Penile%20cancer Treatment

Treatment

Surgical Intervention

Goal is to remove penile cancer completely with negative surgical margins preserving as much of the penis as possible
- Intra-operative frozen sections may confirm negativity of surgical margins

Penile-preserving Techniques

For tumors which are superficial or confined to the glans, a penile-preserving procedure is recommended, though recurrence rates are higher than radical surgical procedures
- Local recurrence depends on tumor grade & presence of lymphovascular invasion
As primary treatment approach for localized lesions, penile-preserving techniques appear to have superior cosmetic & functional results
- Whenever possible, treatment for organ preservation should be offered for better quality of life & sexual function
Surgical excision can lead to scarring, deformity & function impairment

Circumcision

Performed prior to considering conservative non-surgical treatments
Radical circumcision alone may be curative for lesions limited to the prepuce provided that negative surgical margins are confirmed histologically

Wide Local Excision

Wide local excision with circumcision may be done in patients with Tis, Ta, T1 grade 1-4, or stage I penile cancer limited to the foreskin
- For stage I infiltrating tumors of the glans with or without adjacent skin involvement, treatment depends on size of tumor, extent of infiltration, & degree of tumor destruction of normal tissue & options may include penectomy or microscopically controlled surgery
A limited excision can be performed on distal, smaller T2 to T3 tumors as long as a tumor-free margin can be obtained

Laser Therapy

A penile-preserving technique, laser ablation is correlated with a high continuity rate of sexual activity & sexual satisfaction
May be considered in patients with Tis, Ta, & T1 grade 1-2 penile cancer
Nd:YAG or CO₂ laser results in excellent cosmetic & functional results in patients with stage 0 penile cancer
Nd:YAG laser therapy may be done in patients with stage I penile cancer resulting in excellent control with cosmetic appearance & sexual function preservation
Stage II patients with small lesions may be treated with Nd:YAG laser therapy for penis preservation

Glansectomy

Complete removal of the glans & prepuce results in the lowest recurrence rate of the treatments for small penile lesions
Total glansectomy with or without corporeal head resurfacing may be recommended for T2 lesions
Total glansectomy may be considered for patients with Tis or Ta penile cancer

Partial/Total Glans Resurfacing

A surgical procedure primarily used for Tis lesions that removes the epithelial & subepithelial layers of the glans to the corpus spongiosum which is followed by skin graft placement
Offered as a primary treatment for carcinoma in situ or as a secondary treatment when treatment with topical chemotherapy or laser therapy fails
Determination of long-term disease control requires further follow-up

Mohs Micrographic Surgery

Successive horizontal layers of tissue are excised followed by microscopic examination of each layer in frozen section
Used in patients with in situ, T1 grade 1-2, & invasive penile cancer

Cryosurgery

Used in patients with erythroplasia of Queyrat & verrucous penile carcinoma with good cosmetic results

Penectomy

Penectomy is disfiguring & may have an impact on the patient’s quality of life, self-esteem, sexual function, & overall mental health
- Must consider the patient’s preference in the choice of treatment with the risks & benefits carefully weighed
- Counsel patients on the option of penile reconstruction
Depending on extent & location of the neoplasm, penile amputation can be partial or total
- Partial penectomy for glanular & distal penile tumors preserves more length with superior cosmetic & functional results; considered the standard approach for high-grade primary tumors of the penis provided a functional penile stump can be preserved & negative margins are achieved
- Total penectomy is performed on very large tumors that extend down the penile shaft or tumors that cannot be controlled without leaving an adequate penile length for voiding
- Considered in patients with T1 grade 3-4 & T2 or greater penile cancer
Most frequent management for stage II penile cancer

Dynamic Sentinel Node Biopsy (DSNB)

Has a high sentinel node detection rate & sensitivity for lymph node metastases diagnosis in nonpalpable nodes
- The entire lymph node basin should be tumor free if the sentinel nodes are uninvolved
Indicated treatment in intermediate- or high-risk disease & an alternative to surveillance in low-risk disease when inguinal lymph nodes are nonpalpable at physical examination
DSNB reduces morbidity associated with prophylactic lymph node dissection in patients with stage T2 & T3 clinically node-negative penile cancer
Due to the technical challenges related to DSNB, it is recommended that it should be performed in experienced centers
If DSNB is unavailable, visualized nodes may be diagnosed with ultrasound-guided fine-needle aspiration cytology (FNAC) biopsy or an inguinal lymph node dissection

Lymph Node Dissection

Inguinal Lymph Node Dissection (ILND)

