NCCN Penile 2.2020

Question 1

Primary evaluation for suspicious penile lesion

Answer 1

H and PE

Elicit RFs: 
Balanitis
Chronic inflammation
Penile trauma
Tobacco use
Lichen sclerosus
Poor hygiene
STDs

Histologic diagnosis: punch, exicisional, or incisional biopsy!

PN-1

Question 2

PRIMARY TREATMENT:

Tis or Ta

Answer 2

Topical therapy 
OR
Wide local excision
OR
Laser therapy (cat 2B)
OR
Complete glansectomy (cat 2B)
OR
Mohs surgery in select cases (cat 2B)

PN-1

Question 3

PRIMARY TREATMENT:

T1, Grade 1-2

Answer 3

Wide local excision
OR
Partial penectomy
OR
Glansectomy in select cases
OR
Mohs surgery in select cases (cat 2B)
OR 
Laser therapy (cat 2B)
OR
Radiotherapy (cat 2B)

PN-2

Question 4

PRIMARY TREATMENT:

T1, Grade 3-4

Answer 4

Wide local excision
OR
Partial penectomy
OR 
Total penectomy
OR
RT (cat 2B)
OR
ChemoRT (cat 3)

PN-2

Question 5

PRIMARY TREATMENT:

T2

Answer 5

Partial penectomy
OR 
Total penectomy
OR
RT (cat 2B)
OR
ChemoRT (cat 3)

PN-2

Question 6

TREATMENT:

Non-palpable inguinal LNs, low risk (Tis, Ta, T1a)

Answer 6

Surveillance!

PN-3

Question 7

TREATMENT:

Non-palpable inguinal LNs, Intermediate/High risk (T1b, any T2 or greater)

Answer 7

Cross-sectional imaging of chest/abdomen/pelvis (CT, MR, PET/CT, and/or CXR); should be done with contrast unless contraindicated.

Inguinal LN dissection (ILND)
OR
Dynamic sentinel node biopsy (DSNB)

PN-3

Question 8

Verrucous carcinoma

Answer 8

Verrucous carcinoma (Ta) is by definition a well-differentiated tumor, requiring only surveillance of the inguinal LNs.

PN-3

Question 9

TREATMENT: 
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
Low risk primary lesion
Percutaneous LN biopsy: negative

Answer 9

Excisional biopsy
OR
Surveillance

PN-4

Question 10

TREATMENT: 
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
Low risk primary lesion
Percutaneous LN biopsy: positive

Answer 10

ILND
Consider neoadjuvant chemotherapy followed by ILND

If results of LND shows:
pN1 –> surveillance

pN2-3:
PLND -/+ if pelvic nodes positive adjuvant RT or chemotherapy (cat 2B) or chemoRT (cat 2B)
OR
chemoRT (cat 2B)
OR
chemotherapy (cat 2B)

PN-4

Question 11

TREATMENT:
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
High risk primary lesion

Answer 11

ILND
Consider neoadjuvant chemotherapy followed by ILND

If results of LND shows:
pN1 –> surveillance

pN2-3:
PLND -/+ if pelvic nodes positive adjuvant RT or chemotherapy (cat 2B) or chemoRT (cat 2B)
OR
chemoRT (cat 2B)
OR
chemotherapy (cat 2B)

PN-4

Question 12

TREATMENT:
Palpable inguinal LNs
CT showed: Unilateral LNs => 4cm fixed or mobile OR unilateral LNs < 4 cm fixed, OR bilateral LNs fixed or mobile

Answer 12

Treat as BULKY inguinal LNs

PN-5

Question 13

TREATMENT:
Palpable inguinal LNs
CT showed: enlarged pelvic LNs

Answer 13

Percutaneous LN biopsy, if feasible, then:

If NEGATIVE:
Manage depending on LN status

If POSITIVE:
Potentially resectable: give neoadjuvant chemotherapy –> check cross-sectional imaging of chest/abd/pelvis –> if responsive –> consolidation surgery –> surveillance

Non-surgical candidate/unresectable: chemoRT –> surveillance

If biopsy NOT feasible,use PET/CT to evaluate LNs

PN-6

Question 14

Palpable BULKY Inguinal LNs:
Unilateral =>4 cm mobile
Percutaneous LN biopsy: positive

Answer 14

Cisplatin-based neodjuvant chemotherapy followed by ILND (preferred), consider PLND
OR
ILND (preferred), consider PLND (if not eligible for cisplatin-based chemo)
OR 
RT
OR
ChemoRT
---
If ILND: >= 2 positive nodes or ENE
Adjuvant chemotherapy
AND/OR
Pelvic nodes positive: adjuvant RT
OR
ChemoRT (cat 2B)

