Benign lesions

• Papilloma (on corona, usually not HPV)
• Condyloma acuminatum (HPV 6/11)
• Zoon's (plasma cell) balanitis - Uncircumcised men; flat red lesion may look like carcinoma in situ; diagnose with biopsy

Pre-malignant lesions

• Long-term yearly follow up if a/w risk for progression

Squamous cell carcinoma

• ≥ 95% of penile cancers
• Risk factors: uncircumcised, premalignant lesions, chronic inflammation (e.g. phimosis), UV light, tobacco, HPV (6, 16, 18)
  • Circumcision as newborn eliminates risk; before puberty lowers risk; after puberty does not affect risk. Circumcision does not affect CIS risk
  • **hide**Non-risk factors: carcinogens, non-HPV STDs, smegma
• **hide**Variations - classic; verrucous (does not metastasize); sarcomatoid (poor prognosis < 1 yr), warty/basaloid (HPV), papillary, adenosquamous

Lymph nodes: superficial inguinal -> deep inguinal -> pelvic nodes

• Never see pelvic nodes without ipsilateral inguinal nodes
• Para-aortic/para-caval nodes count as metastatic disease

Distant metastasis: lung, liver, bone, brain

**hide**updated in 8th edition (2017) AJCC

Stage

• Mean age 55-60
• Presents as skin thickening or change in color → non-healing lesion
  • Glans > prepuce > shaft
  • Generally not painful
• Palpable inguinal LN in 50%
• Most are superficial/low grade; < 10% present with distant metastasis
• Paraneoplastic syndromes: hypercalcemia

If high risk for LN metastasis, also get:

• CXR, CT A/P, Ca, LFTs (look for lung/liver mets, hypercalcemia).
• Bone scan if bone pain, ↑Ca, ↑Alkphos

Female sexual partners should be screened for cervical cancer with pap smear - 3x higher risk of cervical cancer

Penectomy

• Partial (5mm margin) - leave 2-3cm for upright voiding
• Total (resect distal to pubic bone) - perineal urethrostomy; sitting voiding
• Glansectomy for Ta, T1, T2 (not invading urethra) confined to glans

Penile sparing

• Can be used for Tis or low-grade Ta/T1
• Higher local recurrence rate than partila, but similar cancer-specific survival
• Must biopsy first
• Circumcision, wedge resection, Mohs', laser, glans resurfacing, topical 5-FU/imiquimod, radiation (external beam (≥4 cm) or brachytherapy (< 4 cm); circumcise first to prevent phimosis, 20-30% urethral stenosis, 10-20% glans necrosis.)

Lymph nodes

• 25% of men with non-palpable ILN will have metastases. Early ILND of non-palpable nodes has improved survival.
  • Early (< 3 mo) ILND a/w improved survival compared to delayed (77% vs 38% 5-year recurrence-free survival)
• 50% of palpable ILN will have metastases

• *risk of inguinal lymph node metastases based on stage, tumor grade, and presence of lymphovascular/perineural invasion
• Surveillance: q6-12 mo exam; imaging if cannot examine adequately
• DSNB: Dynamic sentinel node biopsy. Sentinel node typically in superior-medial region of superficial inguinal lymph node group.
  • **hide**False negative rate 50% with non-dynamic biopsy; 15% with dynamic biopsy (Tc-99m + blue dye)
  • FNA (50% inflammation, 50% metastasis)
• ^Bulky LN = fixed, ≥ 4 cm, or bilateral. Non-bulky = unilateral + mobile + < 4 cm.
• Chemotherapy = cisplatin, paclitaxel, ifosfamide

Inguinal lymph node dissection (ILND)

• Surgical atlas. Video - robotic
• Review
• ILND indicated for T2 and above, maybe high-grade T1
• PLND (pelvic lymph node dissection) indicated if ipsi ILN are positive
  • Consider for ≥ pN2, inguinal node > 3 cm, + extranodal extension
  • Consider bilateral PLND if ≥ positive inguinal lymph nodes

Anatomy of femoral triangle Lateral to medial: N(AVEL) Nerve, Artery, Vein, Empty, deep inguinal Lymph nodes Node of Cloquet = most cephalad LN () = femoral sheath Anterior: fascia lata (separates superficial and deep LN) Saphenous vein branches from femoral vein in deep inguinal; pass through fossa ovalis in fascia lata -> superficial inguinal Lateral: Sartorius Medial: adductor longus Superior: inguinal ligament Daseler's Zones: sentinel lymph node usually in SM (superior medial) zone

ILND templates

• Make skin incision parallel to inguinal ligament, about 2 cm below
  • Mark borders: lateral line 20 cm inferior from ASIS, medial line 15 cm inferior from pubic tubercle
• Develop skin flaps deep to Scarpa's fascia, to avoid skin necrosis
• Deep nodes - avoid dissection lateral to femoral artery (injures nerve)
• Modified: lower complication rate (lymphocele, smaller incision) - but higher false negative rate
  • Indicated for non-palpable ILN; convert to standard ILND if + LN
• Post-op: compression stockings; JP drain until < 25 cc/24 hrs

Chemo

• Adjuvant chemo improves survival for pN2/pN3
• Use if unresectable, e.g. cT4 or cN3
• Cisplatin-based

Follow-up

• Most important survival determinant: extent of LN metastasis
• Intensive f/u x 2 years (penis + node exam, chest + A/P imaging)
  • Penile sparing: q3mo
  • Partial/total penectomy: q6mo
• **hide**Spongiosum invasion has better prognosis than cavernosum invasion