SM_238b: Cancer of the Penis Flashcards
Describe epidemiology of penile carcinoma
Epidemiology of penile carcinoma
- Consistently low annual incidence rates among industrialized countries
- Prevalence rates are higher in non-industrialized countries
- Principally in uncircumscribed men
- Neonatal circumcision virtually eliminates risk of invasive squamous cell carcinoma but not CIS
- Adult circumcision does not decrease risk
- Most common between 50-70 years of age
- African American = Caucasian, Asian American lower, and Hispanic American higher
____ and ____ are risk factors for penile cancer
HPV and chronic inflammation are risk factors for penile cancer
Describe signs and symptoms of penile carcinoma
Signs and symptoms of penile carcinoma
- Erythematous precursor lesion
- Visible and palpable mass: glans (60%), prepuce (23%), shaft (9%)
- Large and/or atypical appearing wart
- Frank ulceration
- Carcinoma in situ
- Exophytic mass or ulceration
- Pain
- Periodic bleeding
- Purulent discharge
- 40-80% have palpable inguinal nodes
- Metastases to lung, liver, bone, brain in 1-10% of patients on presentation
Describe pitfalls of clinical staging of penile cancer
Pitfalls of clinical staging of penile cancer
- 30-60% of palpable nodes are secondary to reactive lymphadenitis: infection, chronic inflammation
- Up to 60% of palpably normal groins harbor metastatic disease
- 95% of patients with untreated nodal metastases die within 3 years
Penile cancer most commonly develops from ____, most are ____, half are ____, and half are related to ____
Penile cancer most commonly develops from mucosal surface of the glans of penis or inner prepuce, most are squamous cell carcinoma, half are HPV linked, and half are related to chronic inflammatio
Metastatic cancer to penis presents with ____, ____, ____, ____, and ____
Metastatic cancer to penis presents with priapism, palpable mass, pain, hematuria, and urethral bleeding
This is ___ of penis
This is squamous cell carcinoma of penis
Survival for squamous cell carcinoma of the penis is ____
Survival for squamous cell carcinoma of the penis is presence or absence of inguinal lymph node involvement
HPV has ____ and ____ oncoproteins
HPV has E6 and E7 oncoproteins
- E6: prevents p53 from making damaged cells commit suicide
- E7: binds to Rb and prevents it from stopping damaged cells from growing
____ is a surrogate marker for HPV 16
P16INKA4 is a surrogate marker for HPV 16
Squamous cell carcinoma of penis involves overexpression of ___
Squamous cell carcinoma of penis involves overexpression of epidermal growth factor receptor (EGFR)
Patients with squamous cell carcinoma of penis who are HPV+ have ___ survival
Patients with squamous cell carcinoma of penis who are HPV+ have greater survival
Gardasil is a ___ valent vaccine
Gardasil is a 9 valent vaccine
Describe premalignant penile lesions
Premalignant penile lesions
- HPV related: carcinoma in situ (erythroplasia of Queyrat and Bowen’s disease), Bowenoid papules, giant condyloma accuminatum (Bushke-Lowenstein tumor), warty / basiloid / mixed PeIn
- Non-HPV related: lichen sclerosus, cutaneous penile horn, leukoplakia, pseudoepitheliomatous / keratotic / micacenous balanitis / differentiated PeIN
Describe Bowen’s disease / erythroplasia of Queyrat
Bowen’s disease / erythroplasia of Queyrat
- Considered premalignant lesions or CIS of penis
- Bowen’s occur mainly on shaft, erythroplasia occurs on glans / prepuce
- Bowen’s not associated with visceral malignancies
- Progression to squamous cell carcinoma occurs in 10%
- Treatments vary
Bowenoid papules are ___
Bowenoid papules are a variant of penile intraepithelial neoplasia
Giant condyloma acuminata is ___
Giant condyloma acuminata is Bushke-Lowenstein tumor
This is ___
This is undifferentiated pelvic intraepithelial neoplasia
Lichen sclerosis involves ____ and ____
Lichen sclerosis involves meatal stenosis and urethral stricture
This is a ____
This is a cutaneous penile horn
This is ___
