Campbell Penile CA Review + NCCN Penile 2021 Flashcards
Penile lesion NOT associated with viral infection
BXO
Associated with viruses: HPV infection: Condyloma Bowenoid Erythroplasia of Queyrat
HHV-8:
Kaposi sarcoma
Infection associated with cervical dysplasia: ___
HPV infection: principal etiologic agent in cervical cancer
Major difference between Bowen disease vs. Erythroplasia of Queyrat
Location!
Queyrat: Glans penis or prepuce
Bowen disease: penile shaft skin, perineal, genitalia
Kaposi sarcoma etiologic agent
Human Herpesvirus 8
Where do penile cancers most commonly arise?
Glans
Glans (48%)
Prepuce (21%)
Risk factors for development of SCCA of the penis: ___
Smoking
HPV infection
Phimosis
Tobacco chewing
Campbell: Gonorrhea NOT a risk factor
NCCN: STD = risk factor
Preventive strategies to decrease incidence of penile cancer: ___
HPV vaccination
Daily genital hygiene
Avoid tobacco
Circumcision before puberty
CampbellReview: Adult circumcision appears to offer little or no protection from subsequent development of the disease.
Campbell review TRUE statements:
Cancer may develop anywehere on the penis
Phimosis may obscure the nature of the lesion
Penetration of Buck fascia and tunica albuginea –> permits invasion of the vascular corpora
Cancer cells reach contralateral inguinal region –> lymphatic cross communications at the base of the penis
Penile cancer initial spread: ___
Metastasis initially involves inguinal lymph nodes above the fascia lata
The lymphatics of the prepuce form a connecting network that joins with the lymphatics from the skin of the shaft. These tributaries drain into the superficial inguinal nodes (the nodes external to the fascia lata)
Hypercalcemia in penile cancer
Parathyroid hormone-like substances released from the tumor. Parathyroid hormone and related substances may be produced by both tumor and metastases that activate osteoclastic bone resorption.
Imaging with 100% sensitivity for cavernosal invasion: ___
Ultrasonography
Stage T2 tumors: ___
Invade the corpus spongiosum but not the cavernosum
Strongest prognostic factor for survival of penile cancer: ___
The extent of lymph node metastasis.
The presence and extent of metastasis to the inguinal region are the most important prognostic factors for survival in patients with squamous penile cancer.
Criteria for curative resection (> 70% 5-yr survival) in patients treated for LN mets: ___
no more than two positive inguinal lymph nodes.
no positive pelvic lymph nodes.
absence of extranodal extension of cancer.
unilateral metastasis.
LN > 4 cm is often associated with extranodal extension of cancer
Surgical staging is strongly considered in: ___
palpable adenopathy.
stage T1b or greater primary tumor.
presence of vascular invasion in primary tumor.
presence of predominantly high-grade cancer in primary
tumor.
Inguinal procedures for non-palpable adenopathy: ___
(1) dynamic sentinel node biopsy,
(2) superficial dissection,
(3) modified complete dissections, and
(4) laparoscopic and robotic approaches.
Adjuvant or neoadjuvant chemotherapy for the following: ___
single pelvic nodal metastasis
extranodal extension of cancer
fixed inguinal masses
single 6-cm inguinal lymph node
Histology of majority of penile cancers: ___
SCCA
** The majority of tumors of the penis are squamous cell carcinomas demonstrating keratinization, epithelial pearl formation, and various degrees of mitotic activity.
Chemotherapeutic agent with significant pulmonary toxicity
Bleomycin
** Response rates of bleomycin, whether as a single agent or in combination with other agents, has not been shown to be superior to cisplatin alone, but has been associated with significant pulmonary toxicity and death in several series of patients treated for metastatic penile cancer.
Primary penile melanoma is rare because: ___
Penile skin is protected from exposure to the sun.
Melanoma and basal cell carcinoma rarely occur on the penis, presumably because the organ’s skin is protected from exposure to the sun.
Lymphomatous infiltration of the penis is most likely due to: ___
Diffuse disease
** When lymphomatous infiltration of the penis is diagnosed, a thorough search for systemic disease is necessary.
Most frequent sign of metastatic involvement of the penis: ___
Priapism
** The most frequent sign of penile metastasis is priapism; penile swelling, nodularity, and ulceration have also been reported.
