SlideShare ist ein Scribd-Unternehmen logo
1 von 57
Downloaden Sie, um offline zu lesen
Carcinoma Penis
DR KIRAN KUMAR BR
Benign Lesions
Non cutaneous Cutaneous
•Inclusion/Retention
cysts
•Syringoma
•Neurilemmoma
•Angioma, Fibroma,
Neuroma, Lipoma,
Myoma
•Pseudotumors
•Penile papules
•Hirsute papillomas
•Coronal papillae
•Zoons erythroplasia
•Rashes & ulcerations
secondary to irritation, allergy
and infections
Premalignant lesions
• 42% of pts with SCC
had hx of pre existing
penile lesions.
(Bouchot etal 1989)
•Cutaneous Horn
•Pseudoepitheliomatous
Micaceous & Keratotic
Balanitis
•Balanitis Xerotica
Obliterans
•Leukoplakia
Viral related conditions
•
•
Human Papilloma virus (HPV)
Types 6,11,42,43 & 44
associated with low grade
dysplasia.
Types 16,18,31,33,35 & 39
have higher association with
malignancy.
Human Herpesvirus 8
(HHV 8)
• Condylomata Acuminatum
• Bowenoid Papulosis
• Kaposi’s Sarcoma
Viral related conditions
•
•
Human Papilloma virus (HPV)
Types 6,11,42,43 & 44
associated with low grade
dysplasia.
Types 16,18,31,33,35 & 39
have higher association with
malignancy.
Human Herpesvirus 8
(HHV 8)
• Condylomata Acuminatum
• Bowenoid Papulosis
• Kaposi’s Sarcoma
Buschke-Lowenstein Tumor
•
•
•
•
•
•
(Verrucous Carcinoma, Giant Condyloma
Acuminatum)
initially described in 1925.
true incidence is unknown.
Does not metastasize rather invades locally.
Treatment is excision.
Recurrence is common.
Topical therapy with Podophyllin, 5FU, radiation
and chemotherapy have all been tried with no
great success.
Penile Cancer
•
•
Squamous cell carcinoma. > 95%
Mesenchymal tumors. < 3%
•
•
•
e.g Kaposi sarcoma, angiosarcoma etc
Maligannt Melanoma.
Basal cell carcinoma.
Metastasis. Sufrin & Huben 1991
Carcinoma in situ
•
•
•
Penile intraepithelial neoplasia, Erythroplasia of Queyrat,
Bowen’s disease
can progress to invasive carcinoma.
Histological confirmation with proper determination of
invasion.
Treatment
Circumcission------------Preputial lesions Local
excision------------small & non invasive
Radiotherapy
Topical 5FU as 5% base
Nd:YAG & CO2 laser, liquid nitrogen
Kelley etal 1974, Graham & Helwig 1973, Mortimer etal 1983
Invasive carcinoma
•
•
•
•
•
Uncommon.
0.1 – 0.9 per 100,000 in USA, Europe.
Upto 10% in some asian, african and south
american countries, (Vatamasapt etal 1995)
Disease of older men, 6th decade, reported in
younger men & children. (Narsimharao 1985)
Primary tumor localized to glans (48%), prepuce
(21%), both glans & prepuce (9%), coronal (6%),
shaft (<2%). (Sufrin & Huben 1991)
Etiology
•
•
•
•
•
•
•
Circumcission practice.
Hygiene standards.
Phimosis.
No. of sexual partners.
HPV(16,18) infection.
Exposure to tobacco products.
No convincing association with occupation, gonorrhea,
syphillis & alcohol intake.
Barrasso etal 1987, Maiche 1992, Maden etal 1993
Prevention
• Routine neonatal circumcission.
AAP Paediatric guidelines 1999.
• Good hygiene practice.
• Avoid HPV infection and tobacco.
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.
Presentation
• Symptoms
malaise, wt loss, fatigue, weakness,
hemorrhage, pain.
• Signs
penile lesion.
rarely nodal mass, ulceration, suppuration.
Diagnosis
• Primary lesion.
• Regional lymph
nodes.
• Distant metastasis.
• Physical examination.
• Ultrasound.
• MRI.
• CT.
• Cavernosography.
• Lymphangiography.
Diagnosis
• Histological diagnosis is absolutely necessary
prior to treatment decision.
• Growth pattern of SCC
superficial spreading.
vertical growth.
multicentric.
verrucous.
Cubilla etal 1993
Grading systems
• Broders grading
system (Ann Surg 1921;73:141)
divided into 4 grades
depends on differentiation
based on keratinization,
nuclear pleomorphism, no.
of mitosis
• Maiche system score
(Br J Urol 1991;67:522-526)
modified into 3 grades
5 year survival
Grade 1
Grade 2,3
Grade 4
80%
50%
30%
Staging
• Jackson’s staging system, 1966.
TNM staging system
• Management depends on:
• Location
• Size
• T stage
• N stage
• Histopathological characteristics
• Patient preference (Organ preservation?)
Options
• Surgery
• Radiotherapy
• EBRT
• Brachytherapy
• Chemotherapy
• Local
• Systemic
Surgery
Overview
• Mainstay of treatment
• May involve
• Circumcision
• Laser ablation
• Mohs micrographic surgery
• Penectomy
• Partial or total
• Radical Surgery
• Emasculation/ Hemipelvectomy
• Not performed in common practice
Cirumcision
• Indications/Reasons
• Definitive treatment of carcinoma-in-situ (Tis)
• If phimosis is present, allows better visualization of
disease
• If prepuce is involved, removes some of the tumor bulk
→ facilitates planning of treatment.
• Allows the radiation oncologist to better deal with RT
toxicities (edema/phimosis/painful ulceration)
Laser ablation
• CO2 or Nd:YAG lasers have been reported to provide good
functional and cosmetic results.1
• Tis or T1; high recurrence rates are seen with > T2 lesions1.
