Ca penis

Edmond Wong

Ca Penis

Epidemiology
Risk factor
Pathology
Premalignant lesion & Mx
Investigation and dx
Staging
Mx of local tumor according to stage
Mx of LN
Metastasis
2

Epidemiology
What is the incidence of Ca penis?
1 case per 100 000
~ 0.5 % of all malignancies Western World (decreasing)
Higher incidence in South America (Brazil), East Africa
and South East Asia (10% of all male malignancy)

SEER database: no racial difference between black

and white in US
But poor prognostic factor if African American
ethnicity (Rippentrop et al, 2004)
Overall incidence is decreasing

Risk factors
What are the risk factors?
1. Smoking
2. UV radiation
3. Foreskin: phimosis , poor hygiene
neonatal circumcision eliminate risk by 5x [Daling 2005]
But not circumcision in adult (Maden 1993)

4. HPV infection (16, 18): asso in 50%

Sexual transmission causing genital warts, condyloma acuminate

HPV infects the basal epithelial cell that proliferates
Daling (2005) HPV DNA was detected in 80 % of tumor specimens
Carcinogenesis : interfering with p53 & pRB
Role in prognosis is unclear
Verrucous carcinoma is not related to HPV infection

5. Penile trauma

Prognostic makers:
p53, SCC antigen, P16, Ki-67m E-cadherin and MMP-2
4

Pathology

SCC (95%)
1.
2.
3.
4.
5.
6.

Usual type (60-70%)

Papillary (7%)
Condylomatous (7%)
Verrucous (7%)
Basaloid (4%)
Sarcomatoid (4%)

Malignant Melanoma (2%)

Basal cell carcinoma (2%)
Extra-mammary Pagets disease (adenoCa from penile
skin)
Sarcoma
5

What are the growth patterns and

differentiation grading systems?

What is Broders & Maiche

classification?
Broders grading :Divided into 4 grade (1921)
Define the level of differentiation based on

Keratinization
Nuclear pleomorphism
Number of mitosis
+ other factors

80 % of the Ca penis is low grade lesion ( Gd 1 and 2 )

20% Gd 3 and 4

Maiche grading : divided into 3 grade Maiche

1991

Correlate with 5 year survival

Grade 1
80%
Grade 2,3
50%
Grade 4
30%
7

What is the distribution of Ca

penis?
Glans (50%)
Prepuce (21%)
May be related to constant exposure to
irritants within the prepuce

Glans and prepuce (9%)

Coronal sulcus (6%)
Shaft (less than 2%)
8

Risk factor for metastasis

1. Growth pattern (Cubilla 1993)
Superficiallly spreading, LN met in 42%
Vertical growth, LN met in 82%

2. Basaloid and sarcomatous histologic

pattern [MSKCC review (Cubilla 2001)]
3. Stage
4. Grade
5. Status of vascular invasion (Slaton 2001)
9

How do they present ?

Presentation:
a sore that has failed to heal
a subtle induration in the skin, to a large exophytic growth.
a phimosis may obscures the tumor and allows it to grow undetected.
Rarely, a mass, ulceration, suppuration, or hemorrhage may manifest in the
inguinal area because of nodal metastases.
Pain is infrequent.

Buck fascia, which surrounds the corpora, acts as a temporary barrier.

Eventually, the cancer penetrates the Buck fascia and the tunica albuginea,
where the cancer has access to the vasculature and systemic spread is
possible

Delay presentation (50%) due to

Embarrassment, guilt, fear, ignorance, and neglect
Self treatment with various skin creams and lotions.
Doctor: confuse with other benign penile lesions

Metastasis :
Dehydration : hypecalcemia in 20% on presentation (PTH like) [MSKCC]
SOB
10

Natural History
Begins as small lesion, papillary & exophytic or
flat & ulcerative.
Flat & ulcerative lesions >5cm and extending
>75% of the shaft have higher incidence of
metastasis and poor survival.
Pattern in lymphatic spread.
Metastatic nodes cause erosion into vessels,
skin necrosis & chronic infection.
Distant metastasis uncommon 1 10%
Death within 2 years for most untreated cases.
11

Premalignant lesions

12

What are the benign penile lesion?

