management of carcinoma penis

1. CARCINOMA PENIS
Dr.Ayesha Mahajan
Moderator- Dr.Suneetha

2. CONTENT
1. Anatomy
2. Introduction
3. Etiology
4. Clinical presentation
5. Pathology
6. Diagnosis & staging
7. Treatment
8. Role of radiation therapy
9. Chemotherapy
10. Cases

3. • The penis consists of the paired corporal bodies, the urethra, and the
head or glans.
• The corporal bodies consist of spongy erectile tissue (corpora
cavernosum) surrounded by a double tough layer of connective tissue
(Buck’s fascia or tunica albuginea).
• The proximal penis is split and each body fixed to the ischiopubic ramus by
penile crura.
• The body is the fused portion of the corporal bodies with the urethra
beneath, and the glans is the distal extension of the corpus spongiosum.
• The urethra is surrounded by a delicate layer of erectile tissue (corpora
spongiosum), which is in direct continuity with the glans penis distally,
and is adherent dorsally to the distal corporal bodies.
ANATOMY

4. Male Sexual Anatomy (cont.)
Fig 5.1a Interior structure of the penis: (a) view from above.
(internal, in
pelvic cavity)
(between glans and the body)
(engorge with blood
during arousal)
(expands
to form
the glans)
(head of the
penis; lots of
nerve endings)
Internal structure of the penis: top view

7. LYMPHATIC DRAINAGE
• Penile skin – runs in order
- superficial deep external iliac
LNs
inguinal nodes inguinal nodes
• Glans – may go in superficial inguinal LNs
- or directly to deep
or external iliac LNs
• inguinal lymph nodes constitute the first echelon of drainage.
• Bilateral drainage occurs as a result of free anastomoses and crossover at
the base of the penis.
• Therefore the pattern of nodal metastasis is not limited to one side.

8. LYMPHATIC DRAINAGE
• superficial inguinal nodes are located in the deep portion of
Camper's fascia above the deep fascia of the thigh, the fascia
lata.
• superficial lymphatics drain into the deep inguinal
lymphatics, which surround the femoral vessels deep to the
fascia lata.
• Secondary drainage is to the iliac nodes, although direct
drainage to these nodes (skip metastases) can occur rarely.

9. • Regional LNs-
- superficial and Deep
inguinal LNs
- pelvic LNs (specified)-
- external iliac
- internal iliac
- obturator
• Metastatic –
- retroperitoneal LNs
(outside the true pelvis)

10. CANCER PENIS INTRODUCTION
• Uncommon malignancy in Western countries,
representing 0.4% of male malignancies and 3.0% of
all GU cancers.
• Globacon 2020 - incidence 0.81% (10,677), (rank-
25th).
• Incidence of penile ca has been declining, partly
because of increased attention to personal hygiene.
• Presents in the 6th decade of life but may occur in
men younger than 40 yrs.

11. • Slow-growing tumor with a usually well-defined
pattern of dissemination, first to the inguinal LNs &
subsequently to pelvic nodes.
• Distant spread is a late feature.
• This propensity of penile ca to spread in an orderly
fashion permits definitive locoregional management
of primary tumor in the majority of cases.

12. ETIOLOGY
• Ca penis -- strongly associated with phimosis & poor
local hygiene.
• Phimosis is found in >50% patients.
• The irritative effect of smegma, is well known,
although definitive evidence of its role in
carcinogenesis is lacking.

13. CIRCUMCISION
• Neonatal circumcision (in Jewish population)
virtually eliminates occurrence of penile ca.
• Delaying circumcision until puberty does not have
same benefit as neonatal circumcision.
• Adult circumcision does not provide any protection
against ca penis.

14. • HPV infection, particularly HPV-16, has been implicated in the
development of invasive penile ca, as has the number of sexual
partners.
• HPV infection accounts for about half of penile cancers, with HPV-
16 and -18 the predominant subtypes.
• Evidence now indicates that penile cancer has two primary
etiologies:
- approximately half are related to HPV infection
- the other half related to inflammatory conditions such as
phimosis, chronic balanitis, and lichen sclerosis.
• It is hoped that vaccines that protects against oncogenic HPV
infections also may reduce the risk.
HPV INFECTION

15. • Use of tobacco products is an independent risk factor
in development of penile ca on multivariate analysis.
• Tobacco has been proposed as a promoter of
malignant transformation in the setting of infection
& chronic irritation.
• Thus, avoidance of tobacco products and HPV
infection, penile hygiene, and neonatal circumcision
represent important preventive strategies against
penile cancer.
TOBACCO