• Local recurrences of ~20% are reported; these can be
salvaged by re-treatment, RT or surgery.2
• Extended, careful follow-up required; only 57% of local
recurrences occur within the first 2 years, 30% between 6
and 10 years, and 15% after 10 years.2
1. Meijer et al, Urol 2007
2. Windahl et al, J Urol 2003
• Excision of tissue in successive layers with microscopic scanning
of each layer to identify any tumor outgrowths
• Successive layers removed until margins are histologically clear.
• Local recurrences in upto 1/3rd patients; usually salvageable by
repeat procedures/surgery.1
• May be offered to selected patients (Tis, ? T1) who are reliable for
follow up.
1. Shinde et al, J Urol 2007
Mohs Micrographic
surgery
Penectomy
• Done for bulky lesions; usually T2 and beyond.
• The goal is to leave adequate penile length for hygienic upright
micturition and intercourse.
• Margin needed:
• 2cm has been tradiationally advocated.
• Current data suggests 5-10mm margins are as safe as 2cm margins.1
• When a total penectomy has to be done, perineal urethrostomy
is needed. Phalloplasty may be done at equipped centres.
1. Minhas et al. BJU Int 2005
Results with Surgery
• 5 year overall survivals:
Early stage disease 55-80%
• 87% DFS at 5 years in Node
negative patients.1
1. Ornellas et al. J Urol 1994
Inguinal Lymph Nodes
Clinical Node Negative (N0)
• ~ 20% have occult metastases on prophylactic lymph node
dissection.
• Divided into low and high risk.1
• Low-Risk Group:
• Patients with carcinoma in situ (Tis), verrucous carcinoma (Ta),
and T1 tumors who have grade 1 or 2 tumor histology
• <10% chance of developing lymph node metastases
• Surveillance / DSNB
• High-Risk Group
• T2 and T3 with grade 3 tumors and vascular invasion.
• >50% incidence of inguinal lymph node metastases.
• ILND / DSNB
1. Slaton et al, J Urol 2001 DSNB: Dynamic Sentinel Node Biopsy
SLN Biopsy
• Sentinel lymph node biopsy as originally described by
Cabanas is no longer recommended in view of the high
false-negative rate.1
• Dynamic SLN biopsy can decreased the false-negatives and
morbidity.2-4
• Difficult to adopt at smaller, low volume centres.
• Other approaches involve evaluation of micrometastases and
the size of the SLN to determine whether to perform
lymphadenectomy.5
• Lymphotropic nanoparticle-enhanced MRI (LNMRI) has been
investigated.6
Dynamic SLN Biopsy
• Advocated by modern high
volume centres.
• Suggested algorithm by the
EAU.1
• Resource intensive.
• Has a high sensitivity and
specificity; false negatives
<5%.
• Prospective validation awaited.
1. Yeung LL, Brandes SB. Urol Oncol 2013
Clinically Node Positive (N+)
• ~ 50% present with palpable inguinal nodes.
• Half of these have inflammatory adenopathy secondary to infection
of the primary lesion.
• Two possible approaches.
Node +ve Treat the Primary Antibiotics for 4-6 weeks
Tissue Diagnosis
Treat if Positive
Follow up
Nodal disease Regression
No Yes
Adapted from DeVita’s Cancer, 10th edition.
Inguinal Lymph Nodes
NCCN, 2015
S
U
R
V
E
I
L
L
A
C
E
Inguinal Lymph Nodes
ESMO, 2013
Radiotherapy
Overview
• Brachytherapy
• Interstitital
• Mould based
• EBRT
• Patient position
• Fields (primary/nodal)
• Dose (Primary/Nodal)
• Indications?
• Control rates
• Complications
Indications
• Definitive brachytherapy (ABS consensus statement, 2013):
Node negative disease, with:
• T1b disease
• T2 lesion < 4cm (ideally restricted to the glans)
• T3 disease without disruption of urethral mucosa
• Definitive EBRT as organ preserving treatment:
• When brachytherapy is not available.
• Patient not a surgical candidate
• Neoadjuvant External beam chemoradiotherapy
• Fixed inguinal nodes +ve for mets (ESMO; no role as per NCCN).
• Adjuvant RT
1. After Circumcision for T1-T2, N0
a. Brachytherapy alone
b. EBRT + Chemotherapy
2. After Pelvic LN dissection.
• Multiple nodes +ve for mets
• Nodal disease > 4cm
• Extranodal extension
• B/L Nodes +ve
Brachytherapy
• May be interstitial or mould based.
• Mould based treatments are non-invasive and can be
performed without anesthesia.
• Not suitable for T2 or T3 disease.
• Interstitial treatment may be performed under Local/regional
anesthesia.
• Ir-192 is the source employed (LDR, PDR
and HDR).
• Two to three planes of needles/catheters are
usually sufficient for disease coverage.
• These can be held in place by predrilled
templates (needles) or fixing buttons.
• A Foley’s catheter is placed
during application to assist
urethral localization.
• For an exterior plane, tissue equivalent bolus is
placed between the needle and surface.
a. Active length
b. Treated length
d. Lateral margin
c. Space between
planes
c. Instersource
spacing
Dose:
• LDR: 60 Gy @ 0.5-0.6 Gy/hr, over 5 days (12 hrs/day)
• PDR: 60 Gy, Pulses equal to the hourly dose rate, each hour
