Clinical features, diagnosis and management of carcinoma penis

1. *

2. *

3. *

4. *

5. *
*Carcinoma of the penis is a rare cancer
*<1% of all cancers in males
*Western countries (US & Europe), incidence is 0.4 - 0.6%
*Developing countries (Asia, Africa & S. America) ~ 10%
*In India, as per NCRP statistics (2008),
 accounts for 4% of all cancers in males in the Barshi
registry
 not in 10 leading cancer sites in the other registries

6. *
*Age > 50yrs
*Neonatal circumcision is protective
*Phimosis (25-60 % increased risk), Smegma accumulation,
Poor hygiene (especially postcoital)
*Chronic inflammation, balanitis, penile trauma
*History of STD (syphilis, herpes simplex)
*Tobacco use : 3-4.5 times increased risk
*Lichen sclerosus : 2-9 % risk
*HPV infection (types 16 & 18) : 45–80 % cases
*HIV infection: 8 times increased risk
*Psoriasis patients receiving PUVA (psoralen plus ultraviolet A) :
286 times increased risk

7. *
*Natural history is of slow locoregional progression
*Common sites –
Glans, inner prepucial layer, coronal sulcus,
shaft – rare
*Presentation –
Lesion on penis - maybe obscured by phimosis
 ulcerative – infiltrative
 exophytic –papillary /fungating
 nodular
Penile pain or itching
Bleeding
Urinary symptoms
Groin mass
Secondary infection with discharge & foul smell
Constitutional symptoms – fatigue, wt loss

8. *
* Inguinal LNs – most common site of metastasis
30-45% present with clinically palpable ILNs
50% of palpable LNs are pathologically +ve
20-40% of clinically N0 patients have pathologically +ve ILNs
Overall ~35% patients have pathologically +ve ILNs
*Distant metastasis ~10%
*Fear & embarrassment often lead to delay in presentation &
delayed diagnosis
*Common cause of death
Septic complication
Erosion of large vessel in groin

9. *
*General
 History
 Physical examination
*Histologic confirmation
 Punch, excisional or incisional
 FNAC from ILN
*Laboratory studies
 CBC
 Biochemistry
 Urinanalysis
*Endoscopic examination
 Cystoscopy
 Urethroscopy
*Radiographic examination
 CXR
 CT/MRI
 USG abd
Remarks on examination
of the primary
 Size
 Location on penis
 Number
 Morphology
 Relationship with
other structures –
submucosa, urethra,
corpora spongiosa &
cavernosa

10. *
Jacksons Staging
system
I Tumor confined to glans
and/or prepuce
II Tumor extending onto
shaft of penis
III Tumor with malignant, but
operable, inguinal lymph
nodes
IV Inoperable primary tumor
extending off the shaft of
the penis orinoperable
groin nodes or distant
metastases

11. *
*Most Penile cancers are Squamous cell carcinoma. Subtypes are
Verrucous
Papillary squamous
Warty
Basaloid
*Penile Intraepithelial neoplasia (PIN) is a premalignant
condition which includes
Bowen’s disease
Erythroplasia of Queyrat
*Basal cell carcinoma (1% to 2%)
*Extramammary Paget's disease
*Other uncommon tumours are : soft tissue tumors, lymphomas
& metastatic tumours (from GUT, GIT & respiratory)

12. *
*Grading of tumour is based on degree of cell anaplasia
Grade 1 or well differentiated – no e/o anaplasia
Grade 2 or moderately differentiated - <50% anaplasia
Grade 3 or poorly differentiated - >50% anaplastic cells
Grade 4 - undifferentiated

13. *
*Extent of primary lesion
 Invasion of deeper structures (corpus cavernosum)
*Lymph node involvement
Size
Number
Site
Presence of extracapsular nodal involvement
*Tumour grade/differentiation
*Age of patient
Poorer prognosis in age <50 yrs
*HPV status – no prognostic significance

14. *
Association of Long-term survival/cure with LN involvement
Tumor-free nodes – 80-90%
Inguinal nodes involvement – 40-50%
Pelivc nodes invovlement – 0-20%
Association of 5 yr survival with no. of nodes
 Solitary +ve ILN – 71%
 Multiple +ve ILN – 33%

15. *
*Primary lesion may be addressed by
*WLE with circumcision
*Laser excision
*Glansectomy
*Partial Penectomy
*Total penectomy with
perineal urethrotomy
*Total emasculation (Peno-scroto-orchiectomy) –
*10-20mm margins
*Surgery gives good local control (90%) & 5 yr survival (87%)
*Maybe psychologically devastating & unacceptable for patient
Small lesions of prepuce
Larger lesions involving
glans or shaft
Very advanced proximal
tumours

16. *
*Inguinal LN positivity is a significant risk factor
*Radical ILND gives good control rates
*Associated with high level of morbidity – 50% patients
*Immediate better than delayed : Poor salvage rates after
regional failure
*Management options :
*Risk stratification & surveillance for low-risk cases
*Dynamic sentinel LN biopsy (DNSB)
*Modified inguinal lymphadenectomy (Saphenous v. & sartorius
preservation)
*Video Endoscopic Inguinal Lymphadenctomy (VEIL)
*Robotic assisted laparoscopy
*Radical pelvic dissection justified in patients with positive inguinal
LNs or pelvic LNs seen on imaging