Non cutaneous:

Congenital and acquire inclusion cyst

Retention cyst
Angioma , lipoma
Pyogenic granuloma
Peyronies plaque

Cutaneous:
Pearly Penile papules (PPP)

White, dome-shaped, closely spaced small papules at glans penis

Arranged circumferentially at corona
Histology : angiofibromas similar to lesion TS
25% of young adults (uncircumcised)
NO association with HPV infection/ cervical CIN
Mx: Reassurance
Local destruction: CO2 laser, cryotherapy

Zoon balanitis: shinny , erythematous plaque on glans or prepuce

Lichen Planus :flat-topped violacious papule
13

Zoon balanitis

PPP

Lichen Planus

14

Viral related lesions

1. Condyloma Acuminatum:

Genital warts related to HPV infection (16,18)

Asso with SCC
Soft, multiple lesion on glans, prepuce and shaft
Dx: biopsy
Txn: popdophyllin , diathermy if urethral involvement

2. Bowenoid papulosis:

Resemble CIS , but with benign course

Muliple papules or flat glanular lesion
Dx: bx

3. Kaposis sarcoma :

2nd commonest penile tumor, reticulo-epithelial tumor

Raised , painful , bleeding, violacious papule urethral obstruction
Or bluish ulcer with local edema
Asso with HIV infection
Txn: palliative , intralesional chemo ,
laser or cryo-ablation, RT
15

What are the premalignant lesions?

16

Cutaneous horn:

extreme hyperkeratosis with base malignant txn with wide local excision

Pseudo-epitheliomatous micaceous and keratotic balanitis (PEMKB)

Unusual hyperkeratotic gorwth of the glans

Txn: Excision , may recur

Leukoplakia:

Whitish glanular plaque involve meatus

Asso with CIS
Txn: Excision and FU

Bowenoid papulosis have high risk of progression to SCC (90% long

term)

Giant condyloma acuminata or Buschke-Lwenstein tumor

Displaces, invades, and destroys adjacent structures by compression,

whereas the standard condyloma remains superficial and never invades
Does not metastasis
Treat with excision and recurrence is common
17

Premalignant lesion: CIS

Erythroplasia of Queyrat: [non keratinising CIS]

CIS: as oppose to Bowens disease, occur in glans or inner part of prepuce
Red velvety circumscribed painless lesion , may ulcerate and painful
Histology:

Atypical hyperplastic mucosal cell with malignant features

Hyperchromatic nuclei & multi-level mitotic figures
Submucosa : proliferation of capillaries & inflammatory infiltrate of plasma cell

10x more likely to progress then Bowens disease

Treatment
Penile preserving:

Topical 5-FU or imiquimod

5-FU: block DNA synthesis (structure similar to thymine) SE: erythema , weeping
5% Imiquimod (imidazoguinonin tetracyclicamine): induce IF-alfa

Laser (CO2) , photodynamic therapy , cryotherapy , Mohs MS

If affect large area or recurrence: Total glans resurfacing + skin graft + deep biopsy

High risk of local recurrence in penile preserving txn

Bowens disease: [Keratinising CIS ]

CIS in the genital and perineal skin
Txn : WLE , laser, cryoablation

18

Balanitis Xerotica Obliterans (BXO)

Lichen sclerosis et atrophicus
>10% asso with future Ca penis
Location: White patch on Glans and prepuce, may affect meatus or
fossa navicularis
Aetiology: Infection/ chronic antigenic stimulation, phimosis
Histology :
1.
2.
3.
4.
5.

epidermal atrophy,
loss of rete pegs,
chronic inflammatory change,
hyperkeratosis with collagenized dermis
perivascular infiltration of dermis

Treatment:

Steroid cream 4-6/52 for mild scarring and retractable foreskin

Surgical excision (circumcision), reconstruct if stricture.
Remember not to use genital skin for reconstruction (recurrence)

If still not responsive > biopsy to rule out other causes like
erythroplasia of Queyrat
Koebner phenomenon: BXO recur on split skin graft
19

Circumcision
Consent:

Bleeding (2%)
Infection (2%)
Altered sensitivity of glans
Meatal stenosis (10%)
Need of further bx of suspicious lesion
Unsatisfactory cosmetic result (4%)

Procedure:

Penile block
Midline dorsal slit
Inspect meatus (no hypospadias) & look for lesion
Circumcoronal incision of inner prepuce and outer skin
Meticulous hemostasis (bipolar diathermy)
Skin closed with interrupted undyed absorbable suture
20

Q14

Diagnosis? EPQ
Premalignant? Yes
If occurs on the shaft, what is it called? Bowens disease
21

Diagnostic schedule for penile

cancer

22

What is diagnostic schedule for

penile cancer?