Bushcke-Lowenstein tumor vs. condyloma acuminatum
The Buschke-Löwenstein tumor differs from condyloma acuminatum in that condylomata, regardless of size, always remain superficial and never invade adjacent tissue.
Buschke-Löwenstein tumor displaces, INVADES, and destroys adjacent structures by compression. Aside from this unrestrained local growth, it demonstrates no signs of malignant change on histologic examination and does not metastasize.
Treatment for small lesions of erythroplasia of Queyrat
Topical 5% 5-FU
Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
Local excision
Imiquimod
Standard treatment of choice for condyloma
Imiquimod cream
3 types of penile Tis
Bowenoid papulosis
Bowen disease
Erythroplasia of Queyrat
Initial evaluation of suspicious penile lesion:
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
PRIMARY TREATMENT
Tis or Ta
Topical therapyb or b Wide local excision or b Laser therapy (category 2B) or Complete glansectomy or Mohs surgery in select cases (category 2B)
PRIMARY TREATMENT
T1
Grade 1-2
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
PRIMARY TREATMENT
T1
Grade 3-4
Wide local excisionb or c,d Partial penectomy or c,d Total penectomy or Radiotherapy or Chemoradiotherapy
PRIMARY TREATMENT
T2 or greater
Partial penectomyc,d
or c,d Total penectomy or RT or chemoRT
NON-PALPABLE INGUINAL LNs
LOW RISK:
Surveillance
INTERMEDIATE/HIGH RISK T1b Any T2 or greater -- chest CT and abdominal/pelvic CT -- ILND or DSNB
PALPABLE INGUINAL LNs, NON-BULKY
after Chest CT + abdominal/pelvic CT
Unilateral LN <4 cm mobile
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
PALPABLE INGUINAL LNs,
BULKY
Unilateral lymph nodes
≥4 cm (mobile) –> percutaneous LN biopsy
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
PALPABLE INGUINAL LNs BULKY
Unilateral lymph nodes (fixed)n or bilateral lymph nodes (fixed or mobile) –> percutaneous LN biopsy
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
ENLARGED PELVIC LNs
Percutaneous biopsy if technically feasible
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
SURVEILLANCE SCHEDULE
Anatomic Site
Primary lesion
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
LNs
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
RECURRENT DISEASE
Recurrence of penile lesion:
Treat according to recurrence stage
RECURRENT DISEASE
Local recurrence in inguinal region
No prior inguinal lymphadenectomy or RT
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
RECURRENT DISEASE
Local recurrence in inguinal region
Prior inguinal lymphadenectomy or RT
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
METASTATIC DISEASE
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
TOPICAL THERAPY
• 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.
LASER THERAPY
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
Wide Local Excision
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
Mohs Micrographic Surgery
• 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.
Penectomy
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
Surgical management for inguinal and pelvic LNs
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
NAC prior to ILND or PLND
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.
Adjuvant chemotherapy after ILND or PLND
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
Subsequent-line Systemic Therapy for Metastatic Disease
Preferred:
- Clinical trial
- Pembrolizumab if unresectable or metastatic microsatellite instability high (MSI-H) or mismatch repair-deficient (dMMR)
Useful in Certain Circumstances
- Paclitaxel
- Cetuximab
Radiosensitizing Agents and Combinations (ChemoRT)
Preferred:
- Cisplatin alone or combination with 5-FU
- Mitomycin C in combination with 5-FU
Oher:
- Capecitabine
TIP regimen
preferred
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
5-FU + cisplatin regimen (not recommended for neoadjuvant setting)
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
What is the incidence of penile cancer in Europe and USA?
<1.0/100,000
In what country is penile cancer the most common male malignancy?
Uganda
it is also more common in India and Brazil 8.3/100,000
What are the risk factors for penile cancer?
Phimosis
HPV
Smoking
Penile cancer are caused by HPV in what % of cases?
45%
Penile cancer T1?
Tumour invades subepithelial connective tissue
Penile cancer T1a?
Tumour invades subepithelial connective tissue without lymphovascular invasion and is not poorly differentiated
Penile cancer T1b?