• HDR: 38.4 Gy @ 3.2 Gy twice daily for 6 days
Results with Brachytherapy
• Long-term (5–10 years) local control rates vary between 60% and 90% and
seem more related to tumour characteristics than treatment parameters.
• Compare favourably with surgical series.
1. Sarin et al, IJROBP 1997
• Factors determining prognosis after brachytherapy*
• Tumor size (< 4cm)1
• Depth of invasion (< 1cm)2
• Tumor volume (< 8ml)3
• No. of brachytherapy needles (< 6)3
• Spacing between individual needles (wider spacing)4
Bracketed parameters suggest a good prognosis.
Preparing and applying the mould
EBRT
• Patient Positioning
• Supine or prone with hands above the head
• The organ has to be kept in position by a wax/acrylic block
to create a reproducible setup.
• Figure shows a wax block with a
central cylindrical chamber.
• Tissue equivalent material should be
placed in the chamber distally.
• Catheterization may prevent slumping
of the organ as disease regresses.
Supine setup
EBRT (contd)
• Water bath technique: The patient lies prone
on Styrofoam slabs such that the penis is
suspended in a water bath.
• Transparent sides on the water bath permit a
visual check of penile position.
A: View from above of plastic box with central cylinder. Patient is treated in the prone
position. The penis is placed in the central cylinder, and water is used to fill the surrounding
volume. B: Lateral view.
EBRT: Planning and Doses
• Patient should be circumcised.
• B/L groins, external iliac and hypogastric nodes
should be included.
• Unless the patient has a high disease
burden/positive posterior pelvic nodes, these
may be excluded.
• Bolus may be considered for tumor/nodal
disease close to skin surface.
EBRT: Planning and Doses
• 4-6 MV Photons (Cobalt-60 or LINAC)
• EBRT Dose (when surgery not done)
• Node -ve: 60-65 Gy @ 2 Gy per fraction, 6-6.5 weeks with reduced fields
(GTV boost with 2 cm margin) for the last 5-10 Gy.
• Node +ve: 70-75 Gy @ 2 Gy per fraction, 7-7.5 weeks with reduced fields
after 50 Gy.
• Postoperative setting:
• 45-50.4 Gy to Nodal basins if Node +ve
• Boosted to 60-70 Gy for
• R1 resection
• Areas with gross nodal disease and with ECE
• If Nodal dissection not done, Nodal fields as before.
Results with EBRT
• Most data is from series spanning several years over which staging changed
and management evolved; however results have been concordant.
• Sarin et al noted a higher incidence of local failure was observed with total
dose <60 Gy, dose per fraction <2 Gy and treatment time exceeding 45 days.1
1. Sarin et al, IJROBP 1997
Complications of Radiotherapy
• Acute Reactions:
• Erythema, dry or moist desquamation, swelling of the subcutaneous
tissue of the shaft in virtually all patients.
• Peak at around 3-4 weeks after brachytherapy and towards the end
of EBRT; resolve by 1-2 months post RT.
• Late sequelae:
• Telangiectasia: usually asymptomatic.
• Soft tissue necrosis:
• Most common cause of amputation.
• Peaks 7-18 months after RT
• Associated with a higher dose of RT
• (Late sequelae)
• Urethral strictures
• Mostly meatal; occur in upto 40%.
• Usually before 3 years
• Correlates with urethral dose
• Adhesions in acute phase should be separated, and late phase stenoses
should be managed by repeated dilatations.
• Sexual function
• Can resume as soon as patient is comfortable, but with lubricant
• Appears to correlate with dose to testes; can be shielded by placing a
lead plate/sheet into the Styrofoam collar around the base of penis.
• Tis: Topical 5-FU cream and imiquimod for glandular and
meatal lesions.
• Cisplatin combination chemotherapy regimens are the most
widely used and seem to be the most effective.
• No randomized evidence. Of the various combinations
tested, the following have shown promise:1-3
• Cisplatin / Methotrexate / Bleomycin (CMB)
• Taxane / Cisplatin / 5 FU (TPF)
1. Haas et al, J Urol 1999
2. Bahl et al, JCO 2012
3. Pizzocaro et al, Eur Urol 2009
Chemotherapy
• Indication
• Mostly employed perioperatively for unresectable disease.
• Very high toxicity coupled with dismal disease control rates
(brachytx notavailable)
Penile Conservation Non penile conserving t/t
Management of CA Penis: Summary Outline
Laser
Circumcision
T1a T1b
Psychosocial issues
• Primary surgical management permits durable response
but causes considerable psychosexual morbidity.
• Treatment expectations, outcomes and post treatment
rehabilitation must be discussed with both patient and
his partner.
• Referral to a trained therapist may be warranted.
Summary
• A curable tumor but significant treatment associated
morbidity.
• Treatment is mainly surgical. Radiotherapy may be
Brachytherapy (early disease) or EBRT (unresectable
ds/adjuvant). Role of chemotherapy still evolving.
• Education and awareness needed for early diagnosis
and during management.
Thank You

