Penile

Question 1

PeCa

Localized Workup

4

Answer 1

• History including assessment of risk factors (balanitis, chronic inflammation, trauma, lack of neonatal circumcision, lichen sclerosus, poor hygiene, STIs)
• PE including documentation of diameter, location, number, morphology (papillary, ulcerous, flat or nodular), distance from other structures and lymph node exam
• Biopsy (punch, excisional or incisional)
• Test for HPV status

Question 2

PeCa

Tis or Ta Treatment

5

Answer 2

• Topical therapy (p)
• Wide local excision (p)
• Laser therapy
• Complete glansectomy
• Mohs surgery (select pts)

Question 3

PeCa

Low grade T1 treatment

6

Answer 3

• Wide local excision (p)
• Partial penectomy (p)
• Glansectomy (select pts)
• Mohs surgery (select pts)
• Laser therapy (select pts)
• RT (select pts)

Question 4

PeCa

High grade T1 treatment

5

Answer 4

• Wide local excision (p)
• Partial penectomy (p)
• Total penectomy (p)
• RT (select pts)
• Chemo/ RT (select pts)

Question 5

PeCa

T2-T4 treatment

4

Answer 5

• Parital penectomy (p)
• Total penectomy (p)
• RT (select pts)
• Chemo/RT (select pts)

Question 6

PeCa

Non-palpable Inguinal LN treatment

2

Answer 6

• Low risk pt (Tis, Ta, T1a): surveillance
• Int/ High risk pt (T1b or higher): CT C/A/P and bilateral inguinal LND or bilateral dynamic sentinel node biopsy

Question 7

PeCa

Palpable small (<4cm) unilateral Inguinal LN treatment

3

Answer 7

• CT C/A/P
• Low risk pt (T1a, Ta, T1a): fine needle aspiration/percutaneous biopsy; if negative, excisional biopsy. If positive NAC w/TIP and bilateral ILND
• Int/ High risk pt (T1b or higher): NAC w/TIP and bilateral ILND

Question 8

PeCa

Enlarged pelvic LN treamtent

4

Answer 8

• Percutaneous biopsy
• If negative, observe
• If positive and surgical candidate, NAC w/TIP following by rpt img. if response, consolidation surgery. if progression, systemic therapy.
• If positive and non-surgical candidate, chemo/RT.

Question 9

PeCa

Palpable large or fixed Inguinal LN treatment

2

Answer 9

• Unilateral large LN: Percutaneous biopsy: if negative excisional biopsy. If positive NAC w/TIP and bilateral ILND +/- PLND or bilateral ILND or RT or Chemo/RT
• Unilateral fixed LN or bilateral LNs: Percutaneous biopsy: if negative excisional biopsy. If positive NAC w/TIP (and if responsive) bilateral ILND and PLND (p) or RT or Chemo/RT

Question 10

PeCa

post-op pN2 or pN3 Treatment

4

Answer 10

• Consider PLND
• Adjuvant chemotherapy (if no NAC)
• If pelvic node, + adjuvant RT
• Chemo/RT

Question 11

PeCa

Local Inguinal recurrence

2

Answer 11

• No prior ILND or RT: Percutaneous biopsy, then treat according to stage
• Prior ILND or RT: Chemotherapy followed by ILND or ILND or Chemo/RT (if no RT)

Question 12

PeCa

Metastatic PeCa treatment

3

Answer 12

• Systemic therapy
• Response or stable: consolidation surgery
• No response or progression: second-line systemic therapy or RT for local control

Question 13

PeCa

Topical Therapy

2

Answer 13

• Imiquimod 5%: 3/week at night for 4-16 weeks
• 5-FU cream 5%: BID for 2-6 weeks

Question 14

PeCa

Laser therapy

3

Answer 14

• CO2: 10,600nm, 5-10W, continuous or superpulse 100-200Hz, 0.1mm penetration, 1-5mm spot size
• KTP: 532nm, 5-10W, pulse 10-20ms/ 2Hz, 1-2mm penetration, 400-600um fiber size
• Nd:YAG: 1,064nm, 40W, pulse 1ms/ 10-40 Hz, 3-4mm penetration, 1-5mm spot size

