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ca_penis (1).ppt
- 1. Phimosis,Paraphimosis, Peyronie’s disease, Carcinoma Penis Dr.AmitGupta Associate Professor Dept. of Surgery
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- 3. • Phimosis • Prepucecannot be retracted over the glans penis • Physiologic Phimosis • Pliant, unscarred preputial orifice • Pathologic Phimosis • Failure to retract secondary to distal scarring of the prepuce
- 4. Pathologic Phimosis • Occursmostly by forcefully pulling back the prepuce in infancy • Scarring after Infection • Failure of the phimotic preputial ring to retract after childhood Osburn et al, Pediatrics 1981
- 5. Treatment • No forcefulretraction of the prepuce • If no retraction at all after 5 years or scarring is present from previous attempts • Betamethasone dipropionate 0.05% cream (Diprolene) – no FDA approval under 16 years of age • Most important: Parent education about the natural process • Handouts • Perform circumcision on parents request
- 6. Paraphimosis • Tight preputialring is trapped behind the glans after retraction • Very painful • Edematous preputial skin and glans • Urinary retention • Requires immediate attention • Pain • Possible necrosis • Management • Compression • Dorsal slit
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- 8. Definition • Described byFrancois Gigot de la Peyronie in 1743 • Also known as induratio penis plastica • Fibrotic induration of the penis with concurrent curvature
- 9. Clinical presentation • Peakincidence • 4th to 6th decades • Pain and penile curvature during erection • Difficult intercourse • Impotence in some cases • A hard fibrotic mass is felt on palpation
- 10. Etiology • Fibrosing conditionof the tunica albuginea • Repeatitive microtrauma is most probably the inciting event • Dupuytran’s contracture has been associated with PD • Always examine the hands • Possible genetic aetiology
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- 12. Clinical course • Mostcases are self limiting • Divided into acute and chronic phase • In the acute phase • Pain • Worsening of the deformity • Enlargement of the plaque • 12 to 18 months duration • Chronic phase • No pain • Stable deformity
- 13. Treatment • Medical • Usuallyduring the acute phase • Oral therapy • Vitamin E • Potassium para-amino benzoate • Colchicine • Tamoxifen • Pentoxifylline
- 14. Treatment • Transdermal therapies •Verapamil • Intralesional • Verapamil • INF alpha 2 beta • Saline • Intralesional therapies not for cure, but more for prevention of progression • Other therapies • ESWL
- 15. Surgical treatment • Reservedfor patients with PD for at least 12 months (chronic phase) and a stable deformity for at least 3 months • 3 groups of surgery • Penile shortening • Penile lengthening • Penile prosthesis
- 16. Surgical Treatment ED + - PenileProsthesis Normal length < 30 degrees Short penis > 45 degrees Penile shortening procedure Penile lengthening procedure Nesbit Graft
- 17. Surgical treatment Penile Shortening(Nesbit Plication)
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- 20. Introduction Uncommon malignancy indeveloped countries Higher incidence rates are seen in Africa and Asia (10% to 20%) Commonly affects those between 50 and 70 years of age 22% of patients are less than 40 years of age
- 21. Epidemiology • Intact foreskin •Phimosis (25%) • Precancerous lesions are found in 15%-20% of patients • Human papilloma virus(HPV 16,18) • Chronic inflammatory conditions (eg, balanoposthitis and lichen sclerosus et atrophicus)
- 22.
- 23. Pathology • Primary malignancies(those that originate from either the soft tissues, urethral mucosa, or covering epithelium) • Secondary malignancies (ie, those that represent metastatic disease and often affect the corpus cavernosum
- 24. • MC: squamouscell carcinoma is found on glans: 48%,prepuce: 21%,glans & prepuce:9%,coronal sulcus: 6%, and shaft: <2% • Primary, non squamous malignancies comprise <5% of penile cancers. • Sarcomas are the most frequent non squamous penile cancers, followed by melanomas, basal cell carcinomas, and lymphomas
- 25. Clinical Presentation • Areaof induration or erythema to a non healing ulcer or a warty exophytic growth • Palpable inguinal lymphadenopathy is present at diagnosis in 58% of patients ( 20%-96%) • In non palpable inguinal lymph nodes at the time of resection of the primary tumor, 20% will found to have metastatic disease
- 27. Staging: Two stagingsystems Jackson
- 28. AJCC Cancer StagingManual, 5th ed
- 29.