16. CLINICAL PRESENTATION
• Local penile symptoms & signs most often draw attention.
• The clinical spectrum of penile cancer is varied: subtle areas of erythema
or induration to a frankly ulcerated, fungating, foul-smelling mass.
• As a rule, penile ca is an infected malignancy, with infection playing
important role in pathogenesis and ultimately in the presentation of the
disease.
• Pain is not prominent feature & is definitely not proportional to extent of
local destruction.
• The lesion primarily involves the prepuce & glans, often under a tight
phimotic ring.

17. CLINICAL PRESENTATION
• In late stages, involvement & eventual destruction of shaft of penis
are seen.
• Urethral involvement is usually a late feature, and urethral
obstruction is rarely seen.
• Instead, erosion of urethra with development of multiple fistulas
leading to so-called watering-can perineum may be seen.
• Rarely, inguinal ulceration may be presenting symptom, & in such
cases primary tumor is usually concealed within a phimotic
preputial sac or pt delays seeking medical help for social reasons.

18. PATHOLOGY
• >95% penile ca are SCC.
• Non-SCCs consist of melanomas, BCCs,
lymphomas, and sarcomas.
• Nearly 18% pts with AIDS-related Kaposi's
sarcoma have penile involvement.

19. PATHOLOGY
• SCCs are graded using Broders' classification.
• Low-grade tumors (grade I-II), which typically are
confined to prepuce & glans penis, constitute nearly
80% of penile ca.
• On the other hand, most lesions involving the shaft
are high grade (grade III).
• Thus, grade and stage are often correlated.

21. PATHOLOGY
• The incidence of LN mets from SCC penis is related to histologic grade.
• Verrucous carcinoma, a particularly exuberant variant of SCC, has an extremely low potential for LN spread and, thereby, a good prognosis.
• Another important predictor of LN mets and, hence, prognosis is the presence of vascular invasion in the surgical specimen.

22. Pre-malignant Lesions
1. LEUKOPLAKIA
2. BALANITIS XEROTICA OBLITERANS
3. BUSCHKE-LOWENSTEIN TUMOR
4. BOWEN’S DISEASE
5. Extra mammary pagets disease

23. Leukoplakia
• Characterized by presence of solitary or multiple
whitish plaques involving the glans or prepuce in
setting of chronic or recurrent balanoposthitis.
• TREATMENT - Surgical excision in the form of
circumcision or local wedge resection.

24. Balanitis Xerotica Obliterans
• Inflammatory condition of glans & prepuce of unknown
cause.
• BXO presents as a scaly, indurated, whitish plaque that
produces significant phimosis and meatal stenosis.
• Often associated with development of SCC of penis in
selected reports, treatment remains controversial and
consists of topical steroids and surgical excision.
• Although formal meatoplasty may be required for advanced
meatal stenosis, early circumcision has been found to be the
most effective treatment for BXO.

25. Buschke-Lowenstein Tumor
• Characterized by a large exophytic mass involving the glans
penis and prepuce;
• it is a giant condyloma acuminatum that has a good
prognosis and does not metastasize.
• Except for unrestrained local growth, this lesion does not
have any features of malignancy.
• A viral etiology has been proposed, with identification of
HPV-6 and -11 in these tumors.

26. Buschke-Lowenstein Tumor
• Treatment -- local conservative resection.
• Recurrence is common, close follow-up is essential.
• Systemic interferon therapy combined with Nd:YAG laser
therapy has been reported to be successful in selected
cases.
• RT is essentially C/I in this condition because rapid
malignant degeneration has been described.

27. Carcinoma in situ
• Bowen’s disease – intraepithelial skin neoplasm
(solitary thickened grey white plaque with scab)
- asso. With HPV (80 %)
- converts into SCC (10 %)
• If the disease over glans / prepuce 🡪 Erythroplasia
of Queyrat

28. DIAGNOSIS AND STAGING
• Workup begins with a meticulous physical exam of genitalia &
inguinal LNs to ascertain local extent of lesion & inguinal
adenopathy.
• excisional biopsy of the penile lesion is favoured.
• This must often be preceded by either a dorsal slit of the foreskin
or circumcision to expose the lesion.
• MRI of the penis with prostaglandin E1-induced erection is
considered one of the most sensitive imaging modality and is
recommended for high-grade/high-stage lesions suspected of
involving the corporal bodies.

