EAU & ASCO: Penile Cancer 2023: Difference between revisions

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See [https://pubmed.ncbi.nlm.nih.gov/36906413/ Original Guidelines]

'''See [https://pubmed.ncbi.nlm.nih.gov/36906413/ Original Guidelines]'''

'''See [[Penile Cancer: Squamous Penile Cancer]] Chapter Notes'''

== Background ==

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* Pathological

** pN0 No regional lymph node metastasis

** pN1 Metastasis in ~~one or two~~ inguinal lymph nodes

** pN1 Metastasis in 1-2 inguinal lymph nodes

** pN2 Metastasis in ~~more than two~~ unilateral inguinal nodes or bilateral inguinal lymph nodes

** pN2 Metastasis in >2 unilateral inguinal nodes or bilateral inguinal lymph nodes

** pN3 Metastasis in pelvic lymph node(s), unilateral or bilateral or extranodal extension of regional lymph node metastasis

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=== Multimodal Chemotherapy/Radiotherapy in the management of regional lymph nodes ===

==== ~~Systemic therapy~~ ====

==== Chemotherapy ====

* Have a balanced discussion of risks and benefits ~~of adjuvant chemotherapy~~ with high-risk patients with surgically resected disease, in particular with those with pathological pelvic LN involvement (pN3)

* Adjuvant chemotherapy

** Have a balanced discussion of risks and benefits with high-risk patients with surgically resected disease, in particular with those with pathological pelvic LN involvement (pN3)

==== Radiotherapy ====

* ~~Offer adjuvant radiotherapy~~ (with or without chemo sensitisation) ~~to patients with~~ pN2/N3 disease, including those who received prior neoadjuvant chemotherapy.

* '''Adjuvant radiation (with or without chemo sensitisation)'''

* ~~Offer definitive~~ radiotherapy (with or without chemo sensitisation) ~~to patients~~ unwilling or unable to undergo surgery.

** '''Indications'''

* ~~Offer radiotherapy (with or without chemo sensitisation) to~~ cN3 patients who are not candidates for multi-agent chemotherapy.

*** '''pN2/N3 disease (including those who received prior neoadjuvant chemotherapy)'''

* '''Definitive radiotherapy (with or without chemo sensitisation)'''

** '''Indications'''

*** '''Patients unwilling or unable to undergo surgery'''

*** '''cN3 patients who are not candidates for multi-agent chemotherapy'''

=== Advanced disease ===

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** Localized disease: 81%

** Distant metastasis: 18%

*'''Prognostic ~~factors'''~~

**'''Presence and extent of nodal metastases~~'''~~

=== Prognostic Factors ===

***'''Most important ~~prognostic factor for survival~~'''

#'''Presence and extent of nodal metastases (most important)'''

***'''Extra-capsular extension in even one single LN carries a poor prognosis and is denoted as pN3'''

#*'''Extra-capsular extension in even one single LN carries a poor prognosis and is denoted as pN3'''

**'''Depth of invasion'''

#'''Depth of invasion'''

**'''Grade in the primary tumour'''

#'''Grade in the primary tumour'''

**'''Pathological subtype'''

#'''Pathological subtype'''

**'''Peri-neural invasion'''

#'''Peri-neural invasion'''

**'''Lymphovascular invasion'''

#'''Lymphovascular invasion'''

== Follow-up ==

* Local or regional nodal recurrences usually occur within ~~two to three~~ years of primary treatment

=== Recurrence ===

* ~~After local treatment with negative inguinal nodes, follow-up should include~~ physical examination of the ~~penis and groins for local and/~~or ~~regional~~ recurrence. ~~Additional imaging has no proven benefit~~

* Follow-up also depends on the primary treatment modality. Histology from the glans should be obtained to confirm disease-free status following laser ablation or topical chemotherapy

* Local or regional nodal recurrences usually occur within 2-3 years of primary treatment

* ~~Local recurrence is easily detected by~~ physical examination~~, by~~ the ~~patient himself~~ or ~~his physician~~.

** Local recurrence is easily detected by physical examination, by the patient himself or his physician.

* Regional recurrence requires timely treatment by rILND with (neo)adjuvant chemotherapy/chemoradiotherapy.

