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Zuhirman Zamzami, 2019;3(1):050–054.

International Journal of Medicine in Developing Countries

Characteristic of penile cancer and the management in Arifin Achmad Regional General Hospital, Riau, Indonesia

Zuhirman Zamzami1*

Correspondence to: Zuhirman Zamzami

*Urology Division, Surgery Department, Medical Faculty, Riau University, Riau, Indonesia.

Email: zuhirman.zamzami [at] yahoo.com

Full list of author information is available at the end of the article.

Received: 21 November 2018 | Accepted: 11 December 2018


ABSTRACT

Background:

Penile cancer is one of the urological malignancies and is still one of the concerning health problems due to high incidence and morbidity. The aim of this study was to reveal the characteristics and management of penile cancer.


Methodology:

Medical records of penile cancer patients were reviewed in Arifin Achmad Regional General Hospital, Pekanbaru, Riau Province, Indonesia during 2011–2016. Thirty-five penile cancer patients were included in the study.


Results:

There were 35 penile carcinoma patients in Arifin Achmad Regional General Hospital of Riau Province, of which 22 (62.5%) were in the age group of 46–55 years. The highest number of patients belonged to ethnic group, namely Bataknese. Ulcer was the most common primary lesion found in 14 (40%) patients. Shaft of penile was the most frequent location of primary lesions found in 15 (42.8%) patients. The most frequent symptom was lumps on the penile found in 26 (74.2%) patients. The histopathological finding of all the patients was squamous cell carcinoma. Pathological grade of primary tumor was G1. Most frequent clinical stage found was stage II in 18 (51.4%) patients. The radiological imaging used was chest X-ray and abdominal ultrasound. Total penectomy was the most frequent management found by this study.


Conclusion:

Penile cancer in this hospital was characterized by elderly age, was affected by ethnic group, location was a penile shaft with the presence of a lump on penile, and squamous cell carcinoma with pathological grade G1. It was managed by total penectomy in the current hospital.


Keywords:

Penile cancer, characteristic, squamous cell carcinoma, penectomy.

Introduction

Penile cancer is a malignancy characterized by an uncontrolled cell growth and tends to invade and spread to other body tissues [1]. Until recent times, the exact cause of penile cancer is not clear. There were several studies that showed human papillomavirus (HPV) infection had correlation with penile cancer [13]. HPV subtypes 16 and 18 were considered as the subtypes that influenced the changes to malignancy due to condiloma acuminata [24]. This results in increasing penile cancers as male genital infections due to HPV [3,4].

Penile cancers were seldom found in circumcised men [5]. It was considered smegma as an accumulation, cheese like fluid, in front of uncircumcised penile glans skin, which stimulates chronic infection associated with penile cancers [5,6]. Besides, the patient body cleanliness factor also becomes this disease risk factor [7]. Based on several studies, penile cancer was highly correlated to gen p-53 mutation [5,7]. A study by Zhang showed gen p-53 overexpression of penile squamous cell carcinoma [7].

Penile cancer becomes a rare malignancy. Penile cancer incidences in America and Europe were small. It was reported that penile cancer incidence in America was 0.58 in 100,000 men, in which the incidence was 48% higher in low socio-economic people. Although its incidence was low, the disease mortality rate was quite high. Based on the report of the American Cancer Society, in 2015, there were 1,820 penile cancer patients and 310 (17%) of them died [8]. The mortality rate was quite high as compared with one of prostate cancers which was 3%, while in Europe, it was reported 1.33 per 100,000 men [8]. The incidence of penile cancer in Brazil was quite high, 2.9–6.8 in 100,000 men [8,9]. Lowest penile cancer incidence was reported in Israel [8,9]. The incidence of penile cancer in Asia-Pacific was quite high, 2.4 per 100,000 men [10]. The incidence of this disease was quite high in India as well, being 3.3 in 100,000 men [9]. In Indonesia, there were limited publications on the exact incidence rate of this disease. A study in Hasan Sadikin Hospital, Bandung showed the incidence of penile cancer in 1975–1984 was 6% of all urology malignancies [11].