Detects microscopic metastases without a pelvic dissection in patients with nonpalpable inguinal nodes
- Provides more information than a biopsy; however, the procedure has a higher complication rate than DSNB
Indicated in high-risk disease & is an alternative procedure to DSNB in intermediate-risk patients for treatment & staging of the inguinal region
- ILND is also done if positive nodes are found on DSNB
ILND is the standard treatment of metastases to inguinal lymph nodes & like DSNB is warranted in patients with nonpalpable inguinal lymph nodes if the following high-risk features for nodal metastasis are noted in the primary penile tumor: >50% poorly differentiated, ≥T1G3 or ≥T2 any grade, or presence of lymphovascular invasion
Bilateral lymph node dissection is performed in patients with high-risk features but with nonpalpable lymph nodes as laterality of inguinal nodal metastasis cannot be predicted based on the location of the tumor on the penis
- It is also performed in immediate ILND for high-risk primary tumors or because of palpable nodes as 30% of patients with unilateral palpable node will have contralateral positive nodes that are unpalpable
A percutaneous biopsy is currently favored over the traditional 6-weeks antibiotic course in differentiating reactive lymph nodes from metastatic disease in patients with palpable nodes; however, a bilateral ILND should be done if ≥3 weeks after completing antibiotic therapy & removing infected primary lesion, enlarged lymph nodes are palpated as it is likely to be a metastatic lymph node disease
Modified inguinal lymph node dissection involves removal of the nodes within the fossa ovalis by skeletonizing the femoral vessels
- Has demonstrated a reduction in complications & is performed in patients with nonpalpable inguinal nodes on PE but with a primary tumor that increases their risk for inguinal metastasis

Pelvic Lymph Node Dissection (PLND)

Approximately 20-30% of positive inguinal lymph nodes will also have cancer in the pelvic lymph nodes & its presence is associated with <10% 5-year survival rate
Recommended in patients with ≥2 positive inguinal nodes & in the clinical context of high-grade cancer in the inguinal lymph node pathologic specimen

Nonpalpable Inguinal Lymph Nodes

Low-risk Disease (Tis, TaG1-2 or T1G1)

Patients may undergo surveillance if they are compliant with follow-up recommendations as occult micrometastases in inguinal lymph node is <17%
Inguinal node staging by DSNB should be offered to patients unable to continue with surveillance

Intermediate- (T1G2) or High-risk Disease (≥T2 or any G3 or G4)

Patients in this group should undergo DSNB or a superficial or modified ILND for treatment
After DSNB or ILND, further therapy may include the following:
- Posttreatment surveillance for patients with negative inguinal nodes
- Complete inguinal dissection for patients with 1 involved inguinal node
- Inguinal & pelvic node dissection for patients with >2 involved inguinal nodes

Palpable Inguinal Lymph Nodes

A percutaneous fine-needle aspiration (FNA) biopsy can diagnose lymph node metastases in palpable nodes
- Procedure is omitted for high-risk tumors to prevent delay of initiating inguinal lymph node dissection (ILND)
A repeat biopsy or node excision may be done if FNA is negative but nodes are clinically suspicious
- If results are negative on excisional biopsy, offer surveillance
- If positive, patient should undergo ILND
Positive FNA findings in unilateral, mobile inguinal node indicate immediate ILND
- Patients should also undergo a staging ILND on the opposite side as it is common to have bilateral inguinal drainage from the primary tumor
- A 0-1 positive node finding without extranodal cancer extension on ILND warrants surveillance
- ≥2 positive nodes or presence of extranodal extension requires pelvic lymph node dissection
Positive FNA findings in multiple or bilateral inguinal lymph nodes (mobile or fixed) require neoadjuvant chemotherapy followed by ILND & pelvic lymph node dissection (PLND) as patient possibly has stage N2 metastatic disease & is at risk of failing treatment with surgery alone

Enlarged Pelvic Lymph Nodes

A computed tomography (CT), computed tomography/positron emission tomography (CT/PET), or magnetic resonance imaging (MRI) may be done if with positive FNA to detect adverse nodal features, eg ≥3 positive nodes, extranodal extension or pelvic metastases
- A bulky (≥4 cm nodal size) but resectable pelvic lymphadenopathy should be given neoadjuvant chemotherapy followed by consolidation surgery if disease responds or is stable; chemotherapy with radiation therapy for local control or participation in a clinical trial if disease progresses or is unresectable
- If patient is not a candidate for surgery, radiation therapy with concurrent chemotherapy followed by surveillance can be given for enlarged pelvic lymphadenopathy

Optimizing metastatic hormone-sensitive prostate cancer treatment in advanced prostate cancer

Assoc Prof. Darren Poon, Assoc Prof. Edmund Chiong, 14 Jan 2021

Metastatic hormone-sensitive prostate cancer (mHSPC) refers to the condition whereby patients have metastatic prostate cancer and no prior hormonal therapy or androgen deprivation therapy (ADT). Typically, patients with mHSPC have been treated with ADT alone, following which, the overwhelming majority develop castration resistance over time and head towards eventual mortality. In recent years, the publication of various landmark trials has prompted dramatic changes in the mHSPC treatment landscape, and had favourably impacted overall survival (OS) in these patients. At a recent webinar, A/Prof Darren Poon, Honorary Consultant in Clinical Oncology, Hong Kong Sanatorium & Hospital, and Honorary Clinical Associate Professor, Department of Clinical Oncology, The Chinese University of Hong Kong, reviewed treatment options in mHSPC, while A/Prof Edmund Chiong, Head and Senior Consultant, Department of Urology, National University Hospital, Singapore, presented a case which was discussed by an esteemed panel of experts. This webinar was jointly organized by the Singapore Society of Oncology and the Singapore Urological Association, and supported by Astellas.