Penile tumours
How penile squamous cell carcinoma arises by two routes, high-risk HPV or chronic inflammation under a tight foreskin, through intraepithelial neoplasia to invasion of the erectile bodies and a predictable spread to the groin nodes.
By the end, you can
- Relate the epithelium and deeper tissues of the penis to the tumours that arise from them.
- Contrast the HPV-associated and HPV-independent pathways to penile squamous cell carcinoma, including their precursors.
- Describe the appearance of penile intraepithelial neoplasia and of the main types of invasive carcinoma.
- Explain how the carcinoma invades the corpora and spreads, stepwise, to the inguinal and pelvic lymph nodes.
- Relate the findings of penile cancer, including late presentation under a tight foreskin, to their mechanisms.
- Recognise the classic appearances, staging and tests of penile cancer, including sentinel node biopsy, and explain how topical treatment, organ-sparing surgery, node surgery and radiotherapy act on its mechanism.
What it is
Almost all malignant tumours of the penis are squamous cell carcinomas of the glans, coronal sulcus or inner foreskin. They arise by two routes: HPV-associated, driven by persistent high-risk human papillomavirus, and HPV-independent, driven by chronic inflammation and scarring such as lichen sclerosus under a tight foreskin. Each has its own precursor, penile intraepithelial neoplasia (PeIN). Melanoma, basal cell carcinoma, sarcomas and metastases are rare.
3 types to tell apart
- HPV-associated PeIN and carcinoma
- High-risk HPV (mostly type 16) produces basaloid or warty PeIN, with atypia through most of the epithelium, and basaloid or warty carcinomas. Older clinical names for in-situ disease, erythroplasia of Queyrat, Bowen disease and bowenoid papulosis, describe this lesion.
- HPV-independent (differentiated) PeIN and carcinoma
- Arises in skin scarred by lichen sclerosus or chronic inflammation; atypia is subtle and confined to the lower layers while the surface keratinises. It leads to the usual keratinising carcinoma and to verrucous and papillary types.
- Rare non-squamous tumours
- Melanoma of the glans, basal cell carcinoma of the shaft skin, Kaposi sarcoma (HHV-8, especially with HIV), other sarcomas, and metastases from the bladder, prostate or rectum into the corpora.
US spelling: tumours → tumors, tumour → tumor.
Normal function
Epithelium over erectile bodies
The and the inner surface of the foreskin are covered by a moist, thinly keratinised stratified squamous epithelium; the shaft is covered by thin, hair-bearing skin. Beneath the epithelium of the glans lies a thin lamina propria, then the spongy erectile tissue of the , which carries the . Deeper still, the two are wrapped in the tough tunica albuginea.
These layers matter for cancer: a tumour that starts in the epithelium of the glans meets the lamina propria first, then the corpus spongiosum, then the corpora cavernosa, each richer in vascular spaces than the last. The rim of the glans, the , and the groove behind it, the coronal sulcus, lie under the foreskin where secretions collect.
Lymph from the foreskin and shaft skin drains to the superficial inguinal nodes, and from the glans and erectile bodies to the superficial and deep inguinal nodes; from the groin it passes on to the pelvic (iliac) nodes. Lymphatic channels cross the midline, so either groin can receive lymph from either side.
| Feature | Benign or precursor | Malignant |
|---|---|---|
| Squamous epithelium (glans, foreskin) | Condyloma (HPV 6, 11); PeIN, HPV-associated or differentiated | Squamous cell carcinoma: the great majority |
| Melanocytes | Naevus, melanosis | Melanoma (rare) |
| Shaft skin | Benign skin lesions | Basal cell carcinoma (rare) |
| Vessels and connective tissue | Haemangioma, angiokeratoma | Kaposi sarcoma (HHV-8), other sarcomas (rare) |
| Erectile bodies | None common | Metastases from bladder, prostate or rectum (rare) |
Simplified from the WHO classification; squamous cell carcinoma makes up about 95% of penile cancers.
Underlying change · Step 1 of 5
Two routes: high-risk HPV or chronic inflammation
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Underlying change · Step 2 of 5
Penile intraepithelial neoplasia
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Disrupted function · Step 3 of 5
Invasive squamous cell carcinoma
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Disrupted function · Step 4 of 5
Into the corpora and on to the groin nodes
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Consequences · Step 5 of 5
Hidden under the foreskin: how it shows itself
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Symptoms and signs
Symptoms, signs and findings
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Exam detail
Exam detail
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Treatment
How treatment works
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Recap
Recap
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .
Self-check
Check your understanding
The full lesson is part of Student Pro
It takes you through all 5 steps of the mechanism, explains the symptoms, signs and findings each step causes, adds the exam detail and how treatment works where the lesson has them, then recaps it and lets you check yourself with 10 self-check questions. The full pathophysiology library: guided lessons with self-check questions comes with Student Pro, with 100 tutor answers a month and the full available catalogue.
Free to read: the introduction and .