Although the incidence of penile cancer was quite small, the patients often delayed the treatment because they were embarrassed; this resulted in an advanced stage of the disease [6]. The management of penile cancer might be partial penectomy or total penectomy with urinary diversion (perieostomy). External beam radiotherapy and chemotherapy might also be included in the management. It might influence the patient’s psychological status, emotional status, and sexual life [8].

Based on the above descriptions, the aim of this study was to evaluate the characteristics and the management of penile cancer in Arifin Achmad Regional General Hospital, Riau Province, Indonesia.

Subjects and Methods

The medical records of 35 penile cancer patients were reviewed in Arifin Achmad Regional General Hospital, Pekanbaru, Riau Province, Indonesia during 2011–2016. The research variables were age, ethnic group, lesion location and form, clinical symptoms, histopathological findings, tumor grading and staging, radiological examinations and the management. Statistical analysis used was univariate. Approval on the study was obtained from the Ethical Review Board for Medicine and Health Research, Medical Faculty, University of Riau.

Results

There were 35 penile cancer patients in this study. Age, ethnic group, lesion location and form, and clinical symptoms were shown in Table 1.

The histopathological findings of the patients were shown in Table 2.

The tumor stage and clinical stage of the disease of the penile cancer patients was shown in Table 3.

The radiological examinations performed were shown in Table 4.

The management by the present hospital for the patients was shown in Table 5.

Table 1. Penile cancer patients characteristics.

Characteristics N F (%)
Age (year)
<45
46–55
56–65
>65

4
22
7
2

11
62.5
20
5.7
Ethnic group
Minang
Malay
Java
Batak
Banjar

4
8
4
16
3

11.4
22.8
11.4
45.7
8.6
Primary lesion form
Ulcus
Papillary
Nodule

14
9
12

40
25,7
34,2
Primary lesion location
Glans
Shaft
Both

8
15
12

22
42.8
34.2
Clinical symptom
Lump
Ulcer
Nyeri
Hematuria
Voiding disturbance

26
18
20
10
11

74.2
51.4
57.1
28.5
31.4

Table 2. Histopathology and tumor grading findings in penile cancer patients.

Histopathology N F (%)
Squamous cell Ca
Non-squamous cell Ca
35
0
100
0
Tumor grading
G1 G2

22
13

62.8
37.2

Table 3. TNM and clinical staging.

TNM N (%)
T
TX
T1
T2
T3
T4

0
4
12
12
7

0
11.4
34.2
34.2
20
N
NX
N1
N2
N3
N4

7
18
7
3
0

20
51.4
20
8.5
0
M
MX
M0
M1

8
27
0

22.8
77.2
0
Clinical staging
I
II
IIIa
IIIb
IV

0
18
8
3
6

0
51.4
22.8
8.5
17.1

Table 4. Radiology examinations in penile cancer patients.

Radiology examination N F (%)
1. Abdominal ultrasound 23 65.7
2. Pelvic CT-Scan 13 37.1
3. KUB 16 457
4.Chest X-ray 23 6.7

Table 5. The management of penile cancer patients.

Management N F (%)
Primary management
Biopsy 10 28.5
Partial Penectomy 12 34.2
Total Penectomy 13 37.1
Secondary management
Meatoplasty 5 14.2
Urethroplasty 5 14.2
Perineostomy 10 28.5
Lymph node dissection 6 17.1
Additional management
Chemotherapy 12 34.2
Radiotherapy 6 17.1

Discussion

There were 35 penile cancer patients in this study. This study showed 46–55 years’ age group were mostly affected, i.e., 22 (62.5%) patients, and the least affected age group was >65 years that had two (5.7%) patients. This study results were similar to a study done by Prayoga and Tranggono [12] which showed that penile cancer was mostly (45.7%) in 40–60 years’ age group. This study results were also in line with a study done by Untung and Umbas [13] showed that there were 69 penile cancer patients in <30 years’ age group and >70 years’ age group, and most patients (26.1%) belonged to 40–50 years’ age group. Another study found that penile cancer was mostly (72.7%) found in 45–64 years’ age group [14].

