What causes penile cancer? Signs, tests to diagnose, treatment options,

Human papillomavirus infection may increase the risk of developing penile cancer.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. People who think they may be at risk should discuss this with their doctor. Risk factors for penile cancer include the following:

Circumcision may help prevent infection with the human papillomavirus (HPV). A circumcision is an operation in which the doctor removes part or all of the foreskin from the penis. Many boys are circumcised shortly after birth. Men who were not circumcised at birth may have a higher risk of developing penile cancer.

Other risk factors for penile cancer include the following:

• Being age 60 or older.
• Having phimosis (a condition in which the foreskin of the penis cannot be pulled back over the glans).
• Having poor personal hygiene.
• Having many sexual partners.
• Using tobacco products.

Possible signs of penile cancer include sores, discharge, and bleeding.

These and other symptoms may be caused by penile cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

• Redness, irritation, or a sore on the penis.
• A lump on the penis.

Tests that examine the penis are used to detect (find) and diagnose penile cancer.

The following tests and procedures may be used:

• Physical exam and history: An exam of the body to check general signs of health, including checking the penis for signs of disease, such as lumps or anything else that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

• The stage of the cancer.
• The location and size of the tumor.
• Whether the cancer has just been diagnosed or has recurred (come back).

Stages of penile cancer

After penile cancer has been diagnosed, tests are done to find out if cancer cells have spread within the penis or to other parts of the body.

The process used to find out if cancer has spread within the penis or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. A substance called gadolinium is injected into a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture. This procedure is also called nuclear magnetic resonance imaging (NMRI). Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. There are three ways that cancer spreads in the body. The three ways that cancer spreads in the body are: Through tissue. Cancer invades the surrounding normal tissue. Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body. Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body. When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer. The following stages are used for penile cancer: Stage 0 (carcinoma in situ) In stage 0, abnormal cells are found on the surface of the skin of the penis. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ. Stage I In stage I, cancer has formed and spread to connective tissue just under the skin of the penis. Stage II In stage II, cancer has spread to: connective tissue just under the skin of the penis and to one lymph node in the groin; or erectile tissue (spongy tissue that fills with blood to make an erection) and may have spread to one lymph node in the groin. Stage III In stage III, cancer has spread to: connective tissue or erectile tissue of the penis and to more than one lymph node on one or both sides of the groin; or the urethra or prostate, and may have spread to one or more lymph nodes on one or both sides of the groin. Stage IV In stage IV, cancer has spread: to tissues near the penis and may have spread to lymph nodes in the groin or pelvis; or anywhere in or near the penis and to one or more lymph nodes deep in the pelvis or groin; or to distant parts of the body. Recurrent penile cancer Recurrent penile cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the penis or in other parts of the body. Treatment option overview There are different types of treatment for patients with penile cancer. Different types of treatments are available for patients with penile cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment. Three types of standard treatment are used: Surgery Surgery is the most common treatment for all stages of penile cancer. A doctor may remove the cancer using one of the following operations: Mohs microsurgery: A procedure in which the tumor is cut from the skin in thin layers. During the surgery, the edges of the tumor and each layer of tumor removed are viewed through a microscope to check for cancer cells. Layers continue to be removed until no more cancer cells are seen. This type of surgery removes as little normal tissue as possible and is often used to remove cancer on the skin. It is also called Mohs surgery. Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor. Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue. This type of treatment is also called cryotherapy. Circumcision: Surgery to remove part or all of the foreskin of the penis. Wide local excision: Surgery to remove only the cancer and some normal tissue around it. Amputation of the penis: Surgery to remove part or all of the penis. If part of the penis is removed, it is a partial penectomy. If all of the penis is removed, it is a total penectomy. Lymph nodes in the groin may be taken out during surgery. Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. Radiation therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated. Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly onto the skin (topical chemotherapy) or into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Topical chemotherapy may be used to treat stage 0 penile cancer. New types of treatment are being tested in clinical trials. This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Biologic therapy Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy. Topical biologic therapy may be used to treat stage 0 penile cancer. Radiosensitizers Radiosensitizers are drugs that make tumor cells more sensitive to radiation therapy. Combining radiation therapy with radiosensitizers helps kill more tumor cells. Sentinel lymph node biopsy followed by surgery Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. After the sentinel lymph node biopsy, the surgeon removes the cancer. Stage I penile cancer If the cancer is only in the foreskin, wide local excision and circumcision may be the only treatment needed. Treatment of stage I penile cancer may include the following: Surgery (partial or total penectomy with or without removal of lymph nodes in the groin). External or internal radiation therapy. Mohs microsurgery. A clinical trial of laser therapy. This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site. Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I penile cancer. Stage II penile cancer Treatment of stage II penile cancer may include the following: Surgery (partial or total penectomy, with or without removal of lymph nodes in the groin). External or internal radiation therapy followed by surgery. A clinical trial of sentinel lymph node biopsy followed by surgery. A clinical trial of laser surgery. This summary section refers to specific treatments under study in clinical trials, but it may not mention every new treatment being studied. Information about ongoing clinical trials is available from the NCI Web site. Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage II penile cancer. Stage III penile cancer Treatment of stage III penile cancer may include the following: Surgery (penectomy and removal of lymph nodes in the groin) with or without radiation therapy. Radiation therapy. A clinical trial of sentinel lymph node biopsy followed by surgery. A clinical trial of radiosensitizers. A clinical trial of chemotherapy before or after surgery. Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage III penile cancer. Stage IV penile cancer Treatment of stage IV penile cancer is usually palliative (to relieve symptoms and improve the quality of life). Treatment may include the following: Surgery (wide local excision and removal of lymph nodes in the groin). Radiation therapy. A clinical trial of chemotherapy before or after surgery. Check for clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IV penile cancer. Treatment options for recurrent penile cancer Treatment of recurrent penile cancer may include the following: Surgery (penectomy). Radiation therapy. A clinical trial of biologic therapy. A clinical trial of chemotherapy.