29. DIAGNOSIS AND STAGING
• After biopsy confirmation, no further radiologic
workup is generally needed in pts with T1 , T2 stage
disease & absence of inguinal adenopathy on exam or
other worrisome symptoms.

30. DIAGNOSIS AND STAGING
• Nodal status is the most significant prognostic variable
predicting survival.
• Approx 50% pts with ca penis present with palpable inguinal
nodes.
• However, only half of these pts will have metastatic disease,
whereas the remainder have inflammatory adenopathy.
• Conversely, 20% of pts with a clinically negative groin exam
are found to have mets if prophylactic node dissection is
performed.

31. DIAGNOSIS AND STAGING
• If an inguinal lymph node is palpable and considered
suspicious, the diagnosis should be confirmed by fine needle
aspiration (FNA).
• A prolonged trial of antibiotics is no longer considered
appropriate

32. DIAGNOSIS AND STAGING
• Abd & pelvic CT / penile MRI scanning is recommended in obese
pts or where palpation is unreliable to evaluate the inguinal nodes.
• Conventional CT or MRI should be performed with palpable
inguinal LNs to detect disease in pelvic nodes or distant
nodal groups.
• Currently, MRI is a reasonable choice to supplement physical exam
in individuals in whom access to the inguinal regions is difficult; it
also allows for concurrent evaluation of the primary.

33. DIAGNOSIS AND STAGING
• The MC distant metastatic sites are the lung, bone, and liver.

34. Clinical Primary Tumor (T)
• TX Primary tumor cannot be assessed
• T0 No evidence of primary tumor
• Tis Carcinoma in situ (PeIN)
• Ta Noninvasive localized SCC verrucous carcinoma
• T1 Glans- invades lamina propria
Foreskin- invades dermis,lamina propria or dartos fascia
Shaft- invades connective tissue b/w skin and corpora
All sites with / without LVI, PNI ; high grade or not
- T1a No LVI ,PNI or not high grade
- T1b tumor showing LVI + / PNI + or high grade (gr 3 or sarcomatoid)
• T2 Tumor invades corpus spongiosum with / without urethral invasion
• T3 Tumor invades corpora cavernosum +/- urethral invasion
• T4 Tumor invades other adjacent structures (scrotum,prostate,pubic bone)

36. • NX Regional lymph nodes cannot be assessed
• N0 No palpable or visibly enlarged inguinal LNs
• N1 palpable mobile U/L inguinal LN
• N2 palpable mobile U/L >/=2 inguinal LN
or b/l inguinal LNs
• N3 palpable fixed inguinal or pelvic LNs, u/l or b/l
Clinical N staging

37. • NX LN metastasis cannot be established
• N0 no LN mets
• N1 </=2 u/l inguinal LN mets , no ENE
• N2 >/=3 u/l inguinal LN mets OR b/l mets
• N3 ENE + or pelvic LN mets
Distant Metastasis (M)
• MX Distant metastasis cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis
Pathological nodal staging

39. JAKSON staging
• Stage I – confined to glans or prepuce
• Stage II – extension to shaft
• Stage III – operable inguinal LN mtes
• Stage IV - inoperable inguinal LN mtes
or local or advanced spread

40. TREATMENT MODALITIES
• Depends on local extent of primary neoplasm & status of regional
LNs.
• For Rx of primary lesion, 2-cm proximal margin of resection is
recommended to avoid local recurrence and is the standard of care.
• Leaving the patient with inadequate penile length for hygienic
upright micturition and sexual intercourse should be avoided.
• Thus, depending on extent of the primary tumor, resection may
include partial or total penectomy.
• Local recurrence after a properly planned & executed partial or
total penectomy is rare.

41. TREATMENT MODALITIES
• In advanced cases (T4), more aggressive resections, such as an
emasculation procedure, a hemipelvectomy, or even a
hemicorpectomy, have been reported.
• Although surgery forms the mainstay for treatment of the primary
lesion, RT can be considered for a select group of pts.
• RT permits preservation of the penis, thereby obviating
psychosocial and physical morbidity caused by partial or total
penectomy.
• Although RT has been shown to control early (T1 and T2) lesions with
a 65-80% success rate, treatment of more advanced T-stage penile ca
has often led to local recurrences (20-40%) and the most significant
risk of tumor progression to nodal and systemic disease.

