Ca Penis

SEMINAR “MANAGEMENT OF CARCINOMA PENIS” AMOL PATEL NISHANT KHARE

Introduction  Incidence

worldwide is roughly 1% of the total cancers in male

 Social

stigma and reluctant patient delayes the presentation

 Early

detection can prevent major morbidity and mortality

CLINICAL PRESENTATION  Middle

aged male with or without a precancerous condition

 Most

patients present with mass and ulceration and / or induration

 50%

patients have inguinal adenopathy at initial presentation

DIAGNOSING Ca PENIS  Histology

diagnosis

forms the cornerstone of

 Incisional

biopsy of the lesion is the preferred modality

 Biopsy

provides opportunity to grade the tumor at the time of initial diagnosis

IMAGING MODALITIES  Recommended

for :

– Staging the disease – Follow up of patient – To assess spread and resectability

IMAGING MODALITIES  USG: – To assess extent and resectability of T4 disease – Assessment of lymph nodes

 CT

SCAN:

– Assessment of lymph nodes – Limited utility in primary lesion

 MRI: – Most accurate in detecting primary and nodal disease

IMAGING MODALITIES  FLUOROSCENCE

STUDIES:

– For accurate planning of treatment plan for

laser ablation  Lymphoscintigraphy: – Most accurate in identifying need of LN

dissection

STAGING Ca PENIS: JACKSONS SYSTEM  Jackson

classification for SCC of the penis

– Stage I - Tumor confined to the glans or the prepuce – Stage II - Invasion into the shaft or the corpora; no

nodal or distant metastases – Stage III - Tumor confined to the penis; operable metastases of the inguinal nodes – Stage IV - Tumor involves adjacent structures; inoperable inguinal nodes and/or distant metastasis or metastases

STAGING Ca PENIS: TNM SYSTEM 

Tumor – – – – – –



Tis - Carcinoma in situ (Bowen disease, erythroplasia of Queyrat) Ta - Noninvasive verrucous carcinoma T1 - Tumor invading the subepithelial connective tissue T2 - Tumor invading the corpus spongiosum or cavernosum T3 - Tumor invading urethra or prostate T4 - Tumor invading other adjacent structures

Node – N1 - Involvement of a single superficial inguinal node – N2 - Involvement of multiple or bilateral superficial inguinal nodes – N3 - Involvement of deep inguinal or pelvic nodes, unilateral or bilateral



Metastasis – – – – –

M1 - Distant metastasis present M1a - Occult metastasis (biochemical and/or other tests) M1b - Single metastasis in a single organ M1c - Multiple metastasis in a single organ M1d - Metastasis in multiple organ sites

STAGING Ca PENIS: INVESTIGATIONS 

Biopsy – Depth of invasion – Histological grading



USG abdomen – Assessment of lymph nodes – Detectable metastases



CT Scan – Lymph nodes – Metastases



MRI

OTHER INVESTIGATIONS  Routine

blood investigations:

– Anaemia – Raised ESR – Leucocytosis

 CXR  Others

depending on metastatic suspicion

INVESTIGATIONS FOR METASTATIC DISEASE  CXR

/ CT Scan chest

 LFT  CT

Head

 Bone

scan

TREATMENT OPTIONS  SURGICAL

TREATMENT

 MINIMALY

INVASIVE SURGERY

 LASER

THERAPY

 RADIOTHERAPY  CHEMOTHERAPY

SURGICAL TREATMENT OF PRIMARY DISEASE  Surgery

forms the cornerstone of therapy

 Length

of healthy stump is the most important determinant in deciding the extent of resection

 Urinary

diversion (Perineal Urethrostomy) should accompany total amputation

SURGICAL TREATMENT OF PRIMARY DISEASE

INDICATIONS OF LYMPH NODE DISSECTION  All

patients with palpable non responding adenopathy

 All

patients with cytologically proven disease

 All

patients with T2 disease or more should undergo prophylactic dissection

 Minimum

dissection is bilateral superficial inguinal group dissection

MANAGEMENT OF NODAL DISEASE  Bilateral

superficial inguinal node dissection is the treatment of choice

 Deep

nodes to dissected on the side where the superficial nodes are positive

 Iliac

nodes to be dissected if deep nodes are positive

 Para-aortic

adenopathy contraindicates lymph node dissection

PRODUCTION OF BILIRUBIN

STRUCTURE OF BILIRUBIN 

Terra - Pyrrole ring structure



Extensive hydrogen bonds: Water insoluble



Exposure to light: converts into more polar form

LYMPH NODE DISSECTION: COMPLICATIONS AND CONTRAINDICATIONS  COMPLICATIONS: – – – –

Lower limb lymphoedema Flap necrosis Seroma Infections

 CONTRAINDICATIONS – – – –

Para-aortic lymphadenopathy Verrucous carcinoma Metastatic disease Major surgery contraindicated

ROLE OF RADIOTHERAPY  INDICATIONS: – Small exophytic lesion if patient does not want surgery – Inguinal node irradiation if surgery is not planned  External

beam irradiation or mould may be used

 Circumcision

should be done prior to radiation

 Stenosis

and fistula are the major complications

 Sterility

and Priapism may also occur

ROLE OF CHEMOTHERAPY  Topical

5 – FU may be used for very superficial lesions

 Systemic

chemotherapy (VBM) has limited role after node dissection to prevent metastases

 Neo

– adjuvant therapy is being investigated for advanced lesions with unresectable or fixed nodes

MINIMALLY INVASIVE THERAPY  Laser

therapy

 Mohs

micrographic surgery

 Cryotherapy

CONCLUSION  Surgery

penis

is the mainstay of treatment of carcinoma

 Histological

confirmation is the easiest and most effective mode of diagnosis

 Nodal

dissection improves survival and is hence indicated

 Chemotherapy

indications

 Penile

and radiotherapy have limited

reconstructive procedures may be offered to young males with good prognosis