17. *
Risk stratification to predict Occult LN mets –
Solsona E
Risk Group Stage Occult +ve LNs (%)
Low Tis, T1G1 0
Intermediate T1G2-3, T2G1 33.3
High T2G2, T2-3G3 83
Risk stratification to predict Occult LN mets –
European Association of Urology
Risk Group Stage Occult +ve LNs (%)
Low Tis, TaG1-2, T1G1 17%
Intermediate T1G2
High T2 or G3 68-73%

18. *
*Primary advantage is preservation of phallus
*Patients who experience local failure maybe salvaged
surgically
*Possible modalities of treatment :
*EBRT
*192Ir Interstitial brachytherapy
*192Ir Mold plesiotherapy
*Inguinal LN irradiation for N0 patients
*Regional control is 95% with RT vs 80% without RT
*Postoperative RT to groin adds little to morbidity but significantly
contributes to locoregional tumour control

19. *
*Circumcision should be done prior to starting RT – to reduce
reactions
*Requires specially designed accessories / bolus
*Plastic box with central opening for penis
*Perspex Cylinder with vacuum pump
*Box filled with tissue equivalent material or water
*Prone position allows penis to hang away from body
*Parallel opposed megavoltage beams can be used
*Regional lymphatics may also be treated by RT
*Bilateral inguinal & pelvic LNs should be covered

20. *
*T1-T2, N0 (tumour <4cm)
*Brachytherapy alone
*EBRT±Chemotherapy to a dose of 65-70 Gy (1.8-2.0Gy/#) to
primary penile lesion with 2 cm margins
*Consider prophylactic LN irradiation
*TI-T2, N0 (tumour ≥4cm)
*EBRT±Chemotherapy to a dose of 45-50 Gy (1.8-2.0Gy/#) to a
portion of or whole penile shaft plus pelvic/inguinal LNs then boost
primary lesion with 2 cm margins uoto 60-70Gy
*Brachytherapy in select cases
*T3-T4 or N+
*EBRT±Chemotherapy to a dose of 45-50 Gy (1.8-2.0Gy/#) to a
portion of or whole penile shaft plus pelvic/inguinal LNs then boost
primary lesion with 2 cm margins uoto 60-70Gy

21. *
Postop adjuvant RT
*Primary site margin +ve
*Primary site and surgical scar  EBRT to 60-70 Gy
*Inguinal LN +ve
*Inguinal & pelvic LN  EBRT 45-50 Gy
*Boost gross node sites & areas of ECE upto 60-70 Gy

22. *

23. *
*Neoadjuvant, Cisplatin based chemotherapy is recommended in
patients with ≥4cm inguinal LN if FNAC is +ve for mets
*Initially Unresectable T4 lesions may be downstaged by
response to chemotherapy
*TIP (paclitaxel+ifosfamide+cisplatin) is recommended
*Stable or responding patients should then undergo
consolidation Surgery
*Improved PFS & OS are associated with response to chemo
*Adjuvant chemo may be recommended in
*Pelvic LN mets
*B/L inguinal LN +ve
*ECE
*4cm tumor in LNs

24. *
Penis preserving techniques maybe utilized
• Topical imiquimod (5%)
• 5-flurouracil cream
• Surgery
WLE including circumcision
Mohs surgery
Glansectomy
• Laser therapy (CO2 or Nd-YAG)
Tis or Ta

25. *
Penis preserving techniques maybe utilized if patient is reliable
for close follow-up (2 year recurrence rate may reach 50%)
• Surgery
WLE including circumcision (margins of 10-20mm adequate)
Mohs surgery
Glansectomy
• Laser therapy (CO2 or Nd-YAG)
• Radiotherapy
EBRT
Interstitial brachytherapy
T1G1-2

26. *
Require more extensive surgical intervention
• Surgery (Intra-op Frozen section recommended for -ve margins)
WLE including circumcision
Glansectomy
Partial penectomy
Total penectomy
• Radiotherapy
EBRT
Interstitial brachytherapy
±concurrent chemotherapy
T1G3-4,T≥2

27. *
• Low risk & intermediate risk (without LVI)  Surveillance
• High risk & intermediate risk (with LVI)  Modified or radical
inguinal lymphadenectomy
• If treated with EBRT, inguinal & pelvic LNs should be covered in RT
field
Non-palpable nodes

28. *
• If negative on FNAC &/or excision biopsy  Surveillance
• If negative on FNAC &/or excision biopsy  Radical inguinal
lymphadenectomy
2 or more +ve nodes  PLND
• If treated with EBRT, inguinal & pelvic LNs should be covered in RT
field
Unilateral palpable
nodes <4cm

29. *
• Radical inguinal lymphadenectomy
• Adjuvant treatment :
• Single +ve LN  Observation
• Extranodal extension  Chemotherapy
• 2 or more +ve nodes  PLND or adjuvant Radiotherapy
Palpable nodes ≥ 4cm
(mobile or fixed)

30. *
• Neoadjuvant chemotherapy followed by surgery
• Concurrent chemoradiation
Pelvic LNs enlarged on
imaging

31. *
*Acute
*Brisk erythema
*Dry or moist desquamation
*Subcutaneous tissue swelling
*Late
*Telangiectasia
*Meatal-urethral stricture
*Necrosis of glans & skin
*Ulceration
*Lymphadema of the legs