Campbell Penile CA Review + NCCN Penile 2021 Flashcards

Question

Standard treatment of choice for condyloma

Answer 1

Imiquimod cream

Answer 2

Bowenoid papulosis Bowen disease Erythroplasia of Queyrat

Answer 3

H&P Risk factors ◊ Balanitis, chronic inflammation, penile trauma, lack of neonatal circumcision, tobacco use, lichen sclerosus, poor hygiene, sexually transmitted disease Lesion characteristics ◊ Diameter, location, number of lesions, morphology (papillary, nodular, ulcerous, or flat), relationship to other structures (submucosal, corpora spongiosa, cavernosa, and/or urethra) • Histologic diagnosis Punch, excisional, or incisional biopsy Assess HPV status

Answer 4

``` Topical therapyb or b Wide local excision or b Laser therapy (category 2B) or Complete glansectomy or Mohs surgery in select cases (category 2B) ```

Answer 5

Wide local excisionb or c,d Partial penectomy or b Glansectomy in select cases or b Mohs surgery in select cases or b Laser therapy or d Radiotherapy

Answer 6

``` Wide local excisionb or c,d Partial penectomy or c,d Total penectomy or Radiotherapy or Chemoradiotherapy ```

Answer 7

Partial penectomyc,d | or c,d Total penectomy or RT or chemoRT

Answer 8

LOW RISK: Surveillance ``` INTERMEDIATE/HIGH RISK T1b Any T2 or greater -- chest CT and abdominal/pelvic CT -- ILND or DSNB ```

Answer 9

Low-risk primary lesion --> percutaneous LNB --> if negative, excisional biopsy or surveillance; if positive, ILND, consider NAC then ILND High-risk primary lesion: ILND or consider NAC then ILND --> if pN1, surveillance; if pN2-3: PLND± adjuvant RT or chemotherapy or chemoRT or chemoRT or chemotherapy

Answer 10

Cisplatin-based neoadjuvant chemotherapy followed by ILND c (preferred), consider PLND or c ILND (preferred), consider PLNDc (in patients not eligible for cisplatin-based chemotherapy) if 0-1 positive nodes with viable disease --> surveillance if =>2 positive nodes or extranodal extension --> adjuvant chemotherapy and/or if pelvic nodes positive, adjuvant RT or chemoRT OR RT OR Chemoradiotherapy

Answer 11

Negative biospsy ==> excisional biopsy --> negative, surveillance; if positive --> NAC --> if responsive: ILND and PLND, or RT or chemoRT Positive biopsy --> NAC --> then if responsive --> ILND and PLND or RT or chemoRT If not eligible for NAC --> ILND and PLND or RT or chemoRT then: surveillance

Answer 12

Negative biopsy --> manage according to LN status Positive biopsy: SURGICAL candidate --> NAC --> imaging of chest/pelvis/abdomen --> stable or clinical response --> consolidation surgery Disease progression or non-resectable --> XXX NON-SURGICAL candidate --> chemoRT --> surveillance

