Types, Diagnosis and Investigations
The names or terms used to describe pre-cancerous lesions can be confusing.
The correct medical term is PeIN3 (Penile Intraepithelial Neoplasia 3) but there may be other names for these conditions that the medical team may use.
This is an HPV (Human Papilloma Virus) related lesion, typically a small plaque which may form on the penile shaft. It rarely progresses to penile cancer and can usually be treated by simple surgical removal or other minor surgical techniques.
Bowens disease/ Erythroplasia of Queryat
Bowens disease is found on the shaft skin of the penis and is not associated with the HPV virus.Erythroplasia of Queryat is found on the glans or foreskin of the penis and is more likely to progress to penile cancer.
Types of penile cancer
Squamous cell carcinoma
The most common type of penile cancer is called squamous cell carcinoma. Around 95% of penile cancer will be of this type. Squamous cells are skin cells that can change over time (for instance due to infection with HPV) and become cancerous. They can become cancerous on any part of the penis but usually develop on or under the foreskin. This type of cancer has the potential to spread to other areas around the penis and sometimes to other parts of the body. A rarer form of this type of penile cancer is called verrucous carcinoma. The cells of this type of cancer are slightly different to Squamous cell carcinoma and cancer tends to progress more slowly and is less likely to spread to other areas of the body.
Squamous cell carcinoma can also develop within the urethra and then affect the penis itself.
Basal cell penile cancer
Basal cells are skin cells from the outer lining of the skin which may change and become cancerous. Less than 2% of penile cancers are basal cell cancers.
This cancer sometimes occurs on the surface of the penis and is the same type of melanoma skin cancer. However exposure to sunlight is not necessarily needed for skin cells to become cancerous. Malignant melanoma accounts for less than 1% of penile cancers.
About 1% of penile cancers are sarcomas. These are cancers that develop in the tissues that support and connect the body, such as blood vessels, muscle, and fat.
This type of cancer is extremely rare in developing as a primary or initial cancer within the penis. It tends to be cancer which has spread from another area of the body such as the testicles.
Other types of cancer such as cancer of the bladder and urinary tract, as well as squamous cell carcinoma can also affect or invade the urethra which can affect the penis. They will often be treated in the same way as more common types of penile cancer.
Penile cancer is usually diagnosed by obtaining samples of a suspected cancerous area either by taking a biopsy or by surgically removing a small area of skin (wide local excision). These are minor procedures which are performed at a local hospital or clinic. It may also be identified following circumcision in men.
The tissue which has been removed will be analysed by histo-pathologists (medical scientists) who will be able to identify a specific type of cancer. The results will then be discussed by the specialist medical team, usually at a Multi-Disciplinary Team Meeting (MDT); a meeting of urologists, oncologists and other medical specialists who will then decide on the best course of action.
Because penile cancer is so rare men who are diagnosed with the disease will be referred to a regional treatment centre or supranetwork for further assessment. These centres have more specialised cancer teams with surgeons who specialise in treating penile cancer as well as specialist support services. In the UK the following hospitals act as supranetworks and men will be referred on an urgent basis to the nearest appropriate centre.
Investigations for penile cancer are used to determine the extent to which cancer may be affecting the local area or other parts of the body. These investigations are often referred to as staging investigations and may include some or all of the following.
Fine Needle Aspiration (FNA)
An ultrasound scan can be used to identify any enlarged lymph nodes (see below) around the groin area that may have been affected by possible cancer. A biopsy of these nodes using a surgical needle may be taken. The cells obtained will be sent for laboratory analysis to determine if they are cancerous or not. This procedure is performed under a local anaesthetic.
The Lymphatic System and Lymph Nodes
The human body is covered by a special type of drainage system called the lymphatic system. This system is responsible for transporting excess fluid from the organs and tissues of the body in a fluid called lymph. Lymph fluid will contain various types of cells and substances that are no longer needed. The lymph fluid will be transported through the lymphatic drainage system and pass through small nodules or nodes that act as filters. These are responsible for filtering out the unwanted substances. If one lymph node is not able to filter out the unwanted substances then the lymph fluid will move to the next one. Cancerous cells which break off from an organ which has cancer can also travel along this route and become trapped at the lymph nodes where they can then accumulate and infiltrate a different area of the body.
