UrologySchool.com

Penile Cancer: Squamous Penile Cancer: Difference between revisions

← Older edit
Visual
No edit summary
No edit summary
 
(7 intermediate revisions by the same user not shown)
Line 1: Line 1:
== Squamous Cell Carcinoma of the Penis ==
'''See [[EAU & ASCO: Penile Cancer 2023|EAU & ASCO 2023 Penile Cancer 2023 Guideline Notes]]'''


* Accounts for > 95% of penile malignancies
* '''See [https://pubmed.ncbi.nlm.nih.gov/36906413/ Original Guidelines]'''


=== Epidemiology ===
== Epidemiology ==


* Invasive Squamous Cell Carcinoma of the Penis
* Invasive Squamous Cell Carcinoma of the Penis
** Abrupt increase of incidence in the 6th decade of life
** Accounts for > 95% of penile malignancies
**Abrupt increase of incidence in the 6th decade of life


=== Risk factors ===
== Risk factors ==


# '''<span style="color:#ff0000">Lack of circumcision</span>'''
# '''<span style="color:#ff0000">Lack of circumcision</span>'''
Line 27: Line 28:
#* PUVA is a combination treatment which consists of Psoralens (P) and then exposing the skin to UVA (long wave ultraviolet radiation)
#* PUVA is a combination treatment which consists of Psoralens (P) and then exposing the skin to UVA (long wave ultraviolet radiation)


=== TNM Staging AJCC 8th edition ===
== TNM Staging ==


==== Primary tumour (T) ====
* AJCC 8th edition
 
=== Primary tumour (T) ===
* '''TX: Primary tumour cannot be assessed'''
* '''TX: Primary tumour cannot be assessed'''
* '''T0: No evidence of primary tumour'''
* '''T0: No evidence of primary tumour'''
Line 41: Line 44:
* '''<span style="color:#ff0000">T4: invades other adjacent structures</span>'''
* '''<span style="color:#ff0000">T4: invades other adjacent structures</span>'''


==== Lymph nodes (N) ====
=== Lymph nodes (N) ===
* '''Clinical'''
* '''Clinical'''
** cNX: Regional nodes cannot be assessed
** cNX: Regional nodes cannot be assessed
Line 56: Line 59:
*** A lymph node > 4 cm is often associated with extranodal extension of cancer.
*** A lymph node > 4 cm is often associated with extranodal extension of cancer.


==== Distant metastasis (M) ====
=== Distant metastasis (M) ===
* M0: No distant metastasis (no pathologic M0; use clinical M to complete staging group)
* M0: No distant metastasis (no pathologic M0; use clinical M to complete staging group)
* M1: Distant metastasis: lymph node metastasis outside the true pelvis, or to visceral or bone sites
* M1: Distant metastasis: lymph node metastasis outside the true pelvis, or to visceral or bone sites


=== Natural history ===
== Natural history ==


* '''Tumour architecture'''
* '''Tumour architecture'''
Line 84: Line 87:
* Death occurs in the majority of untreated patients within 2 years
* Death occurs in the majority of untreated patients within 2 years


=== Diagnosis and Evaluation ===
== Diagnosis and Evaluation ==


==== UrologySchool.com Summary ====
=== UrologySchool.com Summary ===


* '''<span style="color:#ff0000">History and Physical exam (including exam of inguinal nodes)</span>'''
* '''<span style="color:#ff0000">History and Physical exam (including exam of inguinal nodes)</span>'''
Line 97: Line 100:
* '''<span style="color:#ff0000">Other (1): biopsy</span>'''
* '''<span style="color:#ff0000">Other (1): biopsy</span>'''


==== History and Physical Exam ====
=== History and Physical Exam ===


* '''History'''
* '''History'''
Line 112: Line 115:
**** '''EAU Guidelines: Palpably enlarged lymph nodes are highly indicative of lymph node metastases. Physical examination should note the number of palpable nodes on each side and whether these are fixed or mobile. Additional imaging does not alter management and is not required'''
**** '''EAU Guidelines: Palpably enlarged lymph nodes are highly indicative of lymph node metastases. Physical examination should note the number of palpable nodes on each side and whether these are fixed or mobile. Additional imaging does not alter management and is not required'''


==== Laboratory ====
=== Laboratory ===


* '''<span style="color:#ff0000">Serum calcium'''
* '''<span style="color:#ff0000">Serum calcium'''
Line 119: Line 122:
**'''Mandatory to determine HPV status when a patient is diagnosed with penile cancer[https://pubmed.ncbi.nlm.nih.gov/36906413/]'''
**'''Mandatory to determine HPV status when a patient is diagnosed with penile cancer[https://pubmed.ncbi.nlm.nih.gov/36906413/]'''