Weitere ähnliche Inhalte

Was ist angesagt?

Renal Tumors, Renal Cell Carcinoma- Dr. Vandana
Renal Tumors, Renal Cell Carcinoma-  Dr. VandanaRenal Tumors, Renal Cell Carcinoma-  Dr. Vandana
Renal Tumors, Renal Cell Carcinoma- Dr. VandanaDr Vandana Singh Kushwaha
 
Soft tissue sarcoma
Soft tissue sarcomaSoft tissue sarcoma
Soft tissue sarcomaIsa Basuki
 
Management Of Testicular Tumours
Management Of Testicular TumoursManagement Of Testicular Tumours
Management Of Testicular Tumoursfondas vakalis
 
Carcinoma Of Prostate and its management
Carcinoma Of Prostate and its managementCarcinoma Of Prostate and its management
Carcinoma Of Prostate and its managementDr Sushil Gyawali
 
Hepatocellular carcinoma
Hepatocellular carcinoma Hepatocellular carcinoma
Hepatocellular carcinoma Arkaprovo Roy
 
Pancreatic neuroendocrine tumors
Pancreatic neuroendocrine tumors Pancreatic neuroendocrine tumors
Pancreatic neuroendocrine tumors suhas k r
 
Premalignant lesions in carcinoma penis
Premalignant lesions in carcinoma penisPremalignant lesions in carcinoma penis
Premalignant lesions in carcinoma penisSaankhyaSekharMallic
 
Sentinel lymph node breast ca
Sentinel lymph node breast caSentinel lymph node breast ca
Sentinel lymph node breast caPannaga Kumar
 
Core Needle Biopsy of Breast : Updates
Core Needle Biopsy of Breast : Updates Core Needle Biopsy of Breast : Updates
Core Needle Biopsy of Breast : Updates Diya Das
 
Renal cell carcinoma for students
Renal cell carcinoma for studentsRenal cell carcinoma for students
Renal cell carcinoma for studentsMohammad Manzoor
 
Treatment of breast cancer
Treatment of breast cancerTreatment of breast cancer
Treatment of breast cancerAnimesh Agrawal
 
Penis carcinoma- premalignant and management algorithm
Penis  carcinoma-  premalignant  and  management algorithmPenis  carcinoma-  premalignant  and  management algorithm
Penis carcinoma- premalignant and management algorithmGovtRoyapettahHospit
 

Was ist angesagt? (20)

Renal Tumors, Renal Cell Carcinoma- Dr. Vandana
Renal Tumors, Renal Cell Carcinoma-  Dr. VandanaRenal Tumors, Renal Cell Carcinoma-  Dr. Vandana
Renal Tumors, Renal Cell Carcinoma- Dr. Vandana
 
Soft tissue sarcoma
Soft tissue sarcomaSoft tissue sarcoma
Soft tissue sarcoma
 
Carcinoma penis
Carcinoma penisCarcinoma penis
Carcinoma penis
 
testicular tumors
testicular tumorstesticular tumors
testicular tumors
 
Anal cancer ppt
Anal cancer pptAnal cancer ppt
Anal cancer ppt
 
Bladder carcinoma
Bladder carcinomaBladder carcinoma
Bladder carcinoma
 
Carcinoma rectum (Rectal Cancer)
Carcinoma rectum (Rectal Cancer)Carcinoma rectum (Rectal Cancer)
Carcinoma rectum (Rectal Cancer)
 
Management Of Testicular Tumours
Management Of Testicular TumoursManagement Of Testicular Tumours
Management Of Testicular Tumours
 
Seminoma
SeminomaSeminoma
Seminoma
 
Carcinoma Of Prostate and its management
Carcinoma Of Prostate and its managementCarcinoma Of Prostate and its management
Carcinoma Of Prostate and its management
 
Hepatocellular carcinoma
Hepatocellular carcinoma Hepatocellular carcinoma
Hepatocellular carcinoma
 
Testicular tumours
Testicular tumoursTesticular tumours
Testicular tumours
 
Pancreatic neuroendocrine tumors
Pancreatic neuroendocrine tumors Pancreatic neuroendocrine tumors
Pancreatic neuroendocrine tumors
 
Premalignant lesions in carcinoma penis
Premalignant lesions in carcinoma penisPremalignant lesions in carcinoma penis
Premalignant lesions in carcinoma penis
 
Carcinoma penis
Carcinoma penisCarcinoma penis
Carcinoma penis
 
Sentinel lymph node breast ca
Sentinel lymph node breast caSentinel lymph node breast ca
Sentinel lymph node breast ca
 
Core Needle Biopsy of Breast : Updates
Core Needle Biopsy of Breast : Updates Core Needle Biopsy of Breast : Updates
Core Needle Biopsy of Breast : Updates
 
Renal cell carcinoma for students
Renal cell carcinoma for studentsRenal cell carcinoma for students
Renal cell carcinoma for students
 
Treatment of breast cancer
Treatment of breast cancerTreatment of breast cancer
Treatment of breast cancer
 
Penis carcinoma- premalignant and management algorithm
Penis  carcinoma-  premalignant  and  management algorithmPenis  carcinoma-  premalignant  and  management algorithm
Penis carcinoma- premalignant and management algorithm
 

Ähnlich wie Penile carcinoma

Anal Cancer Managament.pptx
Anal Cancer Managament.pptxAnal Cancer Managament.pptx
Anal Cancer Managament.pptxDina Barakat
 
Management of malignant melanoma
Management of malignant melanomaManagement of malignant melanoma
Management of malignant melanomaPulasthi Kanchana
 
Soft tissue sarcomas
Soft tissue sarcomasSoft tissue sarcomas
Soft tissue sarcomasReggieL1
 
Penile carcinoma basic sience
Penile carcinoma basic siencePenile carcinoma basic sience
Penile carcinoma basic siencedamuluri ramu
 
Cancer of the skin
Cancer of the skinCancer of the skin
Cancer of the skinSaeed Salman
 
Ca Anal Canal #Surgery
Ca Anal Canal #SurgeryCa Anal Canal #Surgery
Ca Anal Canal #SurgeryJunish Bagga
 
PENILE CARCINOMA
PENILE CARCINOMAPENILE CARCINOMA
PENILE CARCINOMAT Gupta
 
METASTATIC NECK DISEASE FOR ENT & HNS.pptx
METASTATIC NECK DISEASE FOR ENT & HNS.pptxMETASTATIC NECK DISEASE FOR ENT & HNS.pptx
METASTATIC NECK DISEASE FOR ENT & HNS.pptxSatishray9
 