Tumour invades subepithelial connective tissue with lymphovascular invasion or is poorly differentiated
Penile cancer T2?
Tumour invades corpus spongiosum with or without invasion of the urethra
Penile cancer T3?
Tumour invades corpus scavernosum with or without invasion of the urethra
Penile cancer N1?
p?
Palpable mobile unilateral inguinal lymph node
Metastasis in one or two inguinal lymph nodes
Penile cancer N2?
p?
Palpable mobile multiple or bilateral inguinal lymph nodes
Metatstasis in more than two unilataeral inguinal nodes or bilateral inguinal lymph nodes
Penile cancer N3?
p?
Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or bilateral
(Metastasis in pelvic lymph node(s), unilatera or bilateral extranodal or extension of regional lymph node metastasis)
How should you treat penile cancer PeIN(CIS),Ta and T1a (G1-2)?
Localised lesion:
Excision/circumcision
Flat lesions: Local destruction (ex YAG or CO2, laser, cryo) Topical therapy (5-FU, imiquimod, fotodynamic therapy)
alternative: resurfacing (with skin graft)
Mentions two methods of topical therapy you can use for superficial penile cancer?
5-FU
imiquimod
How should you treat penile cancer T1aG3, T1b, T2?
Glansectomy
alternative: Brachyradiotherapy (in lesions <4 cm)
How should you treat penile cancer T3?
Partial/total penectomy
How should you treat penile cancer T4
Emasculation
What treatments for superficial penile cancer have the highest local recurrence?
lasers and brachytherapy
What are the chances of sufficient erection after glansectomy or partial amputation?
66,7%
What are the chances of orgasms after glansectomy or partial amputation?
72,2%
What are the chances of restoration of regular sexual intercourse after glansectomy or partial amputation?
55,6%
What are the complications of Radiotherapy for penile cancer?
Stricture of urethra 20-35%
Necrosis of glans 10-20%
Late fibrosis of corpora cavernosa
What is the success rate for radiotherapy of T1aG3, T1b, T2 penile cancer?
70-90%
What professions should be part of at multidisciplinary team treating penile cancer?
Dermatovenerologist Urologist Pathologist Radiologist Medical oncologist Radiotherapeutist
When should you perform sentinel node in penile cancer?
≥ T1G2
What is an alternative to sentinel node in ≥ T1G2 penile cancer?
bilateral modified inguinal lymphadenectomy (mILND)
What is the advantage of sentinel node over bilateral modified inguinal lymphadenectomy (mILND) in ≥ T1G2 penile cancer?
decreased morbidity
How should your treat penile cancer cN1/N2?
radical inguinal lymphadenectomy (rILND)
How should your treat penile cancer cN3?
chemotherapy followed by radical inguinal lymphadenectomy (rILND)
What measures should be taken to decrease morbidity after inguinal lymphadenectomy (ILND)?
Ligation/clips on lymph vessels instead of diathermia
Saphenous vein preservation
Compression stockings
Prophylactic antibiotics until drains are removed
Vacuum dressings
When is chemotherapy given in penile cancer?
Adjuvant p N2-3
Neoadjuvant T4
Palliative
Most common path of penile cancer?
SCC
Penile cancer path that never mets?
Verrucous carcinoma
Risks of developing penile cancer?
Uncicrumcised with poor hygiene, HPV 16 and 18, inflammatory syndromes (like BXO, LS, phimosis, etc), and smoking
PeIN = penile intraepithelial neoplasia
Path diff vs. undiff
Differentiated = chronic inflammation
Undifferentiated = HPV
PeIN of penile shaft or foreskin
Bowen’s disease
PeIN of glans
Erythroplasia of Queyrat
Penile cancer staging
Tis = PeIN
Ta = no invasion
T1: glans = lamina propria
Foreskin = dermis, lamina propria or dartos
Shaft = connective tissue between epidermis and corpora
T1a = no high grade, no LVI or PNI
T1b = high grade, PNI or LVI
T2 = corpora spongiosum
T3 = corpora cavernosum
T4 = invades adjacent structures
Penile cancer nodal staging
N1 - single palpable mobile inguinal LN
N2 - 2 or more palpable inguinal mobile nodes, bilateral mobile inguinal LNs, bulky or non-bulky mobile nodes
N3 - FIXED inguinal LNs (either unilateral or bilateral), or pelvic LNs
Treatment of primary lesion in PeIN or Ta
Wide local excision, circumcision, laser tx if can get all dz
Topical therapy for PeIN only - 5-FU or imiquimod
Treatment of primary lesion in T1
Low grade dz = penile preservation surgery or laser if can remove completely
High grade = WLE +/- grafting, partial or total penectomy
Treatment of primary lesion in T2/T3
Partial or total penectomy
- Intra-op frozen sections
- > 2cm stump for partial with 2cm margins
What is the differential diagnosis for penile mass?