42. Carcinoma in situ (TIS)
• After biopsy confirmation of the lesion, an approach that
spares penile anatomy and function is generally preferred.
• Preputial lesions are adequately treated with circumcision.
• Topical 5-FU cream has been used with excellent cosmetic
results for glans and meatal lesions.
• A combination of CO2 & Nd:YAG lasers has shown good
local tumor control and highly satisfactory cosmetic results
on long-term follow-up.

43. Carcinoma in situ (TIS)
• Mohs micrographic surgery has been described as a less-
deforming alternative, with local control rates up to 86%
in selected early penile ca.
• RT has also been used successfully to eradicate these
lesions with minimal morbidity.

44. Verrucous Carcinoma
• In view of its benign course, a partial or total penectomy is
usually overtreatment.
• Laser ablation or Mohs micrographic surgical technique have
yielded acceptable results.
• recurrent superficial lesions may be treated with 5-
fluorouracil or 5% imiquimod cream as topical therapy.
• However, RT in any form is C/I in this lesion as it has been
shown to cause subsequent rapid malignant degeneration
and metastases.

45. Invasive Penile Cancer (T1, T2, T3,
and/or N1)
• Distal penile lesions in which a serviceable penis for upright
micturition & sexual function can be achieved are best treated
with partial penectomy.
• For extensive lesions approaching the base of the penis, total
penectomy with excision of both corporal bodies and creation
of a perineal urethrostomy is usually required.
• Local recurrence after a partial penectomy in properly selected
cases is rare.
• Patients with penile recurrence after initial partial penectomy
can be treated by further surgical salvage.

46. Invasive Penile Cancer (T1, T2, T3,
and/or N1)
• Most relapses occur within the first 12-18 months after
penectomy.
• Thus, close follow-up is important.
• RT, although effective for local control of small, 2-4 cm,
T1 and T2 lesions
• Use of brachytherapy is usually limited to T1-T2 tumors.

47. Advanced Penile Cancer (T4, N2/N3,
and/or M1)
• Large proximal shaft tumors require a total penectomy with a
perineal urethrostomy.
• For extensive, proximal tumors with invasion of adjacent
structures, total emasculation consisting of total penectomy,
scrotectomy, and orchiectomy is recommended.
• In extreme cases, a hemipelvectomy or even hemicorporectomy
has been described.
• Multimodal therapy with NACT or CT/RT & salvage surgery has
also been used in this setting.

48. Management of Regional LNs
• Presence & extent of inguinal LN mets are most important
prognostic factors in patients with penile carcinoma.
• Although 50% pts with a penile lesion have clinically
palpable inguinal nodes at presentation, in >half of these
the adenopathy is inflammatory.
• Pts with persistent adenopathy after antibiotic should
undergo biopsy & definitive therapy.
• Once LN mets are discovered, inguinal mets from penile ca
are potentially curable by lymphadenectomy alone.

49. Clinical Node Negative (N0)
• Approx, 20% of clinically negative inguinal nodes harbor occult
lymphatic mets on prophylactic LN dissection.
• Analysis of histopathologic data from the primary penile ca allows
stratification of pts into high- and low-risk groups for LN
metastases.
Low risk
• Tis / Ta
• T1 Grade I-II
• No vascular invasion
<10% LN mets
Surveillance
High risk
• T2-T3
• Grade III
• Vascular invasion
• Non-compliance
>50% LN mets
Early lymphadenectomy

50. Clinical Node Negative (N0)
Dynamic sentinel node biopsy (DSNB) is a newer technique
to assess clinically uninvolved nodes.
Drawbacks:
(1) The false negative rate for DSNB is 20% to 30%
(2) DSNB may not be reliable for palpable lymph nodes that
may be entirely replaced by a tumour
• Sentinel LN biopsy is no longer recommended in view of
the high false-negative rate.

51. Clinical Node Positive (N1, N2, or N3)
• In the case of u/l node + disease, it is standard practice to proceed
with b/l LN dissection in view of high incidence of b/l drainage.
• Individuals with histologically positive nodes should undergo
therapeutic ipsilateral radical inguinal lymph node dissection,42
with modified dissection on the contralateral side.
• The exception is the patient with recurrence.
• The value of pelvic lymphadenectomy in the presence of positive
inguinal LNs is for purposes of staging and for identifying pts who
would be candidates for adjuvant CT.