Management of oral cavity cancer 23072018
Management of oral cavity cancer 23072018Management of oral cavity cancer 23072018
Management of oral cavity cancer 23072018Varshu Goel
 
Carcinoma Buccal Mucosa- Anatomy to Management
Carcinoma Buccal Mucosa- Anatomy to ManagementCarcinoma Buccal Mucosa- Anatomy to Management
Carcinoma Buccal Mucosa- Anatomy to ManagementDrAyush Garg
 

Ähnlich wie Penile carcinoma (20)

Anal Cancer Managament.pptx
Anal Cancer Managament.pptxAnal Cancer Managament.pptx
Anal Cancer Managament.pptx
 
Management of malignant melanoma
Management of malignant melanomaManagement of malignant melanoma
Management of malignant melanoma
 
Soft tissue sarcomas
Soft tissue sarcomasSoft tissue sarcomas
Soft tissue sarcomas
 
Penile carcinoma basic sience
Penile carcinoma basic siencePenile carcinoma basic sience
Penile carcinoma basic sience
 
Carcinoma of esophagus
Carcinoma of esophagusCarcinoma of esophagus
Carcinoma of esophagus
 
Cancer of the skin
Cancer of the skinCancer of the skin
Cancer of the skin
 
Carcinoma Thyroid
Carcinoma ThyroidCarcinoma Thyroid
Carcinoma Thyroid
 
Ca Anal Canal #Surgery
Ca Anal Canal #SurgeryCa Anal Canal #Surgery
Ca Anal Canal #Surgery
 
CA Penis
CA PenisCA Penis
CA Penis
 
Vulva disease
Vulva diseaseVulva disease
Vulva disease
 
PENILE CARCINOMA
PENILE CARCINOMAPENILE CARCINOMA
PENILE CARCINOMA
 
METASTATIC NECK DISEASE FOR ENT & HNS.pptx
METASTATIC NECK DISEASE FOR ENT & HNS.pptxMETASTATIC NECK DISEASE FOR ENT & HNS.pptx
METASTATIC NECK DISEASE FOR ENT & HNS.pptx
 
Lip brachytherapy
Lip brachytherapyLip brachytherapy
Lip brachytherapy
 
Management of oral cavity cancer 23072018
Management of oral cavity cancer 23072018Management of oral cavity cancer 23072018
Management of oral cavity cancer 23072018
 
Carcinoma Buccal Mucosa- Anatomy to Management
Carcinoma Buccal Mucosa- Anatomy to ManagementCarcinoma Buccal Mucosa- Anatomy to Management
Carcinoma Buccal Mucosa- Anatomy to Management
 
Oral cancer
Oral cancerOral cancer
Oral cancer
 
Penile carcinoma
Penile carcinomaPenile carcinoma
Penile carcinoma
 
Anal canal
Anal canalAnal canal
Anal canal
 
Ca esophagus 12th
Ca esophagus 12thCa esophagus 12th
Ca esophagus 12th
 
Ca thyroid
Ca thyroidCa thyroid
Ca thyroid
 

Mehr von Kiran Ramakrishna (20)

Radiosensitivity and cell age in mitotic cycle .pptx
Radiosensitivity and cell age in mitotic cycle .pptxRadiosensitivity and cell age in mitotic cycle .pptx
Radiosensitivity and cell age in mitotic cycle .pptx
 
Cancer susceptibility syndromes.pptx
Cancer susceptibility syndromes.pptxCancer susceptibility syndromes.pptx
Cancer susceptibility syndromes.pptx
 
LEUKEMIA.pptx
LEUKEMIA.pptxLEUKEMIA.pptx
LEUKEMIA.pptx
 
CSI.pptx
CSI.pptxCSI.pptx
CSI.pptx
 
Cancer pain management.pptx
Cancer pain management.pptxCancer pain management.pptx
Cancer pain management.pptx
 
CA ENDOMETRIUM.pptx
CA ENDOMETRIUM.pptxCA ENDOMETRIUM.pptx
CA ENDOMETRIUM.pptx
 
penilecarcinoma-DR KIRAN.pptx
penilecarcinoma-DR KIRAN.pptxpenilecarcinoma-DR KIRAN.pptx
penilecarcinoma-DR KIRAN.pptx
 
Carcinoma Bladder.pptx
Carcinoma Bladder.pptxCarcinoma Bladder.pptx
Carcinoma Bladder.pptx
 
CA PROSTATE
CA PROSTATECA PROSTATE
CA PROSTATE
 
Carcinoma Prostate
Carcinoma Prostate Carcinoma Prostate
Carcinoma Prostate
 
APBI-Dr Kiran
APBI-Dr Kiran APBI-Dr Kiran
APBI-Dr Kiran
 
LAND MARK TRIALS - KIRAN.pptx
LAND MARK TRIALS - KIRAN.pptxLAND MARK TRIALS - KIRAN.pptx
LAND MARK TRIALS - KIRAN.pptx
 
ORAL CAVITY.pptx
ORAL CAVITY.pptxORAL CAVITY.pptx
ORAL CAVITY.pptx
 
ORO PHARYNX.pptx
ORO PHARYNX.pptxORO PHARYNX.pptx
ORO PHARYNX.pptx
 
CANCER SCREENING AND NCCP.pptx
CANCER SCREENING AND NCCP.pptxCANCER SCREENING AND NCCP.pptx
CANCER SCREENING AND NCCP.pptx
 
