Penile Cancers
what is the lymphatic drainage of the penis
drains first to the inguinal nodes to the external iliac nodes to the internal iliac nodes to the pre sacral nodes and then to the para aortic nodes
what is the treatment for stage IV penile cancers?
intent is strictly palliative surgery to get control of the local lesion, and infection or hemorrhage, EBRT to palliate the primary tumor, regional adenopathy or bone mets
what role does chemotherapy play in penile cancers?
it is limited bleomycin, 5FU, cisplatin and methotrexate it is usually reserved for metastatic recurrence
what are the routes of spread for penile cancers
local invasion: superficially at first and then invasion into the shaft of the penis lymphatic spread: spread early to the inguinal nodes hematological spread: -rarely happens, if it does it seeds into the lungs -very late staged disease
where do tumors of the bulbomembranous and prostatic urethra spread to?
metastasize first to the pelvic lymph nodes
brachytherapy for urethra carcinoma?
mold brachy with radioactive sources (needles or wires) dose of 60-65Gy at the surface and ~50Gy at the centre of the organ delivered in 6-7 days. or 60-70 Gy in 5-7 days using double plane technique
what is the pathophysiology of penile cancers?
most carcinomas star in the preputial area, arising in the glands, the coronal sulcus or the prepuce, the cancer will then spreads to the inguinal node and distantly most commonly to the lungs
Phimosis
narrowing of the opening of the prepuce -common in men with penil carcinoma
is there a TD5/5 for the penis?
no
is there a correlation between histologic grade and survival time?
no
are distant mets common for penile cancers?
no (10%), even patients with advanced locoregional disease, and usually occur in patients who have inguinal node involvement
how are positive nodes treated for penile cancers?
observation and delayed intervention when signs of nodal involvement appear. this approach has replaced nodal dissection because of the mortality rate of the surgery, the morbidity of the surgery and the relatively low incidence rate of nodal mets
what does the treatment selection depend on for penile cancers?
size, location, invasiveness and stage of the tumor
bowens disease
squamous cell carcinoma in situ that may involve the shaft of the penis and hairy skin of the inguinal and suprapubic areas
stage groupings for penile cancers
stage 0 = Tis N0 M0, Ta N0 M0 stage 1 = T1 N0 M0 stage II = T1 N0 M0, T2 N0 M0, T2 N1 M0 stage III = T1 N2 M0, T2 N2 M0, T3 N0 M0, T3 N1 M0, T3 N2 M0 stage IV = T4 any N M0, any T N3 M0, any T any N M0
smegma
a white secretion that collects under the prepuce of the foreskin can be a carcinogenic
stage groupings for urethra carcinoma
stage 0a = Ta N0 M0 stage 0ais = Tis N0 M0, Tis pu N0 M0, Tis pd N0 M0 stage I = T1 N0 M0 stage II = T2 N0 M0 stage III = T1 N1 M0, T2 N2 M0, T3 N0 M0, T3 N1 M0 stage IV = T4 N0 M0, T4 N1 M0, any T N2 M0, any T any N M1
corpus spongiosum
surrounds the urethra
where do adenocarcinomas of the urethra occur?
the bulbomembranous urethra
what are the principal prognostic factors in carcinoma of the penis?
the extent of the primary lesion and the status of the lymph nodes (tumor free regional LN is an excellent long term disease free survival rate 85-90%) the incidence of nodal involvement is related to the extent and location of the primary lesion
what are the most common side of spread for penile cancers?
the superficial inguinal nodes
chemotherapy for penile cancers?
this treatment option is under clinical investigation for stages III and IV disease cisplatin neoadjuvant with continuous 5Fu infusion
how can Bowens disease and erythroplasia of Queyrat be treated?
topical 5FU, a local excision or superficial x-rays (4500-5000cGy)
what is the disease free long term survival rate for patients with regional LN involvement?
40-50%
what dose of radiation is used to treat penile cancer?
4500-5000cGy
what is the TD5/5 for the colon?
4500cGy for obstruction or perforation
what is the prognosis of penile cancers?
5 year survival: stage I 90% stage II 60% stage III 30-40%
what doses are used for urethra carcinoma?
50-55Gy in 250-300cGy fractions or 65-70Gy in 180-200cGy fractions (last 500-1000cGy delivered to reduced size fields) it is preferred to use smaller dose per fraction to reduce the risk of late fibrosis both dose regimes can be used for the primary lesions and involved LN
what dose of radiation is used to treat inguinal lymph nodes?
50Gy
extensive primary lesions may involve what structures?
corpora cavernosa or the abdominal wall
where do tumors of the penile urethra spread to?
inguinal lymph nodes
what is the most common site of metastasis for penile cancers?
inguinal nodes
what is the average age of penile and urethra cancer?
58-60 although 10% of these tumors occur in men younger than 40
what is the TD5/5 for the rectum?