52. Clinical Node Positive (N1, N2, or N3)
• Pts with advanced nodal disease or bulky fixed inguinal nodes (N3)
may require NACT or RT before any surgical intervention.
• Other issues to the use of RT for inguinal LNs is –
- the difficulty in clinical evaluation of the groin because of post-
radiation tissue changes,
- that the inguinal area tolerates RT poorly & is prone to skin
maceration and ulceration.
• Thus, RT can be used as a palliative measure in pts with fixed
inoperable inguinal nodes or in those with advanced unresectable
penile cancer in which the primary and the ilioinguinal region can
be treated with RT.

53. INGUINO-PELVIC LYMPHADENOPATHY
Good Prognostic Factors
• Minimal nodal disease (2 or less nodes)
• Unilateral involvement
• No extranodal extension
• Absence of pelvic node metastases
Indication of PLND - >2 i/l inguinal L.N +ve or
ENE.
Indications for adjuvant therapy
• >2 metastatic inguinal nodes
• Extranodal extension of disease
• Pelvic lymph node metastases

54. ROLE OF RADIATION THERAPY
CURATIVE
• selected stage 1,2 tumors with size<4cm and <1cm invasion into
corpora cavernosa - INTERSTITIAL BRACHYTHERAPY
• EBRT - selected stage ⅔ caes unfair for surgery or refusing surgery
ADJUVANT
• single node with ECE - radiation to ipsilateral side considered.
• multiple or bilateral L.N involved - RT to involved groin nd adjacent
pelvic nodes.
PALLIATIVE
• inoperable cases, to treat fixed or fungating inguinal nodes
• metastatic sites.

55. EXTERNAL BEAM RADIATION
THERAPY
Primary advantage is of organ preservation.
If indicated, circumcision must be performed before start of radiation
therapy
Circumcision helps in examining the gross tumor better, as well as
minimizes radiation related toxicities like swelling, skin irritation, moist
desquamation, secondary infections
Early stage tumor ineligible for brachytherapy/ eligible for EBRT - ie.
• size>4cm
• invasion >1cm
• most stage 3

56. EXTERNAL BEAM RADIATION
THERAPY
• IMMOBILISATION- BOX TECHNIQUE - a plastic box 10X10cm
OR 10X15cm with central circular opening fitted over penis
and space between skin and the box is filled with tissue
equivalent material (wax).
• Lateral parallel opposed beams are used.
• alternatively a water-filled container can be used to envelop
the penis while the patient is in prone position.
• Perspex tube attached to base plate. Vacuum pump
connected to tube and suction effect to keep penis at site

57. EXTERNAL BEAM RADIATION
THERAPY

58. EXTERNAL BEAM RADIATION
THERAPY
• A line joining ASIS and pubic
tubercle is joined.
• cranial - 4 cm above the line
• caudal - 6 cm below the line
• lateral - anterior superior iliac spine
• medial - pubic symphysis or pubic
tubercle
• single AP portal is used.

59. EXTERNAL BEAM RADIATION
THERAPY
• For conformal techniques pelvic cast or vacloc can be used.
• simulate patient in supine position with foleys catheter and
suspended penis surrounded with tissue bolus.
• frog leg position for inguinal node radiation.
• penis can be secured cranially if pelvic nodes are treated.

60. EXTERNAL BEAM RADIATION
THERAPY
VOLUMES
1. GTV - gross disease on examination and imaging
2. CTV - GTV + whole penile shaft +/- inguinal nodes +/- pelvic
nodes
3. PTV - CTV + margins according to institutional protocol.
• CIS - 125-250kv orthovoltage or 13MeV electrons to 35Gy/10#.
• CARCINOMA - 45-50.4Gy to whole penile shaft, followed by boost
upto 60-70Gy to gross disease with 2cm margin.
• for INGUINAL NODES- 50Gy for node negative disease or post op
cases . For palpable/unresectable nodes - upto 70-75Gy.

61. BRACHYTHERAPY
• ideal tumor for brachytherapy
– tumor <4cm
– invasion <1cm
– tumor volume <8cc
Reserved for T1, T2, early T3 lesions.
TYPES
• interstitial brachytherapy
• mold pleisiotherapy

62. MOLD BRACHYTHERAPY
• indicated for very superficial lesions (<5mm thick) with well
defined limits.
• mold is usually made of box/cylinder with a central opening for
placement of penis and channels for placement of radioactive
needles/wires in the periphery.
• cylinder and sources should be long enough to prevent
underdosage to the tip of penis.
• DOSE PRESCRIPTION - 55-60Gy on surface with 46-50Gy over
central axis over 84hrs (12hr/day)

64. INTERSTITIAL BRACHYTHERAPY
• implant placement requires 30-40min under spinal or
general anesthesia.
• catheterization help to identify urethra and avoid
transfixation with needles/catheters during implantation.
Patient is catheterised for the entire duration of treatment.
• needle placement (10-18mm) should be planned such that
prescription isodose should cover 10mm beyond gross
disease.

