Penile Flashcards
PeCa
Localized Workup
- History including assessment of risk factors (balanitis, chronic inflammation, trauma, lack of neonatal circumcision, lichen sclerosus, poor hygiene, STIs)
- PE including documentation of diameter, location, number, morphology (papillary, ulcerous, flat or nodular), distance from other structures and lymph node exam
- Biopsy (punch, excisional or incisional)
- Test for HPV status
PeCa
Tis or Ta Treatment
- Topical therapy (p)
- Wide local excision (p)
- Laser therapy
- Complete glansectomy
- Mohs surgery (select pts)
PeCa
Low grade T1 treatment
- Wide local excision (p)
- Partial penectomy (p)
- Glansectomy (select pts)
- Mohs surgery (select pts)
- Laser therapy (select pts)
- RT (select pts)
PeCa
High grade T1 treatment
- Wide local excision (p)
- Partial penectomy (p)
- Total penectomy (p)
- RT (select pts)
- Chemo/ RT (select pts)
PeCa
T2-T4 treatment
- Parital penectomy (p)
- Total penectomy (p)
- RT (select pts)
- Chemo/RT (select pts)
PeCa
Non-palpable Inguinal LN treatment
- Low risk pt (Tis, Ta, T1a): surveillance
- Int/ High risk pt (T1b or higher): CT C/A/P and bilateral inguinal LND or bilateral dynamic sentinel node biopsy
PeCa
Palpable small (<4cm) unilateral Inguinal LN treatment
- CT C/A/P
- Low risk pt (T1a, Ta, T1a): fine needle aspiration/percutaneous biopsy; if negative, excisional biopsy. If positive NAC w/TIP and bilateral ILND
- Int/ High risk pt (T1b or higher): NAC w/TIP and bilateral ILND
PeCa
Enlarged pelvic LN treamtent
- Percutaneous biopsy: If positive and surgical candidate, NAC w/TIP following by rpt img. if response, consolidation surgery. if progression, systemic therapy. If positive and non-surgical candidate, chemo/RT.
PeCa
Palpable large or fixed Inguinal LN treatment
- Unilateral large LN: Percutaneous biopsy: if negative excisional biopsy. If positive NAC w/TIP and bilateral ILND +/- PLND or bilateral ILND or RT or Chemo/RT
- Unilateral fixed LN or bilateral LNs: Percutaneous biopsy: if negative excisional biopsy. If positive NAC w/TIP (and if responsive) bilateral ILND and PLND (p) or RT or Chemo/RT
PeCa
post-op pN2 or pN3 Treatment
- Consider PLND
- Adjuvant chemotherapy (if no NAC)
- If pelvic node, + adjuvant RT
- Chemo/RT
PeCa
Local Inguinal recurrence
- No prior ILND or RT: Percutaneous biopsy, then treat according to stage
- Prior ILND or RT: Chemotherapy followed by ILND or ILND or Chemo/RT (if no RT)
PeCa
Metastatic PeCa treatment
- Systemic therapy
- Response or stable: consolidation surgery
- No response or progression: second-line systemic therapy or RT for local control
PeCa
Topical Therapy
- Imiquimod 5%: 3/week at night for 4-16 weeks
- 5-FU cream 5%: BID for 2-6 weeks
PeCa
Laser therpay
- CO2: 10,600nm, 5-10W, continuous or superpulse 100-200Hz, 0.1mm penetration, 1-5mm spot size
- Nd:YAG: 1,064nm, 40W, pulse 1ms/ 10-40 Hz, 3-4mm penetration, 1-5mm spot size
- KTP: 532nm, 5-10W, pulse 10-20ms/ 2Hz, 1-2mm penetration, 400-600um fiber size
PeCa
Wide Local Excision
- cTis, cTa, cT1
- May require split- or full-thickness skin graft
- May re-resect for positive margins
PeCa
Glansectomy
- Negative margins should be confirmed with frozen sections of cavernosal bed and urethral stump
- May create neoglans with split- or full-thickness skin graft
PeCa
Mohs Microsurgery
- Thin layers of cancerous skin are resected and veiwed microscopically until tissue layer is negative for tumor
- Preferred for superficial lesions on proximal shaft to avoid penectomy in low-risk lesions
- Success rate declines with higher stage disease
PeCa
Partial Penectomy
- Must provide functional penile stump and negative margins
- Functional stump is 3-4cm
PeCa
Tis, Ta and T1 staging
Tis -> Carcinoma in situ
Ta -> Non-invasive SCC
T1a -> Invades LP without LVI, PNI or HG
T1b -> Invades LP with LVI, PNI or HG
PeCa
T2 Staging
T2 -> Invades Corpora Spongiosum +/- urethral invasion
PeCa
T3 Staging
T3 -> Invades Corpora Cavernosum +/- urethral invasion
PeCa
T4 Staging
T4 -> Invades adjacent structures
PeCa
cN Staging
cN1 -> Single palpable mobile unilateral inguinal LN
cN2 -> Multiple palpable moble unilateral inguinal LNs or bilateral LNs
cN3 -> Palpable fixed inguinal LN mass or pelvic LAD
PeCa
pN Staging
pN1 -> 2 or less unilateral inguinal LNs without ENE
pN2 -> 3 or more unilateral inguinal LNs or bilateral LNs
pN3 -> ENE or pelvic LN
PeCa
M Staging
M1 -> Distant metastasis
PeCa
Primary Radiation Treatment (penile preserving)
- <4cm: circumcison then brachytherapy or EBRT +/- chemotherapy
- consider ppx radiation to inguinal LNs
- > 4cm circumcision then Chemo/RT (select cases) covering inguinal and pelvic LNs with penile boost or brachytherapy (select cases)
PeCa
Primary Radiation Treatment (unresectable)
- circumcision then Chemo/RT covering inguinal and pelvic LNs with penile boost
PeCa
Radiation s/p positive surgical margin
- Microscopic disease: EBRT to primary site and scar
- Gross disease: Chemo/RT covering inguinal and pelvic LNs with penile boost
- Consider LN treatment if no LND or inadequate LND
- Brachytherapy (select cases)
PeCa
Adjuvant Chemo/RT
- Positive inguinal or pelvic LNs
- Consider for pN2-3 or local recurrence
- COnsider boost for gross noes or areas of ENE
- Consider for positive margin
PeCa
Karposi Sarcoma
- HIV: Treat with HAART therapy
- Immunosuppressed (transplant): Reduce immunosuppresive medications
- Unresponsive: Local therapy (laser, wide excision, topical, cryotherapy)
- Metastatic: comination chemotherapy
Lymph Node Involvement
Most predictive is LVI
Other factors include superficially growth pattern, grade, tumor thickness, involvement of corporal tissue and urethra