==== Imaging ====
=== Imaging ===


===== Primary tumour =====
==== Primary tumour ====
* '''<span style="color:#ff0000">For small-volume glanular lesions, imaging studies are not needed'''
* '''<span style="color:#ff0000">For small-volume glanular lesions, imaging studies are not needed'''
* '''<span style="color:#ff0000">For larger lesions/lesions suspicious for invasion, US can provide information about infiltration of the corpora'''
* '''<span style="color:#ff0000">For larger lesions/lesions suspicious for invasion, US can provide information about infiltration of the corpora'''
Line 128: Line 131:
*** '''CT has poor soft-tissue resolution and is not useful for imaging the extent of the primary tumour'''
*** '''CT has poor soft-tissue resolution and is not useful for imaging the extent of the primary tumour'''


===== Metastases =====
==== Metastases ====
* '''<span style="color:#ff0000">Regional'''
* '''<span style="color:#ff0000">Regional'''
** '''<span style="color:#ff0000">Physical exam of the inguinal region remains the clinical gold standard for evaluating the presence of metastasis in the non-obese patients'''
** '''<span style="color:#ff0000">Physical exam of the inguinal region remains the clinical gold standard for evaluating the presence of metastasis in the non-obese patients'''
Line 139: Line 142:
**'''CT/PET scan'''
**'''CT/PET scan'''


==== Other ====
=== Other ===


* '''<span style="color:#ff0000">Biopsy</span>'''
* '''<span style="color:#ff0000">Biopsy</span>'''
Line 156: Line 159:
**# '''<span style="color:#ff0000">Vascular invasion</span>'''
**# '''<span style="color:#ff0000">Vascular invasion</span>'''


==== Differential diagnosis ====
=== Differential diagnosis ===


# Condyloma acuminatum (HPV warts)
# Condyloma acuminatum (HPV warts)
Line 164: Line 167:
# Tuberculosis
# Tuberculosis


=== Management ===
== Management ==


==== CIS ====
=== CIS ===


* '''<span style="color:#ff0000">Non-surgical</span>'''
* '''<span style="color:#ff0000">Non-surgical</span>'''
Line 187: Line 190:
* '''<span style="color:#ff0000">Moh's surgery</span>'''
* '''<span style="color:#ff0000">Moh's surgery</span>'''


==== Favourable histologic features (stage Ta, T1; grade 1 and 2) ====
=== Favourable histologic features (stage Ta, T1; grade 1 and 2) ===


* '''<span style="color:#ff0000">Organ-sparing or glans-sparing surgical procedures</span>'''
* '''<span style="color:#ff0000">Organ-sparing or glans-sparing surgical procedures</span>'''
Line 207: Line 210:
***'''Because recurrence rates are higher with organ-preserving strategies, compliance with follow-up is also a consideration in recommending organ preservation versus amputation'''  
***'''Because recurrence rates are higher with organ-preserving strategies, compliance with follow-up is also a consideration in recommending organ preservation versus amputation'''  


==== Indications for partial or total penectomy (3): ====
=== Penectomy ===
==== Indications for partial or total penectomy (3):====
#'''<span style="color:#ff0000">High grade (grade ≥ 3) lesions</span>'''
#'''<span style="color:#ff0000">High grade (grade ≥ 3) lesions</span>'''
#'''<span style="color:#ff0000">[stage ≥ T2]; deep invasion into the glans urethra or corpora cavernosa</span>'''
#'''<span style="color:#ff0000">[stage ≥ T2]; deep invasion into the glans urethra or corpora cavernosa</span>'''
#'''<span style="color:#ff0000">Tumours >4cm</span>'''
#'''<span style="color:#ff0000">Tumours >4cm</span>'''


==== Treatment of Primary Penile Tumour Summary ====
=== Treatment of Primary Penile Tumour Summary ===
* Tis (glans): Laser therapy, glans resurfacing; alternative: topical therapy
* Tis (glans): Laser therapy, glans resurfacing; alternative: topical therapy
* Ta, Tis (foreskin, shaft skin): Surgical excision to achieve negative margin; alternatives: laser therapy, topical therapy (Tis only)
* Ta, Tis (foreskin, shaft skin): Surgical excision to achieve negative margin; alternatives: laser therapy, topical therapy (Tis only)
Line 224: Line 228:
* Radiotherapy: Select patients with T1-T2 tumors involving glans, coronal sulcus <4 cm
* Radiotherapy: Select patients with T1-T2 tumors involving glans, coronal sulcus <4 cm