6000cGy for ulcer stricture
what is the TD5/5 for the bladder?
6500cGy for contracture
what is the etiology of penile cancers?
(causes of penile cancer) -poor personal hygiene -HPV infection -permalignant conditions -phymosis -men with a lifetime history of many sexual partners -smokers -etiology for carcinoma of the urethra is unknown, but some correlation exists between chronic irriation and infections, venereal diseases and strictures
what accessories can be used to help deliver radiation therapy for urethra lesions
-bolus (for primary lesion and inguinal nodes) -plastic box with a central circular opening (to make the target a box for better dose distribution) -water filled container to surround the penis and the patient is positioned prone -perspex tube (plexiglass) connected to a vaccum pump, to keep the penis in a fixed position, patient is prone for this
diagnosis and detection of urethral lesions?
-evaluated with urethroscopy and cystoscopy
what types of radiation techniques can be used for penile cancers?
-interstitial implants -external beam
what are the prognostic indicators for penile cancers?
-location and size of tumor -stage of the cancer and involvement of nodes -tumor differentiation -incidence of nodal involvement related to extent and location of the primary tumor free regional nodes = excellent long term survival if the inguinal nodes are involved survival rates drop to 40-50%, if there is pelvic node involvement the survival rate drops to less than 20%
what is the pathology of penile cancers
-most common type of penile cancer is squamous cell carcinoma -varrucous carcinoma is often seen in people who chew tobacco or use snuff orally "snuff dippers cancer" -warty carcinoma and basaloid carcinoma (less common but highly associated with HPV) -neuroendocrine (rare)
clinical presentation of urethra carcinoma
-obstructive symptoms -tenderness -dysuria -urethral discharge -initial hematuria (blood in urine) -lesions of the distal urethra are often associated with palpable inguinal LN at the time of presentation
what is the surgical treatment for penile cancers
-penectomy , partial or whole, requires surgical reconstruction after surgery -moh's microsurgery -wide local excision -laser surgery (gives good results and preserves sexual function -circumcision (although results in a higher recurrence rate) -lymohadenectomy (post RT, sampling of nodes as they are resected so they dont take out more than they have to)
epidemiology of penile cancers
-rare, <1% of cancer in men -occurs in men aged 60 years and older, peaks at 80 years -higher incidence in south America, south east Asia, china and Africa (seems to be because of the absence of practice of neonatal circumscism) -rare in circumsized jews, circumscism protects against penile cancers (except if the procedure is done in adult hood) -carcinoma of the urethra is also rare, no racial or geographic predisposition is recognized
what is the clinical presentation of penile cancers
-redness -secondary infection and associated foul smell -irritation -priapism -sores on the penis -bloody discharge -appear as warty growth or harden ulcers -dysuria -hematuria -palpable inguinal LN 30-45% at presentation, enlarged LN are often related to inflammatory processes phimosis may obscure the primary lesion
natural history and spread of urethra cancers
-similar to penile cancers -most tumors are low grade and progress slowly at primary and regional sites rather than spreading to distant areas
what are the late side effects of RT penile treatment?
-telangiectasia -skin atrophy -fibrosis -fibrosis stricture of the urethra, which is treated with urethral dilation -if the RT is focused on the leg you can get lymphedema of the leg -necrosis occurs in <10%
what is the most common pathology of the prostatic urethra?
-transitional cell (90%)
how can carcinoma of the urethra be treated?
-transurethral resection -penectomy -radiation therapy -invovled LN are treated with lymphadenectomy
what are the basic structural components of the penis?
-two corpora cavernosa -the corpus spongiosum these are encased in a dense fascia (buck fascia) which is separated from the skin by a layer of loos connective tissue
how many phases is treatment delivered in for penile cancer? what are they?
2 phases 1) initial management of the primary tumor 2) treatment of regional LN
megavoltage RT for penile cancers
6Mv photons, because the separation of the penis is not that big, using POP lateral fields with a wax block to immobilize the penis OR RASO and LASO fields with wedges to avoid hotspots dose of 5000-6000cGy in 25-30 fraction megavoltage is also used for the treatment of nodes for palliation only with a dose of 3000cGy/10 fraction, however nodal involvement is best treated by dissection with the primary lesion
what is the prognosis if pelvic LN are invovled?
<20%
phymosis
A condition in which the foreskin of the penis is too tight to be pulled back to reveal the glans. This usually causes no problems and nothing needs be done.
M staging for urethral carcinoma?