23

What is 2009 Staging of Ca penis?

SCC penis invading prostate is T3

24

What is the shortcoming of the

staging?
Prognosis of patients with tumour invasion of the
corpus spongiosum is much better than invasion
of the corpus cavernosum in terms of local
recurrence and mortality
Rees et al

Authors proposed defining

T2a patients by spongiosum-only invasion
T2b patients by involvement of tunica or corpus
cavernosum

No differences in long-term survival between T2

and T3
No differences between N1 and N2
25

What is the proposed modification to 2009 TNM

classification?

26

Jacksons staging system, 1966.

27

Case:

Patient present with a penile mass

Painless
Not affecting urination
P/E:
1.5cm solid growth at glans of penis
1cm Right groin LN

What is your approach?

28

History

Age
Previous duration of phimosis
LUTS
Smoking history
Sexual history: HPV infection
Exposure to UV radiation

29

PE

30

Penile biopsy
The most important diagnostic test
Circumcision and excisional biopsy if the cancer is
small
Incisional biopsy should contain tissue beneath and
beside the tumor in order to help stage the disease

Confirm histological diagnosis

Determine the depth of invasion
Detect the presence of vascular invasion
Evaluate the grading of the tumour ( Broders
classification )
31

How would you stage the

tumor?

Local staging
1. USG, 7.5 MHz
Tumor appear as hypoechoic
Adv : detect corpus cavernosal invasion with sensitivity of 100 %
Disadv: Could not differentiate Ta from T1
2. MRI penis with intracavernosal prostaglandin
Accurate in demonstrating invasion of the corpora,
and the extent of the cancer
3. CT:
Not useful in local tumour staging because of poor
soft tissue resolution
For LN status
32

LNs staging

33

What is the lymphatic drainage

of penis?
First to the inguinal LN and then to the pelvic LN
Bilateral drainage of the penis to the LN
The inguinal LN
Superficial group that lie deep to the Scarpas fascia
but superficial to the fascia lata (8-25 LNs)
The deep group (deep to the fascia lata) is a smaller
group that lie around the junction of the long
saphenous and femoral veins

The commonest detected group of LN which

include the LN of cloquet lies cranimedial to the
junction between the long saphenous and
femoral veins
34

What is the accuracy of P/E of

lymadenopathy?
High (90%) sensitivity but a low specificity (20%)
of clinical examination detecting pathologically
positive inguinal lymphadenopathy
50% of patients with penile cancer will have
clinically palpable inguinal LN at presentation
50% of patients with pathologically positive
unilateral inguinal LN will have contralateral
metastatic disease

35

What is the imaging

investigation for LN?
CT / MRI
Predict LN involvement by size only
Sensitivity : 35 %, specificity : 100 %

Strongest predictor for survival is the

presence or absence of nodal metastases

36

Treatment strategies for penile

cancer

37

38

What are options of organ

preserving therapy?
Circumcision
Small tumors confined to the prepuce
But with recurrence 40%
Local wedge excision
Margin of 5 mm
50% recurrence rate
Glansectomy : T1 (not involving the CC)
Tourniquet control
subcoronal incision down to Bucks fascia
proximal margin at least 5mm
the glans cap is mobilized off the head of the corpora cavernosa
Urethra is transected and split and fixed
Shaft skin is anchored to the new corona
Raw surface is covered with partial thickness skin graft
T1G3 - lowest recurrence rate of 2%
39

What is organ preserving therapy?

Mohs micrographic surgery (MMS)
shaving the tumour mass by excising thin layers of tissue and
examining them microscopically till clear deep resection margin is
confirmed by frozen section
Adv :
With a surgeon experienced in MMS, it is able to remove the cancerous
tissue while preserving normal structures

Disadv :
Messy and bloody and time consuming
Required expert technique
Experienced pathologist is needed to confirm clear margin by frozen
section
Wound may healed with scarring result in disfiguration
Urethra is sometime involved and required urethroplasty
Recurrence rate was high at 30%
40

What is organ preserving therapy?

Laser surgery

For local and limited invasive disease

Four types of lasers have been used
1.
2.
3.
4.

