This document provides information on the management of carcinoma penis, including: 1. Details on staging, diagnosis, and treatment options for primary penile lesions and regional lymph nodes. 2. Recommendations for surveillance versus lymphadenectomy in patients with non-palpable nodes based on risk level. 3. Treatment guidelines for palpable positive nodes including bilateral radical inguinal lymphadenectomy. 4. Follow-up guidelines based on treatment provided for the primary tumor and regional nodes.

1. Management of Carcinoma Penis Dr Akhilesh Mishra Senior Resident Radiation Oncology IRCH , AIIMS

18. TNM staging system

45. EAU guidelines on diagnosis Primary tumor PE mandatory, recording morphology & characteristics of lesion. Histological diagnosis or cytology is mandatory. Penile US advisable, if inconclusive MRI optional. Regional lymph nodes PE mandatory. Impalpable nodes, no indication for imaging or histology, DSNB adviable in intermediate & high risk pts. Palpable nodes, record morphology and characteristics, histology reqd

46. EAU guidelines on diagnosis Distant metastasis (only in pts with inguinal nodes) Pelvic / abdominal CT (pelvic nodes) Chest xray Bone scan only if symptomatic Laboratory determinations for specific conditions optional

47. EAU guidelines on treatment Primary Lesion Penile intraepithelial neoplasia Penis preserving strategy. Ta-1 G1-2 Penis conservation, partial amputation in non compliance to follow up. T1G3, T ≥ 2 Partial / total amputation standard, conservative option in selected pts Local recurrence following conservative therapy Second conservative procedure in no invasion cases Partial / total amputation in infiltrating recurrences.

48. EAU guidelines on treatment RN therapy in non palpable nodes Low risk of occult mets (pTis, pTaG1-2, pT1G1) Surveillance, MLND is optional in unreliable to follow pts. Intermediate risk (pT1G2) Strict surveillance is an option in cases with no lymphovas invasion & favourable growth pattern MLND is an option with poor histology, role of DSLNB MLND enlarged to RLND in presence of + ve nodes High risk (pT ≥2 or G3) MLND or RLND recommended.

49. EAU guidelines on treatment Palpable positive RLN Bilateral radical inguinal LND is standard recommendation. PLND can be performed in cases with at least 2 +ve LNs or extracapsular invasion. MLND can be considered on contralateral groin with no palpable nodes. Induction chemo followed by RLND for fixed inguinal mass or clinically +ve pelvic nodes, alternative is neo adjuvant DTx. Bilat RLND or LND at site of palpable nodes during surveillance, adjuvant chemo & DTx are options.

50. EAU guidelines for follow up Primary tumor Conservative therapy, every 2/12 for 2 yrs, 3/12 for 1yr, 6/12 long term. Partial / total penectomy, every 4/12 for 2 yrs, twice during third yr, then annually long term. Regional nodes & distant metastasis Primary tumor removed, 2/12 for 2 yrs, 3/12 for 1 yr, 6/12 for 2 yrs Lymphadenectomy (pN0), 4/12 for 2 yrs, 3/12 for 1 more yr Lymphadenectomy (pN1-3), PE, CT & CXR at regular intervals Bone scan if symptomatic