Penis carcinoma- overview

Penis carcinoma- overview

1. CARCINOMA PENIS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

1

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,

Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. Introduction
•Disease of developing country
•5
th
– 7
th
decade of life
•10 % of male malignancies in asia and africa.
•Carries significant morbidity like disfigurment.
•Left untreated causes death in 2 years.
3 Dept of Urology, GRH and KMC, Chennai.

4. ANATOMY

4 Dept of Urology, GRH and KMC, Chennai.

5. Lymphatic drainage
•Prepucial skin + shaft skin –
Superficial inguinal LN.

•Glans / Corporal Bodies –
Lymphatic collar at the Base of
penis

Superficial ing. L.N

Deep Inguinal LN

-External iliac LN
-Internal iliac LN
-Obturator LN
5 Dept of Urology, GRH and KMC, Chennai.

6. Lymphatic vessels - Crossing
6 Dept of Urology, GRH and KMC, Chennai.

7. Lymphatic drainage
Superficial :
•Level I – V, 5 – 25 nodes
Deep:
•Deep to fascia lata
•3-5 nodes
•Most caudal – nodes of
cloquet


2 1
3 4
5
7 Dept of Urology, GRH and KMC, Chennai.

8. RISK FACTORS
•Phimosis
•Chronic inflammation
•BXO
•HPV - Type16, 18
•Psoralin / UV –A
•Smoking
•Multiple sexual partners

RELEVANCE
Odds Ratio 11-16
Increased risk

Present in 22-66% of cases
Risk – 9 folds
Risk - 5 folds
Risk 3- 5 folds

8 Dept of Urology, GRH and KMC, Chennai.

9. Premalignant lesions
HPV related
- Condylomata acuminata
- Bowenoid papillosis
- Bushke lowenstein tumour
Non HPV related
- Cutaneous horn
- Pseudoepitheliomatous
Micaceous and Keratotic
Balanitis
- Male Lichen Sclerosus
(BXO)
- Leukoplakia
9 Dept of Urology, GRH and KMC, Chennai.

10. Leukoplakia
Penile Horn with SCC
Verrucous carcinoma
Condyloma acuminata
10 Dept of Urology, GRH and KMC, Chennai.

11. Clinical features

• Ulcer / Swelling.
• Phimosis.
• Foul preputial odor, and discharge.
• Pain ( dispropotinate ).
•Constitutional symptoms.
• Bleeding from primary or nodes.
•Urinary retention or urethral fistula.
•Symptoms referable to metastases are rare.

11 Dept of Urology, GRH and KMC, Chennai.

12. Various presentations
12 Dept of Urology, GRH and KMC, Chennai.

13. Investigations
1) LABORATORY STUDIES
•Anemia
•Leukocytosis
• Hypoalbuminemia
•Azotemia
•Hypercalcemia
13 Dept of Urology, GRH and KMC, Chennai.

14. 2) BIOPSY
•Confirmation of the diagnosis
•Asessment of the Depth of invasion,
•Presence of Neurovascular invasion
•Histologic Grade of the lesion
14 Dept of Urology, GRH and KMC, Chennai.

15. 3.RADIOLOGIC STUDIES

A)CXR – for lung metastasis
B) PENILE ULTRASONOGRAPHY
•sensitivity 57% and specificity 91%
•can not delineate invasion into the subepithelial connective
tissue of the glans penis from corpus spongiosum
involvement.
•Imaging inguinal region & guided biopsy

15 Dept of Urology, GRH and KMC, Chennai.

16. C) CT SCAN

•Sensitivity 36% and specificity 100%
•Assessment of inguinal & pelvic LNs and abdominal
secondaries.
•In obese individuals, prior inguinal surgery, doubtful
clinical examination.
◦ CT-guided biopsy of enlarged pelvic nodes
16 Dept of Urology, GRH and KMC, Chennai.