Penile cancer was mostly suffered by old age men in –five to six decades of life. Penile cancer was highly associated with infections and inflammation, especially HPV, HIV, and chronic infection due to smegma accumulation in preputium.

This study results showed penile cancer patients were mostly 16 (45.7%) of Bataknese tribe. Similar result was found by a study done by Pakpahan [15], who found penile cancer patients mostly (66.7%) belonged to Bataknese tribe [15]. Although one study differed, where most patients (24.6%) were of Tionghoa tribe [12]. It was due to geographical and time differences of study populations.

Circumcision and self-hygiene might be risk factors for penile cancer. Smegma accumulation beneath the uncircumcised preputium skin resulted in chronic inflammation, which was highly correlated with penile cancer. Bataknese and Tionghoa were tribes which did not have obligation to undergo circumcision resulting in high incidence of penile cancers in these tribes [16].

This study showed that the most common 14 (40%) primary lesion of penile cancer was ulcer. The same result was found by a study that showed ulcer as the most common (40%) primary lesion [12]. Primary lesions that form penile cancer could be in several forms, such as ulcer, a nodule, or a papillary. The ulcer could be with high edge, irregular base, and enclosed by necrotic tissues. The patients might complaint of non-healing ulcers for a long time [17,18].

This study showed the location of the primary lesion in 15 (42.8%) penile cancer patients was the penile shaft. This study suited a study of Untung and Umbas (2008) who showed penile shafts were the most common (34.8%) primary lesions [12]. Another study by Prayoga and Tranggono [12] showed that most patients’ (68.4%) primary location was in the penile shaft. The primary locations of penile cancer to grow could be in preputium, penile glans, penile shaft, or mixed. The lesion location would influence the management of the disease. The farther the lesion location, the more penile tissue should be executed.

This study showed the lump of 26 (74.2%) patients in penile. Penile ulcer and pain were the most common clinical symptoms found in 18 (51.4%) and 20 (57.1%) patients, respectively. This result was in line with other studies that showed symptoms [14,19].

The final diagnosis of penile cancer was based on histopathological examination. The frequent initial symptom was a color change of the penile skin, which would develop into incurable lumps and ulcer. The penile skin change was frequent without pain resulting in delay for patients toward searching for the management. Discharge, hematuria, and voiding disturbances might follow the penile cancer symptoms [20].

This study showed all patients of penile cancer had squamous cell carcinoma in histopathological findings. This result was also found by a study done by Koifman et al. [21] that showed 230 (100%) penile cancer patients had squamous cell carcinoma in histopathological findings. Similar results were also found by Hansen et al. [22] that found 1,474 (92.4%) patients out of 1,596 had squamous cell carcinoma [22] and GranLand et al. [23] study found squamous cell carcinoma in 94% patients. Another histopathological finding of penile cancer patients was non-squamous cell carcinoma [24].

This study showed the penile cancer grading were mostly grade 1 (G1) in 22 (62.8%) patients, while grade 2 (G2) were in 13 (37.2%) patients. A study done by Chalya et al. [25] also found that G1 were in 60.6% patients, a study by Thiago (2014) found G1 in 79.6% patients [26], and a study by Sastrodiharjo [27] found G1 in 63.3%. The tumor grading was based on histopathological examination assessing the tumor cell differentiation to other surrounding tissues and cell mitosis. The tumor grading is important for assessing the tumor cell ability to invade other healthy tissues [28,29].

This study results showed that penile cancer staging was stage 2 in 18 (51.4%) patients. Based on TNM, this study showed T2 and T3 were both found in 12 (34.2%) patients. In N staging, N0 was the most frequent found in 18 (51.4%) patients, while in M staging, M0 was the most frequent in 27 (77.2%) patients. This result was along another study done by Junior et al. [30] that showed 42 (51%) of 82 penile cancer patients were in clinical staging II and also by another study with 56.9% patients [21].