MANAGEMENT OF PITUITARY TUMORS.pptx
MANAGEMENT OF PITUITARY  TUMORS.pptxMANAGEMENT OF PITUITARY  TUMORS.pptx
MANAGEMENT OF PITUITARY TUMORS.pptx
 
CA ENDOMETRIUM-KIRAN.pptx
CA ENDOMETRIUM-KIRAN.pptxCA ENDOMETRIUM-KIRAN.pptx
CA ENDOMETRIUM-KIRAN.pptx
 
Pancreatic Cancer.pptx
Pancreatic Cancer.pptxPancreatic Cancer.pptx
Pancreatic Cancer.pptx
 
Soft tissue sarcoma
Soft tissue sarcomaSoft tissue sarcoma
Soft tissue sarcoma
 
Total body irradiation
Total body irradiationTotal body irradiation
Total body irradiation
 

Kürzlich hochgeladen

Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...bkling
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...Ganesan Yogananthem
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxsumanchaulagain3
 
concept of total quality management (TQM).
concept of total quality management (TQM).concept of total quality management (TQM).
concept of total quality management (TQM).kishan singh tomar
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?Ryan Addison
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 

Kürzlich hochgeladen (20)

Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
Moving Forward After Uterine Cancer Treatment: Surveillance Strategies, Testi...
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
QUESTIONS & ANSWERS FOR QUALITY ASSURANCE, RADIATIONBIOLOGY& RADIATION HAZARD...
 
World-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptxWorld-TB-Day-2023_Presentation_English.pptx
World-TB-Day-2023_Presentation_English.pptx
 
concept of total quality management (TQM).
concept of total quality management (TQM).concept of total quality management (TQM).
concept of total quality management (TQM).
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 

