Cancer of the Penis the Staging, Grading and Treatment

The staging of a cancer is a term used to describe its size and whether or not it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the best treatment for you.

• Stage 1 The cancer only affects the skin covering the penis, the head of the penis (glans) or the foreskin.

•   Stage 2 The cancer has begun to spread into the shaft of the penis or into one of the lymph nodes in the groin.

•   Stage 3 The cancer has spread deep into the shaft of the penis or to many lymph nodes in the groin.

•   Stage 4 The cancer has spread to lymph nodes deep in the pelvis, or to other parts of the body.

If your cancer comes back after initial treatment, this is known as recurrent cancer.

Grading
Grading refers to the appearance of the cancer cells under the microscope and gives an idea of how quickly the cancer may develop. Low-grade means that the cancer cells look very like normal cells; they are usually slow-growing and are less likely to spread. In high-grade tumors, the cells look very abnormal, are likely to grow more quickly, and are more likely to spread.

Treatment There are many types of treatment for penile cancer including surgery, radiotherapy and chemotherapy. Surgery of the penis has now advanced to a stage now where it doesn't mean the loss of the penis. It is also possible to now reconstruct a penis that has been operated on.

The type of treatment that you are given will depend on a number of things, including the position and size of the cancer, whether or not it has spread, the grade of the cancer, and your general health.

Men with cancer of the penis should be treated in a specialist cancer center.

Surgery
Small, surface cancers that have not spread are treated by removing only the affected area. The cancer can be removed with conventional surgery, using laser or by freezing (cryotherapy). Cryotherapy is carried out with a cold probe, which freezes and kills the cancer cells.

If the cancer is affecting only the foreskin, it may be possible to treat it with circumcision alone.

All the above treatments can usually be given to you as an outpatient. They may be done under local or general anesthetic, depending on individual circumstances.

Wide local excision If the cancer has spread over a wider area, you will need to have an operation known as a wide local excision. This means removing the cancer with a border of healthy tissue around it. This border of healthy tissue is important as it reduces the risk of the cancer coming back in the future. The operation is done under general anesthetic and will involve a short stay in hospital.

Removing the penis (penectomy) This may be advised if the cancer is large and is covering a large area of the penis. Amputation may be partial (where part of the penis is removed) or total (removal of the whole penis). The operation most suitable for you depends on the position of the tumor. If the tumor is near the base of the penis, total amputation may be the only option.

The surgeon may also remove lymph nodes from the groin if there is evidence that cancer cells have spread to these nodes, or a possibility that they may have.

Re constructive surgery It is often possible to have a penis reconstructed after amputation. This requires another operation. The techniques that may be used include taking skin and muscle from your arm, and using this to make a new penis. Sometimes it is also possible for surgeons to reconnect some of the nerves, to provide sensation and the necessary blood flow to allow the reconstructed penis to become erect. This type of surgery is carried out by surgeons who have specialist experience, and you may need to travel to a specialist hospital to have the surgery done.

Radiotherapy
Radiotherapy treats cancer using high-energy rays to destroy cancer cells, while doing as little harm as possible to healthy cells. It can be used before or after surgery. Radiotherapy may also be given to treat symptoms, such as pain, if the cancer has spread to other parts of the body, like the bones.

External radiotherapy is normally given as a series of short daily treatments in the hospital's radiotherapy department. High-energy x-rays are directed from a machine at the area of the cancer. The treatments are usually given from Monday to Friday, with a rest at the weekend. Each treatment takes 10-15 minutes. The number of treatments will depend on the type and size of the cancer, but the whole course of treatment for early cancer will usually last for up to six weeks. Your doctor will discuss the treatment and possible side effects with you.

Before each session of radiotherapy, the radiographer will position you carefully on the couch and make sure that you are comfortable. During your treatment you will be left alone in the room, but you will be able to talk to the radiographer who will be watching you carefully from the next room.

Radiotherapy is not painful, but you do have to lie still for a few minutes while your treatment is being given. The treatment will not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.

Radioactive implants Radiotherapy can be given using a radioactive implant. This is also known as brachytherapy. Under a general anesthetic, small radioactive wires are very carefully positioned in the affected area of the penis. The wires stay in place for about 4-5 days and are then removed. This method of treatment is usually used for smaller cancers on the end of the penis (the glans). While the implant is in place, you need to stay in an isolated room in the hospital so that other people are not exposed unnecessarily to the radiation.

Side effects of radiotherapy
There are sometimes side effects from radiotherapy treatment to the penis. Towards the end of your treatment, the skin on your penis can become sore and may break down. Long-term, radiotherapy can cause thickening and stiffening of healthy tissues (fibrosis). In some men, this can result in narrowing of the tube that carries urine through the penis (the urethra) and so can cause difficulty in passing urine. If narrowing of the urethra does develop, it can usually be relieved by an operation to stretch (dilate) the area. This is done by passing a tube into the urethra and is performed under a general anesthetic.

Chemotherapy
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. It can be one drug or several drugs used together. It is not commonly used to treat cancer of the penis. Chemotherapy cream may sometimes be used to treat very small, early cancers that are confined to the foreskin and end of the penis (glans).

Chemotherapy may also be given as tablets, or by injection, into a vein for more advanced cancer. It may be given along with surgery or radiotherapy (or both).