17. CT – PENIS & Inguinal region
17 Dept of Urology, GRH and KMC, Chennai.

18. D) MRI
•Sensitivity 100% and specificity 91%
•Assesses local staging of the tumor
•Assessment of inguinal & pelvic LNs
•Better with artificial erection



18 Dept of Urology, GRH and KMC, Chennai.

19. MRI PENIS
19 Dept of Urology, GRH and KMC, Chennai.

20. E) NEWER MODALITIES
Nanoparticle (Ferumoxtran-10 particles )
(LN- MRI ) & PET/CT of the inguinal region

20 Dept of Urology, GRH and KMC, Chennai.

21. LN-MRI
•Allows the characterization of lymph nodes / To
detect nodal micrometastasis
•Performed with ferumoxtran-10 - consists of
USPIO – ultra small paramagnetic iron oxide
particles
•Normal lymph nodes contain macrophages, which
engulf the iron oxide nanoparticles – appears Dark.
•Malignant lymph nodes lack the phagocytic cells
needed to take up the nanoparticles - Bright.

21 Dept of Urology, GRH and KMC, Chennai.

22. LN - MRI
22 Dept of Urology, GRH and KMC, Chennai.

23. CARCINOMA IN SITU
•Erythroplasia of Queyrat – glans penis &
prepuce
•Bowens disease – penile shaft
•Progress to invasive carcinoma ( 10-30%)
•Red ,velvety, well marginated lesion
•Metastasis very rare
•Treatment A. foreskin – circumcision
B. Glans penis – Glans
resurfacing, 5 flurouracil, 5% imiquimod
23 Dept of Urology, GRH and KMC, Chennai.

24. Histological subtypes
Squamous cell ca (95%)
1)Usual type
2)papillary
3)Condylomatoid
4)Verrucous
5)Basaloid
6)Sarcomatoid
Spread – Direct, Lymphatic, blood
•Basal cell ca
•Malignant melanoma
•Kaposi sarcoma
•Extramammary paget
•Sarcoma
•Metastasis

24 Dept of Urology, GRH and KMC, Chennai.

25. 25 Dept of Urology, GRH and KMC, Chennai.

26. TNM staging
26 Dept of Urology, GRH and KMC, Chennai.

27. T stage
27 Dept of Urology, GRH and KMC, Chennai.

28. 28 Dept of Urology, GRH and KMC, Chennai.

29. 29 Dept of Urology, GRH and KMC, Chennai.

30. UPDATES BETWEEN 7
TH
& 8
TH
EDITIONS
•Ta : Tumor is localised & non-invasive
•T1a & T1b subdivision is also based on the presence
or absence of perineural invasion
•T2 : tumor invasive into corpus spongiosum with or
without urethral invasion
•T3 : tumor invasive into corpus cavernosum including
tunica albuginea, with or without urethral invasion
30 Dept of Urology, GRH and KMC, Chennai.

31. Treatment of Primary

•CIS - 5 flurouracil, 5% imiquimod
•Ta – Verrucus Ca – Excision ( 1
st
choice), Mohs Sx
•T1a 1.Foreskin – circumcision
2.Glans penis – Excision / Nd YAG laser
•T1b 1.Foreskin – circumcision
2.Glans penis – WLE with skin transplant / Laser
excision / Glansectomy
31 Dept of Urology, GRH and KMC, Chennai.

32. • T2 – Glans : Total glansectomy
• T2 – Shaft : Partial penectomy
•T3 : Total penectomy with spatualted perineal
urethrostomy
•T4 : Neoadjuvant Chemotherapy

Response Good - Total penectomy
No response – continue Chemo / RT
32 Dept of Urology, GRH and KMC, Chennai.

33. Laser Therapy
•Lasers
1. CO2
2. Nd:YAG
3. Potassium titanyl
phosphate (KTP)
4. Holmium: YAG
•Circumcision –
recommended

Drawbacks
•Healing time : 5to8 wks - CO2
8 to 12 weeks - Nd : YAG / KTP
•Local recurrence rate - 20%
(for Ca. in situ and T1 lesion)
–Difficulty in determining the
exact depth of laser coagulation
–Inability to treat larger lesions
–need long-term surveillance
33 Dept of Urology, GRH and KMC, Chennai.

