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EAMC Urology > NCCN Penile 2.2020 > Flashcards

NCCN Penile 2.2020 Flashcards

To become an NCCN master.

1
Q

Primary evaluation for suspicious penile lesion

A

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

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2
Q

PRIMARY TREATMENT:

Tis or Ta

A 
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

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3
Q

PRIMARY TREATMENT:

T1, Grade 1-2

A 
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

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4
Q

PRIMARY TREATMENT:

T1, Grade 3-4

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

PN-2

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5
Q

PRIMARY TREATMENT:

T2

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

PN-2

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6
Q

TREATMENT:

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

A

Surveillance!

PN-3

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7
Q

TREATMENT:

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

A

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

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8
Q

Verrucous carcinoma

A

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

PN-3

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9
Q 
TREATMENT: 
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
Low risk primary lesion
Percutaneous LN biopsy: negative
A

Excisional biopsy
OR
Surveillance

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10
Q 
TREATMENT: 
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
Low risk primary lesion
Percutaneous LN biopsy: positive
A

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

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11
Q

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

A

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

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12
Q

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

A

Treat as BULKY inguinal LNs

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13
Q

TREATMENT:
Palpable inguinal LNs
CT showed: enlarged pelvic LNs

A

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

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14
Q

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

A 
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)

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15
Q

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

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

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16
Q

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

A

Surveillance

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17
Q

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

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

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18
Q

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

A

Surveillance

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19
Q

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

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

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20
Q

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

A

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

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21
Q

SURVEILLANCE SCHEDULE:

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

A

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

PN-7

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22
Q

SURVEILLANCE SCHEDULE:

After partial/total penectomy

A

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

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23
Q

SURVEILLANCE SCHEDULE:

Nx

A

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

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24
Q

SURVEILLANCE SCHEDULE:

N0, N1

A

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

PN-7

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25
Q

SURVEILLANCE SCHEDULE:

N2, N3

A 
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

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26
Q

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

A 
Partial penectomy
OR 
Total penectomy
OR
Repeat penile-sparing treatment (cat 2B)

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27
Q

Recurrence of penile lesion after penile-sparing treatment: invasive

A

Treat according to recurrence stage

PN-8

28
Q

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

A

Surveillance

PN-8

29
Q 
Local recurrence in inguinal region
No prior inguinal LND or RT
Single mobile <4 cm LN
Percutaneous biopsy: positive
ILND: pN1
A

Surveillance

PN-8

30
Q 
Local recurrence in inguinal region
No prior inguinal LND or RT
Single mobile <4 cm LN
Percutaneous biopsy: positive
ILND: pN2-3
A 
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

31
Q

Local recurrence in inguinal region

Prior inguinal LND or RT

A 
Chemotherapy followed by ILND
OR
ILND
OR 
Chemotherapy (if no prior RT)

PN-8

32
Q

Topical therapy: indications and administration

A

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

33
Q

Laser therapy: indications and types

A

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

34
Q

Wide local excision

A

For Tis, Ta, T1

Shaft: with or without circumcision
Distal prepuce: circumcision alone may be reasonable
Re-resection if positive surgical margins

PN-A

35
Q

Glansectomy

A

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

36
Q

Mohs surgery

A

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

PN-A

37
Q

Partial and total penectomy

A

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

38
Q

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

A

Lymphovascular invasion
>= pT1G3 or >= T2 any grade
>50% poorly differentiated

Do standard/modified ILND or DSNB (in experienced centers)

PN-B

39
Q

PLND after ILND if:

A

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

PN-B

40
Q

Bilateral PLND after ILND if:

A

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

PN-B

41
Q

Neoadjuvant chemotherapy prior to ILND: preferred regimen

A

TIP (paclitaxel, ifosfamide, and cisplatin)

PN-D

42
Q

Adjuvant chemotherapy prior to ILND: preferred regimen

A

TIP (paclitaxel, ifosfamide, and cisplatin)

Other: 5-FU + cisplatin

PN-D

43
Q

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

A

TIP (paclitaxel, ifosfamide, and cisplatin)

Other: 5-FU + cisplatin

PN-D

44
Q

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

A

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

Other: paclitaxel, cetuximab

45
Q

Radiosensitizing Agents and Combinations (ChemoRT): preferred

A

Cisplatin alone or + 5-FU
Mitomycin C in combination + 5-FU

Other: capecitabine

PN-D

46
Q

Ta

A

Non-invasive localized SCCA

47
Q

T1a

A

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

48
Q

T1b

A

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

49
Q

T2

A

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

ST-1

50
Q

T3

A

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

ST-1

51
Q

T4

A

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

ST-1

52
Q

cN1

A

Palpable, mobile unilateral inguinal LNs

ST-1

53
Q

cN2

A

Palpable, mobile >= unilateral inguinal nodes or bilateral inguinal LNs

ST-1

54
Q

cN3

A

Palpable fixed inguinal nodal mass or pelvic lymphadenopathy unilateral or bilateral

ST-1

55
Q

pN1

A

<= 2 unilateral inguinal metastases, no ENE

ST-1

56
Q

pN2

A

> = 3 unilateral inguinal metastases or bilateral metastases

ST-1

57
Q

pN3

A

ENE of LN metastases or pelvic LN metastases, no ENE

ST-1

58
Q

Stage I

A

T1a N0 M0

59
Q

Stage IIA

A

T1b N0 M0

T2 N0 M0

60
Q

Stage IIB

A

T3 N0 M0

61
Q

Stage IIIA

A

T1-3 N1 M0

62
Q

Stage IIIB

A

T1-3 N2 M0

63
Q

Stage IV

A

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

64
Q

Full template ILND boundaries

A

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

65
Q

Modified ILND

A

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

EAMC Urology (7 decks)

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