Squamous cell carcinoma of penis
Verrucous carcinoma or Giant condyloma (Buschke-Lowenstein tumor)
Bowenoid Papulosis
Carcinoma in situ (Erythroplasia of Queyrat, Bowen’s disease, PIN)
Lichen Sclerosus (Balanitis Xerotica Obliterans)
Leukoplakia
Cutaneous Horn
Condyloma acuminata
Zoon’s (Plasma cell) balanitis
How does penile carcinoma present?
Penile mass (50%)
Sore or ulcer of penis (35%)
Phimosis
Irritative/obstructive voiding sxs
Systemic sxs: weakness, weight loss, malaise, fatigue
How do yo make the diagnosis of penile carcinoma?
Must obtain tissue bx
Prepuce → excisional biopsy w/circ
Glans → excisional bx including margin to assess invasion
Shaft → excisional bx including margin to assess invasion
What is metastatic workup for penile cancer ?
CXR
CT A/P (most are stages, especially with + nodes on exam)
MRI (if exam of inguinal region difficult due to obesity)
LFTS and serum Ca (hypercalcemia is often related to bulk of inguinal dz)
PET (mets optional)
bone scan (sxs or elevated ALP)
TNM staging for penile cancer
Risk categories for penile cancer for developing nodal mets?
Low risk: pTis, pTa (G1-2), or pT1a (no LVI/PNI, connective tissues)
Intermediate risk: pT1b (+LVI/PNI)
High risk: pT2 +
What are the most important prognostic factor for penile cancer?
tumor stage
lymph node status (most important after stage)
tumor grade
presence of LVI
Describe margins and partial penectomy and progression to total?
remove primary lesion, must obtain negative margin
surgical margins 5-10 mm are as safe as 2 cm, and 10-20 mm provide adequate cancer conrol
if negative margin cannot be obtained or too short → proceed to total with perineal urethrostomy (always consent for total)
Describe partial penectomy surgical technique:
- Minimize contamination of tumor
- Wrap a glove or sponge around distal penis
- Place an occluding tourniquet at base to minimize blood loss
- Make circumferential incision 2-3 cm proximal to tumor
- Carry incision down to Buck’s fascia
- Ligate neurovascular bundles
- Mobilize urethra and corpus spongiosum from cavernosa
- Transect urethra but allow to protrude slightly from penile shaft
- Transect and suture-ligate each corpora cavernosa
- Evert and suture urethral margins to skin
- Insert foley
Describe total penectomy:
- Exclude tumor from field (cover in glove)
- Make circumscribing incision around base of penis
- Mobilize urethral at penoscrotal junction
- Transect the urethra and mobilize it down on GU diaphragm
- Divide and ligate NVBs
- Divide and suture-ligate corporal bodies
- Leave a drain
- Close the incision
Describe a perineal urethrostomy:
- Dorsolithotomy position
- Vertical incision in perineum, or U shaped
- Split the bulbocavernosus muscles
- Mobilize the urethra and bring through perineal incision
- Spatulate and evert urethra
- Sew urethra to perineal skin
- Insert foley
Consequences of untreated metastatic inguinal adenopathy?
- Distant metastatic spread
- Local invasion with skin necrosis
- Infection
- Sepsis
- Hemorrhage from erosion into femoral vessels
- Death from exsanguination
Management of penile lesions?