- 30. Prognostic Factors • Grade •Depth of invasion • Number of positive lymph nodes • Unilateral or bilateral inguinal extension • Pelvic nodes involvement • Presence of lymph node extracapsular extension
- 31. Diagnosis • Physical examination •Cytological and/or histological diagnosis • Chest x-ray • CT scan/PET-CT scan • Bone scan
- 32.
- 33. Treatment of thePrimary Lesion • Small tumors limited to foreskin: • circumcision+2-cm margin Circumcision alone, especially with tumors in the proximal foreskin, may be associated with recurrence rates of 32% • Small superficial penile cancers: • Moh’s micrographic surgery • Radiation therapy (EBRT/brachytherapy) • RT has yielded local control rates similar to surgical resection:
- 34. • Carcinomas involvingthe glans & distal shaft: • partial penectomy excising 1.5 to 2 cm of normal tissue proximal to the margin of the tumor. This should leave a 2.5- to 3-cm stump of penis
- 35. • Bulky T3or T4 proximal tumors involving the base of the penis: total penectomy with perineal urethrostomy
- 36. • Lymphadenectomy isindicated in patients with palpable inguinal lymphadenopathy that persists after treatment of the primary penile lesion following a course of antibiotic therapy Srinivas 1987, Ornellas 1994 Lymphadenectomy in Penile Cancer
- 37. N0 Groin: TreatmentOptions • Fine needle aspiration cytology • Isolated node biopsy • Sentinel node biopsy • Extended sentinel LN dissection • Intraoperative lymphatic mapping • Superficial dissection • Modified complete dissection
- 38. Fine needle aspirationcytology • Requires pedal / penile lymphangiograhy for node localization & aspiration under fluoroscopy guidance • Multiple nodes to be sampled • Sensitivity 71% (Scappini 1986, Horenblas 1993) • Can provide useful information to plan therapy when +ve
- 39. Sentinel Node Biopsy •Based on penile lymphangiographic studies of Cabanas (1977) • Accuracy questioned: False –ve 10=50% (Cabanas 1977, McDougal 1986, Fossa 1987) • Extended sentinel node biopsy: 25% false –ve • False –ve due to anatomic variation in position of sentinel node Unreliable method: Not recommended
- 40. Intraoperative Lymphatic Mapping •Potential for precise localization of sentinel node • Intradermal inj of vital blue dye or Tc- labeled colloid adjacent to the lesion • Horenblas 11/55: All +ve False –ve in 3 • Pettaway 3/20: All +ve No false –ve • Tanis (2002): 18/23 +ve detected (Sensitivity 78%) Promising technique for early localization of nodal metastases Long-term data needed
- 41. Superficial Inguinal LND •Removal of nodes superficial to fascia lata • If nodes +ve on FS: Complete inguino-pelvic LND • Rationale: No spread to deep inguinal nodes when superficial nodes –ve (Pompeo 1995, Parra 1996) • No clinical evidence of direct deep node mets when corporal invasion present
- 42. Complete Modified LND (Catalona1988) • Smaller incision • Limited inguinal dissection (superficial + fossa ovalis) • Preservation of saphenous vein • Thicker skin flaps • No sartorius transposition Identifies microscopic mets without morbidity (Colberg 1997, Parra 1996)
- 43. Cancer Penis: Managementof N+ groin • Surgical treatment recommended for operable inguinal metastatic disease • Most patients with inguinal LN mets will die if untreated. • 20-67% patients with metastatic inguinal LN disease free 5 years after LND. • Better survival 82-88% with single / limited mets
- 44. Pelvic Lymphadenectomy • Stagingtool • Identifies patients likely to benefit from adjuvant chemo • Adds to locoregional control • No additional morbidity • If pre-op pelvic node identified : NACT followed by surgery in responders Value of pelvic LND unproven Patients with minimal inguinal disease & limited pelvic LN mets may benefit
- 45. Inguinopelvic Lymphadenectomy: Indications foradjuvant therapy • >2 metastatic inguinal nodes • Extranodal extension of disease • Pelvic lymph node metastases
- 46. Penile Cancer Management offixed nodes • Neoadjuvant chemo + surgery in responders • Palliative chemotherapy • Chemotherapy + radiation therapy
- 47. Complications of lymphadenectomy •Persistent lymphorrhoea • Wound breakdown, necrosis, infection • Lymphocyst • Femoral blowout • Lymphangitis • Lymphoedema of lower extremity
- 48. Conclusion • Uncommon disease •No systematic study & complete absence of RCTs • Small no of patients over a long time • RCTs to develop guidelines essential