The carbon dioxide laser

vaporizes tissue
penetrates only to a depth of 1mm
coagulate blood vessels less than 0.5 mm

The ND:YAG laser

Carbon dioxide
Neodymium:yttrium-aluminum-garnet (ND:YAG)
Argon
Potassium-titanyl-phosphate (KTP) lasers

penetrate 5 mm depending on the power

Can coagulate vessels up to 5 mm

The argon and KTP lasers have less tissue penetration than the
carbon dioxide laser and are rarely used
Result : 7% recurrence in 4yr FU [Frimberger 2002]
41

What are the problems of

conservative treatment?
Not be suitable in cases of multifocal
lesions
Mohs micrographic surgery,
photodynamic and topical therapy with 5fluorouracil ( 5-FU) or 5% imiquimod
cream have been reported for superficial
lesions with relatively high recurrence rate
Best results are achieved with laser
surgery
42

What is Partial penectomy?

When the cancer involves the glans and distal shaft

T1a to T2 (not for T3 !!!!)
Traditionally, partial amputation has required removal of 2-cm tumour-free
margins, to lower risk of local recurrence T (50% reduced to 6%)
Pathological confirmation a surgical margin of 5-10 mm is safe
Frozen sections at the time of surgery are often helpful, and a careful review of
the specimen and permanent sections with the pathologist help to determine if
the resection has been adequate
If margin + ve: local recurrence in 10%
Patient should be counsell about poor cosmetic and functional result
He will need to sit to void
He cannot have sexual intercourse

If surgical resection by either wedge or partial penectomy does not provide an

adequate margin, a total penectomy should be considered
If the amount of residual penis and urethra is inadequate to allow the patient to
urinate while standing, a perineal urethrostomy can be performed

Berry suggested to have 3cm penile functioning length and 2cm clear margin before
consideration of partial penectomy

Recurrence of partial or total penectomy: 0-8%

43

How to perform partial

penectomy?

Tourniquet control, cover tumor with glove finger

Deglove the penis
Mark the extent of tumor free margin
Mobolise the neurovascular bundle and ligated
Mobolise the urethra
Send the proximal margin for frozen-section
Oversew the corpora and Bucks fascia and cover the corpora
with penile skin or skin graft
Spatulate the urethra, creation of neoglan with split skin graft
Further lengthening can be achieved by dividing suspensory
ligament +/- full thickness SG
Foley to BSB

44

What is total Penectomy ?

Total amputation of penis + excision of
scrotum and its content
Formation of perineal urethrostomy
Complication:
Urethral meatal stenosis

45

 CIS, Ta-1 G1-2 (i.e T1a)

Penis-preserving strategy for those guarantee regular FU (70%)
local excision + reconstructive syrgery / glansectomy (depend on
size and location of tumor)
Laser , cryoablation, RT & brachytherapy
Mohs MS or photodynamic therapy for (CIS, TaG1)
Local 5-FU (for CIS only)

No difference in local recurrence rate between micrographic

surgery, EBRT, insterstitial brachy and laser
Overall recurrence 15-20%
Partial amputation for those who dont comply with regular FU.

T1b G3, T2 (glans only)

V. carefully selected patients with tumour less than half of glans
& close FU can be carried out conservative strategy
Glansectomy +/- Tip amputation or reconstruction
Margin 3mm is consider safe
46

 T2 (invasion to copora)
Partial amputation
Margin 5-10mm
If no LN on presenstation 5yr survival 66%

T3 (invasion to urethra)
Total amputation with perineal urethrostomy

T4 (invasion to other structure)

Neo-adj chemo + surgery in responsive patient (selected)
Others: RT

Local disease recurrence

2nd conservative procedure if < T2
If large or deep infiltrating recurrence partial / total amputation
External beam radiotherapy / brachytherapy for lesions < 4cm diameter

47

What are treatment strategies

for penile cancer?

48

What are treatment strategies

for penile cancer?

49

RT?

Indications:
1. Organ-preserving treatment in young pt with T1-2 lesions < 4 cm
EBRT: Response rate: 50% Local failure rate: 40%
Brachytherapy: response rate 70%, failure 16%.
2. Alternative to chemo + surgery in T4 diseas
3. Those who have metastatic disease and need some form of palliative therapy

Procedure:

High dose: 60cGy during 3 weeks

Circumcision prior to initiating radiation therapy

Prepuce will fuse with the glan

Allows better evaluation of the tumor stage

Minimizes the morbidity associated with the therapy, includes swelling,

irritation, moist desquamation, phimosis, and infection

Prophylaxis

NOT recommended. (fails to prevent mets, morbidity, difficult to follow)

Neo adjuvant

can render fixed nodes operable.

Adjuvant

may be used to reduce local recurrence.

50

Radiotherapy?

