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
 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:
– 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
– 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

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SEMINAR

 Social stigma and reluctant patient delayes

 Earlydetection can prevent major morbidity

 Most patients present with mass and

 50% patients have inguinal adenopathy at

 Incisionalbiopsy of the lesion is the

 Biopsy provides opportunity to grade the

– Staging the disease

– To assess spread and resectability

 Others depending on metastatic suspicion

 MINIMALY INVASIVE SURGERY

 Length of healthy stump is the most

 Urinarydiversion (Perineal Urethrostomy)

 All patients with cytologically proven disease

 Allpatients with T2 disease or more should

 Minimum dissection is bilateral superficial

 Deep nodes to dissected on the side where the

 Iliacnodes to be dissected if deep nodes are

 Para-aorticadenopathy contraindicates lymph

 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

 Systemic chemotherapy (VBM) has limited

 Neo– adjuvant therapy is being

 Mohs micrographic surgery

 Histologicalconfirmation is the easiest and most

 Nodal dissection improves survival and is hence

 Chemotherapy and radiotherapy have limited

 Penilereconstructive procedures may be offered to

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