Penile

Epidemiology

  • US - 1500 cases annually, <2% of GU cancers
  • Incidence rises dramatically in developing world
  • Uganda - most common male malignancy

Risk factors

  • Phimosis - narrowed opening of the prepuce resulting in non-retractile foreskin. Odds ratio 10
  • (un)Circumcision - uncircumcised penis can accumulate Smegma
  • HPV - 16 prevalence 30-70%
  • Age - meadian age at diagnosis in US is 60
  • Tobacco

Histology

  • Squamous cell (95%)
    • Papillary
    • Basaloid
    • Warty
    • Sarcomatoid
    • Verrucous (up to 25%)
  • Melanoma
  • Lymphoma
  • Basal cell

Staging

'''T-stage:'''

  • Tis - carcinoma in situ
  • Ta - non-invasive verrucous carcinoma
  • T1 - invades subepithelial connective tissue
  • T2 - invades corpus spongiosum or cavernosum
  • T3 - invades urethra or prostate
  • T4 - invades other adjuacent structures

'''N-stage:'''

  • N0 - none
  • N1 - single superficial inguinal lymph node
  • N2 - multiple or bilateral superficial inguinal lymph nodes
  • N3 - deep inguinal or pelvic lymph nodes (unilateral or bilateral)

'''M-stage:'''

  • M0 - no
  • M1 - yes

'''Overall stage:'''

  • I - T1 N0
  • II - T1 N1, T2 N0-1
  • III - T1-2 N2, T3 N0-2
  • IV - T4, N3, M1

Spread

'''Lymph Nodes'''

  • Drainage to superficial inguinal -> deep inguinal -> external iliac

At presentation

50% clinically enlarged 50% clinically negative
50% disease 50% reactive* 20% occult disease 80% Truly negative
  • so clinically enlarged node should be treated first with a course of ABX
  • Decision on who should undergo inguinal dissection one of the hardest in penile CA management. Sentinel LN reasonable option

*Highly correlats with T-stage and grade (PMID 11342906)
T1 11%, T2 63%, T3 63%
G1 15%, G2 67%, G3 75%

Risk Group Stage & Grade LN (+)
Low T1 G1 0%
Intermediate T1 G2-3, T2 G1 33%
High T2 G2-3, T3 G1-3 83%

LN+ correlates with 5-year survival:

  • N0 - 80-90%
  • N1 - 70%
  • N2-3 inguinal - 35%
  • N3 pelvic - 20%
  • Overall N+ 40-50%

'''Mets'''
*<10% M+ at presentation

Treatment Guidelines

  • NCI Guidelines are driven by TNM staging
'''NCI Guidelines''' Stage TNM Recommendation
Stage 0 Tis Mohs surgery
Ta Laser, cryosurgery, Iquimod, topical 5-FU
Stage 1 T1 N0 Foreskin: wide local excision
Penile amputation
Mohs surgery
RT
Stage 2 T1 N1
T2 N0-1
Penile amputation
EBRT/BT
Stage 3 T1-2 N2
T3 N-2
Penile amputation, with LN dissection if clinically LN+
Penile amputation, with nodal RT if clinically LN+ and not surgical candidate
Stage 4 T4
Any T N3
M1
Palliative surgery
Palliative RT

Surgery vs. RT

*'''Lausanne, 2006''' (Switzerland) PMID 16949770 — "Treatment of penile carcinoma: To cut or not to cut?" (Ozsahin M, Int J Radiat Oncol Biol Phys. 2006 Nov 1;66(3):674-9.)
Retrospective. 60 patients, 5 surgery, 22 surgery + adjuvant RT, 29 primary RT. Mean F/U 62 months
5-year OS: surgery 53% vs. RT 56% (NS). RT failures underwent surgical salvage
Local failure: Median time to LR failure 14 months; Surgery (+/- RT) 13% vs. RT 56% (SS)
Patients treated with RT: penis preservation 52%. 5-year probability of intact penis 43%
**Conclusion: Surgery better LR rate, RT better penile preservation, OS same

Brachytherapy

  • Cylindrical-mold therapy is less appropriate for short penis

Princess Margaret, 2005''' (Canada) [1]
**Retrospective. 49 patients.
T1 51%
T2 33%
G1 31%
G2 45%

RT mean dose of 60 Gy with

  • 23 with pulsed dose rate brachytherapy,
  • 22 iridium wire
  • 4 iridium seeds

Medium F/U 2.7 years

  • 5-year OS: 78%, CSS 90%
  • Local failure: 15%, all salvaged by surgery. Regional failure 20%. Distant failure 10%
  • 5-year penile preservation: 86%
  • Side effects: soft tissue necrosis 16%, urethral stenosis 12%
Bibliography
1. Crook JM, Penile brachytherapy: results for 49 patients. Int J Radiat Oncol Biol Phys. 2005 Jun 1;62(2):460-7. PMID 15890588
Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-Share Alike 2.5 License.