34. Mohs Micrographic Surgery
•Removal of cancer by excision of tissue in thin layers
•Local control rate - 94%
•Best suited in- Ca. in situ, small T1

34 Dept of Urology, GRH and KMC, Chennai.

35. Local excision
•Excision of lesion with negative margin.
Reconstruction-
Primary closure
Preputial skin flap
 Full-thickness graft of penile skin , SSG
 Local recurrence - 8% to 11%
35 Dept of Urology, GRH and KMC, Chennai.

36. Surgical glans defect covered with outer preputial flap
•Superficial glans tumor
•Outer preputial flap
outlined
• Tumor excised and
circumcision performed
• Glans defect filled with
outer preputial flap
36 Dept of Urology, GRH and KMC, Chennai.

37. Skin graft quilted to glans defect after superficial
tumor excision
37 Dept of Urology, GRH and KMC, Chennai.

38. Partial Penectomy
•Goals
–Successful local control (at least 2 cm proximal
margin)
–Preserve voiding in standing position
–Possible sexual function

38 Dept of Urology, GRH and KMC, Chennai.

39. 39 Dept of Urology, GRH and KMC, Chennai.

40. Partial Penectomy
40 Dept of Urology, GRH and KMC, Chennai.

41. Total Penectomy with Perineal Urethrostomy
•Indication : After adequate surgical margin – if
remnant not sufficient for upright voiding

•Radical penectomy:
Excision of the corporeal bodies in their entirety

41 Dept of Urology, GRH and KMC, Chennai.

42. RISK BASED MANAGEMENT OF
THE INGUINAL REGION
42 Dept of Urology, GRH and KMC, Chennai.

43. Based on histology of 1* tumor and its grading

1. Low risk patients
- Carcinoma in situ (Tis)
- Verrucous carcinoma (Ta)
- Stage T1a , grade 1 & 2
•Low incidence of positive lymph nodes (0% to
16%)
• watchful waiting / survillance.
43 Dept of Urology, GRH and KMC, Chennai.

44. 2.High risk patients

•Patients with AJCC stage T1b or greater
•50% - Incidence of inguinal metastasis
•Inguinal staging procedure – warranted even if patient
with clinically negative groin.

44 Dept of Urology, GRH and KMC, Chennai.

45. Management
nodal disease
in of low risk
pts
45 Dept of Urology, GRH and KMC, Chennai.

46. High-risk patients (T1b and above)
46 Dept of Urology, GRH and KMC, Chennai.

47. FIXED INGUINAL NODES
47 Dept of Urology, GRH and KMC, Chennai.

48. INDICATIONS FOR MODIFIED INGUINAL
PROCEDURES

•Clinically Node positive Groin – Low risk pts

•Clinically Node negative Groin – High risk pts



Goal - define inguinal metastasis with minimal
morbidity
48 Dept of Urology, GRH and KMC, Chennai.

49. 1.FNAC
A.In Clinically negative Groin :
•Inguinal nodes guided by either lymphangiography or
ultrasonography
• 20% false-negative / sensitivity 39% in
subsequent surgical staging.

At present, fine-needle aspiration cytology of clinically
negative groins does not exhibit the sensitivity / Not considered as a
reliable staging modality.


49 Dept of Urology, GRH and KMC, Chennai.

50. FNAC

B. Clinically positive Groin

•Sensitivity of 93% in a recent study

•If FNAC positive, it provides immediate
information about further treatment
50 Dept of Urology, GRH and KMC, Chennai.

51. 2. Sentinel lymph node Biopsy

•Described by Cabanas (1977)
•Concept - Penile lymphangiographic studies
consistent drainage of the penile lymphatics
into a sentinel node or group of nodes
•located at superomedial to SF junction in the area of the superficial
epigastric vein.
•In this series, when this sentinel node was negative , metastases to
other ilioinguinal lymph nodes did not occur.
•SLN positive - indicated the need for complete superficial and deep
inguinal dissection.

