Thursday, July 13, 2006

Carcinoma penis in brief

premalignant cutaneous lesions
cutaneous horn
2. pseudoepitheliomatous mycaceous and kearatitic balanitis
balanitis xerotica obliterans
leukoplakia


virus related
1. condyloma acuminatum
2. bowenoid papulosis
3. kaposi’s sarcoma

buschke Lowenstein tumor-verrucous carcinoma, giant condyloma acuminatum

SCC

Ca in situ – erythroplasia of queyrat, Bowens disease
Invasive ca

ETIOLOGY
Circumcision- smegma
Hygiene
Trauma
VD
Viral infection

NATURAL HISTORY
Papillary and exophytic
Flat and ulcerative – nodal metastasis + and poor survival
Bucks fascia
Lymphatic drainage

Prepuce—shaft—superficial inguinal nodes
Glans—corporeal bodies—base oof penis—superficial nodes
Superficial nodes to deep nodes—pelvic nodes
Distant metastses

Relentless progressive course
No spontaneous remission
Modes of presentation

Signs
Penile lesion
Phimosis
Inguinal node complications


SYMPTOMS
Pain not usual
Systemic malaise
Blood loss

DIAGNOSIS
Delay

EXAMINATION
PENILE LESION—size location, fixation,corporeal bodies
Base of penis, scrotum
Rectal and bimanual
Inguinal area
Biopsy
Histology
SCC—keratinisation, epithelial pearls, mitoses
Grading
Strongest prognostic indicator of survival—presence or absence of nodal metastases

Lab studies
Se ca ++
Radiology – IVP, lymphangiography, CT, MRI, USG penis, MRI penis

Classification for tumors of penis
Jackson’s
IA glans prepuce both
IIB shaft
IIIC inguinal mets operable
IVD adjacent structure inoperable inguinal mets, distant mets

TNM classification
PRIMARY TUMOR
TX
TO
Tis
Ta noninvasive verrucous
T1 subepithelial connective tissue
T2 corpus cavernosum or spongiosum
T3 urethra or prostate
T4 other adjacent structures

REGIONAL LYMPH NODES(N)
NX
N0
N1 Single superficial ing node
N2 multiple or bilateral superficial ing nodes
N3 deep inguinal or pelvic, unilateral or bilateral

DISTANT METASTASES(M)
MX
M0
M1 Distant

Treatment
Gold standard—partial or total penectomy
Aggressive therapy whenever possible—low incidence of distant mets, morbidity from untreated disease, and success with

Conventional surgical treatment
Glans and distal shaft – partial amputation wih 2 cm margin
If less than 2 cm margin or inadequate phallic stump – total penectomy
Mohs micrographic surgery removing skin cancer by excising tissue in thin layers
Radiation therapy
Primary – careful selection, high dose required, complications
Young, small lesion 2 to 3 cm
Refusing surgery
Inoperable tumor, distant mets but desire to retain penis

Inguinal nodes
Lymphadenectomy should be performed in presence of clinically palpable nodes after appropriate treatment of the primary lesion and subsidence of inflammation

Lymphadenectomy should be performed if primary lesion invades through the Basement membrane of penile skin even if nodes are negative
Bilateral drainage is the rule
Bilateral lymphadenectomy is recommended in patients presenting with unilateral adenopathy

Increase in probability of pelvic nodal involvement when 2 or more positive inguinal nodes are there

Tis Ta T1 N0 M0 jackson 1,2
Low grade -- treat primary + follow up
High grade – immediate prophylactic inguinal lymphadenectomy

T2 T3 N0 M0 J1,2
Penectomy + bilat LND

T1-3 N1-3 M0 J3
Penectomy + bialateral LND

M1, T4, inoperable N, J4
Palliative chemo, radio
Aggressive chemosurgery

Radiation
Not effective, lot of complications, may be used for palliation

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