PENILE LESIONS : CONSERVATIVE TREATMENT · 2015. 4. 25. · CVA, MI, AF, Pacemaker. Biopsy: SCC ....
Transcript of PENILE LESIONS : CONSERVATIVE TREATMENT · 2015. 4. 25. · CVA, MI, AF, Pacemaker. Biopsy: SCC ....
PENILE LESIONS :
CONSERVATIVE TREATMENT
Joan Palou MD, FEBUChief of Urology Oncology
Associate Professor UABDirector of ESU
Fundació PuigvertBarcelona
General concepts in SCC
Represents 0.4 % of tumors in USA and from 10 % to 30% of all tumors in Asia, Africa and South America
In Brasil the incidence is 8 / 100,000 menIn Spain is 1.7 /100.000 menIn Uganda is the most common cancer, 1% of males have
penile cancer before 75 years
Etiology and epidemiology
European Guidelines, 2015
Penile Ca – Premalignant Lesions
LeukoplakiaKeratotic changesBalanitis xerotica obliterans /
Lichen Sclerosus
Penile Ca – Premalignant Lesions
Condylomata acuminata (HPV)
Giant condyloma (Bushke-Loewenstein)
Case 1
70 year-old man
Lesion on foreskin for 3 months
No treatment yet
What´s next?
Local Excision and Closure
SCC TaGrade 2
No Invasion
What´s next?
Case 1
45 year old
6 month history
Has tried antifungals for 2 months
Worse
What is it ?
What´s next ?
Case 2
General concepts in local lesions
42% of the patients with SCC had previous lesions in the penis
Bouchot.1989
Whenever there is a doubt or a long lasting lesion:
BIOPSY
Diagnosis of CIS
What´s next ?
Case 2
Local Surgery
Non-Operative
• 5% of 5FU (50 % rec)• Imiquimod cream 5%
(30 % rec)• Laser. Carbon dioxide
and YAG laser
Moderate results
Operative
• Circumcision• Glansectomy• Wide excision
Circumcision first and close control necessary
Laser Treatment
6,2 to 66
• Glansectomy
• Split Skin Graft
Case 2
78 yr old
Lesion for 4 months
Past history:CVA, MI,
AF, Pacemaker
Biopsy: SCC
What other modalities might be available for treatment?
Case 3
Outcome of Penile Preserving Surgery
Int consultation on Penile cancer, 2008
0 to 32
BDX Mould
EBRT or BT for Penile Cancer
55 to 63 43 to 65
Int consultation on Penile cancer, 2008
70 to 85 70 to 85
Penile Cancer: Side Effects of Radiotherapy
Acute Mucositis100% helped by circumcision, cleanliness, antibiotics
Late Radionecrosis
0% - 14% incidence (peak 7-18 months)
Urethral stenosis
3% - 45% incidence
Fibrosis, Telangiectasia
Finally: 20-39 % require partial penectomy
Int consultation on Penile cancer, 2008
68 yr old
Lesion for over 12 months and getting worse
What´s next?
Case 4
Biopsy Confirms SCC Penis Grade 3
What´s next ?
Case 4
Q of L after surgery:
No sexual relations because shortening of the penis or absence of glans.
Reconstructive surgery may help…
Case 4
Skeppner et al, Eur Uorl 2008Romero et al, Urology 2005
Results
No complications 10/12 cases
Meatal stenosis 2 cases
Sexual activity
Previously potent and active 8/11
Conclusions:
simple technique that offers good cosmetic and functional results and low morbidity
Bracka technique
10 casos
Necrosis parcial del injerto en 2 casos.
Sexual activity
Previously potent and active 6/10
Ninguna recurrencia local
Gómez-Ferrer A et al, Actas Urol Esp, 2011
Partial amputation: margin?
• Gold Standard was 2 cms
• Consensus in 2015: > 3 mm
Minhas BJU-Int 2005, Agarwal BJU-Int 2000, Hoffman Cancer 1999
Partial Penectomy Outcome
• Lont 2006– T1/T2 (n = 100)– Follow-up 100 months– Recurrence at 5 years
12%• 90% died
Message:Good follow upEarly diagnosis and treatment
Guidelines for stage-dependant local treament
In all techniques !!
Penile Cancer: Global results 2015
European Guidelines, 2015
Penile Cancer: Global results 2015
European Guidelines, 2015
Treating the Primary Lesion
Clinical Assessment(MR/CXR in advanced/selected cases if accurate
staging at this point is felt necessary)
Primary Surgery as indicated
Tis/PIN
5-FU, Imiquimod, glansectomy +
reconstruction or laser
T1G3, > T2
Partial/Total penectomy,
glansectomy, +/-reconstruction
Ta-1 G1-2
XRT, Local excision, glansectomy +/-reconstruction
Thank you !