characteristics, management and survival . In: BJU international . tape 117 , no. 2 , 2016, ISSN  1464-410X , p. 287-292 , doi : 10.1111 / bju.12993 , PMID 25395083 .
  13. ↑ E. Preis, G. Jakse: Options of palliative therapy for penile carcinoma . In: Urologist . Volume 46, January 2007, pp. 49-53, PMID 17203267

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