This study result showed that most radiology examination used was abdominal ultrasound and chest X-ray each in 23 (65.7%) patients. Computed tomography (CT) scan of pelvis was the second most radiological examination used in 16 (45.7%) patients. This result was in line with a study done by Chalya et al. [25], who found abdominal plain X-ray and abdominal ultrasound were the most frequent radiological examinations in 68.6% of penile cancer.

The radiological examinations in penile cancer are used for assessing the local or farther metastasis and the clinical staging of the disease. Abdominal ultrasound is used for assessing tumor penetration to penile and lymph node enlargement. Abdominal ultrasound, chest X-ray, and CT scan of pelvic are used for assessing the distant metastasis [31].

This study results showed, the primary management of penile cancer was mostly total penectomy in 13 (37.1%) patients, followed by partial penectomy in 12 (34.2%) patients and the least used was biopsy of penile cancer found in 10 (28.5%) patients. Perineostomy was the secondary management found in 10 (28.5%) patients. Other secondary managements were meatoplasty, urethroplasty, and lymph node dissection each done in five (14.2%) patients. The additional managements were chemotherapy in 12 (34.2%) patients and radiotherapy in six (17.1%) patients. These results were similar to studies done by Untung and Umbas [13] and Chalya et al. [25].

The management of penile cancer consisted of primary management and lymph node management. The primary tumor management aims to omit the primary lesion, while the lymph node management is to overcome the micro metastasis. European Urology Association guideline (2009) on penile cancer managements is based on clinical staging according to TNM staging [32].

Conclusions

Penile cancer in the present hospital is characterized by elderly age, half of the patients were Bataknese, location was penile shaft, clinical symptom was lump on the penile, squamous cell carcinoma in histopathology, pathology grade G1 of primary tumor, stage II, chest X-ray and abdominal ultrasound as radiological examination, and managed by total penectomy.

Acknowledgment

None.


List of Abbreviations

CT Computed tomography

G1 Grade 1

HPV Human papillomavirus


Funding

None.


Declaration of conflicting interests

None.


Consent for publication

Informed consent was obtained from all participants.


Ethical approval

Approval on the study was obtained from the Ethical Review Board for Medicine and Health Research, Medical Faculty, University of Riau.


Author details

Zuhirman Zamzami1

  1. Urology Division, Surgery Department, Medical Faculty, Riau University, Riau, Indonesia

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How to Cite this Article
Pubmed Style

Zuhirman Zamzami. Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia. IJMDC. 2019; 3(1): 50-54. doi:10.24911/IJMDC.51-1523183252


Web Style

Zuhirman Zamzami. Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia. https://www.ijmdc.com/?mno=296049 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1523183252


AMA (American Medical Association) Style

Zuhirman Zamzami. Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia. IJMDC. 2019; 3(1): 50-54. doi:10.24911/IJMDC.51-1523183252



Vancouver/ICMJE Style

Zuhirman Zamzami. Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia. IJMDC. (2019), [cited October 15, 2021]; 3(1): 50-54. doi:10.24911/IJMDC.51-1523183252



Harvard Style

Zuhirman Zamzami (2019) Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia. IJMDC, 3 (1), 50-54. doi:10.24911/IJMDC.51-1523183252



Turabian Style

Zuhirman Zamzami. 2019. Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia. International Journal of Medicine in Developing Countries, 3 (1), 50-54. doi:10.24911/IJMDC.51-1523183252



Chicago Style

Zuhirman Zamzami. "Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia." International Journal of Medicine in Developing Countries 3 (2019), 50-54. doi:10.24911/IJMDC.51-1523183252



MLA (The Modern Language Association) Style

Zuhirman Zamzami. "Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia." International Journal of Medicine in Developing Countries 3.1 (2019), 50-54. Print. doi:10.24911/IJMDC.51-1523183252



APA (American Psychological Association) Style

Zuhirman Zamzami (2019) Characteristic of Penile Cancer and the Management in Arifin Achmad Regional General Hospital, Riau, Indonesia. International Journal of Medicine in Developing Countries, 3 (1), 50-54. doi:10.24911/IJMDC.51-1523183252