4cm superficial foreskin lesion s/p circumcision with negative deep and peripheral margins to 4mm. T1a lesion. No lvsi or invasion of corpora. Surprisingly ended up having multiple bilateral groin nodes. What would you treat? Penis + groin/external iliac or nodes alone?
Penile ca case
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Never actually treated one myself but I seen one done- Whole penis gets like 50-60 Gy with boost to tumor. He was treated also to the whole pelvis, including inguinals to around 45 Gy and a boost was given to gross disease up to 70. Pretty gruesome.
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Without any data whatsoever I would treat the pelvis alone with chemo and surveil the penis. It's hanging right there looking at you, keep an eye on it would be my vote. Pray the chemo deals with any microscopic penile shmegma or cancer stuff.
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Were the nodes biopsied? These folks tend to have reactive enlarged groin nodes, 25-50% of nodes that are enlarged are negative, and 15-25% of patients that are clinically N0 have positive nodes. If you're at a specialized center, some people are performing sentinal lymph node biopsy, which is pretty accurate. I had a guy with a small ween cancer treated with PCS, and he had enlarged lymph nodes, so was sent for consult. Nodes were negative, so didn't treat, since was widely locally excised. These guys tend to have STDs, so it's not uncommon for them to have enlarged groin nodes.
Anyway, if biopsied and positive, would treat pelvis (external, internal, obturator) and inguinal nodes. Boost the positive ones. If it looks like multiple, maybe even chemoRT like vulvar.
I'm +/- on whole peen radiation therapy (WPRT), in this case, if the nodes are positive. Seems like it was completely removed.
The setup for treatment is interesting. Here is a useful guide.
EDIT: What was the grade?
EDIT #2: On second thought, if he's medically operable, if positive nodes, I think maybe dissection is probably warranted.
Anyway, if biopsied and positive, would treat pelvis (external, internal, obturator) and inguinal nodes. Boost the positive ones. If it looks like multiple, maybe even chemoRT like vulvar.
I'm +/- on whole peen radiation therapy (WPRT), in this case, if the nodes are positive. Seems like it was completely removed.
The setup for treatment is interesting. Here is a useful guide.
EDIT: What was the grade?
EDIT #2: On second thought, if he's medically operable, if positive nodes, I think maybe dissection is probably warranted.
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Had dissection
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ChemoRT then. Groins and pelvis
Leave the peen alone
Leave the peen alone
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I agree.
Thanks guys--that's the plan I submitted, but I started having second thoughts. For vulvar CA, indications for XRT to nodes and primary site are distinct, and if I treat this like a vulva (which is what I was thinking), I wouldn't treat the penis itself. Conversely, with say a node positive skin CA, I've heard people recommend XRT to primary site along with nodes regardless of margins at the primary skin lesion.
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This is a case where you go with your gut over going with the scant data available IMO. Hard to reach any real conclusions on the crappy available data for this setting..
My personal gut agrees with chemoRT to pelvis and spare this guy penile RT.
Hopefully that's not killing with kindness..but I do think that a primary recurrence should be easy to detect early in this location and you could always go back and treat just the scar with margin probably with electrons later rather than trying to incorporate it all in one complex plan now that is pretty dang hard to setup anyway. So at least "delaying" penile RT may make sense from that standpoint too..
My personal gut agrees with chemoRT to pelvis and spare this guy penile RT.
Hopefully that's not killing with kindness..but I do think that a primary recurrence should be easy to detect early in this location and you could always go back and treat just the scar with margin probably with electrons later rather than trying to incorporate it all in one complex plan now that is pretty dang hard to setup anyway. So at least "delaying" penile RT may make sense from that standpoint too..
Strictly speaking, you would not block primary site in N+ vulvar cancer if tumor was 4 cm in size, 4mm closest margin.
Here though, I would not treat penis. Probably possible to detect and salvage early recurrence, compared to vulvar cases.
Here though, I would not treat penis. Probably possible to detect and salvage early recurrence, compared to vulvar cases.
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The question of whether to treat the primary site or not when treating the lymphatics can be approached with logic.
VulvaCa is the distinct entity, where NOT treating the primary when treating the lymphatics has worked, extrapolating this to other entities is not trivial.
The logic is simple:
1. Once tumor cells are found in the regional nodes, this means that tumor cells have used the lympatic vessels to get there.
2. When you dissect the primary and the regional nodes you may either do it
a) en-bloc (for example rectal cancer: primary tumor + mesorectum) or
b) with individual approaches (for example breast cancer: lumpectomy + axillary dissection)
3. The problem with b) is is you leave the lymphatic vessels between primary site and lymph node metastasis not dissected.
Those are the very lymphatic vessels that were used by the tumor cells to get to the nodes in the first place.
This also happens in a) sometimes, yet to a lesser degree (simple because the surgeon cannot cut out every single lymph vessel, which he cannot see anyway).
4. If you irradiate only the lymphatics, you risk missing tumor cells in the lymphatic vessels between primary site and affected lymph node areas.
5. This is why we often see recurrences in melanoma patients, who have a melanoma removed in their leg, their groins dissected and irradiated, but the relapse with an in-transit metastasis somewhere in between. Irradiating the entire area between primary site and groins would theoretically work, but giving 50 Gy to a whole leg is not very appealing.
And this is also the reason we should treat the chest wall with adjuvant radiation therapy in a pT1b pN2 breast cancer and not only the axilla.
Although the primary is small (pT1) the lymphatic vessels of the chest wall between primary and axilla may still harbor tumor cells. This actually might happen even more nowadays, since surgeons tend to be less radical in their operating techniques (skin sparing mastectomy, etc)
In this case of penile cancer one needs to weight toxicity versus efficacy.
Irradiating the penis is going to cause morbidity to the patient, yet surely tumor cells can still be in the penis along the lymphatic vessels on their way to the groins, which now where dissected.
VulvaCa is the distinct entity, where NOT treating the primary when treating the lymphatics has worked, extrapolating this to other entities is not trivial.
The logic is simple:
1. Once tumor cells are found in the regional nodes, this means that tumor cells have used the lympatic vessels to get there.
2. When you dissect the primary and the regional nodes you may either do it
a) en-bloc (for example rectal cancer: primary tumor + mesorectum) or
b) with individual approaches (for example breast cancer: lumpectomy + axillary dissection)
3. The problem with b) is is you leave the lymphatic vessels between primary site and lymph node metastasis not dissected.
Those are the very lymphatic vessels that were used by the tumor cells to get to the nodes in the first place.
This also happens in a) sometimes, yet to a lesser degree (simple because the surgeon cannot cut out every single lymph vessel, which he cannot see anyway).
4. If you irradiate only the lymphatics, you risk missing tumor cells in the lymphatic vessels between primary site and affected lymph node areas.
5. This is why we often see recurrences in melanoma patients, who have a melanoma removed in their leg, their groins dissected and irradiated, but the relapse with an in-transit metastasis somewhere in between. Irradiating the entire area between primary site and groins would theoretically work, but giving 50 Gy to a whole leg is not very appealing.
And this is also the reason we should treat the chest wall with adjuvant radiation therapy in a pT1b pN2 breast cancer and not only the axilla.
Although the primary is small (pT1) the lymphatic vessels of the chest wall between primary and axilla may still harbor tumor cells. This actually might happen even more nowadays, since surgeons tend to be less radical in their operating techniques (skin sparing mastectomy, etc)
In this case of penile cancer one needs to weight toxicity versus efficacy.
Irradiating the penis is going to cause morbidity to the patient, yet surely tumor cells can still be in the penis along the lymphatic vessels on their way to the groins, which now where dissected.
