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ABU Oral Boards > Penile Carcinoma > Flashcards

Penile Carcinoma Flashcards

1
Q

What is the differential diagnosis for penile mass?

A

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

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2
Q

How does penile carcinoma present?

A

Penile mass (50%)

Sore or ulcer of penis (35%)

Phimosis

Irritative/obstructive voiding sxs

Systemic sxs: weakness, weight loss, malaise, fatigue

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3
Q

How do yo make the diagnosis of penile carcinoma?

A

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

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4
Q

What is metastatic workup for penile cancer ?

A

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)

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5
Q

TNM staging for penile cancer

A
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6
Q

Risk categories for penile cancer for developing nodal mets?

A

Low risk: pTis, pTa (G1-2), or pT1a (no LVI/PNI, connective tissues)

Intermediate risk: pT1b (+LVI/PNI)

High risk: pT2 +

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7
Q

What are the most important prognostic factor for penile cancer?

A

tumor stage

lymph node status (most important after stage)

tumor grade

presence of LVI

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8
Q

Describe margins and partial penectomy and progression to total?

A

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)

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9
Q

Describe partial penectomy surgical technique:

A
  1. Minimize contamination of tumor
  2. Wrap a glove or sponge around distal penis
  3. Place an occluding tourniquet at base to minimize blood loss
  4. Make circumferential incision 2-3 cm proximal to tumor
  5. Carry incision down to Buck’s fascia
  6. Ligate neurovascular bundles
  7. Mobilize urethra and corpus spongiosum from cavernosa
  8. Transect urethra but allow to protrude slightly from penile shaft
  9. Transect and suture-ligate each corpora cavernosa
  10. Evert and suture urethral margins to skin
  11. Insert foley
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10
Q

Describe total penectomy:

A
  1. Exclude tumor from field (cover in glove)
  2. Make circumscribing incision around base of penis
  3. Mobilize urethral at penoscrotal junction
  4. Transect the urethra and mobilize it down on GU diaphragm
  5. Divide and ligate NVBs
  6. Divide and suture-ligate corporal bodies
  7. Leave a drain
  8. Close the incision
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11
Q

Describe a perineal urethrostomy:

A
  1. Dorsolithotomy position
  2. Vertical incision in perineum, or U shaped
  3. Split the bulbocavernosus muscles
  4. Mobilize the urethra and bring through perineal incision
  5. Spatulate and evert urethra
  6. Sew urethra to perineal skin
  7. Insert foley
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12
Q

Consequences of untreated metastatic inguinal adenopathy?

A
  1. Distant metastatic spread
  2. Local invasion with skin necrosis
  3. Infection
  4. Sepsis
  5. Hemorrhage from erosion into femoral vessels
  6. Death from exsanguination
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13
Q

Management of penile lesions?

A

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*
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14
Q

Important factors when assessing clinical nodes in penile carcinoma?

A

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

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15
Q

Management of NON-PALPABLE inguinal nodes in penile cancer?

A

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

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16
Q

Management of PALPABLE inguinal nodes in penile cancer?

A

CT C/A/P

+

17
Q

Surveillance after primary treatment for penile cancer:

A
18
Q

Discuss modified and standard ILND for penile cancer:

A

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

19
Q

Complications of ILND?

A
  1. Skin sloughing: flap necrosis w/insufficient subq tissue, make a thick flap, depends on anastomotic vessels the run in Camper’s fascia
  2. Infection: wound infection and seromas occur in devascularized spaces, closed suction drain, abx
  3. Bleeding: flap too thin, arterio-cutaneous or venous-cutaneous fistula w/o sartorious flap
  4. Lymphocele: lymphatic drainage runs in Camper’s fascia, try to preserve and leave attached to skin flap
  5. Nerve injury: femoral nerve, proper ID key (rare)
  6. DVT: SCD, early ambulation, AC carries risk of lymphocele
  7. Lymphedema: Use TED stockings, elevate feet in bed
20
Q

When do you now to perform a PLND for penile cancer?

A

if positive pelvic LN
>2 inguinal nodes are positive on frozen
presence of extranodal extension (ENE) on final path

21
Q

Describe lymphatic drainage of penis?

A

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

22
Q

Prognostic factors for OS in penile cancer?

A

and site of + LN

tumor stage and grade

size of primary tumor

presence of extranodal extension

23
Q

Types of penile cancer?

A

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)

24
Q

Metastatic sites of penile cancer?

A

prostate

bladder

rectum

*sxs can include priapism and local swelling

25
Q

DDX of penile ulcer?

A

ulcer firm, raised edges, red, indurated, tender, warm

Erythroplasia of Queyrat (CIS on prepuce/glans)

Chancre

Chancroid

Circinate balanitis (Reiter’s dz)

Penile carcinoma

26
Q

Risks for penile cancer?

A

Phimosis (carcinoma rare in circumcised men, adult circ not protective)

Chronic irritation, poor hygiene

BXO

HPV (type 16 and 18)

27
Q

Describe neoadjuvant chemotherapy. When is it used?

A

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

28
Q

Describe adjuvant chemotherapy. When is it used?

A

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

29
Q

If ILN enlarged, does that mean met?

A

50% have palpable ILAN at presentation

30-50% inflammation

50% mets

30
Q

Incidence of micromets in ILN?

A

In presence of negative nodes, 20% micromets

Stage I, 11%

Stage II, 60%

31
Q

What are salvage options for recurrent inguinal dz in penile cancer?

A

very poor prognosis
surgery, systemic chemo, or RT
salvage ILND has been proven beneficial (preferred)
increased risk of morbidity!

clinical trials, monocolonal

32
Q

T1 Penile Cancer

A

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

33
Q

T1a and T1b Penile Cancer

A

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)

34
Q

Penile Cancer - Clinical Staging

cN0

cN1

cN2

cN3

A

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

35
Q

Penile Cancer - Pathologic Staging

pN0

pN1

pN2

pN3

A

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

36
Q

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.

A

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.

ABU Oral Boards (36 decks)

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