Mx= distant mets cannot be assessed M0 = no distant mets M1 = distant mets
N staging for urethral carcinoma
Nx = regional LN cannot be assessed N0 = no regional LN N1 = mets in a single LN 2cm or less N2 = mets in single LN 2cm or greater N3 = mets in deep inguinal pelvic LN, unilateral or bilateral
what is the TNM staging for penile cancers
T1 = tumor invades the subepithelial connective tissue T2 = tumor invades corpus spongiosum or cavernosum T3 = tumor invades urethra and prostate T4 = tumor invades other adjacent structures N0 = no regional lymph nodes N1 = mets in single superficial inguinal LN N2= mets in multiple or bilateral superficial inguinal nodes N3 = mets in deep inguinal or pelvic lymph nodes unilateral or bilateral M0 = no distant mets M1 = distant mets
what are the two systems of staging for penile cancers
TNM and Jackson
T staging for urethra (male) cancer
Tis pu = carcinoma in situ, involvement of prostatic urethra Tis pd = carcinoma in situ, involvement of the prostatic ducts T1 = tumor invades supepithelial connective tissue T2 = tumor invades any of the following: prostatic stroma, corpus spongiosum, periurethral muscle T3= tumor invades any of the following: corpus cavernosum, beyond prostatic capsule, bladder neck (extraprostatic extension) T4 = tumor invades other adjacent organs (invasion of the bladder)
glans penis
aka Prepucee
what are the most common cancers that metastasize to the penis
carcinomas of the GU organs followed by carcinomas from the GI and respiratory systems
what must be performed if radiation is used to treat urethra carcinoma?
circumcision to minimize radiation associated morbidity
erthroplasia of Queyrat
epidermoid carcinoma in situ that involves the mucosal or mucocutaneous areas of the prepuce or glans appears red, elevated, or ulcerated lesion some patients with erthroplasia of Queyrat have invasive SCC at the time of diagnosis
what are the acute side effects of RT penile treatment?
erythema, swelling, moist desquamation, urethral inflammation causing discomfort and dysuria (severe reaction may lead to catherization) and fatigue
what is the grading for penile cancers
grade 1 = well differentiated grade 2 = moderately differentiated grade 3 = poorly differentiated grade 4 = undifferentiated
what is the advantage of using radiation for penile cancer?
organ preservation, so men can keep their penis
what is the treatment for stage III staged penile cancers?
penile amputation + bilateral inguinal lymph node dissection with or without EBRT OR Penile amputation with EBRT
diagnosis and detection of penile cancers
penile lesions can be seen on examination and documented with biopsy LN should be palpated and thoroughly evaluated. nodal involvement can be confirmed with biopsy or dissection -urinalysis -CBC -chest Xray -clinical exam to assess the primary lesions and inguinal node involvement (30% are palpable at presentation) -biopsy under local anesthetic -CT to determine LN involvement (pelvic and para-aortic) -MRI and ultrasound of penis
Priapism
persistent and painful erection of the penis.
lymphatic drainage of the penis
prepuce and skin of the shaft of the penis spread into the superficial inguinal nodes lymphatic drainage is bilateral superficial inguinal nodes--> deep inguinal nodes the bulbomembranous and prostatic urethra may follow 3 routes: -external iliac, obturator and internal iliac and pre-sacral LN the pelvic lymph nodes are rarely involved if there is no inguinal node involvement
where do most carcinomas of the penis start?
preputial area and arise in the glands, the coronal sulcus or the prepuce
what are the pros and cons of surgery for penile cancers?
pro: highly effective treatment cons: not a good option for sexually active patients
surgical management for primary penile lesions
ranges from local excision or chemosurgery in a small group of highly selected patients, particularly those with small lesions of the prepuce, to a partial or total penectomy
Extramammary paget disease
rare intraepithelial apocrine carcinoma. the most common sites are the scrotum, inguinal folds and perineal region
what is the radiation therapy treatment for penile cancers
used for T1-T2 tumors, usually used adjuvantly with surgery (reduces risk of recurrence) RT is used to avoid penectomy can use otherovoltage, megavoltage, brachytherapy with iridium 192 the extent and site of the disease is the deciding factor for which type of radiation treatment is used
orthovoltage for penile cancers
used for small superficial tumors only, 100-250kvp with a 0.5cm margin 5000cGy/15/3 weeks
brachytherapy for penile cancers
uses iridium 192, a 2cm margins is used around the tumor, the dose is 4500cGy, using 3Gy per fraction, testicular sheilds are often used with this * tumors greater than 4 cm are not treated with brachytherapy
what are the prognostic indicators for urethral cancers?
varies considerably with the location of the primary lesion: -distal lesions = same for penile cancers -bualbomembranous urethra are usually extensive and associated with poor prognosis -prostatic urethra = similar the bladder cancers -superficial lesions = good prognosis, can be managed with transurethral resection
cancers that metastasize to the penis
very rare
primary lymphoma of the penis
very rare
what are most malignant penile tumors are what type of pathology?
well differentiated Squamous cell carcinoma
what is the most common pathology of urethral carcinoma in males?
well or moderately differentiated SCC others include: - transitional cell carcinoma (15%) -adenocarcinoma (5%) -undifferentiated or mixed carcinoma (1%)
