EAU & ASCO: Penile Cancer 2023: Difference between revisions

Line 256:

=== Primary Tumour ===

* Aims of the treatment of the primary tumour is complete tumour removal with as much organ preservation as possible (without compromising oncological control)

** Fully functional penis is central to

*** Sexual functioning

*** Urination

*** Sense of wholeness, desirability and masculinity

* No RCTs or observational comparative studies for any of the treatment options for localised penile cancer

* Penile preservation appears to be superior in functional and cosmetic outcomes as compared to partial or total penectomy and is considered to be the primary treatment method for localised penile cancer

* With surgical treatment, negative surgical margins for invasive carcinoma must be obtained.

* Local treatment modalities for small and localised penile cancer include

** Topical therapy

** Laser ablation

** Excisional surgery

** External beam radiotherapy (EBRT)

** Brachytherapy

==== Treatment of superficial non-invasive disease (PeIN, Ta) ====

* Most PeIN lesions are located on the mucosal surfaces of the glans or prepuce whilst lichen sclerosus also affects the prepuce

* Management

** Circumcision should be the primary surgical option

*** Following circumcision, the glans mucosa keratinizes over a period of 3–6 months and any residual PeIN or lichen sclerosus may resolve. Close monitoring before starting additional therapy has been advocated

** '''Topical therapies'''

*** '''Options'''

**** '''Imiquimod'''

***** Commonly used 3 times per week for 12 weeks

**** '''5-fluorouracil'''

***** Although no standard protocol exists, leaving the 5-FU ointment on for 12 hours every 48 hours during a 4 to 6-week treatment course is often recommended

**** Discontinuation of topical agents due to side effects observed in 12% of cases

**** '''Insufficient responses and recurrences may signify underlying invasive disease, hence, if topical treatment fails, it should not be repeated'''

** Laser ablation

*** Options

**** Neodymium:Yttrium-Aluminium-Garnet (Nd:YAG, penetration 4–6 mm, wavelength 1064 nm)

**** Carbon dioxide (CO2, penetration < 1 mm, wavelength 10600 nm) lasers

**** Photodynamic therapy

** Surgery

*** Extensive PeIN, residual PeIN in resection margins or recurrent disease after ablative or topical therapy, can be treated by surgical excision

*** Glans resurfacing consists of full thickness removal of the glandular epithelium followed by reconstruction with a graft

* Despite treatment, penile intra-epithelial neoplasia can progress to invasive lesions in 2.6–13% of patients

==== Treatment of invasive disease confined to the glans (cT1/T2) ====

* Treatment choice depends on tumour size, histology, stage and grade, localisation and patient preference.

** When feasible, small and localised invasive lesions should receive organ-sparing treatment.

*** Organ-sparing surgery associated with higher recurrence rates than amputative surgery

* Foreskin tumours are treated by ‘radical’ circumcision.

* For glandular and coronal lesions, wide local excision, partial glansectomy or total glansectomy with reconstruction, are surgical options while additional circumcision is advised in glandular tumours. External beam radiotherapy and brachytherapy are radiotherapeutic options for these patients. Laser therapy of small lesions has been reported but the risk of invasive disease must be recognised, and the recurrence risk is high, possibly as a result of the limited tissue penetration depth of laser ablation.

* Macroscopic margins can indeed be minimal, specifically in smaller and less aggressive lesions

** Standard excision must include a margin of clinically normal-appearing skin around the tumour and surrounding erythema. However, for bulky or higher-grade lesions where local recurrence may have an impact on survival, adoption of a wider margin or partial penectomy may be prudent

==== Locally advanced disease (T3–T4) ====

==== Local recurrence after organ-sparing surgery ====

=== Regional Lymph Nodes ===

@@ Line 256: / Line 256: @@
 === Primary Tumour ===
+* Aims of the treatment of the primary tumour is complete tumour removal with as much organ preservation as possible (without compromising oncological control)
+** Fully functional penis is central to
+*** Sexual functioning
+*** Urination
+*** Sense of wholeness, desirability and masculinity
+* No RCTs or observational comparative studies for any of the treatment options for localised penile cancer
+* Penile preservation appears to be superior in functional and cosmetic outcomes as compared to partial or total penectomy and is considered to be the primary treatment method for localised penile cancer
+* With surgical treatment, negative surgical margins for invasive carcinoma must be obtained.
+* Local treatment modalities for small and localised penile cancer include
+** Topical therapy
+** Laser ablation
+** Excisional surgery
+** External beam radiotherapy (EBRT)
+** Brachytherapy
+==== Treatment of superficial non-invasive disease (PeIN, Ta) ====
+* Most PeIN lesions are located on the mucosal surfaces of the glans or prepuce whilst lichen sclerosus also affects the prepuce
+* Management
+** Circumcision should be the primary surgical option
+*** Following circumcision, the glans mucosa keratinizes over a period of 3–6 months and any residual PeIN or lichen sclerosus may resolve. Close monitoring before starting additional therapy has been advocated
+** '''Topical therapies'''
+*** '''Options'''
+**** '''Imiquimod'''
+***** Commonly used 3 times per week for 12 weeks
+**** '''5-fluorouracil'''
+***** Although no standard protocol exists, leaving the 5-FU ointment on for 12 hours every 48 hours during a 4 to 6-week treatment course is often recommended
+**** Discontinuation of topical agents due to side effects observed in 12% of cases
+**** '''Insufficient responses and recurrences may signify underlying invasive disease, hence, if topical treatment fails, it should not be repeated'''
+** Laser ablation
+*** Options
+**** Neodymium:Yttrium-Aluminium-Garnet (Nd:YAG, penetration 4–6 mm, wavelength 1064 nm)
+**** Carbon dioxide (CO2, penetration < 1 mm, wavelength 10600 nm) lasers
+**** Photodynamic therapy
+** Surgery
+*** Extensive PeIN, residual PeIN in resection margins or recurrent disease after ablative or topical therapy, can be treated by surgical excision
+*** Glans resurfacing consists of full thickness removal of the glandular epithelium followed by reconstruction with a graft
+* Despite treatment, penile intra-epithelial neoplasia can progress to invasive lesions in 2.6–13% of patients
+==== Treatment of invasive disease confined to the glans (cT1/T2) ====
+* Treatment choice depends on tumour size, histology, stage and grade, localisation and patient preference.
+** When feasible, small and localised invasive lesions should receive organ-sparing treatment.
+*** Organ-sparing surgery associated with higher recurrence rates than amputative surgery
+* Foreskin tumours are treated by ‘radical’ circumcision.
+* For glandular and coronal lesions, wide local excision, partial glansectomy or total glansectomy with reconstruction, are surgical options while additional circumcision is advised in glandular tumours. External beam radiotherapy and brachytherapy are radiotherapeutic options for these patients. Laser therapy of small lesions has been reported but the risk of invasive disease must be recognised, and the recurrence risk is high, possibly as a result of the limited tissue penetration depth of laser ablation.
+* Macroscopic margins can indeed be minimal, specifically in smaller and less aggressive lesions
+** Standard excision must include a margin of clinically normal-appearing skin around the tumour and surrounding erythema. However, for bulky or higher-grade lesions where local recurrence may have an impact on survival, adoption of a wider margin or partial penectomy may be prudent
+==== Locally advanced disease (T3–T4) ====
+==== Local recurrence after organ-sparing surgery ====
 === Regional Lymph Nodes ===