This is leukoplakia of the penis
This is ____
This is pseudoepitheliomatous, keratotic, and micaceous balanitis
This is ___
This is differentiated penile intraepithelial neoplasia
Primary surgical management of superficial lesions of penis (Ta, T1) is ___
Primary surgical management of superficial lesions of penis (Ta, T1) is conservative excision
- Recurrence rates: 8-11%
Verrucous carcinoma of penis is caused by ____
Verrucous carcinoma of penis is caused by HPV 6 and 11
____ for invasive cancer of penis has lower recurrence rate than ____
Total penectomy and perineal urethrostomy for invasive cancer of penis has lower recurrence rate than partial penectomy
Describe determination of stage of penile cancer
Determination of stage of penile cancer
- Superficial vs invasive
- Inguinal lymph node involvement
- Pelvic lymph node involvement
- Non-nodal visceral metastases
Soft tissue detail of penile tumors is best imaged by ___
Soft tissue detail of penile tumors is best imaged by MRI
___ should be performed expeditiously for penile cancer if indicated
Bilateral inguinal lymph node dissection should be performed expeditiously for penile cancer if indicated
Describe regional lymph nodes for penis
Regional lymph nodes for penis
- First echolon drainage is to superficial ad deep inguinal lymph nodes and may occur bilaterally
- Second echelon drainage is from inguinal lymph nodes to ipsilateral external iliac nodules
Lymphadenectomy is ___
Lymphadenectomy is both diagnostic and curative
- Performed one level above positivity
- Indications: persistent palpable inguinal adenopathy, poorly differentiated tumor, stage T2 or greater, angiolymphatic invasion
___ yields better survival than therapeutic lymphadenectomy
Prophylactic lymphadenectomy yields better survival than therapeutic lymphadenectomy
- 18% of clinically normal nodes contain tumor
Sentinel lymph node mapping is performed with ___
Sentinel lymph node mapping is performed with radioactive sulfur colloid + vital dye injection
Describe implications of inguinal and / or pelvic node involvement
Implications of inguinal and / or pelvic node involvement
- Recurrence will manifest within first 2 years
- Prognosis: bilateral inguinal nodes, > 2 inguinal nodes, extracapsular tumor, pelvic nodes
Advanced stage penile cancer should be treated with ___
Advanced stage penile cancer should be treated with neoadjuvant chemoradiation
- Indicated for unresectable local tumor or distant metastatic disease
- Lung, liver, and bone are the most common sites of extranodel metastases
Metastatic penile cancer may also be treated with ____ and ____
Metastatic penile cancer may also be treated with EGFR inhibition and PD-1/PD-L1 inhibition
Lichen sclerosis ___ HPV related
Lichen sclerosis is NOT HPV related
Most penile cancers arise from the ____
Most penile cancers arise from the glans
HPV-16 ___ protein interacts with EGF receptors to activate mitogenic signaling pathways
HPV-16 E5 protein interacts with EGF receptors to activate mitogenic signaling pathways
HPV-16 E6 protein negatively affects the cell cycle regulator ____
HPV-16 E6 protein negatively affects the cell cycle regulator p53
Bowenoid papulosis is ___
Bowenoid papulosis is HPV-related
Pelvic intraepithelial neoplasia involving the glans penis is called ____
Pelvic intraepithelial neoplasia involving the glans penis is called erythroplasia of Queyrat
____ is the best management option for invasive penile cancer involving the proximal shaft
Total penectomy is the best management option for invasive penile cancer involving the proximal shaft
___ provides best soft tissue detail of penile cancers
MRI provides best soft tissue detail of penile cancers
Describe femoral triangle
Femoral triangle
- Superior: inguinal ligament
- Medial: adductor longus
- Lateral: sartorius
____, ____, and ____ comprise TIP chemotherapy regimen used for advanced stage penile cancer
Paclitaxel, ifosfamide, and cisplatin comprise TIP chemotherapy regimen used for advanced stage penile cancer