Adv
Avoid the psychological trauma associated with partial or complete penectomy
Potential to maintain potency
Local control rate 60-90%

Disadv
Squamous cell carcinomas tend to be resistant
High tumor dose (ie, 60 cGy) required
Complication:
1.
2.
3.
4.
5.
6.
7.

Meatal stenosis + urethral stricture (30%)

glans necrosis
Telangiectasia (90%)
Late fibrosis of the corpora cavernosa
Late fistula and pain
Testicular damage
Secondary neoplasia

Disfiguration and associated pain may in fact make the phallus practically
useless
Close FU is necessary
Difficulty in distinguishing tumour recurrence and post RT fibrosis / scarring
making multiple Bx necessary
Local recurrence rate 40% (EBRT), 16% (Brachytherapy)

51

Mx of LNs in Ca Penis

52

What is the draining LNs of Ca

penis?

Femoral and inguinal lymph nodes are the earliest path for tumor
dissemination
The lymphatics of the prepuce join with those from the shaft. These
drain into the
sentinal LN ( superomedial to the saphenofemoral junction )
other superficial inguinal nodes. ( superficial to the fascia lata )
deep inguinal nodes, which are beneath the fascia lata.
to the pelvic nodes
Multiple cross connections exist at all levels, permitting penile
lymphatic drainage to proceed bilaterally (80%)
Untreated, metastatic enlargement of the regional nodes leads to skin
necrosis, chronic infection, and, eventually, death from sepsis or
hemorrhage secondary to erosion into the femoral vessels
No lymphatic drainage was observed from the penis to the inferior two
regions of the groin and no direct drainage to the pelvic nodes

53

LN spread in Ca Penis
Regional LN of penis are located in inguinal region :
superficial or deep
Then drain to 2nd line LN: Iliac & obturator fossa
Most constant node:
Cloquets (or Rosenmullers)
Medial side of the femoral vein
Mark the transition btw inguinal and pelvic region

Superficial: under subcutaneous fascia and above fascia

lata, 25 LN on the muscle of the upper thigh in Scarpas
triangle
Deep: region of fossa ovalis where greater saphenous vein
drain into femoral vein through an opening of the fascia lata
Most met found in medial superior Daseler group
Sentinel LN of Ca penis only found in superior and central
zones of the inguinal region (by SPECT-CT)
54

Daseler region

Inguinal region is divided into four sections by a horizontal and a vertical line drawn through the
fossa ovalis
Five anatomical subgroups with the central zone being located at the confluence of the greater
saphenous vein and the femoral vein. The four other zones are described as lateral superior,
lateral inferior, medial superior, and medial inferior

55

Incidence
Depends on:
Tumor grade: 30% G1 vs 40% G3
Local stage : 60% in pT2 & 75% in pT3-4
T1G2: 50% [Naumann BJU 2008]
Type of local tumor: Basoloid vs Classic

56

Prognostic significant of LN met

Presence and extent of inguinal LN metastasis

are the most important factors for the
prognosis of the pt
Pelvic LN worse then inguinal LN
Predictor of DFS:

Extra capsular growth in met node

Bilateral inguinal LN met
Pelvic nodal disease

3yr Cancer specific survival:

Inguinal LN ve or pN1: ~ 100%

pN2 : 70%

57

Predictor of LN met
Variable if only take primary tumor into
account (pT stage, grade , depth of
invasion & histological subtype)
Lymphovascular and vascular invasion
was reported to predict LN met
Risk scoring system: Solsona
Ficarra nomogram (2006)
58

What are the risk factors for LN

metstasis ?

Risk factors
1. Lymphovascular invasion & Perineural invasion(5x risk, Ficarra)
2. Histology Grade 3 (75% LN+, EAU)
3. pT2 (75% LN+, EAU)
4. Histological subtypes :
Sarcomatoid (75% LN+), adenosquamous (50%), basaloid (50%)
5. Tumour thickness >5mm (2x risk, Ficarra)
6. Infiltrating growth pattern (4x risk)
7. Molecular markers: p53, E-cadherin
8.

Nomograms to predict pathological inguinal LN involvement

Ficarra (accuracy 88%)

Bhagat (accuracy 75%)

59

60

61

62

63

Molecular marker
HPV DNA status: conflicting results
Ki-67: conflicting result on LN met
Reduce KAI1/CD82 expression: predictive
on LN involvement in one study
P53 ve: better survival & less LN +ve
Conclusion: no tissue parameter is
sufficiently validated as a prognostic
marker for LN involvement to be used as a
bssis for clinical decisions
64

What is the approach for nonpalpable nodes?

