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Risk factors of penile cancer? (general conditions)
Phimosis Circumcision reduces risk Premalignant conditions e.g. Bowen’s disease, leukoplakia, Paget’s disease HPV
Risk factors of penile cancer? (Foreskin)
- Not circumcised
- Being in circumcised after neonatal period compared to being circumcised in the neonatal period
Presenting signs and symptoms of penile cancer?
- Obvious (visible) mass
- Ulceration and bleeding
- Glans or inner surface of prepuce
- Discharge
- Pain
Patterns of spread? (local)
- Wide surface extension
- Deeper invasion
- Urethra, corpora cavernosa
Patterns of spread? (lymphatic)
-inguinal and regional pelvic nodes
Patterns of spread? (Distant)
Uncommon: prostate and bladder
Blood borne to skin, lungs, bone
Histology?
- SCC
- BCC
- melanoma
- Karposi’s sarcoma
Staging?
- TNM
- Jacksons Staging
Surgery options?
-Total excision
-Small lesions: Cryosurgery, Laser
-Deeper lesions: Wider excision, Partial or full amputation
Moh’s micrographic, Nodal involvement, Block dissemination
EBRT options?
- Brachytherapy: Interstitial iridium implants
- EBRT: Superficial, Ortovoltage, MV – Photons, Electrons
Surgery for salvage (very unpopular option)
Brachytherapy options?
60-65 GY 6-7 days
Chemotherapy options?
-Very limited
(bleomycin, 5-FU, methotrexate,
cisplat)
Some topical options
What is the dose fractionation for the whole shaft? What energy type is used?
50-55Gy in 20f, or 60Gy in 30f
(possible boosts 5-10Gy to reduced volume)
MV photons
What is the dose fractionation for bilateral inguinal and pelvic node irradiation? (no gross disease)
50Gy in 25-28f if no gross disease
+/- 5Gy to reduced volume
What
is the dose fractionation for
bilateral inguinal
and pelvic node irradiation? (Palpable disease)
60-65Gy in 30-36f if palpable disease
+/- 5Gy to reduced volume
Palliative fractionation for penile cancer?
30Gy in 10f (MV)
For a patient with T3N2M0 Penile SCC, what is the optimal treatment?
Total Penectomy + bilateral inguinal node dissection
Post-op local and nodal EBRT
What is the treatment technique for a primary lesion?
Opposed pair, lateral fields
Perspex or wax block
-> full bolus + homogenous distribution
What is the treatment technique for high stage nodal disease?
Range of options
- Opposed pair (Ant & Post)
- Multiple field conformal
- IMRT
What would be the treatment for a T4N0M0 Penile SCC, where a penectomy has been declined?
Definitive EBRT to penis shaft
Up to 70Gy in 35f
What is the purpose of ankle stocks?
Separate legs to minimise inguinal skin folds
What is the CT procedure for penile patients?
- Talk to and ID patient
- Prepare couch
- Prepare patient
- remove pants and shoes
- Position patient – Straight and Level
- Make &/or position Perspex/wax block
- Set isocentre and mark for CT
- Scan: All of pelvis with good sup and inf margins
- Photos, set-up notes, and tattoos
What is a common problem with treatment set up for penile patients?
-swelling may cause difficulty positioning the block
What are the acute side effects of EBRT for penile cancer?
Erythema, Subcutaneous swelling, Moist desquamation, dysuria, Diarrhoea, Psychosocial impact
What are the standard equipment and set up for a penile patient?
Supine, straight & level Arms on chest Headrest Knee-bolster – small or none Ankle- &/or Foot-stocks
Patient care and management?
Urinary discomfort- Monitor fluid intake & Possible catheterisation
Subcutaneous swelling- Possible re-plan, Advise, monitor, and medicate as needed
Moist desquamation- Hygiene!
Diarrhoea- Dietary advice, Imodium
Psychosocial impact- Support
Late side effects of EBRT for penile cancer? And patient care?
- Telangiectasia & fibrosis
- Ulceration and/or tissue necrosis
- Urethral stricture- Dilation and catheterisation
- Erectile impotence
- Psychosocial impact- Psychosocial support
Late side effects of EBRT for penile cancer?
- Telangiectasia and fibrosis
- Ulceration and/or tissue necrosis
- Urethral stricture
- Erectile impotence
- Psychosocial impact