51 Dept of Urology, GRH and KMC, Chennai.

52. •In Cabanas’s series (1992) - false-negative rate - 10%.
& McDougal and associates(1986) reported a 50%
false-negative

•Pettaway and colleagues (1995) - Additional nodes
around the sentinel node area were removed, even this
Extended dissection associated with a false-negative
rate of 25%


52 Dept of Urology, GRH and KMC, Chennai.

53. •False negative - result of anatomic variation in
the position of the sentinel node within the
inguinal field.

Thus, biopsies directed to a specific anatomic area can
be unreliable in identifying microscopic metastasis and
are no longer recommended.

53 Dept of Urology, GRH and KMC, Chennai.

54. 3. Dynamic sentinel node biopsy
•Precise localization of the sentinel node with the lowest
morbidity of any surgical staging technique

•20% of patients with clinically negative groin harbor occult
metastases

•Goal : Define where the sentinel lymph node resides by using
combination of visual (vital blue dyes) & gamma emission (hand-
held gamma probe) techniques
54 Dept of Urology, GRH and KMC, Chennai.

55. Technique
•Tc labeled nano colloid sulphur : Around the lesion , night before Sx
•Iso sulphur Blue(Methylene blue): Intradermal around and into the
lesion: 30min before surgery
55 Dept of Urology, GRH and KMC, Chennai.

56. DSNB
Biopsy - Via small inguinal
incisions / Guided by blue
dye and gamma probe –
Record radioactive count
•Sensitivity 98%, specificity
90%.


56 Dept of Urology, GRH and KMC, Chennai.

57. 4. Superficial inguinal dissections

•clinically negative Groin of high risk pts
• removal of nodes superficial to fascia lata
•Complete IILND is performed if the superficial nodes
are positive by frozen-section analysis

The rationale for superficial dissection is no positive nodes deep
to the fascia lata unless superficial nodes are positive

57 Dept of Urology, GRH and KMC, Chennai.

58. 5. Modified Complete Inguinal Dissection.
•Proposed by Catalona (1988)
•Advantages
- Smaller skin incision / Limited field of
inguinal dissection
- Preservation of the saphenous vein
- Thicker skin flaps
- Avoids sartorius muscle transposition
- Unlike in superficial dissection, deep nodes
within the fossa ovalis are also removed
58 Dept of Urology, GRH and KMC, Chennai.

59. Modified inguinal node dissection …..
•Boundaries
Medial – Adductor longus
Lateral – Lateral border of Femoral
artery
Upper – 2 cm above inguinal
ligament
Lower – Lower border of fossa
ovalis
•A 10-cm skin incision is made
approximately 1.5 to 2 cm below the
inguinal crease.
•Skin flaps are developed in the plane
just beneath the Scarpa fascia for a
distance of 8 cm superiorly and 6 cm
inferiorly.
•All superficial and deep group of nodes
are removed saphenous vein preserved

59 Dept of Urology, GRH and KMC, Chennai.

60. •The false-negative rate - 0% to 5.5% in the majority of
published reports

Morbidity after the procedure
•minor complications
- Seroma or lymphocele (0% to 26%),
- Wound infection or skin necrosis (0% to 15%)
60 Dept of Urology, GRH and KMC, Chennai.

61. Standard template Inguinal dissection
61 Dept of Urology, GRH and KMC, Chennai.

62. Margin :
•Upper : ASIS to superior margin of external iliac ring
•Lateral : a vertical line of 20 cm from the ASIS
•Medial : a vertical line of 15 cm from the pubic tubercle
•Lower : joining the lateral and medial border
Content :
•Superficiall inguinal LN deep to the Scarpa fascia
•Deep inguinal LN deep to the fascia lata
•LN remove: all 5 Daseler region + deep inguinal LN
•Saphenous vein is ligated and divided, Femoral artery and vein
are skeletonized dissection posterior to the femoral vessel is not
required
•Sartorius transposition.
•Skin rotation flaps + MC flaps for primary wound closure
62 Dept of Urology, GRH and KMC, Chennai.