Explained :
25% risk of lymph node metastases
Radical LND for all will result in > 75% of over treatment

Any investigation suitable ?

No value in dx of inguinal LN met
Ultrasound + FNAC
may reveal abnormal nodes & guide for fine-needle aspiration biopsy

Non palpable LN: SV 40% , SP 100%

Sentinel node Bx not recommended due to high false ve rate (25%)
Dynamic SNB - 100% specificity and 95% sensitivity, false negative rate 5%
CT/MRI groin cannot detect micrometastasis
Pelvic CT/MRI scan is not necessary in patients with no inguinal node metastases
(SV 40%)

Nanoparticle-enhance MRI :SV 100%, SP 97% , PPV 80%

18FDG PET/CT: SV 80% , SP 100%

Thus: risk adapted approach is more appropriate

65

Non-palpable LN : by pT stage

Low risk gp: pTis, pTaG1/2, pT1 G1 (LN met < 17%)
Active surveillance
Optional: modified inguinal LND

Intermediate risk gp: pT1G2 or higher (LN met 50%)

DSNB , follow by complete LND if tumor +ve
If DSNB not available base on risk factor + nomogram
Superficial growth + no vascular invasion: Active surveillance
vascular or lymphatic invasion OR infiltrating growth pattern: modified LND radical if tumor
+ve

High risk gp: pT2-4 , any G3 (LN met 70%)

Active surveillance is not appropriate:
Higher risk of recurrence [Leijte]

Immediate LN staging
DSN then LND if +ve
3 yr DSS: 91% vs 80% (surveillance) [Lont]

Modified radical inguinal LND (if FZ +ve in MILND)

Immediate vs delay LND:
3yr survival: 84% vs 35%

Which side? Both side

66

67

What is the approach for palpable LN ?

Explained:

Palpable LN present at diagnosis in 58% patients

Traditional : 50% +ve for metastasis, 50% inflammatory [Brazil]
Todays thinking: > 90% palpable LN are met
If LN +ve on one side there is 50% chance to be +ve on the other side

Any investigation suitable ?

No value in dx of inguinal LN met
Ultrasound + FNAC
may reveal abnormal nodes & guide for fine-needle aspiration biopsy

Palpable LN: SV 93% , SP 91%

If negative repeat biopxy

Dynamic SNB No role is palpable LN

Pelvic CT/MRI scan are widely done but with low SV/SP

Nanoparticle-enhance MRI :SV 100%, SP 97% , PPV 80%

18FDG PET/CT: SV 80% , SP 100%

But since LND is going to be perform irrespective of FNA result , FNA

may not be useful
Thus early & bilateral radical LND is the standard procedure

68

Palpable mobile LN
If T1 & G1 & no vascular invasion, mobile LN
Antibiotics for 4 weeks & reassess (50% inflammatory)
USG guide FNAC: may not be necessary
+ve
Ipsilateral radical inguinal LN dissection
Contralateral superficial inguinal LN dissection & frozen section-> proceed to
radical LN dissection if FZ +ve (Pompeo)
Pelvic LND if
Cloquet LN+, or 2 inguinal LN+, or extracapsular involvement
To be done on the side (uni or bi) whenever the above criteria is reach

-ve :
Repeat bx
Excised suspicious LN
Proceed to LND
69

Summary
Whenever there is palpable LN RLND
Whenever FZ show LN +ve RLND

70

Pelvic LND

Incase of uninvolved inguinal LN, pelvic LND not indicated

Risk of +ve pelvic LN: Culkin J Urol 2003;170:359-365
23% if < 2 inguinal LN involved
56% if > 3 inguinal LN involved or 1 with extracapsular spread

Indication of pelvic LND:

Extracapsular spread
Cloquet node invovled
> 2 inguinal LN metastases

Consider if basaloid subtype or strong expresssion of p53

Approach: Extraperitoneal , midline incision
Includes external iliac lymphatic chain and ilio-obturator chain with the
following borders:
proximal boundary:
lateral boundary:
medial boundary:

iliac bifurcation
ilio-inguinal nerve
obturator nerve

Provide cure rate: 14-54%

Unanswered questions:
If extensive unilateral inguinal LN involvement , should pelvic LND be unilateral or
bilateral?
When is the most suitable timing of pelvic LND?