** Regional recurrence requires timely treatment by rILND with (neo)adjuvant chemotherapy/chemoradiotherapy.

* Men should be assessed for genital and lower limb lymphoedema at each outpatient clinic appointment, advised about good skin care, compression, exercise, massage, and elevation when resting as the mainstay of treatment. Following nodal surgery, ideally, ~~they would be referred~~ to specialist lymphoedema services for assessment and management before any significant lymphoedema occurs.

* Follow-up also depends on the primary treatment modality

** Histology from the glans should be obtained to confirm disease-free status following laser ablation or topical chemotherapy

* After local treatment with negative inguinal nodes

** Follow-up should include physical examination of the penis and groins for local and/or regional recurrence. Additional imaging has no proven benefit

=== Lymphedema ===

* Following nodal surgery, ideally, refer to specialist lymphoedema services for assessment and management before any significant lymphoedema occurs.

** Specialist lymphoedema services offer a range of made-to-measure compression garments or multi-layer lymphoedema bandaging for lower limb and genital lymphoedema

*** For lower limb compression adjustable Velcro garments also exist.

* Assess for genital and lower limb lymphoedema at each outpatient clinic appointment

*** Good skin care is critical to prevent infection that can damage remaining lymphatic channels.

* Advise good skin care, compression, exercise, massage, and elevation when resting as the mainstay of treatment.

*** Prophylactic antibiotics should be used following any episode of cellulitis~~, with penicillin~~ V, erythromycin or clindamycin recommended, except in genital lymphoedema where prophylactic trimethoprim can be used

** For lower limb compression adjustable Velcro garments also exist.

** Good skin care is critical to prevent infection that can damage remaining lymphatic channels.

** Prophylactic antibiotics should be used following any episode of cellulitis

*** Penicillin V, erythromycin or clindamycin recommended, except in genital lymphoedema where prophylactic trimethoprim can be used

== References ==

Brouwer, Oscar R., et al. "European Association of Urology-American Society of Clinical Oncology collaborative guideline on penile cancer: 2023 update." ''European urology'' 83.6 (2023): 548-560.