==== Treatment of Inguinal Nodes ====
=== Treatment of Inguinal Nodes ===


* '''<span style="color:#ff0000">Lymph node involvement is most important prognostic factor for survival</span>'''
* '''<span style="color:#ff0000">Lymph node involvement is most important prognostic factor for survival</span>'''
** 5-year survival: lymph node involvement vs. without: 73% vs. 60% (range 0-86% depending on extent of lymph node involvement)
** 5-year survival: lymph node involvement vs. without: 73% vs. 60% (range 0-86% depending on extent of lymph node involvement)


===== '''<span style="color:#ff0000">Clinically negative groins</span>''' =====
==== <span style="color:#ff0000">Clinically negative groins</span> ====
* '''<span style="color:#ff0000">≈20% of patients with clinically nonpalpable inguinal nodes harbor occult metastases</span>'''
* '''<span style="color:#ff0000">≈20% of patients with clinically nonpalpable inguinal nodes harbor occult metastases</span>'''
**Cross-sectional imaging studies such as CT and magnetic resonance imaging (MRI) are unable to accurately detect these cases and are only largely used to assess for the presence of pelvic lymph node involvement
**Cross-sectional imaging studies such as CT and magnetic resonance imaging (MRI) are unable to accurately detect these cases and are only largely used to assess for the presence of pelvic lymph node involvement
Line 273: Line 277:
**#**Video-endoscopic surgery
**#**Video-endoscopic surgery


===== <span style="color:#ff0000">Palpable adenopathy</span> =====
==== <span style="color:#ff0000">Palpable adenopathy</span> ====
* '''Associated with metastasis in 43% of cases, secondary to inflammation in the remainder'''; can consider fine-needle aspiration to differentiate
* '''Associated with metastasis in 43% of cases, secondary to inflammation in the remainder'''; can consider fine-needle aspiration to differentiate
* '''Lymphadenectomy can be curative''' due to the prolonged locoregional phase before distant dissemination
* '''Lymphadenectomy can be curative''' due to the prolonged locoregional phase before distant dissemination
Line 284: Line 288:
** '''Lymphadenectomy in the context of verrucous carcinoma should be reserved for cases of biopsy-proven metastases.'''
** '''Lymphadenectomy in the context of verrucous carcinoma should be reserved for cases of biopsy-proven metastases.'''


===== <span style="color:#ff0000">Fixed inguinal lymph nodes (cN3)</span> =====
==== <span style="color:#ff0000">Fixed inguinal lymph nodes (cN3)</span> ====
* '''<span style="color:#ff0000">Neoadjuvant chemotherapy followed by radical inguinal lymphadenectomy in responders</span>'''
* '''<span style="color:#ff0000">Neoadjuvant chemotherapy followed by radical inguinal lymphadenectomy in responders</span>'''


* '''2018 EAU Penile Cancer Guidelines: Summary of treatment strategies for nodal metastases'''
==== Lymph node involvement (pN+) ====
*'''Prognosis'''
**'''Pathologic criteria associated with improved long-term survival after attempted curative surgical resection of inguinal metastases include:'''
**# '''Unilateral involvement'''
**# '''Minimal nodal disease (≤2 involved nodes in most series (pN1))'''
**# '''No evidence of extra nodal extension of cancer (pN3)'''
**# '''Absence of pelvic nodal metastases (pN3)'''
**## '''i.e. pN1, and lack of features associated with pN2 and pN3'''
* '''No anatomic or lymphangiographic studies demonstrating direct lymphatic drainage to the pelvic lymph nodes from the penis, which is evidenced by the lack of metastatic spread to the pelvic lymph nodes from a primary penile tumor in the absence of metastatic spread to the inguinal lymph nodes[https://link.springer.com/book/10.1007/978-3-319-60858-7]'''
*'''<span style="color:#ff0000">Indications for pelvic lymph node dissection in patients undergoing inguinal lymph node dissection for curative intent (no pelvic adenopathy) (2):</span>'''
*# '''<span style="color:#ff0000">≥2 positive inguinal lymph nodes</span>'''
*# '''<span style="color:#ff0000">Extra-nodal extension is present</span>'''
*## '''PLND in this setting serves as staging tool to identify patients who should be considered for adjunctive therapy'''
*## '''PLND includes the distal common iliac, external iliac, and obturator groups of nodes.'''