Tis
excisional bx to dx
laser (Co2 or Nd-YAG)
cryotherapy
Photodynamic therapy
Topical Imiquimod
5-FU cream
Local excision
MOHS
T1 (Grade 1-2) invades connective tissue, w/o LVI or PNI
wide local excision
or partial penectomy
or glansectomy (select)
or Mohs surgery (select)
or possibly laser therapy or radiotherapy (2B rec)
T1 (Grade 3-4) → LVI and/or PNI, high grade
wide local excision
or partial penectomy
or total penectomy
radiotherapy (category 2B)
chemoradiotherapy (category 3)
T2 or greater
partial penectomy
total penectomy
radiotherapy (recommendation rated category 2B)
chemoradiotherapy (recommendation rated category 3)
- Category 2B: based on lower level evidence, NCCN consensus*
- Category 3: based on any level evidence, NCCN disagreement*
Important factors when assessing clinical nodes in penile carcinoma?
Diameter of nodes/masses
Unilateral or bilateral
of nodes in each inguinal area
mobile or fixed
relationship to other structures (skin, cooper’s ligament) in regards to infiltration, perforation
presence of edema on leg and/or scrotum
Management of NON-PALPABLE inguinal nodes in penile cancer?
Tis, Ta, T1a → surveillance
Intermediate risk → T1b, any T2 or greater → CT C/A/P → b/l ILND (frozen, if + superficial and deep, ipsi) or dynamic sentinel node bx
Management of PALPABLE inguinal nodes in penile cancer?
CT C/A/P
+
Surveillance after primary treatment for penile cancer:
Discuss modified and standard ILND for penile cancer:
Modified: excludes area lateral to femoral artery and caudal to fossa ovalis, preserves saphenous vein and eliminates need to transect sartorious
(NAVEL: nerve, artery, vein, empty, lymphatic)
*removes the superficial cluster of LN around sapheno-femoral junction above fascia lata
Standard:
Femoral triangle:
Lateral → sartorious
Medial → adductor longus
Base of triangle → inguinal ligament
Apex of triangle → apex of femoral triangle
Sartorious flap: detached from ASIS to cover femoral vessels
Complications of ILND?
- Skin sloughing: flap necrosis w/insufficient subq tissue, make a thick flap, depends on anastomotic vessels the run in Camper’s fascia
- Infection: wound infection and seromas occur in devascularized spaces, closed suction drain, abx
- Bleeding: flap too thin, arterio-cutaneous or venous-cutaneous fistula w/o sartorious flap
- Lymphocele: lymphatic drainage runs in Camper’s fascia, try to preserve and leave attached to skin flap
- Nerve injury: femoral nerve, proper ID key (rare)
- DVT: SCD, early ambulation, AC carries risk of lymphocele
- Lymphedema: Use TED stockings, elevate feet in bed
When do you now to perform a PLND for penile cancer?
if positive pelvic LN
>2 inguinal nodes are positive on frozen
presence of extranodal extension (ENE) on final path
Describe lymphatic drainage of penis?
Prepuce and penile skin → superficial inguinal nodes (above fascia lata)
Glans, urethra, corpora → superficial and deep inguinal nodes, and pelvic nodes (external iliac, internal iliac, obturator)
*SCC spreads via lymph, and penile drainage crosses midline
Prognostic factors for OS in penile cancer?
and site of + LN
tumor stage and grade
size of primary tumor
presence of extranodal extension
Types of penile cancer?
SCC (MC, aggressive, need ILND)
Basal cell (rare, wide local excision)
Melanoma (rare, two thirds occur on glans, poor prognosis, surgery, RT, chemo, immuno)
Kaposi’s sarcoma (50% malignant, bx before tx, wide local excision/partial penectomy, only ILND if palpable nodes)
Metastatic sites of penile cancer?
prostate
bladder
rectum
*sxs can include priapism and local swelling
DDX of penile ulcer?
ulcer firm, raised edges, red, indurated, tender, warm
Erythroplasia of Queyrat (CIS on prepuce/glans)
Chancre
Chancroid
Circinate balanitis (Reiter’s dz)
Penile carcinoma
Risks for penile cancer?
Phimosis (carcinoma rare in circumcised men, adult circ not protective)
Chronic irritation, poor hygiene
BXO
HPV (type 16 and 18)
Describe neoadjuvant chemotherapy. When is it used?