71

Fixed inguinal LN
Neo-adjuvnat chemotherapy (response rate 20-60%)

[Pizzocaros series]
3-4 courses of cisplatin & 5FU in 16 patients for fixed LN
60% could be radically resected following primary chemoTx
30% have probably cured
Survival rate 25%

Subsequent radical ilio-inguinal LNectomy strongly

recommended
Should be used as part of a clinical trial
Or Radiotherapy followed by lymphadenectomy but
higher morbidity
Problem: high toxicity + high number of non responder
72

73

Surgical LN staging
Direct histological examination of inguinal
LN is the most reliable method of
assessing their involvement by metastses
Approach:
Radical inguinal LND
Modified inguinal LND
Sentinel node biopsy
Video endoscopic LND
74

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SEV, superficial epigastric; SEPV, superficial external

pudendal; MCV, medial cutaneous; LCV, lateral cutaneous;
SCIV, superficial circumflex iliac.

Deep inguinal lymph nodes

77

What is the boundary of femoral

triangle?

Superior: Inguinal ligament

Lateral: Medial border of sartorius
Medial: lateral border of adductor longus
Floor:
Medial: Pectineus muscle
Lateral: iliopsoas muscle
Femoral A & V
78

Radical inguinal
lymphadenectomy

Modified inguinal
lymphadenectomy

Margin :

Upper : anterior superior iliac spine to

superior margin of external iliac ring

Lateral : a vertical line of 20 cm from the

anterior superior spine

Medial : a vertical line of 15 cm from the

pubic tubercle

Lower : joining the lateral and medial border

Content :

Superficiall inguinal LN deep to the Scarpa

fascia

Deep inguinal LN deep to the fascia lata

LN remove: all 5 Daseler region + deep

inguinal LN

Saphenous vein is ligated and divided

Femoral artery and vein are skeletonized

dissection posterior to the femoral vessel is

not required

Sartorius is divided at the origin and

transposed to cover the femoral vessel

Skin rotation flaps + MC flaps for primary

wound closure
Morbidity:

wound infection , skin necrosis , wound

dehiscence , lymph edema, lymphocele

Proposed by Catalona
Exclusion of area lateral to femoral artery &
caudal to fossa ovalis
Boundary reduced by 1-2cm

Margin :

Upper : inguinal ligament

Medial : margin of adductor longus muscle

Lateral : lateral border of the femoral artery

Lower : apex of the femoral triangle

Content :

The superficial LN deep to the Scarpa fascia,

superficial to the fascia lata

But should dissect central and superior zones

If + ve LN is identified on modified approach,

formal radical lymphadenectomy is
proceeded.

Complications: early (7%) , late (3.4%)

Morbidity reduced : Skin necrosis (2.5% vs
8%) , lymphoedema (3% vs 20%) , DVT
(none vs 12%)
False ve rate increase

79

Describe the difference between radical vs

modified inguinal lymphadenectomy
1. Shorter skin incision
2. Limitation of the dissection by excluding the
area lateral to the femoral artery and caudal to
the fossa ovalis
3. Femoral vessel need not skeletonised deep to
fascia lata
4. Preservation of the saphenous vein (less
edema)
5. Elimination of the need to transpose the
sartorius muscle
80

Complications
Early minor complications :40%
Hemorrhage
Wound infection
Flap necrosis

Major complications: 15%

Debilitating lymphedema
Lymphocele
Prolong lymph drainage
Patchy sensory loss of thigh
81

How to decrease morbidity of LND?

Prevention:

Prophylatic antibiotic
Care and diligent tissue handling
Use of vacuum drain
Elastic stocking +/- pneumatic stocking
Early ambulation & anticoagulant (controversial)

Treatment of lymphedema:
Supporting underwear
Avoid trauma to skin
Scrotoplasty
82

Dynamic sentinel node biopsy

(DSNB)

Identification of the LN in pt which is the first drainage node

Assumption: there is stepwise and orderly progression of lymphatic
metastatic spread from the sentinel node to secondary LN
Usage: in non palpable LN met (> pT1G2)
Method:
Technetium-99m nanocolloid injection around the penile tumor
intradermally 1d before surgery
Shortly before OT: 1ml of patent blue dye injection intradermally
Sentinel LN indentify by lymphoscintigraphy , & area marked on skin
Dissection: sentinel LN identify by intra-op gamma-ray detection probe +
patent blue dye staining
LN then isolated and removed for FZ
If FZ +ve formal inguinal LND perform