==== Summary of treatment strategies for nodal metastases ====
{| class="wikitable"
{| class="wikitable"
|'''Lymph node status'''
|'''Lymph node status'''
Line 313: Line 331:
|'''Not recommended for nodal disease except as a palliative option'''
|'''Not recommended for nodal disease except as a palliative option'''
|}
|}
'''2018 EAU Penile Cancer Guidelines'''


==== Lymph node involvement ====
=== Radiation ===
*'''Pathologic criteria associated with improved long-term survival after attempted curative surgical resection of inguinal metastases include:'''
*# '''Unilateral involvement'''
*# '''Minimal nodal disease (≤2 involved nodes in most series (pN1))'''
*# '''No evidence of extra nodal extension of cancer (pN3)'''
*# '''Absence of pelvic nodal metastases (pN3)'''
*## '''i.e. pN1, and lack of features associated with pN2 and pN3'''
* '''No anatomic or lymphangiographic studies demonstrating direct lymphatic drainage to the pelvic lymph nodes from the penis, which is evidenced by the lack of metastatic spread to the pelvic lymph nodes from a primary penile tumor in the absence of metastatic spread to the inguinal lymph nodes[https://link.springer.com/book/10.1007/978-3-319-60858-7]'''
*'''<span style="color:#ff0000">Indications for pelvic lymph node dissection in patients undergoing inguinal lymph node dissection for curative intent (no pelvic adenopathy) (2):</span>'''
*# '''<span style="color:#ff0000">≥2 positive inguinal lymph nodes</span>'''
*# '''<span style="color:#ff0000">Extra-nodal extension is present</span>'''
*## '''PLND in this setting serves as staging tool to identify patients who should be considered for adjunctive therapy'''
*## '''PLND includes the distal common iliac, external iliac, and obturator groups of nodes.'''
 
==== Radiation ====


* '''An option for those with invasive SCC refusing surgical treatment'''
* '''An option for those with invasive SCC refusing surgical treatment'''
Line 341: Line 346:
* '''Palliative radiotherapy among patients with inoperable inguinal nodes may provide some benefit'''
* '''Palliative radiotherapy among patients with inoperable inguinal nodes may provide some benefit'''


==== Chemotherapy ====
=== Chemotherapy ===


* '''Treatment with a cisplatin-containing regimen in advanced metastatic penile cancer should be considered''' and this may facilitate curative resection. The optimal regimen has yet to be determined.
* '''Treatment with a cisplatin-containing regimen in advanced metastatic penile cancer should be considered''' and this may facilitate curative resection. The optimal regimen has yet to be determined.
* Among patients whose tumour progresses through chemotherapy, surgery is not recommended
* Among patients whose tumour progresses through chemotherapy, surgery is not recommended
== Non-squamous Penile Cancers ==
* '''Extremely rare'''
=== Basal cell carcinoma ===
* Frequently encountered on other sun-exposed cutaneous surfaces, it is '''rare on the penis'''
* Treatment is by local excision, which is virtually always curative
=== Melanoma ===
* Aggressive form of cancer but can be cured if diagnosed and treated with the appropriate surgical treatment at an early stage
** '''Surgery is the primary mode of treatment'''; radiation therapy and chemotherapy are of only adjunctive or palliative benefit
=== Sarcoma ===
* Prone to local recurrence; regional and distant metastases are rare.
* Superficial lesions can be treated with less radical procedures
=== Extramammary Paget Disease ===
* Appearance
** Erythematous, eczematoid, well-demarcated area
** Cannot be clinically distinguished from erythroplasia of Queyrat, Bowen disease, or carcinoma in situ of the penis
** See Figure
* Clinical presentation
** Local discomfort, pruritus, and occasionally a serosanguineous discharge involving the penis, the scrotum, or even the perianal area
* '''Behaves as a slow-growing intraepithelial adenocarcinoma'''
** With time the cells may become invasive with dermal tumor deposits metastasizing to regional lymph nodes via dermal lymphatics penoscrotal
* '''May be associated with other malignancies of the genitourinary tract, such as prostate, bladder, and renal malignancies and should be evaluated for their presence'''
* '''Management'''
** '''In most cases, only the skin and dermis must be resected with a gross margin of up to 3 cm'''. '''Positive margins may still occur, and frozen sections are recommended to guide the extent of resection.'''
*** Patients with a positive surgical margin are at a higher risk for recurrence, and additional resection is advised
** Local skin or scrotal flaps can be used to cover the defects.
** In a minority of cases the tumor may invade deeper structures, necessitating more extensive resection and reconstruction
** If inguinal adenopathy is present, radical node dissection is advised but prognosis is poor
=== Adenosquamous carcinoma ===
=== Lymphoreticular malignant neoplasm ===
=== Metastases ===
* Most often represent spread from a clinically obvious existing primary tumor.
* Prognosis is poor, and therapy should be directed toward the primary tumor site histology and local palliation
* '''Priapism is the most frequently encountered sign of metastatic involvement of the penis'''
'''Lymphomatous infiltration of the penis is most likely secondary to diffuse disease'''


== References ==
== References ==
Retrieved from "https://urologyschool.com/wikiuro/index.php/Penile_Cancer:_Squamous_Penile_Cancer"