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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

 Earlydetection can prevent major morbidity


and mortality
CLINICAL PRESENTATION
 Middleaged 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 forms the cornerstone of
diagnosis

 Incisionalbiopsy 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

 Urinarydiversion (Perineal Urethrostomy)


should accompany total amputation
SURGICAL TREATMENT OF
PRIMARY DISEASE
INDICATIONS OF LYMPH
NODE DISSECTION
 Allpatients with palpable non responding
adenopathy

 All patients with cytologically proven disease

 Allpatients with T2 disease or more should


undergo prophylactic dissection

 Minimum dissection is bilateral superficial


inguinal group dissection
MANAGEMENT OF NODAL
DISEASE
 Bilateralsuperficial inguinal node dissection is the
treatment of choice

 Deep nodes to dissected on the side where the


superficial nodes are positive

 Iliacnodes to be dissected if deep nodes are


positive

 Para-aorticadenopathy 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
 Topical5 – 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 is the mainstay of treatment of carcinoma
penis

 Histologicalconfirmation is the easiest and most


effective mode of diagnosis

 Nodal dissection improves survival and is hence


indicated

 Chemotherapy and radiotherapy have limited


indications

 Penilereconstructive procedures may be offered to


young males with good prognosis