Question 15

PeCa

Wide Local Excision

3

Answer 15

• cTis, cTa, cT1
• May require split- or full-thickness skin graft
• May re-resect for positive margins

Question 16

PeCa

Glansectomy

2

Answer 16

• Negative margins should be confirmed with frozen sections of cavernosal bed and urethral stump
• May create neoglans with split- or full-thickness skin graft

Question 17

PeCa

Mohs Microsurgery

3

Answer 17

• Thin layers of cancerous skin are resected and veiwed microscopically until tissue layer is negative for tumor
• Preferred for superficial lesions on proximal shaft to avoid penectomy in low-risk lesions
• Success rate declines with higher stage disease

Question 18

PeCa

Partial Penectomy

2

Answer 18

• Must provide functional penile stump and negative margins
• Functional stump is 3-4cm

Question 19

PeCa

Tis, Ta and T1 staging

4

Answer 19

• Tis -> Carcinoma in situ
• Ta -> Non-invasive SCC
• T1a -> Invades LP without LVI, PNI or HG
• T1b -> Invades LP with LVI, PNI or HG

Question 20

PeCa

T2 Staging

1

Answer 20

T2 -> Invades Corpora Spongiosum +/- urethral invasion

Question 21

PeCa

T3 Staging

1

Answer 21

T3 -> Invades Corpora Cavernosum +/- urethral invasion

Question 22

PeCa

T4 Staging

1

Answer 22

T4 -> Invades adjacent structures

Question 23

PeCa

cN Staging

3

Answer 23

• cN1 -> Single palpable mobile unilateral inguinal LN
• cN2 -> Multiple palpable moble inguinal LNs (unilateral or bilateral)
• cN3 -> Palpable fixed inguinal LN mass or pelvic LAD

Question 24

PeCa

pN Staging

3

Answer 24

• pN1 -> 2 or less unilateral inguinal LNs without ENE
• pN2 -> 3 or more unilateral inguinal LNs or bilateral LNs
• pN3 -> ENE or pelvic LN

Question 25

# PeCa M Staging | 1

Answer 25

M1 -> Distant metastasis

Question 26

# PeCa Primary Radiation Treatment (penile preserving) | 3

Answer 26

* <4cm: circumcison then brachytherapy or EBRT +/- chemotherapy * consider ppx radiation to inguinal LNs * >4cm circumcision then Chemo/RT (select cases) covering inguinal and pelvic LNs with penile boost or brachytherapy (select cases)

Question 27

# PeCa Primary Radiation Treatment (unresectable) | 1

Answer 27

* circumcision then Chemo/RT covering inguinal and pelvic LNs with penile boost

Question 28

# PeCa Radiation s/p positive surgical margin | 4

Answer 28

* Microscopic disease: EBRT to primary site and scar * Gross disease: Chemo/RT covering inguinal and pelvic LNs with penile boost * Consider LN treatment if no LND or inadequate LND * Brachytherapy (select cases)

Question 29

# PeCa Adjuvant Chemo/RT | 4

Answer 29

* Positive inguinal or pelvic LNs * Consider for pN2-3 or local recurrence * COnsider boost for gross noes or areas of ENE * Consider for positive margin

Question 30

# PeCa Karposi Sarcoma | 4

Answer 30

* HIV: Treat with HAART therapy * Immunosuppressed (transplant): Reduce immunosuppresive medications * Unresponsive: Local therapy (laser, wide excision, topical, cryotherapy) * Metastatic: comination chemotherapy

Question 31

# PeCa Lymph Node Involvement | 2

Answer 31

* Most predictive is LVI * Other factors include superficially growth pattern, grade, tumor thickness, involvement of corporal tissue and urethra

Question 32

# PeCa Stage 0-I | 3

Answer 32

* Stage 0is- Tis N0 M0 * Stage 0a- Ta N0 M0 * Stage I- T1a N0 M0

Question 33

# PeCa Stage II | 2

Answer 33

* Stage IIa - T1b-T2 N0 M0 * Stage IIb - T3 N0 M0

Question 34

# PeCa Stage III | 2

Answer 34

* Stage IIIa - T1-3 N0-1 M0 * Stage IIIb - T1-3 N2 M0

Question 35

# PeCa Stage IV | 1

Answer 35

* Stage IV - T1-4 N 0-3 M0-1