Tumors of the Penis (Chap 90 12th ed)

Question 1

What is the standard topical treatment of choice for condyloma?

Answer 1

Imiquimod cream is now the standard topical treatment of choice for
condyloma.

Question 2

What is penile carcinoma in situ and what are the malignant processes related to it?

Answer 2

Penile carcinoma in situ (Tis) is an intraepithelial malignant process
manifesting as three differing clinical entities including Bowenoid
papulosis, Bowen disease, and erythroplasia of Queyrat.

Question 3

How does metastasis occur in penile ca?

Answer 3

Metastasis occurs by embolization of tumor deposits from the penile
tumor through penile lymphatics to the inguinal lymph nodes.

Question 4

What are the important factors to note in pathologic staging of penile ca?

Answer 4

Pathologic description of anatomic structures invaded (i.e., stage),
the grade, and the status of vascular and perineural invasion provide
important information to assess the risk of metastasis.

Question 5

What is the best imaging to use to see soft-tissue detail of penile tumors?

Answer 5

Soft-tissue detail of penile tumors is best imaged by MRI. Penile MRI especially performed in combination with artificial
erection may provide unique staging information when physical
examination findings are equivocal.

Question 6

What is the gold standard in evaluating the presence of metastasis in the non-obese patients? What imaging do you use for obese patients?

Answer 6

Physical examination of the inguinal region remains the clinical gold
standard for evaluating the presence of metastasis in the nonobese
patient.

CT or MRI can be useful in evaluating the inguinal region of obese
patients and in those who have had prior inguinal surgery.

Question 7

Is there a role for PET/CT in penile ca?

Answer 7

Positron emission tomography (PET)/CT may be useful among
patients with clinically detected inguinal metastases to define the
presence of pelvic or distant metastasis.

Question 8

What is the best determinant for survival in penile ca?

Answer 8

Both clinical and pathologic factors related to the presence and
extent of lymph node involvement determine survival and should be
recorded.

Question 9

Who are the best candidates for organ preservation?

Answer 9

Patients with small lesions of low grade and stage (Tis, Ta, T1; grade
1 and grade 2) are the optimal candidates for organ preservation to
maintain sexual quality of life. The goals of organ preservation are to maintain glanular tissue for
sensory purposes when possible and/or to maintain penile length
when glans penis preservation is not possible.

Question 10

How do you assess the risk of LN mets from the histologic features of the primary tumor?

Answer 10

On the basis of the histologic features of the primary tumor, the risk
of lymph node metastases can be assessed in patients with no
palpable adenopathy based upon the TMN staging system. Dynamic
sentinel node biopsy (DSNB), superficial inguinal lymph node
dissection (ILND), or close follow-up can be recommended based
upon TMN stage and other histologic features.

Question 11

What are the factors associated with high cure rate?

Answer 11

Factors associated with a high cure in surgically treated patients
include no more than two inguinal metastases, unilateral
involvement, no extranodal extension (ENE) of cancer, and the
absence of pelvic metastases. Patients with higher volumes of disease
should be considered for adjuvant or neoadjuvant therapy.

Question 12

What is a low morbidity option of determining microscopic inguinal disease?

Answer 12

Modified DSNB techniques to determine microscopic inguinal
disease exhibit low morbidity, have been validated externally in
higher-volume centers, and are now a recommended procedure in
such centers.

Question 13

When is PLND recommedned?

Answer 13

Pelvic lymph node dissection (PLND) is now recommended when
more than one inguinal lymph node exhibits metastasis or when ENE
of cancer is present.

Question 14

When can radiation be used in penile-preservation?

Answer 14

Radiation provides an effective penile-preserving approach for T1 to
T2 squamous cell carcinomas less than 4 cm using either externalbeam
radiotherapy or brachytherapy.

Question 15

How do you render unresectable nodes to become operable?

Answer 15

Unresectable lymph nodes may be rendered operable by neoadjuvant
chemotherapy or chemo-radiation.

Question 16

What are the options for patients with lymph node metastases?

Answer 16

Palliative radiotherapy may be beneficial for metastatic disease.
Neoadjuvant chemotherapy with a cisplatin-containing regimen
should be considered for patients with lymph node metastases, as
responses in this setting may facilitate curative resection. In the
absence of Level 1 evidence, the optimal or standard multimodal
strategy remains undefined.

Question 17

For patients who underwent chemotherapy, when can is surgical consolidation considered?

Answer 17

Surgical consolidation to achieve disease-free status or palliation
should be considered in fit patients with a proven objective response
to systemic chemotherapy. Among patients who progress through chemotherapy, surgery is not
recommended.

Question 18

What are the other histologies of primary penile cancers and what are their characteristics?

Answer 18

Basal cell carcinoma represents a highly curable variant with a
relatively low metastatic potential.

Sarcomas are prone to local recurrence; regional and distant
metastases are rare. Superficial lesions can be treated with less
radical procedures.

Melanoma is an aggressive form of cancer but can be cured if
diagnosed and treated with the appropriate surgical procedure at an
early stage. Novel immunotherapy strategies may improve survival
in recurrent or advanced disease.

Extramammary Paget disease (EMPD) disseminates by
intraepidermal spread initially. Wide local excision to achieve
negative margins is the therapy of choice. Invasive EMPD can be
lethal.