PENILE CONSERVATION BY RADIOTHERAPY

1. PENILE CONSERVATION
TO CUT OR NOT TO CUT
DR KANHU CHARAN PATRO
RADIATION ONCOLOGY
MAHATMA GANDHI CANCER HOSPITAL
VISAKHAPATNAM

2. GLIMPSE
• Squamous carcinoma (SCC) of the penis
affects about 1 in 100,000 men in western
societies.
• Circumcision protects.
• Circumcision to total panectomy is the
common approach.
• Conservation is being less practiced as
minimal referrals from surgeons and even in
less popular in radiation oncologists.

3. A SURGEON’S PROSPECTIVE AND DOMINANCE
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6. ALGORITHM FOR PRIMARY

7. To cut or not to cut
Ozsahin M /Int J Radiat Oncol Biol Phys./2006

8. ANALYSIS
• 60 PATIENTS
• SX-45, RT-29,PORT-22
• MED-F UP
62 MONTH
• LOCAL FAILURE RATE
SX vs RT 13 % vs 36%
• PENILE PRESERVATION RATE-52%
• 5 YR & 10 YR SURVIVAL
43 % AND 26%
• OS (SX vs RT)
56 % vs 53%

9. A 10-YEAR RETROSPECTIVE AUDIT OF PENILE
CANCER MANAGEMENT IN THE UK
• RT was given to 18/65 patients as primary radical
treatment,
• Immobilization of the penis using a wax block, with a
field arrangement of two opposing lateral photon
fields.
• Doses used varied from 55 Gy in 16 # to 50 Gy in 20 #
(dose /#-3.4–2.5 Gy).
• The equivalent dose in 2 Gy fractions was 52–62 Gy,
• Complications associated with local RT were necrosis
(two patients) and one each with phimosis, erectile
dysfunction and urethral stricture
Tina Mistry/2007/Bju

12. RADIOTHERAPY
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TELETHERAPY
BRACHYTHERAPY

13. CASE SELECTION FOR RADIOTHERAPY
• Superficial or exophytic lesions.
• Lesions of <4 cm, and tumour located on the glans or
coronal sulcus.
• Lesions of <4 cm on the glans penis with no tumour
extension onto the shaft may be suitable for BT.
• Circumcision should be performed before radiotherapy
with glans tumor to reduce radiation-induced
complications.
• Radiotherapy may be offered to patients medically
unfit for surgery or as palliative treatment.
• Efficacy depends on careful planning and appreciation
of dosimetry.

14. MRI
• When MRI scans are used to look at penile
tumors, the pictures are better if the penis is
erect.
• The doctor can inject a substance called
prostaglandin into the penis to make it erect.

16. Inguinal evaluation

26. TESTICULAR SHIELD

27. PUT WET GAUGE
PUT WET GAUGE

28. EBRT
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
28

38. BARCHYTHERAPY IN SITU
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40. Analysis
• 03/2006 to 08/2013-12 patients
• T1-T2 (<4 cm) non-metastatic
• TEMPLATE.
• 36 Gy in 9 fractions over 5 days ADJ.
• 39 Gy in 9 fractions over 5 days RAD
• median follow-up of 27 months
• 5-year relapse-free, cause-specific and overall survival rates
were 83%,100% and 78% respectively.
• pre and post treatment evaluation, no IPSS or IIEF-5 are
same.
• G3 successfully treated with hyperbaric oxygen therapy.
One urethral meatus stenosis G3 required meatotomy

42. TORONTO & OTTAWA EXPERIENCE
• 49 men
• (SQCC) of the penis
• From September 1989 to September 2003
• Mean age, 58 years; brachytherapy for penile SCC.
– 51% were T1,
– 33% T2, and
– 8% T3;
– 4% were in situ
– 4% Tx. Grade
– well differentiated in 31%,
– moderate in 45%, and poor in 2%;
– grade was unspecified for 20%.
• All tumors in Toronto had pulsed dose rate (PDR) brachytherapy (n = 23), whereas those in
Ottawa had either Iridium wire (n = 22) or seeds (n = 4).
• with no correction in total dose, which was 60 Gy in all cases.
• Median follow-up was 33.4 month
• At 5 years, actuarial overall survival was 78.3% and cause-specific survival 90.0%.
Crook JM /Int J Radiat Oncol Biol Phys./2005

