238. Cancer of Penis

Question 1

Penis Cancer

• epidemiology
• demographics
• what do you need to get it
• RF groups

Answer 1

Epi: RAREST GU cancer, lower incidence in industrialized
Demo: 50-70yo (old), Hispanics > AA=white > Asian
Overall incidence decreasing

Only occurs in men who were not circumcised as neonate (neonatal circumcision eliminates risk)

RF

1. HPV assoc (# infections, HIV+)
2. Chronic Inflammation: phimosis (cannot retract foreskin), poor hygeine, smegma, tobacco, genital lichen sclerosis

Question 2

Penis Cancer

• signs and sx (where common locations)
• what is a pitfall of clinical staging

Answer 2

Erythematous precursor lesion
visible/palpable mass: Glans > Prepuce > Shaft (large/atypical wart, frank ulceration)

CP:
CIS - raw/inflamed
Exophytic mass/ulceration can be purulent
Penile Ca: pain, periodic bleeding, purulent discharge, 40-80% have BILATERAL inguinal LNs, mets to liver, lung, bone brain (rare at initial dx)

Pitfall: 30-60% palpable LNs are due to reactive lymphadenitis (HPV, chronic inflammation) - NOT mets, but <60% harbor metastatic disease, but 95% with untx mets will die in 3 years (CRITICAL TO MANAGE LNs)

Question 3

Signs sx of malignant mets to penis

common primary sites that met to penis

Answer 3

Sx: priapism, palpable mass, pain, hematuria, urethra bleeding

From: GU (bladder, prostate), GI tract, Lung, Melanoma, Primary Osseus tumor

Question 4

HPV related lesions

• Erythroplasia of Queyrat: define, tx
• Bowen’s disease: define, tx
• Bowenoid Papulosis: gross, histo
• Condyloma Acuminata: cause
• Penile Intraepithelial Neoplasia: types

Answer 4

E of Queyrat: erythema on urethra meatus/glans/prepuce (tx excision/biopsy, laser, topical 5FU, Mohs micrographic surgery)
Bowens Disease: erythema on shaft (tx excision biopsy laser Mohs)
Bowenoid Papulosis: variant of PeIN
- gross: dark papules on shaft
- histo: squamous dysplasia, koilocytes

Condyloma Acuminata: HPV 6,11

PeIN: undifferentiated types (basaloid, warty)

Question 5

Non HPV Related Lesions

• Lichen Sclerosis: define
• Leukoplakia of Penis: define
• Cutaneous Penile horn: define
• PeIN: types

Answer 5

LS: pale tissue around meatus, meatal stenosis/stricture, involvement of foreskin, glans, shaft

Leukoplakia: white patches, ulceration, erythema on penis

Cutaneous horn: exuberant squamous hyperplasia, CIS

PeIN: differentiated type

Question 6

Primary Tumor Mgmt: Superficial vs. Deep

Answer 6

Superficial (tissue Preserving)

• local excision
• circumcision
• topicals - 5FU cream
• Mohs micrographic surgery
• local irradiation
• laser surgery

Deep Invasive Lesion: invades corpus cavernosum/spongiosum

• distal: partial penectomy/reconstitute urethra
• proximal: total penectomy/perineal urethrostomy (pt must sit to urinate)

Question 7

What is the Gold Standard to identify Mets?

What is the Regional 1st and 2nd echelon drainage for penis cancer?

when is lymphadenectomy performed?

What makes up the femoral triangle?

Answer 7

PE inguinal region (CT/MRI only if obese)

1st echelon: superficial and deep inguinal LNs (bilaterally)
2nd: from inguinal LNs to ext iliac nodes

LND: both dx and therapeutic, dissection performed 1 level above positivity

• persistently palpable mets
• poorly differentiated primary tumor
• stage T2 or greater
• histo shows angiolymphatic invasion

triangle: inguinal ligament, sartorius m, adductor longus m. (cancer is terminal if mets beyond here)

Question 8

What determines poor prognosis in penis cancer (4 factors)?

Answer 8

1. Bilateral inguinal LNs
2. > 2 inguinal LNs
3. Extracapsular tumor
4. Pelvic LN involvement

Question 9

Mgmt for advanced stage disease

- most common extra nodal met site

Answer 9

Consider neoadjuvant radiation when surgery alone not curative

Immunotherapy

• EGFR inhibitors
• PD1, PDL1 inhibitors

Most common extra-nodal mets: lung, liver, bone