Result:
With improved technique (combine with USG FNAC): false negative rate of
5% achieved (vs 25%)
Specificity : 95%, sensitivity : 95%
Netherlands Cancer Institute
83

How was the FN rate of DSNB

improved?
Before : FN rate of DSNB is 25%
Now: 5%
This is achieved by combination of USG guided
FNAC before OT
Reasons:
LN with extensive tumor does not have normal lymph
drainage and TF not detect by DSNB
However, they are shown by USG + FNAC
Thus USG improved detection of extensive tumor
involved LN which are clinical not palpable and not
detected by DSNB

Thus reduced the FN rate of DSNB

84

Video endoscopic LND

Recently described technique

Lower risk of skin complication
Higher risk of lymphocele (23%)
Reliability is not yet possible

85

86

Treatment for local recurrence

87

What is the treatment for local

recurrence?
For local recurrence after conservative therapy, a
second conservative procedure is strongly
advised if there is no corpora cavernosa invasion
Palpable inguinal nodes on FU - Nearly 100% is
metastatic
Local recurrence at groin after penile amputation
Poor prognosis
Bilateral inguinal LND
If more then 2 node combined chemotherapy and
radiotherapy
88

Chemotherapy

89

How about chemotherapy?

For distant metastasis disease
Drugs :
cisplatin, bleomycin, methotrexate (CBM), and fluorouracil
Cisplatin monotherapy
Partial short duration response rate15-23%,

Bleomycin +/- radiation or vincristine and methotrexate

Partial and/or complete response rate of 45%

Overall response is partial and short live (20-60%)

Adjuvant setting in high risk gp

3 course Cipslatin + 5-FU in pN2-N3 patients with relapses
(<10%) & survival benefit

90

Chemotherapy
cis platin +/- 5FU, VMB, CMB.
Adjuvant following RLND, 82% 5 yr survival.
Pizzocaro Acta Oncol 1988;27:823-4

Neo adjuvant, fixed inguinal nodes, 56%

resectable & 31% cured. Pizzocaro J Urol 1995;153:246
Advanced disease, 32% response rate, 12% Rx
related deaths.
Haas J Urol 1999;161:1823-1825, Kattan Urol 1993;42:559-62

91

Neo-adj chemo
Neoadjuvant chemotherapy for high risk groups :
extranodal extension
pelvic LN
bilateral metastasis

combination regimen :
vincristine
bleomycin
methotrexate ( VBM )

improve 5- years survival of the high risk group

from 40 % to 80 %
( Milan National Tumour Institute )
92

Follow-up schedule for penile

cancer
Most relapses in first 2 years.
0-7% chance of relapse after partial / total
penectomy.
Development of palpable nodes with non
palpable nodes initially means metastasis ~
100%.
Physical exam, CT & CXR.

93

94

Prognosis

95

What is the prognosis of Ca

penis?
5 Yr Survival
Localized disease

70-95%

T2 70%

LN met
Metastasis SCC

50%
<10%

Poor prognostic factors to survival:

presence of +ve LN
no. & site of +ve nodes
extracapsular nodal involvement
96

Primary urethral tumor

97

SCC (80%) Bulbomembranous urethra (60%)

Risk factors HPV, UV, chronic inflammatory or stricture condition, STD
Presentation

P/E:

Palpable mass at female urethral meatus or along course of male urethra

LN: pelvic LN (posterior) , inguinal LN (ant)

Ix

Late with metastasis

Bloody urethral discharge or painless hematuria (initial/end)
LUTS or perineal pain
Peri-urethral abscess or UC fistula

FC + biopsy first
EUA
MRI scan for local staging
CT abdomen and pelvis for LN

Tx

Localized anterior urethral Ca

Posterior or prostatic urethral Ca

Wide local excision with adjacent tunica albuginea,

Urethral recontstruction either perineal urethrostomy or hypospadiac urethra if adequate length
Total penectomy if advanced disease
Cystogrostatourethrectomy in men
Anterior pelvic exenteration in women (PLND, bladder , urethra, ureterus , ovaries, vagina)

For LN > same as CA penis

Locally advance: RT + surgery
Met : Chemo

5-yr survival:

Surgery ant urethra

Surgery post urethra
RT
RT + surgery

50%
15%
30%
50%

98

Ca scrotum
SCC, < 50yr
Chimmey worker: chronic exposure to
soot , tar or oil
Presentation: painless lump or ulcer in
scrotal wall, inguinal LN
Txn: Wide local excision +/- LND
Adj chemo
Poor prognosis in metastatic disease
99