PN-5

Question 15

Palpable BULKY Inguinal LNs:
Unilateral =>4 cm mobile
Percutaneous LN biopsy: negative
Excisional biopsy: positive

Answer 15

ILND (preferred)
AND
PLND (preferred)
OR
RT
OR
ChemoRT

PN-5

Question 16

Palpable BULKY Inguinal LNs:
Unilateral =>4 cm mobile
Percutaneous LN biopsy: negative
Excisional biopsy: negative

Answer 16

Surveillance

PN-5

Question 17

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: negative
Excisional biopsy: positive

Answer 17

ILND (preferred)
AND
PLND (preferred)
OR
RT
OR
ChemoRT

PN-5

Question 18

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: negative
Excisional biopsy: negative

Answer 18

Surveillance

PN-5

Question 19

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: positive
Neoadjuvant chemotherapy –> responsive

Answer 19

ILND (preferred)
AND
PLND (preferred)
OR
RT
OR
ChemoRT

PN-5

Question 20

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: positive
Neoadjuvant chemotherapy –> no response

Answer 20

Treat as metastatic:

Systemic chemotherapy
OR
RT
OR
ChemoRT

Do cross-sectional imaging check for response:

If responsive –> consolidation surgery –> surveillance

If no response --> subsequent-line systemic therapy
OR
Consider RT
OR
Best supportive care/clinical trial

PN-9

Question 21

SURVEILLANCE SCHEDULE:

After penile-organ sparing approaches, glansectomy, wide local excision

Answer 21

Clinical exam:
years 1-2, every 3 mo then
years 3-5, every 6 mo then
years 5-10, every 12 mo

PN-7

Question 22

SURVEILLANCE SCHEDULE:

After partial/total penectomy

Answer 22

Clinical exam:
years 1-2, every 6 mo then
years 3-5, every 12 mo

PN-7

Question 23

SURVEILLANCE SCHEDULE:

Nx

Answer 23

Clinical exam:
years 1-2, every 3 mo then
years 3-5, every 6 mo

PN-7

Question 24

SURVEILLANCE SCHEDULE:

N0, N1

Answer 24

Clinical exam:
years 1-2, every 6 mo then
years 3-5, every 12 mo

PN-7

Question 25

SURVEILLANCE SCHEDULE: | N2, N3

Answer 25

``` Clinical exam: years 1-2, every 3-6 mo then years 3-5, every 6-12 mo Imaging: Chest CT or CXR: years 1-2 every 6 mo Abd/pelvic CT or MRI: year 1 every 3 mo then year 2 every 6 mo ``` PN-7

Question 26

Recurrence of penile lesion after penile-sparing treatment: non-invasive

Answer 26

``` Partial penectomy OR Total penectomy OR Repeat penile-sparing treatment (cat 2B) ``` PN-8

Question 27

Recurrence of penile lesion after penile-sparing treatment: invasive

Answer 27

Treat according to recurrence stage PN-8

Question 28

Local recurrence in inguinal region No prior inguinal LND or RT Single mobile <4 cm LN Percutaneous biopsy: negative

Answer 28

Surveillance PN-8

Question 29

``` Local recurrence in inguinal region No prior inguinal LND or RT Single mobile <4 cm LN Percutaneous biopsy: positive ILND: pN1 ```

Answer 29

Surveillance PN-8

Question 30

``` Local recurrence in inguinal region No prior inguinal LND or RT Single mobile <4 cm LN Percutaneous biopsy: positive ILND: pN2-3 ```

Answer 30

``` PLND -/+ if pelvic nodes positive adjuvant RT or chemotherapy (cat 2B) or chemoRT (cat 2B) OR chemoRT (cat 2B) OR chemotherapy (cat 2B) ``` PN-8

Question 31

Local recurrence in inguinal region | Prior inguinal LND or RT

Answer 31

``` Chemotherapy followed by ILND OR ILND OR Chemotherapy (if no prior RT) ``` PN-8

Question 32

Topical therapy: indications and administration

Answer 32

For Tis and Ta Imiquimod 5% apply at night 3x/week for 4-16 weeks 5-FU cream 5% apply 2x/day for 2-6 weeks

Question 33

Laser therapy: indications and types

Answer 33

For Tis, Ta, and T1 (Grade 1-2) CO2, Nd:YAG (deepest penetration) and KTP Use 3%-5% acetic acid -- HPV infected skin turns white upon exposure -- targetable for laser ablation Use plume evacuator during laser treatment PN-A

Question 34

Wide local excision

Answer 34

For Tis, Ta, T1 Shaft: with or without circumcision Distal prepuce: circumcision alone may be reasonable Re-resection if positive surgical margins PN-A