NAC TIP used prior to ILND in patient with > 4 cm ILN (fixed or mobile), if FNA +
Also patient with pT4 may be downstaged
A Tx, N2-3, M0, 4 cycles TIP, stable or responders undergo sx with curative intent
Describe adjuvant chemotherapy. When is it used?
4 cycles, 5-FU can be considered as alternative, also EBRT or chemotRT can be given with high risk features:
PLN mets
Extra-nodal extension
b/l ILN involvement
4 cm tumor in LN
If ILN enlarged, does that mean met?
50% have palpable ILAN at presentation
30-50% inflammation
50% mets
Incidence of micromets in ILN?
In presence of negative nodes, 20% micromets
Stage I, 11%
Stage II, 60%
What are salvage options for recurrent inguinal dz in penile cancer?
very poor prognosis
surgery, systemic chemo, or RT
salvage ILND has been proven beneficial (preferred)
increased risk of morbidity!
clinical trials, monocolonal
T1 Penile Cancer
Glans: Tumor invades lamina propria
Foreskin: Tumor invades dermis, lamina propria, or dartos fascia
Shaft: Tumor invades connective tissue between epidermis and corpora regardless of location
All sites with or without lymphovascular invasion or perineural invasion and is or is not high grade
T1a and T1b Penile Cancer
T1a - Tumor is without lymphovascular invasion or perineural invasion and is not high grade (i.e., grade 3 or sarcomatoid)
T1b - Tumor exhibits lymphovascular invasion and/or perineural invasion or is high grade (i.e., grade 3 or sarcomatoid)
Penile Cancer - Clinical Staging
cN0
cN1
cN2
cN3
cNX Regional lymph nodes cannot be assessed
cN0 No palpable or visibly enlarged inguinal lymph nodes
cN1 Palpable mobile unilateral inguinal lymph node
cN2 Palpable mobile ≥ 2 unilateral inguinal nodes or bilateral inguinal lymph nodes
cN3 Palpable fixed inguinal nodal mass or pelvic lymphadenopathy unilateral or bilateral
Penile Cancer - Pathologic Staging
pN0
pN1
pN2
pN3
pNX Lymph node metastasis cannot be established
pN0 No lymph node metastasis
pN1 ≤2 unilateral inguinal metastasis without extranodal extension
pN2 ≥3 unilateral inguinal metastases or bilateral metastases
pN3 Extranodal extension of lymph node metastases or pelvic lymph node metastases
In patients with clinical stage T1 high-grade or higher stage tumors, patients can harbor occult inguinal lymph node metastasis in up to ____ of cases.
In patients with clinical stage T1 high-grade or higher stage tumors, patients can harbor occult inguinal lymph node metastasis in up to 50-80% of cases.
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
Tis
Carcinoma in situ
Ta
Non-invasive verrucous carcinoma
T1
Tumour invades the subepithelial connective tissue
T1a
Tumour invades the subepithelial connective tissue without lymphovascular invasion and is not poorly differentiated
T1b
Tumour invades the subepithelial connective tissue with lymphovascular invasion or is poorly differentiated
T2
Tumour invades corpus spongiosum with or without invasion of the urethra
T3
Tumour invades corpus cavernosum with or without invasion of the urethra
T4
Tumour invades other adjacent structures
NX
Regional lymph nodes cannot be assessed
N0
No palpable or visibly enlarged inguinal lymph nodes
N1
Palpable mobile unilateral inguinal lymph node
pN1 Metastasis in one or two inguinal lymph nodes
N2
Palpable mobile multiple or bilateral inguinal lymph nodes
pN2 Metastasis in more than two unilateral inguinal nodes or bilateral inguinal lymph nodes
N3
Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or bilateral
pN3 Metastasis in pelvic lymph node(s), unilateral or bilateral or extranodal extension of regional lymph node metastasis
M0
No distant metastasis
M1
Distant metastasis
pM1 Distant metastasis microscopically confirmed
GX
Grade of differentiation cannot be assessed
G1
Well differentiated
G2
Moderately differentiated
G3
Poorly differentiated
G4
Undifferentiated
