NCCN Penile 2.2020 Flashcards Preview

EAMC Urology > NCCN Penile 2.2020 > Flashcards

Flashcards in NCCN Penile 2.2020 Deck (65)
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1

Primary evaluation for suspicious penile lesion

H and PE

Elicit RFs:
Balanitis
Chronic inflammation
Penile trauma
Tobacco use
Lichen sclerosus
Poor hygiene
STDs

Histologic diagnosis: punch, exicisional, or incisional biopsy!


PN-1

2

PRIMARY TREATMENT:
Tis or Ta

Topical therapy
OR
Wide local excision
OR
Laser therapy (cat 2B)
OR
Complete glansectomy (cat 2B)
OR
Mohs surgery in select cases (cat 2B)


PN-1

3

PRIMARY TREATMENT:
T1, Grade 1-2

Wide local excision
OR
Partial penectomy
OR
Glansectomy in select cases
OR
Mohs surgery in select cases (cat 2B)
OR
Laser therapy (cat 2B)
OR
Radiotherapy (cat 2B)


PN-2

4

PRIMARY TREATMENT:
T1, Grade 3-4

Wide local excision
OR
Partial penectomy
OR
Total penectomy
OR
RT (cat 2B)
OR
ChemoRT (cat 3)

PN-2

5

PRIMARY TREATMENT:
T2

Partial penectomy
OR
Total penectomy
OR
RT (cat 2B)
OR
ChemoRT (cat 3)

PN-2

6

TREATMENT:
Non-palpable inguinal LNs, low risk (Tis, Ta, T1a)

Surveillance!


PN-3

7

TREATMENT:
Non-palpable inguinal LNs, Intermediate/High risk (T1b, any T2 or greater)

Cross-sectional imaging of chest/abdomen/pelvis (CT, MR, PET/CT, and/or CXR); should be done with contrast unless contraindicated.

Inguinal LN dissection (ILND)
OR
Dynamic sentinel node biopsy (DSNB)


PN-3

8

Verrucous carcinoma

Verrucous carcinoma (Ta) is by definition a well-differentiated tumor, requiring only surveillance of the inguinal LNs.


PN-3

9

TREATMENT:
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
Low risk primary lesion
Percutaneous LN biopsy: negative

Excisional biopsy
OR
Surveillance


PN-4

10

TREATMENT:
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
Low risk primary lesion
Percutaneous LN biopsy: positive

ILND
Consider neoadjuvant chemotherapy followed by ILND

If results of LND shows:
pN1 --> surveillance

pN2-3:
PLND -/+ if pelvic nodes positive adjuvant RT or chemotherapy (cat 2B) or chemoRT (cat 2B)
OR
chemoRT (cat 2B)
OR
chemotherapy (cat 2B)


PN-4

11

TREATMENT:
Palpable inguinal LNs
CT showed: unilateral LNs < 4cm (mobile)
High risk primary lesion

ILND
Consider neoadjuvant chemotherapy followed by ILND

If results of LND shows:
pN1 --> surveillance

pN2-3:
PLND -/+ if pelvic nodes positive adjuvant RT or chemotherapy (cat 2B) or chemoRT (cat 2B)
OR
chemoRT (cat 2B)
OR
chemotherapy (cat 2B)


PN-4

12

TREATMENT:
Palpable inguinal LNs
CT showed: Unilateral LNs => 4cm fixed or mobile OR unilateral LNs < 4 cm fixed, OR bilateral LNs fixed or mobile

Treat as BULKY inguinal LNs



PN-5

13

TREATMENT:
Palpable inguinal LNs
CT showed: enlarged pelvic LNs

Percutaneous LN biopsy, if feasible, then:

If NEGATIVE:
Manage depending on LN status

If POSITIVE:
Potentially resectable: give neoadjuvant chemotherapy --> check cross-sectional imaging of chest/abd/pelvis --> if responsive --> consolidation surgery --> surveillance