67. INTERSTITIAL BRACHYTHERAPY
• LDR BRACHYTHERAPY - 0.4-0.5Gy/hr, upto 60-65Gy
over 4-5 days (100-120hrs).
• HDR BRACHYTHERAPY- twice daily - 3Gy x 18# or
3.2Gy x 12# (ABS).

68. COMPLICATIONS
1. dermatitis
2. dysuria
3. telangiectasia
4. meatal stenosis
5. urethral strictures
6. fistulas
7. impotence
8. penile fibrosis/necrosis

70. • Acute side effects of RT in form of skin edema, maceration
& dysuria usually subside within 2 weeks of treatment but
may persist for 6-8 weeks.
• Telangiectasia and fibrosis are found in >90% of cases, but
pts usually do not complain of these.
• Most serious late effects are urethral fistula, meatal
stenosis, and penile necrosis.
• Post-radiation fibrosis, scar, and necrosis may be difficult to
distinguish from recurrent cancer, and repeated biopsies
may be needed.

71. • Thus, in summary, RT for primary penile ca
should be considered only in a select group
of pts:
--young pts with small (2-4 cm) superficial
lesions of distal penis who wish to maintain
penile integrity,
--pts who refuse surgery, and
--pts with inoperable cancer or those
unsuitable for major surgery.

72. Role of CT & Multimodality Therapy
• The role of CT in the management of penile ca is still
evolving, and has not been established.
• Penile cancer is sensitive to CT.
• Besides the use of 5-FU in the treatment of superficial penile
ca, single-agent CT with cisplatin, methotrexate, & bleomycin
has modest activity in advanced penile ca.
• The combination of methotrexate, bleomycin, and cisplatin
(MBP) is more active than cisplatin alone but is associated
with marked toxicity.

73. Role of CT & Multimodality Therapy
Adjuvant Chemoradiation
• bulky inguinal L.N - pN2-3
• pelvic L.N +ve
preferred drugs - Cisplatin +/-5 FU
• Neoadjuvant CT –
- bx proven bulky mets in multiple or b/l inguinal nodes
(>4cm)
- fixed nodes
- pelvic adenopathy
preferred - Paclitaxel, ifosfamide and cisplatin.

78. Figure 32-1 Surgical glans defect
covered with outer preputial flap as
described by Ubrig and colleagues
(2001). A, Superficial glans tumor. B,
Outer preputial flap outlined. C, Tumor
excised and circumcision performed. D,
Glans defect filled with outer preputial
flap.

79. Partial Penectomy
Figure 32-3 Partial penectomy. A, Incision with
ligation and division of dorsal penile vessels
within Buck's fascia (inset). B, Corpora
transected and urethra spatulated. C and D,
Closure of corpora cavernosa. E, Final closure
with construction of urethrostomy.

80. Total Penectomy
Figure 32-5 Total penectomy. A, Incision.
B, Transection of the corpora near the
level of the pubis. C, Mobilization of the
remaining urethra off of the proximal
corporal bodies. D, Transposition of the
urethra through a curvilinear perineal
incision. E, Completion of perineal
urethrostomy.
(Total penectomy is a bit of a misnomer,
as the penis is amputated at or near the
level of the suspensory ligament of the
penis without removal of the corpora
cavernosa more proximally.)

81. Radical Penectomy

84. Clinical Node Positive (N1, N2, or N3)
• Modified inguinal LN dissection as described
by Catalona in 1988 has replaced the standard
complete inguinal lymphadenectomy.
• It involves a smaller incision, limited field of
inguinal dissection, and preservation of the
saphenous vein in an effort to reduce the
morbidity of the standard procedure while
adhering to standard oncologic principles.

89. • The SWOG reported on the largest prospective
clinical trial in pts with penile ca.
• In 40 evaluable pts treated with a combination of
MBP, an overall response of 32.5% and a
complete response of 12.5% were observed.
• The median duration of response was 16 weeks,
and the median survival was 28 weeks.