Penile carcinoma

  • 2. Benign Lesions Non cutaneous Cutaneous •Inclusion/Retention cysts •Syringoma •Neurilemmoma •Angioma, Fibroma, Neuroma, Lipoma, Myoma •Pseudotumors •Penile papules •Hirsute papillomas •Coronal papillae •Zoons erythroplasia •Rashes & ulcerations secondary to irritation, allergy and infections
  • 3. Premalignant lesions • 42% of pts with SCC had hx of pre existing penile lesions. (Bouchot etal 1989) •Cutaneous Horn •Pseudoepitheliomatous Micaceous & Keratotic Balanitis •Balanitis Xerotica Obliterans •Leukoplakia
  • 4. Viral related conditions • • Human Papilloma virus (HPV) Types 6,11,42,43 & 44 associated with low grade dysplasia. Types 16,18,31,33,35 & 39 have higher association with malignancy. Human Herpesvirus 8 (HHV 8) • Condylomata Acuminatum • Bowenoid Papulosis • Kaposi’s Sarcoma
  • 5. Viral related conditions • • Human Papilloma virus (HPV) Types 6,11,42,43 & 44 associated with low grade dysplasia. Types 16,18,31,33,35 & 39 have higher association with malignancy. Human Herpesvirus 8 (HHV 8) • Condylomata Acuminatum • Bowenoid Papulosis • Kaposi’s Sarcoma
  • 6. Buschke-Lowenstein Tumor • • • • • • (Verrucous Carcinoma, Giant Condyloma Acuminatum) initially described in 1925. true incidence is unknown. Does not metastasize rather invades locally. Treatment is excision. Recurrence is common. Topical therapy with Podophyllin, 5FU, radiation and chemotherapy have all been tried with no great success.
  • 7. Penile Cancer • • Squamous cell carcinoma. > 95% Mesenchymal tumors. < 3% • • • e.g Kaposi sarcoma, angiosarcoma etc Maligannt Melanoma. Basal cell carcinoma. Metastasis. Sufrin & Huben 1991
  • 8. Carcinoma in situ • • • Penile intraepithelial neoplasia, Erythroplasia of Queyrat, Bowen’s disease can progress to invasive carcinoma. Histological confirmation with proper determination of invasion. Treatment Circumcission------------Preputial lesions Local excision------------small & non invasive Radiotherapy Topical 5FU as 5% base Nd:YAG & CO2 laser, liquid nitrogen Kelley etal 1974, Graham & Helwig 1973, Mortimer etal 1983
  • 9. Invasive carcinoma • • • • • Uncommon. 0.1 – 0.9 per 100,000 in USA, Europe. Upto 10% in some asian, african and south american countries, (Vatamasapt etal 1995) Disease of older men, 6th decade, reported in younger men & children. (Narsimharao 1985) Primary tumor localized to glans (48%), prepuce (21%), both glans & prepuce (9%), coronal (6%), shaft (<2%). (Sufrin & Huben 1991)
  • 10. Etiology • • • • • • • Circumcission practice. Hygiene standards. Phimosis. No. of sexual partners. HPV(16,18) infection. Exposure to tobacco products. No convincing association with occupation, gonorrhea, syphillis & alcohol intake. Barrasso etal 1987, Maiche 1992, Maden etal 1993
  • 11. Prevention • Routine neonatal circumcission. AAP Paediatric guidelines 1999. • Good hygiene practice. • Avoid HPV infection and tobacco.
  • 12. 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.
  • 13. Presentation • Symptoms malaise, wt loss, fatigue, weakness, hemorrhage, pain. • Signs penile lesion. rarely nodal mass, ulceration, suppuration.
  • 14. Diagnosis • Primary lesion. • Regional lymph nodes. • Distant metastasis. • Physical examination. • Ultrasound. • MRI. • CT. • Cavernosography. • Lymphangiography.
  • 15. Diagnosis • Histological diagnosis is absolutely necessary prior to treatment decision. • Growth pattern of SCC superficial spreading. vertical growth. multicentric. verrucous. Cubilla etal 1993
  • 16. Grading systems • Broders grading system (Ann Surg 1921;73:141) divided into 4 grades depends on differentiation based on keratinization, nuclear pleomorphism, no. of mitosis • Maiche system score (Br J Urol 1991;67:522-526) modified into 3 grades 5 year survival Grade 1 Grade 2,3 Grade 4 80% 50% 30%
  • 19. • Management depends on: • Location • Size • T stage • N stage • Histopathological characteristics • Patient preference (Organ preservation?)
  • 20. Options • Surgery • Radiotherapy • EBRT • Brachytherapy • Chemotherapy • Local • Systemic
  • 22. Overview • Mainstay of treatment • May involve • Circumcision • Laser ablation • Mohs micrographic surgery • Penectomy • Partial or total • Radical Surgery • Emasculation/ Hemipelvectomy • Not performed in common practice
  • 23. Cirumcision • Indications/Reasons • Definitive treatment of carcinoma-in-situ (Tis) • If phimosis is present, allows better visualization of disease • If prepuce is involved, removes some of the tumor bulk → facilitates planning of treatment. • Allows the radiation oncologist to better deal with RT toxicities (edema/phimosis/painful ulceration)
  • 24. Laser ablation • CO2 or Nd:YAG lasers have been reported to provide good functional and cosmetic results.1 • Tis or T1; high recurrence rates are seen with > T2 lesions1. • Local recurrences of ~20% are reported; these can be salvaged by re-treatment, RT or surgery.2 • Extended, careful follow-up required; only 57% of local recurrences occur within the first 2 years, 30% between 6 and 10 years, and 15% after 10 years.2 1. Meijer et al, Urol 2007 2. Windahl et al, J Urol 2003
  • 25. • Excision of tissue in successive layers with microscopic scanning of each layer to identify any tumor outgrowths • Successive layers removed until margins are histologically clear. • Local recurrences in upto 1/3rd patients; usually salvageable by repeat procedures/surgery.1 • May be offered to selected patients (Tis, ? T1) who are reliable for follow up. 1. Shinde et al, J Urol 2007 Mohs Micrographic surgery
  • 26. Penectomy • Done for bulky lesions; usually T2 and beyond. • The goal is to leave adequate penile length for hygienic upright micturition and intercourse. • Margin needed: • 2cm has been tradiationally advocated. • Current data suggests 5-10mm margins are as safe as 2cm margins.1 • When a total penectomy has to be done, perineal urethrostomy is needed. Phalloplasty may be done at equipped centres. 1. Minhas et al. BJU Int 2005
  • 27. Results with Surgery • 5 year overall survivals: Early stage disease 55-80% • 87% DFS at 5 years in Node negative patients.1 1. Ornellas et al. J Urol 1994
  • 29. Clinical Node Negative (N0) • ~ 20% have occult metastases on prophylactic lymph node dissection. • Divided into low and high risk.1 • Low-Risk Group: • Patients with carcinoma in situ (Tis), verrucous carcinoma (Ta), and T1 tumors who have grade 1 or 2 tumor histology • <10% chance of developing lymph node metastases • Surveillance / DSNB • High-Risk Group • T2 and T3 with grade 3 tumors and vascular invasion. • >50% incidence of inguinal lymph node metastases. • ILND / DSNB 1. Slaton et al, J Urol 2001 DSNB: Dynamic Sentinel Node Biopsy
  • 30. SLN Biopsy • Sentinel lymph node biopsy as originally described by Cabanas is no longer recommended in view of the high false-negative rate.1 • Dynamic SLN biopsy can decreased the false-negatives and morbidity.2-4 • Difficult to adopt at smaller, low volume centres. • Other approaches involve evaluation of micrometastases and the size of the SLN to determine whether to perform lymphadenectomy.5 • Lymphotropic nanoparticle-enhanced MRI (LNMRI) has been investigated.6