63. 7. Minimally invasive inguinal lymphadenectomy
•Laparoscopic / Robotic techniques

•Both offer the potential for removing all of the inguinal
lymph nodes with minimal complications.

•To date, the results of laparoscopic and robotic ILND
have been comparable to open inguinal lymph dissection
63 Dept of Urology, GRH and KMC, Chennai.

64. VEIL
64 Dept of Urology, GRH and KMC,
Chennai.

65. Radiotherapy
•Potential curative and organ preserving.
•External-beam RT and interstitial brachytherapy
•Circumcision is mandatory.
•Ideal for tumour less than 4 cm.
65 Dept of Urology, GRH and KMC, Chennai.

66. EXTERNAL BEAM - RT
•Dose : 60 – 74 Gy.
•Position – supine

• Encasing the penis in a vertical
position in a block of wax or
Perspex with a central cylinderic
chamber

•Water bath technique
66 Dept of Urology, GRH and KMC, Chennai.

67. INTERSTITIAL BRACHYTHERAPY
•Iridium-192
•Dose of 60Gy (55-65Gy)
•Superior to EBRT, with 5-year
local control rates of 70% to 87%.
• Penile preservation rates are
highest at 5 years (74% to 88%)

Complications :
• Urethral Stenosis (20-35%)
• Glans necrosis ( 10-20%)
• Corpora cavernosa- Late fibrosis
67 Dept of Urology, GRH and KMC, Chennai.

68. Inguinal area
•Prophylactic RT - not recommended
•Adjuvant treatment - more than 2 nodes positive
•Palliation - in the situation of inoperable nodes
•Chemo –radiotherapy - may render inoperable disease
resectable. ( downstage )

68 Dept of Urology, GRH and KMC, Chennai.

69. Adjuvant chemotherapy
Patients with high risk features

•Pelvic lymph node metastasis.

•Extranodal extension.

•B/L involvement & 4 cm tumor in lymph node.

•4 cycles of TIP (Paclitaxel+ Ifosphamide +Cisplatin)

•Alternative: 5-FU + cisplatin

69 Dept of Urology, GRH and KMC, Chennai.

70. Neoadjuvant chemotherapy
•>/=4 cm inguinal lymph nodes (fixed or mobile)
•Initially unresectable (T4) primary tumors

4 cycles of TIP
Response rate: 50%
Long term progression free survival -36.7%
Median OS: 17.1 months

70 Dept of Urology, GRH and KMC, Chennai.

71. TIP
•Paclitaxel ( Taxol ) 175mg/m2 IV over 3 hrs on D1
•Ifosphamide 1200mg/m2 IV over 2 hrs on D1-3
•Cisplatin( Platinol ) 25mg/m2 IV over 2 hrs on D1-3
Repeat every 3 weeks

5-FU + cisplatin (not recommended for neoadjuvant)
•Continuous infusion 5-FU 800-1000mg/m2 IV on D1-4 or D2-5
•Cisplatin 70-80mg/m2 IV on D1
Repeat every 3 weeks

71 Dept of Urology, GRH and KMC, Chennai.

72. Metastatic / Recurrent
•Monotherapy: Cisplatin, Bleomycin, Methotrexate

•Combination therpies

•BMP (SWOG) – response rate: 32.5%



•Bleomycin containing regimen – NOT recommended
72 Dept of Urology, GRH and KMC, Chennai.

73. OTHER MALIGANCES
Type of tumour Primary Mx LN Dissection

Basal cell ca Wide excision No need
2cm clearance

Melanoma Excision Must

Sarcoma Excision only if +

Paget Wide excision No need
3cm clearance

Secondaries Excision ( poor prognosis )

73 Dept of Urology, GRH and KMC, Chennai.

74. THANK YOU
74 Dept of Urology, GRH and KMC, Chennai.