SUNARYO HARDJOWIJOTO

Profesor of Urology
Department of Urology
Airlangga School of Medicine
Dr. Soetomo Hospital
Surabaya-Indonesia

EPIDEMIOLOGY

A rare malignancy with incidence 0,3-8%/100.000

population
High incidence in South America/Brazil-8%
Low incidence in countries with traditional early
circumcision (Israel, Middle East)
In Indonesia highest incidence in BALI (B.
Laksono)
In Soetomo Hospital Surabaya :

Misra et al 2004 : Lancet Oncology 5(4) : 240-247

Stancik & Holtl 2003 : Curv. Opin. Urol : 13(6) : 467-472
Dept. Urologi FK Unair/RSDS

ETIOLOGY
RISK

FACTORS :

Phimosis

chronic infection of the glans & prepuce

(chronic balanoposthitis)
Persistent infection with human papilloma virus (HPV) in 30%
of Penile Cancer
Chronic inflammatory conditions :
Lichen sclerosis et atrophicus (LSA) 5-10%
will develop
squamous cell carcinoma
Smoking
Penile intra epithelial neoplasia

PATHOLOGY
95%

squamous cell carcinoma

5% melanoma, basalioma
etc
STAGING: TNM system
GRADING

: based on Broders system

PROGNOSTIC FACTORS : T, Grade, N

STAGING, TNM
T : primary tumor
SYSTEM :
TX
TO
Tis
Ta
T1
T2
T3
T4

Primary tumor cannot be assessed

No evidence of primary tumor
Carcinoma in situ
Non-invasive verrucous carcinoma
Tumor invades subepithelial connective
tissue
Tumor invades corpus spongiosum or cavernosum
Tumor invades urethra or prostate
Tumor invades other adjacent structures

N : Regional Lymph nodes

NX
N0
N1
N2
N3

Regional lymph nodes cannot be assessed

No Regional lymph node metastasis
Metastasis in a single superficial inguinal lymph node
Metastasis in multiple or bilateral superficial inguinal lymph node
Metastasis in deep inguinal or pelvic lymph node(s), unilateral or bilateral

M : Distant metastasis
M0
M1

No Distant metastases
Distant metastases positive

CLINICAL FEATURES

Chief Complain :
The

presence of the primary lesion

of inguinal lymph node

Involment/enlargement

Primary Tumor :
Mostly

originates in the sulcus coronarius glans or foreskin

retractile prepuce
Foul smelling penile discharge
Non

CLINICAL FEATURES

Regional Mode :
Unilateral/bilateral
Signs

enlargement of inguinal lymphnode

of inflammation : hyperanima, pain, edema

Signs of Metastases :
Lymphatic

obstruction, lumb edema

obstruction
Bone pain
Ureteral

MANAGEMENT
Primary

Tumor :

Tis, Ta,T1, G1-2

: - simple excision (circumcion),
glanulectomy (glan excision)
- laser surgery : CO2, Nd YAG
- Radiotherapy (<4cm)
T2-3
: - amputation, partial or total with
T4

radiation

perineostomy
- palliative surgery, chemotherapy,

Regional Lymph node :

N0

: Surveillance, dynamic sentinel

node biopsy
N1
: Inguinal LND
N2-3 : - Chemotherapy
- Radiotherapy

DISTANT MESTASTASES
CHEMOTHERAPY :
Cisplatin

and 5-fluorouracil
Vincristine, MTX, Bleomycin (12
weekly courses)

RESULT
Local

recurrence
Stenosis of neourethra
5 y SR :
node
Bilateral/multinode
Single

Hard/fixed

prognosis

nodes

: 19 37%
: 5 10%

: 70%
: 50%

: poorly