Non-surgical candidate/unresectable: chemoRT --> surveillance

If biopsy NOT feasible,use PET/CT to evaluate LNs


PN-6

14

Palpable BULKY Inguinal LNs:
Unilateral =>4 cm mobile
Percutaneous LN biopsy: positive

Cisplatin-based neodjuvant chemotherapy followed by ILND (preferred), consider PLND
OR
ILND (preferred), consider PLND (if not eligible for cisplatin-based chemo)
OR
RT
OR
ChemoRT
---
If ILND: >= 2 positive nodes or ENE
Adjuvant chemotherapy
AND/OR
Pelvic nodes positive: adjuvant RT
OR
ChemoRT (cat 2B)


PN-5

15

Palpable BULKY Inguinal LNs:
Unilateral =>4 cm mobile
Percutaneous LN biopsy: negative
Excisional biopsy: positive

ILND (preferred)
AND
PLND (preferred)
OR
RT
OR
ChemoRT


PN-5

16

Palpable BULKY Inguinal LNs:
Unilateral =>4 cm mobile
Percutaneous LN biopsy: negative
Excisional biopsy: negative

Surveillance


PN-5

17

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: negative
Excisional biopsy: positive

ILND (preferred)
AND
PLND (preferred)
OR
RT
OR
ChemoRT


PN-5

18

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: negative
Excisional biopsy: negative

Surveillance


PN-5

19

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: positive
Neoadjuvant chemotherapy --> responsive

ILND (preferred)
AND
PLND (preferred)
OR
RT
OR
ChemoRT


PN-5

20

Palpable BULKY Inguinal LNs:
Fixed or bilateral
Percutaneous LN biopsy: positive
Neoadjuvant chemotherapy --> no response

Treat as metastatic:

Systemic chemotherapy
OR
RT
OR
ChemoRT

Do cross-sectional imaging check for response:

If responsive --> consolidation surgery --> surveillance

If no response --> subsequent-line systemic therapy
OR
Consider RT
OR
Best supportive care/clinical trial


PN-9

21

SURVEILLANCE SCHEDULE:
After penile-organ sparing approaches, glansectomy, wide local excision

Clinical exam:
years 1-2, every 3 mo then
years 3-5, every 6 mo then
years 5-10, every 12 mo


PN-7

22

SURVEILLANCE SCHEDULE:
After partial/total penectomy

Clinical exam:
years 1-2, every 6 mo then
years 3-5, every 12 mo


PN-7

23

SURVEILLANCE SCHEDULE:
Nx

Clinical exam:
years 1-2, every 3 mo then
years 3-5, every 6 mo


PN-7

24

SURVEILLANCE SCHEDULE:
N0, N1

Clinical exam:
years 1-2, every 6 mo then
years 3-5, every 12 mo


PN-7

25

SURVEILLANCE SCHEDULE:
N2, N3

Clinical exam:
years 1-2, every 3-6 mo then
years 3-5, every 6-12 mo
Imaging:
Chest CT or CXR: years 1-2 every 6 mo
Abd/pelvic CT or MRI:
year 1 every 3 mo then
year 2 every 6 mo


PN-7

26

Recurrence of penile lesion after penile-sparing treatment: non-invasive

Partial penectomy
OR
Total penectomy
OR
Repeat penile-sparing treatment (cat 2B)


PN-8

27

Recurrence of penile lesion after penile-sparing treatment: invasive

Treat according to recurrence stage


PN-8

28

Local recurrence in inguinal region
No prior inguinal LND or RT
Single mobile <4 cm LN
Percutaneous biopsy: negative

Surveillance



PN-8

29

Local recurrence in inguinal region
No prior inguinal LND or RT
Single mobile <4 cm LN
Percutaneous biopsy: positive
ILND: pN1

Surveillance



PN-8

30

Local recurrence in inguinal region
No prior inguinal LND or RT
Single mobile <4 cm LN
Percutaneous biopsy: positive
ILND: pN2-3

PLND -/+ if pelvic nodes positive adjuvant RT or chemotherapy (cat 2B) or chemoRT (cat 2B)
OR
chemoRT (cat 2B)
OR
chemotherapy (cat 2B)


PN-8