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 !