CA penis: The basic understanding. useful for Undergraduates and general surgery residents. ref: Campbell 10th volume. Dr SN medical College

1. Ca Penis
Dr. Dharma Ram Poonia
MS,DNB Surgical Oncology
Consultant Surgical oncologist & lecturer
Dr. SN Medical college, Jodhpur
06.12.2017

2. • Epidemiology & Risk factors

3. Epidemiology
– <1 case per 100 000 globally &
– accounts for ~ 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)
• Annual age-adjusted incidence is
– 0.7-3.0/100,000 men in India,
– 8.3/100,000 men in Brazil & even higher in Uganda,
– linked with HPV prevalence
• Overall incidence is decreasing

4. Risk factors
• Phimosis: Muslim/jews (neonatal)
• Circumcision practice
• Smoking & other tobacco products
• UV radiation: PUVA
• Poor personal hygiene.
• HPV infection  16/18 & multiple sexual partners
• Penile trauma
• Lichen planus
So Preventable cancer: hygiene/ HPV vaccination/
circumcision, condom, avoid PUVA, No smoking etc.

5. Pathological types
• SCC 95%  Usual/ papillary/ condylomatous/
verrucous/ Basaloid/ Sarcomatoid variants
– Grading:
• Broders 4 tier
• Maiche 3 tier
– Growth pattern
• Superficial spreading  LNs mets less common (42%)
• Vertical pattern  More likely LNs mets (>80%)
• Melanoma
• BCC
• Paget dsease
• Sarcoma

6. Natural History
• Growth (Ulcer, Proliferative, UPG).
• Buck’s fascia is temporary natural barrier & protect corporal bodies.
• Once corporal bodies  access to lymphatic's  SILNs  DILNs  Pelvic
LNs. Orderly pattern, no skip mets.
• Distant mets is rare without Pelvic LNs involvement,
• Multiple cross connection, so Bilaterally is > 50%.
• Die within 2 year of diagnosis
– Metastatic enlargement of the regional nodes eventually leads to skin necrosis,
chronic infection, and death from inanition, sepsis, or hemorrhage secondary to
erosion into the femoral vessels.
– Cancer cachexia
– Secondary infections
– MODS

7. Distribution
• Glans: 50%
• Prepuce: 21%
• Corona:6%
• Shaft: 2%

8. Clinical presentation
1. Non healing Ulcer/Growth/UPG
– A subtle induration in the skin, to a large exophytic growth.
2. A mass, ulceration, suppuration, or hemorrhage  in the inguinal
area because of nodal metastases.
1. Weakness, weight loss, fatigue, and systemic malaise occur
secondary to chronic suppuration.
3. Urinary retention or urethral fistula rare.
4. Pain is infrequent.
Delay presentation (50%)
– Embarrassment, guilt, fear, ignorance, and neglect
– Self treatment with various skin creams and lotions.
– Doctor: confuse with other benign penile lesions
– A phimosis may obscures the tumor and allows it to grow
undetected.

9. Premalignant lesions
• Lesions sporadically associated with Ca
– Cutaneous horn
– BXO
– Leukoplakia
– Bowenoid papulosis
– Gaint condyloma acuminata: blt
• Lesions truly premalignant
– EoQ: Glans, Red velvety lesion, 10-30% progr
– BD: Shaft, same, 5% progression
When in doubt, biopsy of penile lesions should be considered.

10. BL tumor/ Verrucous Ca/ GCA
• Initially described in 1925.
• Buschke-Löwenstein tumor invades locally, compressing
and destroying adjacent tissues to produce urethral
erosion and fistulization.
• The Buschke-Löwenstein tumor differs from condyloma
acuminatum in that condylomata, regardless of size,
always remain superficial and never invade adjacent
tissue.
• Does not metastasize rather invades locally.
• Treatment is excision. Never give RT.
• Recurrence is common, and close follow-up is essential.
• Topical therapy with Podophyllin, 5FU, radiation and
chemotherapy have all been tried with no great success.

11. • Staging and work up

12. Staging 7th edition 2010

13. Nevine/Robson/Astler/Manchester/
Columbia…....

14. Work up
Pathology
Imaging

15. Staging workup summary
• T stage 
– clinical examination
– Large tumor T4  Imaging
• N stage
– Clinical examination
– MRI/CT if fatty patients/ equivocal local findings
– Some advise USG too.
– If palpable nodes in groin  assess Pelvis  CT/MRI
pelvis, upper abdomen and chest.
– In all T1b or T2  image groin (occult +ve >20%)
• Physical examination incorrectly established actual pathologic stage in 26% of
cases,
– understating in 10% and
– overstating in 16%.

16. • Treatment guidelines

20. Summary

21. • Standard or modified ILND or DSNB is indicated in
N0 groin if
– Lymphovascular invasion
– ≥pT1G3 or ≥T2, any grade
– >50% poorly differentiated
• If DSNBx done  if +ve  IILND is indicated.
• ≥2 positive inguinal nodes on the ipsilateral ILND
site I/L PLND
• If ≥4 positive inguinal nodes or ECE or Bilateral
≥2 positive  B/L PLND
SLNBx : established in which cancers

22. • Treatment options:
– primary and groin

23. N0 groin
• Ta/Tis
– Imiquimod 5%, apply at night three times per week
for 4–16 weeks.
– 5-FU cream 5%, apply twice daily for 2–6 weeks.
• cT1a 
– Mx (WLE/Glansectomy/PP/Mohs/Laser/ RT)
– with observation/ DSLNBx
• If cT1b on wards 
– WLE/PP/TP/RT/CTRT
– with bil Groin dissection/ DSLNBx

24. Penile preservation appraoches
• Laser therapy.
• Local excision including Partial penectomy &
Glansectomy
• 5 FU cream.
• Cryotherapy.
• Photodynamic therapy.
• 5% topical imiquimod.
Available for Tis/Ta/T1a

25. Approaches
• Radical ILNDs
• Modified IILNDs to reduce morbidity
• Sentinel & DSLNBx to reduce morbidity
• VEIL (video endoscopic I ND)  lap & Robotic
• Superficial ILND  Frozen  Deep  FS 
Pelvic

26. Adjuvant Rx

27. • Surgical principles
– Penis:
• PP
• TP
• RP
– Groin
• RILND
• Modified RILND
• DSLNBx

30. Daseler’s Regions/Zones

32. • Shorter skin incision
• Small template of dissection
• Femoral vessels not skeletonized.
• GSV preservation
• No need of transposition of Sartorius.
• Seroma or lymphocele (0% to 26%)
• lymphorrhea (9% to 10%)
• wound infection or skin necrosis (0% to 15%)
• Drain out when output <20ml/day

34. • Superficial group that lie deep to the Scarpa’s 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
craniomedial to the junction between the long saphenous and femoral
veins
• 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
• CT / MRI
o Predict LN involvement by size only
o Sensitivity:35%,specificity:100%
o Strongest predictor for survival is the presence or absence of nodal
metastases

35. • Thank you