  • 31. Dynamic SLN Biopsy • Advocated by modern high volume centres. • Suggested algorithm by the EAU.1 • Resource intensive. • Has a high sensitivity and specificity; false negatives <5%. • Prospective validation awaited. 1. Yeung LL, Brandes SB. Urol Oncol 2013
  • 32. Clinically Node Positive (N+) • ~ 50% present with palpable inguinal nodes. • Half of these have inflammatory adenopathy secondary to infection of the primary lesion. • Two possible approaches. Node +ve Treat the Primary Antibiotics for 4-6 weeks Tissue Diagnosis Treat if Positive Follow up Nodal disease Regression No Yes Adapted from DeVita’s Cancer, 10th edition.
  • 33. Inguinal Lymph Nodes NCCN, 2015 S U R V E I L L A C E
  • 36. Overview • Brachytherapy • Interstitital • Mould based • EBRT • Patient position • Fields (primary/nodal) • Dose (Primary/Nodal) • Indications? • Control rates • Complications
  • 37. Indications • Definitive brachytherapy (ABS consensus statement, 2013): Node negative disease, with: • T1b disease • T2 lesion < 4cm (ideally restricted to the glans) • T3 disease without disruption of urethral mucosa • Definitive EBRT as organ preserving treatment: • When brachytherapy is not available. • Patient not a surgical candidate • Neoadjuvant External beam chemoradiotherapy • Fixed inguinal nodes +ve for mets (ESMO; no role as per NCCN).
  • 38. • Adjuvant RT 1. After Circumcision for T1-T2, N0 a. Brachytherapy alone b. EBRT + Chemotherapy 2. After Pelvic LN dissection. • Multiple nodes +ve for mets • Nodal disease > 4cm • Extranodal extension • B/L Nodes +ve
  • 39. Brachytherapy • May be interstitial or mould based. • Mould based treatments are non-invasive and can be performed without anesthesia. • Not suitable for T2 or T3 disease. • Interstitial treatment may be performed under Local/regional anesthesia.
  • 40. • Ir-192 is the source employed (LDR, PDR and HDR). • Two to three planes of needles/catheters are usually sufficient for disease coverage. • These can be held in place by predrilled templates (needles) or fixing buttons. • A Foley’s catheter is placed during application to assist urethral localization.
  • 41. • For an exterior plane, tissue equivalent bolus is placed between the needle and surface. a. Active length b. Treated length d. Lateral margin c. Space between planes c. Instersource spacing Dose: • LDR: 60 Gy @ 0.5-0.6 Gy/hr, over 5 days (12 hrs/day) • PDR: 60 Gy, Pulses equal to the hourly dose rate, each hour • HDR: 38.4 Gy @ 3.2 Gy twice daily for 6 days
  • 42. Results with Brachytherapy • Long-term (5–10 years) local control rates vary between 60% and 90% and seem more related to tumour characteristics than treatment parameters. • Compare favourably with surgical series. 1. Sarin et al, IJROBP 1997
  • 43. • Factors determining prognosis after brachytherapy* • Tumor size (< 4cm)1 • Depth of invasion (< 1cm)2 • Tumor volume (< 8ml)3 • No. of brachytherapy needles (< 6)3 • Spacing between individual needles (wider spacing)4 Bracketed parameters suggest a good prognosis.
  • 45. EBRT • Patient Positioning • Supine or prone with hands above the head • The organ has to be kept in position by a wax/acrylic block to create a reproducible setup. • Figure shows a wax block with a central cylindrical chamber. • Tissue equivalent material should be placed in the chamber distally. • Catheterization may prevent slumping of the organ as disease regresses. Supine setup
  • 46. EBRT (contd) • Water bath technique: The patient lies prone on Styrofoam slabs such that the penis is suspended in a water bath. • Transparent sides on the water bath permit a visual check of penile position. A: View from above of plastic box with central cylinder. Patient is treated in the prone position. The penis is placed in the central cylinder, and water is used to fill the surrounding volume. B: Lateral view.
  • 47. EBRT: Planning and Doses • Patient should be circumcised. • B/L groins, external iliac and hypogastric nodes should be included. • Unless the patient has a high disease burden/positive posterior pelvic nodes, these may be excluded. • Bolus may be considered for tumor/nodal disease close to skin surface.
  • 48. EBRT: Planning and Doses • 4-6 MV Photons (Cobalt-60 or LINAC) • EBRT Dose (when surgery not done) • Node -ve: 60-65 Gy @ 2 Gy per fraction, 6-6.5 weeks with reduced fields (GTV boost with 2 cm margin) for the last 5-10 Gy. • Node +ve: 70-75 Gy @ 2 Gy per fraction, 7-7.5 weeks with reduced fields after 50 Gy. • Postoperative setting: • 45-50.4 Gy to Nodal basins if Node +ve • Boosted to 60-70 Gy for • R1 resection • Areas with gross nodal disease and with ECE • If Nodal dissection not done, Nodal fields as before.
  • 49. Results with EBRT • Most data is from series spanning several years over which staging changed and management evolved; however results have been concordant. • Sarin et al noted a higher incidence of local failure was observed with total dose <60 Gy, dose per fraction <2 Gy and treatment time exceeding 45 days.1 1. Sarin et al, IJROBP 1997
  • 50. Complications of Radiotherapy • Acute Reactions: • Erythema, dry or moist desquamation, swelling of the subcutaneous tissue of the shaft in virtually all patients. • Peak at around 3-4 weeks after brachytherapy and towards the end of EBRT; resolve by 1-2 months post RT. • Late sequelae: • Telangiectasia: usually asymptomatic. • Soft tissue necrosis: • Most common cause of amputation. • Peaks 7-18 months after RT • Associated with a higher dose of RT
  • 51. • (Late sequelae) • Urethral strictures • Mostly meatal; occur in upto 40%. • Usually before 3 years • Correlates with urethral dose • Adhesions in acute phase should be separated, and late phase stenoses should be managed by repeated dilatations. • Sexual function • Can resume as soon as patient is comfortable, but with lubricant • Appears to correlate with dose to testes; can be shielded by placing a lead plate/sheet into the Styrofoam collar around the base of penis.
  • 52. • Tis: Topical 5-FU cream and imiquimod for glandular and meatal lesions. • Cisplatin combination chemotherapy regimens are the most widely used and seem to be the most effective. • No randomized evidence. Of the various combinations tested, the following have shown promise:1-3 • Cisplatin / Methotrexate / Bleomycin (CMB) • Taxane / Cisplatin / 5 FU (TPF) 1. Haas et al, J Urol 1999 2. Bahl et al, JCO 2012 3. Pizzocaro et al, Eur Urol 2009 Chemotherapy
  • 53. • Indication • Mostly employed perioperatively for unresectable disease. • Very high toxicity coupled with dismal disease control rates
  • 54. (brachytx notavailable) Penile Conservation Non penile conserving t/t Management of CA Penis: Summary Outline Laser Circumcision T1a T1b
  • 55. Psychosocial issues • Primary surgical management permits durable response but causes considerable psychosexual morbidity. • Treatment expectations, outcomes and post treatment rehabilitation must be discussed with both patient and his partner. • Referral to a trained therapist may be warranted.
  • 56. Summary • A curable tumor but significant treatment associated morbidity. • Treatment is mainly surgical. Radiotherapy may be Brachytherapy (early disease) or EBRT (unresectable ds/adjuvant). Role of chemotherapy still evolving. • Education and awareness needed for early diagnosis and during management.