Penis

Question 1

epidemiology

Answer 1

incident rate is high but mortality is low
males 50-70, mainly 60, rare in under 40s
more common in Africa and china
2016-2018 = 2 new diagnoses every day

Question 2

aetiology

Answer 2

rare in circumsised males due to the build up of smegma holding a bacterial environment
poor penile health
HPV [one group is linked to penile warts]
phimosis: unretractable foreskin, tightened so can move freely
presence of erythroplasia of Queyrat: rare intraepithelial SCC which has red flat plaques on the glans

Question 3

what is the microscopic pathology

Answer 3

SCC: fast growing, proliferation of the small cells creates large masses
melanoma, BCC, Kaposi’s sarcoma

Question 4

what is the macroscopic pathology

Answer 4

warty growths/ulcers on the glans

Question 5

are mets rare

Answer 5

yes mets and deposits are rare however if they are present it probably originated from the bladder or prostate

Question 6

what is the direct spread

Answer 6

surrounding skin tissue
later invasion to the corpora (deeper skin tissue)

Question 7

what is the lymphatic spread

Answer 7

prepuce and skin drain into the superficial inguinal nodes
glans penis and the corpora will drain into the inguinal nodes and the external iliac nodes
predepositon via the lymphatic drainage

Question 8

what is the presentation

Answer 8

symptoms are often present for a long period before presentation
infected or bloody discharge from under the prepuce
offensive odour
visible lesion
ulceration and function of superficial inguinal nodes

Question 9

what is often treated instead of primary

Answer 9

the met disease

Question 10

what is the haematological spread

Answer 10

liver and lung but RARE

Question 11

investigations

Answer 11

FBC
U&E
LFT
biopsy: if there’s a physical lesion, rules out any malignancies, rules out any non malignant conditions
FNA: of an infected LN
mumps: enlarged LN
CT: extent of local spread, good imaging modality, for lymphatic involvement
chest x-ray rules out any mets if there’s lung involvement

Question 12

what staging is used

Answer 12

Jackson and TNM staging

Question 13

give the Jackson staging

Answer 13

I = limited to glans or prepuce
II = invading shafts, no nodes
III= invasion of shaft, node positive
IV = fixed inoperable nodes or distant mets

Question 14

give the TNM stages

Answer 14

T1 = superficial invasion of sub-epithelial tissue
T2 = invasion of the corpora
T3 = invasion of the prostate or urethra
T4 = invasion of other structures

Question 15

treatment types

Answer 15

surgery
implantation RT
superficial RT
mega RT

Question 16

describe surgery option

Answer 16

choice for elderly
partial or complete penectomy - loss of normal urine function, bag outside the abdomen, loss of sexual activity
cryosurgery or laser excision for smaller lesions, can be repeated - doesn’t lose urine function and sexual function
radical even if inguinal nodes are involved

Question 17

describe RT implantation

Answer 17

circumsised so there is opening to the glands making it easier to access
two plane implant, which covers the entire circumference, with a 1-2cm margin, left around the palpable and visible tumour
2-3 sources are used per plane with the active length extending beyond the penis
iridium - 192
shielding is used due to wires exiting the penis, prevents the sources coming into contact with normal skin
60Gy over 1-10 days with the mould worn 8-10 hours a day

Question 18

superficial RT

Answer 18

for small lesions
Pb cut out
6MeV
50Gy in 15 fractions in 3 weeks
high dose per fraction, over a short period of time
increases acute SE
keep area clean, pain meds

Question 19

mega RT

Answer 19

extensive disease
POP - non isocentric or isocentric
penis is enclosed by a wax block, providing a homogeneous doe, keeps the tests from the prostate, maintains the penis position
CT localisation should use 5mm slices, two lat oblique fields
50-60Gy in 20-30 fractions in 4-6 weeks with 6MV
Hoskin suggests 64Gy in 32 fractions, in 6.5 weeks at 6MV

Question 20

acute SE

Answer 20

skin reaction: keep area clean, moisturise, lukewarm showers, avoid sex, loose underwear, antihistamines
if MDS don’t use moisturiser, use non absorbent hydrocolloid gels
urethral discomfort/dysuria: catheterisation

Question 21

late SE

Answer 21

talengectasia
urethral stricture
permanent catheter or penectomy
necrosis <10% of cases

Question 22

five year survival for stage I

Answer 22

90%

Question 23

five year survival for stage II

Answer 23

60%

Question 24

five year survival for stage III

Answer 24

30-40%

Question 25

five year survival for stage IV

Answer 25

11%