Question 35

Glansectomy

Answer 35

For distal tumors Ta, Tis, and T1 on the glans/prepuce Negative surgical margins from frozen sections of the cavernosal bed and urethral stump Treatment followed by STSG and FTSG to form neoglans PN-A

Question 36

Mohs surgery

Answer 36

Alternative to wide local excision For small proximal superficial lesions to avoid total penectomy PN-A

Question 37

Partial and total penectomy

Answer 37

Standard for high-grade primary penile tumors Functional penile stump can be preserved and negative margins must be obtained If partial not possible --> total penectomy Intraop frozen sections: determine negative margins PN-B

Question 38

High-risk features for nodal metastasis seen in the primary penile tumor

Answer 38

Lymphovascular invasion >= pT1G3 or >= T2 any grade >50% poorly differentiated Do standard/modified ILND or DSNB (in experienced centers) PN-B

Question 39

PLND after ILND if:

Answer 39

>= 2 positive inguinal LNs on the ipsilateral ILND site or presence of ENE on pathological review. PN-B

Question 40

Bilateral PLND after ILND if:

Answer 40

>= 4 positive inguinal LNs (total among both sides) PN-B

Question 41

Neoadjuvant chemotherapy prior to ILND: preferred regimen

Answer 41

TIP (paclitaxel, ifosfamide, and cisplatin) PN-D

Question 42

Adjuvant chemotherapy prior to ILND: preferred regimen

Answer 42

TIP (paclitaxel, ifosfamide, and cisplatin) Other: 5-FU + cisplatin PN-D

Question 43

First-line Systemic Therapy for Metastatic/Recurrent Disease: preferred

Answer 43

TIP (paclitaxel, ifosfamide, and cisplatin) Other: 5-FU + cisplatin PN-D

Question 44

Subsequent-line Systemic Therapy for Metastatic/Recurrent Disease: preferred

Answer 44

Clinical trial Pembrolizumab, if unresectable or metastatic, MSI-H or dMMR no alternative treatment options Other: paclitaxel, cetuximab

Question 45

Radiosensitizing Agents and Combinations (ChemoRT): preferred

Answer 45

Cisplatin alone or + 5-FU Mitomycin C in combination + 5-FU Other: capecitabine PN-D

Question 46

Ta

Answer 46

Non-invasive localized SCCA

Question 47

T1a

Answer 47

Glans: lamina propria Foreskin: dermis, lamina propria, dartos fascia Shaft: connective tissue between epidermis and corpora regardless of location Without LVI or PNI, not high grade ST-1

Question 48

T1b

Answer 48

Glans: lamina propria Foreskin: dermis, lamina propria, dartos fascia Shaft: connective tissue between epidermis and corpora regardless of location With LVI and/or PNI or high grade ST-1

Question 49

T2

Answer 49

Corpus spongiosum (either glans or ventral shaft) with/without urethral invasion ST-1

Question 50

T3

Answer 50

Corpora cavernosa (including tunica albuginea) with/without urethral invasion ST-1

Question 51

T4

Answer 51

Adjacent structures (i.e. scrotum, prostate, pubic bone) ST-1

Question 52

cN1

Answer 52

Palpable, mobile unilateral inguinal LNs ST-1

Question 53

cN2

Answer 53

Palpable, mobile >= unilateral inguinal nodes or bilateral inguinal LNs ST-1

Question 54

cN3

Answer 54

Palpable fixed inguinal nodal mass or pelvic lymphadenopathy unilateral or bilateral ST-1

Question 55

pN1

Answer 55

<= 2 unilateral inguinal metastases, no ENE ST-1

Question 56

pN2

Answer 56

>= 3 unilateral inguinal metastases or bilateral metastases ST-1

Question 57

pN3

Answer 57

ENE of LN metastases or pelvic LN metastases, no ENE ST-1

Question 58

Stage I

Answer 58

T1a N0 M0

Question 59

Stage IIA

Answer 59

T1b N0 M0 | T2 N0 M0

Question 60

Stage IIB

Answer 60

T3 N0 M0

Question 61

Stage IIIA

Answer 61

T1-3 N1 M0

Question 62

Stage IIIB

Answer 62

T1-3 N2 M0

Question 63

Stage IV

Answer 63

T4 Any N M0 Any T N3 M0 Any T/N M1

Question 64

Full template ILND boundaries

Answer 64

ie, Daseler's quadrilateral area: Superior: inguinal ligament Inferior: fossa ovalis Lateral: medial border of sartorius Medial: lateral edge of adductor longus 4-6 weeks after chemotherapy MS-10

Question 65

Modified ILND

Answer 65

Full template, but: Exclude area lateral to femoral artery and caudal to fossa ovalis, with preservation of saphenous vein Elimination of need to transpose sartorius muscle Include central and superior zones of the inguinal region 4-6 weeks after chemotherapy MS-10