CARCINOMA PENIS powerpoint presentations

power presentation of carcinoma penis reference from campbell urology useful for both post graduates and superspeciality urology resident

2. ANATOMY OF PENIS

4. PENILE CARCINOMA
It accounts for 0.4-0.6% of all malignant
neoplasms among men in us and europe,it
represents upto 10% of malignant neoplasm in
asian,south american countries
It is disease of olden men, incidences increases in
sixth decade of life
More than 95% of lesions are squamous cell
carcinoma

5. PREMALIGNANT LESIONS
Cutaneous Horn-rare solid skin over growth ,wide local excision done
Bowenoid papulosis-multiple papules appears on penile skin or flat
glanular lesion
Pseusoepitheliomatous micaceous and kerototic balanitits-unusual
hyperkeratotic growths on glans requires excision
Condyloma acuminata- genital warts,soft multiple lesions on glans
prepuce and shaft
Leukoplakia-solitary or multiple whitis glanular plaques involve
metus ,excision done
Balanitis xerotica obliterans- also known as lichen sclerosus et
atrophicus seen over glans and prepuce
Buschke lowenstein tumor-verucous ca ,aggressive locally advanced
tumor of the glans wide excision done
Bowens disease-red cutaneous patch on the shaft of penis ,treatment
topical 5 FU,co2 laser ablation or surgical excision
Erythroplasia of queyrat – red velvet circumscribed painless
lesion ,requires wide local excision

6. Bowenoid
papules
Cutaneous horn
Condyloma acuminata
Erythroplasia
of queyrat

7. Buschke lowenstein tumor
Invades locally
Compresses the adjacent tissues causing urethral
erosion and fistulisation
Never metastasis
No sign of malignant change
C/f bleeding discarge and foul odour
Treatment is excision
Laser is effective,topical 5-FU,

8. PENILE CARCINOMA
Mc type is SCC {95%}
Mesenchymal tumors{3%} like kaposi,angiosarcoma etc
Basal cell ca,malignant melanoma,metastasis
Carcinoma in situ: Tis of penis is called as erythroplasia
of queyrat it involves glans penis and prepuce
It consists of red velvety well marginated lesions of glans
penis or may ulcerate with discharge
Bowens disease it involves penile shaft or
perineum,characterized by sharply defined plaques of
scaly erythema on penile shaft

9. Treatment
Preputial lesion- circumcision or excision with
5mm margins
Glanular lesion-topical 5 flurouracil cream or
ablation therapy
Radiotherapy for resistant cases

10. Penile carcinoma
Etiology
1.Lack of neonatal circumcision
2.Poor hygeine
3.Phimosis/BXO
4.Hpv infections
5.Exposure to tobacco products
6.Penile trauma mutilating circumcision,penile
tear

11. Penile ca arises anywhere on penis but most
commonly on:
1.Glans 48%
2.Prepuce 21%
Other tumors involve gans and prepuce 9% ,
coronal sulcus 6% and shaft <2%.

12. Presentation
Begins as small lesion papillary and
exophytic/flat/ulcerative growth
Lymphatic spread
Flat&ulcerative lesions morethan 5 cm and
extending more than 75% of shaft have higher
incidence of metastasis and poor survival
Bucks fascia protects corporeal invasion
Distant metastasis uncommon
Bladder and urethra involvement rare

13. CLINICAL FEATURES
Patients present with swelling or ulcer on penis
Pain is usually not a presenting complaints
Weakness ,weight loss ,fatigue and significant blood loss from penile lesion or
nodal lesion
Many present late by the time presentation it ranges from subtle induration to
small papule to warty or exophytic growth or ulcerative growth
Phimosis may obscure lesion allow tumor progress Erosion through the
prepuce,foul smelling discharge with or without bleeding wit little or no pain
Mass,ulceration,suppuration or hemorrage in the inguinal area due to
metastasis
Urinary retention or urethral Fistula due to local corporeal involvement is
rare presentation
Distant metastasis sites lung bone liver

14. EXAMINATION
At presentation most of lesions are confined to penis
penile lesion assesed with regard to size,location
fixation and involvement of corporeal bodies.
Inspection of base of penis and scrotum too r/o
extension
Rectal and bimanual examination provides info
regarding perineal body involvement and presence
of pelvic mass
Bilateral palpation for inguinal area for adenopathy

15. Investigations
Anemia,leucocytosis,hypercalcemia,hypoalbuminemia
BIOPSY:confirmation of diagnosis
Asessment of depth of invasion,vascular invasion and
histological grade of the lesion mandatory before
initiating any therapy
Dorsal slit is required for adequate exposure of lesion
Histologically mostly are scc demonstrating
keratinization,epitelial pearly and degree of mitotic
activity
Histological types includes 15% papillary,10% warty
and basaloid,3% verrucous and sarcomatoid
Among these sarcomatoid and basloid (hpv
associaion)are aggresive

16. BRODERS CLASSIFICATION
Used in scc to define level of differentiation on
basis of keratinization nuclear pleomorphism
and number of mitosis
Low grade lesions(grade 1 nd 2) constitue 70-80%
these are well differentiated demonstrate keratin
keratin pearls
High grade(grade 3 and 4) poorly differentiated
almosts orginates from shaft,10% located in the
prepuce

18. RADIOLOGICAL DIAGNOSIS
CXR: for lung metastasis
USG:cannot delineate invasion into subepithelial connective tissue of
glans penis from corpus spongiosum involvement
CT SCAN: sensitivity and specificity of ct are 36% and 100%
Mainly for assessment of inguinal & pelvic lymph noe and secondaries
Ct guides biopsy of enlarged pelvic nodes
MRI : sensitivity and specificity of 100% and 91%
1.Assesses local staging of tumor
2.Assessment of inguinal and pelvic LNs
3.Better with artificial erection
Newer modalities
1.PET CT of inguinal region detects minimal inguinal metastasis when
lymph nodes are normal on ct/mri

22. TREATMENT
Organ preservation
Penile amputations
Organ preservation:
Goal : to preserve glans sensation and to maximize
penile shaft length
Indication:
primary tumor exhibiting favorable histologic
features
Stages Tis ,Ta,T1 grade 1 and 2 tumors

24. Circumcision and limited excision
strategies:
1.2 cm surgical margin required for all patients
undergoing partial penectomy
2.Maximum proximal histologic extent of 5mm for
grade1 and grade 2 tumors and 10mm for grade 3
tumors recommended
Limitations:
1.proximal and distal deeply invasive tumors
2.High grade tumors
3.Skip lesions
4.Pts with poor compliance who would not be
candidate for salvage procedures
Recurrence rate is 4-6%

38. DASELER REGION
Inguinal region is
divided into four sections by a horizontal and a vertical
line
drawn through the fossa ovalis. Five anatomical subgroups with the
central
zone being located at the confluence of the greater saphenous vein
and
the femoral vein.