Penile Carcinoma:
Management
Dr. Animesh Agrawal
Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow

• 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
Nodal disease Regression
Tissue Diagnosis
Treat if Positive
Follow up
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 not available)
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