Carcinoma of Penis , its diagnosis and management by staging.

1. PENILE MALIGNACY

2. Introduction
•Is a relatively uncommon cancer that most likely to
occurs on the glans of penis, or foreskin.
•Mostly are primary.
•Among 10 most common is scc.
•Others include melanoma,adenocarcinoma from
Tyson’s gland, bcc.
•20 may also occur and are mostly of urological
origin.

3. Risk factors/Etiologies/Premalignant conditions
• Uncircumcision.
• Chronic balanoposthitis,
• phimosis.
• Sexually transmitted diseases.
• Leukoplakia of glans.
• Long-standing genital warts.
• Paget’s disease of penis (Erythroplasia of
Queyrat is persistent rawness of glans penis).

5. Risk factors cont..
• Condyloma acuminata (by human papilloma
virus),balanitis xerotica obliterans.
• HIV infection
• HPV - 16.
• Age >50yrs.
• Smoking cigarette and chewing tobacco
• Poor genital hygiene

6. Clinical Presentation
• Many patients present in late stages.
• Mostly are obvious clinically except those hidden by
phimosis.
• A painless lesion on the glans penis/inner aspect of
prepuce skin.
• Papillary vs ulcerative.
• Penile discharge
• Dysuria
• 50% palpable inguinal lymph nodes at presentation..
Inflammatory vs malignant.

8. Spread
Local spread - Usually starts in glans or prepusal
ares spreads proximally towards shaft causing
induration.
Spread to deeper structure causes deformity and
micturtion abnormalities
Lymphatic spread - To horizontal group of deep
inguinal LN. External iliac located above inguinal
ligament.
LN may ulcerate and cause painful ulcer in inguinal
region.
Erode into Femoral vessels.
Nodal enlargement can be from an infected tumor.
Blood spread is rare.

10. Investigations
• Punch or excisional biopsy confirms the
diagnosis.
• FNAC from enlarged Lymphnodes
• Sentinal lymphnode biopsy
Role of imaging in staging…
• USG - for external ilaic LN
• MRI
• CT scan
• PET/CT

11. TNM
TX Primary tumour cannot be assessed
TO No evidence of primary tumour
Tis Carcinoma in situ
Ta Non invasiive carcinoma
T1 Tumour invades sub epithelial tissue
• T1a without lymphovascular invasion and is not
poorly differentiated or undifferentiated
• T1b with either of the above
T2 Tumour invades corpus spongiosum and/or corpora cavernosa
T3 Tumour invades urethra
T4 Tumour invades other adjacent structures

12. N Regional lymph nodes
Nx Regional lymph nodes cannot be assessed
No No palpable or visibly enlarged inguinal lymph node
N1 Palpable mobile unilateral inguinal lymph node
N2 Palpable mobile multiple unilateral or bilateral inguinal lymph nodes
N3 Fixed inguinal nodal mass or pelvic lymphadenopathy, unilateral or
bilateral
M Distant metastasis
Mo No distant metastasis
M1 Distant metastasis

13. TREATMENT
• Management is divided into
• 1. Treatment of Primary tumor
• 2. Treatment of inguinal LN

14. For Primary tumor
• Surgical excision is mainstay of treatment
• Conservative view of Penile preserving surgery.
• Glansectomy
• Partial penectomy
• Total penectomy and perineal urethrostomy
• Surgery is indicated even for advanced diseases for
local control of disease

15. For Lymphnodes
• Delay of 3 weeks after treatment of primary lesion
• FNAC confirms diagnosis
• Block dissection of both groins
• When nodes are not palpable SLNB and dissection
done
• For pelvic LN options are Observation, Pelvic
lymphadenectomy, Rediotherapy.
• Chemotherpay is relatively ineffective and reserved
for palliation.

16. Stage Modality of rx
CIS • Topical chemotherapy eg imiquimod
or 5FU
• Glans resurfacing
Ta/T1a Penile preserving modalities
• Radical circumcision, glansectomy,
laser therapy, moh’s surgery.
• radiotherapy
T1b /T2 • Glansectomy +/- resurfacing of the
corporeal heads
T3 • Partial or total penectomy with
perineal uresthrostomy.
• Radiotherapy
T4 • Total penectomy
• Neoadjuvant chemotherapy

17. • NOTE; that for the early stages modality of
treatment should depend on the;
• Size, site relative to the meatal opening,
histology, stage.
• No significant differences in terms of long term
recurrence rate among the different
modalities.
• Cancer free margin of 10mm is considered
oncologically safe.

18. Prognosis
• 5 years survival rate
• Tumors confined to Penis - 80%
• Nodal involvement - 40%

19. Prevention
• Circumcision- neonatal.
• HPV vaccination.
• Hygiene.
• Early management of premalignant conditions.
• Early refferal