Computerised Tomography (CT Scan)
A CT scan checks for any signs of cancer which may have spread to other areas of the body. The CT scan takes a series of x-rays, which are fed into a computer to build up a three-dimensional picture of the inside of the body and will take from 10 to 30 minutes. Men may be given a drink or injection of a dye that allows particular areas to be seen more clearly. The scan is painless, but it will mean lying still for 10 – 20 minutes. A scan will be requested on a very urgent basis and will usually be performed within a few weeks of the request.
For further information on having a CT scan please click here
Positron Emission Tomography (PET)
This may be used to find out whether penile cancer has spread beyond the penis or to examine any residual areas of abnormality that remain after treatment to see whether they are scar tissue or whether cancer cells are still present. A PET scan uses low-dose radioactive sugar to measure the activity of cells in different parts of the body. A very small amount of a mildly radioactive substance is injected into a vein, usually in the arm. Areas of cancer which are usually more active than surrounding tissue then show up on the scan. It is not usually used on a routine basis but may be performed after initial treatment.
For further information on having a PET scan please click here
Magnetic Resonance Imaging (MRI)
This test can be used to provide further information about the extent of cancer which may be affecting the penis or other parts of the body and may be performed during treatment. It creates cross-sectional pictures of the human body. Some people are given an injection of dye into a vein in the arm to improve the image. During the scan men will be asked to lie very still on a couch inside a long chamber for up to an hour. This can be unpleasant if they don’t like enclosed spaces. MRI scanning is also very noisy and men will be given earplugs. The chamber is a very powerful magnet, so before entering the room men should remove any metal belongings.
Sometimes an injection may be given into the penis to cause an erection which may then help provide more detail of the area in the penis affected by cancer.
For further information on having an MRI scan please click here
Dynamic Sentinel lymph node biopsy
This procedure is used to detect cancer cells which may have spread into the lymph nodes closest to the penis on either side of the groin. It is not a procedure that is available in every part of the UK and men may be referred to a specialist centre for this procedure.
A local anaesthetic will first be applied to several areas of the penis and then a radioactive dye injected. X-rays will be taken of the area to visualise the lymph nodes in the groin. Once the lymph node nearest to the cancer has been identified the area will be marked with a special pen and then a surgical plaster will be applied. This procedure may take several hours.
An operation requiring a general anaesthetic will then be performed usually later on the same day in which a blue dye will be injected into the same areas of the penis as before. The dye will be absorbed by the lymph nodes and a special camera can then be used along with the X-rays from the previous procedure to identify the sentinel lymph nodes. These can then be removed by a small surgical incision. The operation may take around 45 minutes to perform.
Providing that men feel well enough after the operation they will usually be allowed home.
- Men will need to have a family member or friend who can make sure they are well for the next 24 hours.
- Dressings on the biopsy site can be removed after 48 hours when men should be able to bath or shower normally. They should use a clean towel or gauze dressing to pat dry the area.
- There may be small dissolvable stitches at the site of the biopsy and these may take a few weeks to fully dissolve.
- Men may experience some bruising or some swelling in the groin area. This is usually due to an accumulation of lymph fluid which will improve as the body heals.
Men should contact their health team if they experience any of the following problems:
- Persistent bleeding from the wound.
- Uncontrolled pain.
- A high temperature and shaking or feeling as if you have a bad cold which could be a sign of infection.
- Prolonged swelling, redness or a foul smelling discharge from around your wound site which could indicate localised infection.
Men will be given the results of their biopsy a few weeks later when the need for any further treatment will be discussed.
For information on how penile cancer is assessed (staged), please click here
References available on request.
Reviewed February 2022. Next review November 2022.