Answer 13

``` Initial treatment: • Topical therapy • Laser therapy • Radiation/Chemoradiation therapy • Wide local excision • Glansectomy • Mohs surgery ==> Clinical exam: years 1–2, every 3 mo then years 3–5, every 6 mo then years 5–10, every 12 mo ``` • Partial penectomy • Total penectomy ==> Clinical exam years 1–2, every 6 mo then years 3–5, every 12 mo

Answer 14

Nx: Clinical exam:x,y years 1–2, every 3 mo then years 3–5, every 6 mo N0,N1: Clinical exam:x,y years 1–2, every 6 mo then years 3–5, every 12 mo N2,N3: • Clinical exam:x years 1–2, every 3–6 mo then years 3–5, every 6–12 mo Imaging: g Chest (CT or x-ray) ◊ years 1–2, every 6 mo Abdominal/pelvic (CTg or MRIg) ◊ year 1, every 3 mo then ◊ year 2, every 6 mo

Answer 15

Treat according to recurrence stage

Answer 16

Single, mobile, <4cm LN --> percutaneous LN biopsy --> if negative, surveillance; if positive, ILND, then if pN1, surveillance; if pN2-3 --> PLND ± adjuvant chemotherapy or chemoRT OR Chemoradiotherapy OR Chemotherapy

Answer 17

Fixed node, ≥4 cm node, or cN2/N3 disease --> Perc. LN biopsy --> treat accordingly ``` Chemotherapy then ILND OR ILND OR ChemoRT (if no prior RT) ``` Then surveillance

Answer 18

Systemic chemotherapy Cross-sectional imaging of chest/abdomen/pelvis Complete/partial response or stable --> consolidation surgery --> surveillance No response: subsequent line systemic therapy or consider radiotherapy for local control or clinical trial/best supportive care

Answer 19

• For patients with Tis or Ta disease: | Imiquimod 5%, apply at night three times per week for 4–16 weeks. 5-FU cream 5%, apply twice daily for 2–6 weeks.

Answer 20

selected (clinical stage Tis, Ta, and T1 Grade 1–2) primary penile tumors Application of 3%–5% acetic acid to the potentially affected genital skin can be used to identify suspected sites of human papillomavirus (HPV)-infected skin that turns white upon exposure smoke) evacuator is required during penile laser treatments CO2, Nd:YAG, KTP

Answer 21

Early stage penile cancer Margins depend on location: - Shaft = wide local excision, with or without circumcision - Distal prepuce = circumcision alone STSG or FTSG Positive margins = re-resection may be considered Glans resurfacing in highly select patients

Answer 22

• Mohs surgery is an alternative to wide local excision in select cases. Thin layers of cancerous skin are excised and viewed microscopically until a tissue layer is negative for the tumor. Allows for increased precision, though the success rate declines with higher stage disease. • May be preferable for a small superficial lesion on the proximal shaft to avoid total penectomy for an otherwise fairly low-risk lesion.

Answer 23

Standard for high-grade Functional penile stump must be preserved, negative margins must be obtained Partial or total penectomy when invasion into corpora cavernosa is necessary to achieve negative margins INTRAOP FROZEN sections to determine margins

Answer 24

Standard or modified ILND or DSNB is indicated in patients with penile cancer in the absence of palpable inguinal adenopathy if high-risk features for nodal metastasis are seen in the primary penile tumor: Lymphovascular invasion ≥pT1G3 or ≥T2, any grade >50% poorly differentiated • DSNB is only recommended if the treating physician has experience with this modality. • If positive lymph nodes are found on DSNB, ILND is recommended. • PLND should be considered at the time or following ILND in patients with ≥2 positive inguinal nodes on the ipsilateral ILND site or in the presence of extranodal extension on final pathologic review. • A bilateral PLND should be considered either at the time or following ILND in patients with ≥4 positive inguinal nodes (in total among both sides).1

Answer 25

TIP: paclitaxel, ifosfamide, cisplatin NAC with TIP preferred (prior to ILND) for >= 4 cm ILN if fNA is positive for metastatic penile CA **Patients not eligible to receive TIP and are surgical candidates should undergo surgery without neoadjuvant chemotherapy.

Answer 26

Preferred regimen: TIP Other: 5-FU + cisplatin ``` Consider adjuvant EBRT or chemoRT for patients with high-risk features: PLN metastates Extranodal extension Bilateral inguinal LNs involved 4-cm tumor in LNs ```

Answer 27

Preferred: - Clinical trial - Pembrolizumab if unresectable or metastatic microsatellite instability high (MSI-H) or mismatch repair-deficient (dMMR) Useful in Certain Circumstances - Paclitaxel - Cetuximab

Answer 28

Preferred: - Cisplatin alone or combination with 5-FU - Mitomycin C in combination with 5-FU Oher: - Capecitabine

Answer 29

Paclitaxel 175 mg/m2 IV over 3 hours on Day 1 Ifosfamide 1200 mg/m2 IV over 2 hours on Days 1–3 Cisplatin 25 mg/m2 IV over 2 hours on Days 1–3 Repeat every 3 to 4 weeks

Answer 30

Continuous infusion 5-FU 800–1000 mg/m2/day IV on Days 1–4 or Days 2–5 Cisplatin 70–80 mg/m2 IV on Day 1 Repeat every 3 to 4 weeks