43. TORONTO & OTTAWA EXPERIENCE
• COMPLICATION
• The soft tissue necrosis rate was 16%
• the urethral stenosis rate 12%.
• 8 men with regional failure, 5 were salvaged by lymph node dissection
with or without external radiation.
• 4 men with distant failure died of disease.
• Of 49 men, 42 had an intact and tumor-free penis at last follow-up or
death.
• The actuarial penile preservation rate at 5 years was 86.5%.
• CONCLUSIONS:
• Brachytherapy is an effective treatment for T1, T2, and selected T3 SCC of
the penis. Close follow-up is mandatory because local failures and many
regional failures can be salvaged by surgery.
Crook JM /Int J Radiat Oncol Biol Phys./2005

44. LITERATURE REVIEW

50. STAGING

55. TEMPLATE BASED BRACHY

62. BOLUS & EXTERIOR PLANE

63. POST EXPLANT MANAGEMENT
• Moist desquamation throughout the treated area is expected and usually starts
within 10 TO 15 days
• Loose tubular non-stick dressing will prevent the healing skin from adhering to
underclothes
• Tightly bandaged with an occlusive dressing as this maneuver promotes
infection and delays healing
• Multiagent antibiotic cream or ointment Can be applied for the first 2 TO 4
weeks, and
• Some authors recommend that vitamin E ointment be applied later on as re-
epithelialization progresses
• Smoking is discouraged as it is believed to delay wound healing.
• Complete healing usually occurs within 2 months but in some cases may take 3
to 4 months or longer, especially in patients with diabetes or vascular disease.
• Intercourse can be resumed when the patient is comfortable, although the
healing Epithelium is fragile, and extra water-based lubrication is recommended

64. BRACHYTHERAPY DOSE
• 3.2 Gy bid
• 38.4 Gy in 6 days for volume implants is well
tolerated.
• The interval between fractions should be at
least 6 hour
• IGBT-CT based plan should be

65. DOSE DISTRIBUTION

66. TARGET AND OAR

67. MOIST DESQUAMATION

68. PENILE ULCERATION

69. HYPERBAERIC OXYGEN THERAPY

70. MEATAL STENOSIS- 9 to 45%

71. TELANGIECTASIA

72. BEFORE AND AFTER
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74. PENIS AND LUNGI BOTH PRESERVED

76. NODAL MANAGEMENT
 Lymph node observation is appropriate for small (T1)
well-differentiated tumors .
 Radiographic assessment and directed biopsies are
warranted in moderate or poorly differentiated or
larger tumors more than 4 cm or >T2 tumors.
 Surgical management of positive or suspicious lymph
nodes is preferred
 EBRT is an option if the patient is not a surgical
candidate
 Suitable primary brachytherapy can be combined with
surgical management of the lymph nodes in a
multidisciplinary approach.

78. ADVANTAGES OF BRACHYTHERAPY
• Shorter duration
• Good homogenous dose distribution
• Sparing the shaft from radiation effect
• BT offers good success rates particularly for
low-stage disease and in general is more
successful than EBRT.
• The 5-year rate of penile preservation after BT
ranges from 70% to 88%, which is higher than
the corresponding 36–66% rates for EBRT.

79. TAKE HOME MESSAGE
• After treatment, most patients reported that PB has
little or no effect on their sexuality.
• More than half of patients remained sexually active
after treatment .
• Almost all Continued to have erections even if they
were of lower quality. There was little damage to
body image and sense of manliness.
• This information may play a key role in the choice of
cancer treatment leading to the maintenance of a
good sexual life.

82. NO AMPUTATION PLEASE
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