@@ Line 1: / Line 1: @@
-See [https://pubmed.ncbi.nlm.nih.gov/36906413/ Original Guidelines]
+'''See [https://pubmed.ncbi.nlm.nih.gov/36906413/ Original Guidelines]'''
+'''See [[Penile Cancer: Squamous Penile Cancer]] Chapter Notes'''
 == Background ==
@@ Line 120: / Line 122: @@
 * Pathological
 ** pN0 No regional lymph node metastasis
-** pN1 Metastasis in one or two inguinal lymph nodes
+** pN1 Metastasis in 1-2 inguinal lymph nodes
-** pN2 Metastasis in more than two unilateral inguinal nodes or bilateral inguinal lymph nodes
+** pN2 Metastasis in >2 unilateral inguinal nodes or bilateral inguinal lymph nodes
 ** pN3 Metastasis in pelvic lymph node(s), unilateral or bilateral or extranodal extension of regional lymph node metastasis
@@ Line 568: / Line 570: @@
 === Multimodal Chemotherapy/Radiotherapy in the management of regional lymph nodes ===
-==== Systemic therapy ====
+==== Chemotherapy ====
-* Have a balanced discussion of risks and benefits of adjuvant chemotherapy with high-risk patients with surgically resected disease, in particular with those with pathological pelvic LN involvement (pN3)
+* Adjuvant chemotherapy
+** Have a balanced discussion of risks and benefits with high-risk patients with surgically resected disease, in particular with those with pathological pelvic LN involvement (pN3)
 ==== Radiotherapy ====
-* Offer adjuvant radiotherapy (with or without chemo sensitisation) to patients with pN2/N3 disease, including those who received prior neoadjuvant chemotherapy.
+* '''Adjuvant radiation (with or without chemo sensitisation)'''
-* Offer definitive radiotherapy (with or without chemo sensitisation) to patients unwilling or unable to undergo surgery.
+** '''Indications'''
-* Offer radiotherapy (with or without chemo sensitisation) to cN3 patients who are not candidates for multi-agent chemotherapy.
+*** '''pN2/N3 disease (including those who received prior neoadjuvant chemotherapy)'''
+* '''Definitive radiotherapy (with or without chemo sensitisation)'''
+** '''Indications'''
+*** '''Patients unwilling or unable to undergo surgery'''
+*** '''cN3 patients who are not candidates for multi-agent chemotherapy'''
 === Advanced disease ===
@@ Line 588: / Line 595: @@
 ** Localized disease: 81%
 ** Distant metastasis: 18%
-*'''Prognostic factors'''
-**'''Presence and extent of nodal metastases'''
+=== Prognostic Factors ===
-***'''Most important prognostic factor for survival'''
+#'''<span style="color:#ff0000">Presence and extent of nodal metastases (most important)'''
-***'''Extra-capsular extension in even one single LN carries a poor prognosis and is denoted as pN3'''
+#*'''<span style="color:#ff0000">Extra-capsular extension in even one single LN carries a poor prognosis and is denoted as pN3'''
-**'''Depth of invasion'''
+#'''<span style="color:#ff0000">Depth of invasion'''
-**'''Grade in the primary tumour'''
+#'''<span style="color:#ff0000">Grade in the primary tumour'''
-**'''Pathological subtype'''
+#'''<span style="color:#ff0000">Pathological subtype'''
-**'''Peri-neural invasion'''
+#'''<span style="color:#ff0000">Peri-neural invasion'''
-**'''Lymphovascular invasion'''
+#'''<span style="color:#ff0000">Lymphovascular invasion'''
 == Follow-up ==
-* Local or regional nodal recurrences usually occur within two to three years of primary treatment
+=== Recurrence ===
-* After local treatment with negative inguinal nodes, follow-up should include physical examination of the penis and groins for local and/or regional recurrence. Additional imaging has no proven benefit
-* Follow-up also depends on the primary treatment modality. Histology from the glans should be obtained to confirm disease-free status following laser ablation or topical chemotherapy
+* Local or regional nodal recurrences usually occur within 2-3 years of primary treatment
-* Local recurrence is easily detected by physical examination, by the patient himself or his physician.
+** Local recurrence is easily detected by physical examination, by the patient himself or his physician.
-* Regional recurrence requires timely treatment by rILND with (neo)adjuvant chemotherapy/chemoradiotherapy.
+** Regional recurrence requires timely treatment by rILND with (neo)adjuvant chemotherapy/chemoradiotherapy.
-* Men should be assessed for genital and lower limb lymphoedema at each outpatient clinic appointment, advised about good skin care, compression, exercise, massage, and elevation when resting as the mainstay of treatment. Following nodal surgery, ideally, they would be referred to specialist lymphoedema services for assessment and management before any significant lymphoedema occurs.
+* Follow-up also depends on the primary treatment modality
+** Histology from the glans should be obtained to confirm disease-free status following laser ablation or topical chemotherapy
+* After local treatment with negative inguinal nodes
+** Follow-up should include physical examination of the penis and groins for local and/or regional recurrence. Additional imaging has no proven benefit
+=== Lymphedema ===
+* Following nodal surgery, ideally, refer to specialist lymphoedema services for assessment and management before any significant lymphoedema occurs.
 ** Specialist lymphoedema services offer a range of made-to-measure compression garments or multi-layer lymphoedema bandaging for lower limb and genital lymphoedema
-*** For lower limb compression adjustable Velcro garments also exist.
+* Assess for genital and lower limb lymphoedema at each outpatient clinic appointment
-*** Good skin care is critical to prevent infection that can damage remaining lymphatic channels.
+* Advise good skin care, compression, exercise, massage, and elevation when resting as the mainstay of treatment.
-*** Prophylactic antibiotics should be used following any episode of cellulitis, with penicillin V, erythromycin or clindamycin recommended, except in genital lymphoedema where prophylactic trimethoprim can be used
+** For lower limb compression adjustable Velcro garments also exist.
+** Good skin care is critical to prevent infection that can damage remaining lymphatic channels.
+** Prophylactic antibiotics should be used following any episode of cellulitis
+*** Penicillin V, erythromycin or clindamycin recommended, except in genital lymphoedema where prophylactic trimethoprim can be used
 == References ==
 Brouwer, Oscar R., et al. "European Association of Urology-American Society of Clinical Oncology collaborative guideline on penile cancer: 2023 update." ''European urology'' 83.6 (2023): 548-560.