22 Penis Cancer

Penis Cancer 481

− for the primary tumour: biopsy, urethrocystoscopy; in case of difficulty in evaluating tumour infiltration, ultrasound and/or CT and/or MRI can be performed; (36,17) − for the nodes (groin, pelvic and paraaortic areas): ultrasound and/or CT and/or MRI; whenever possible percutaneous needle aspiration or biopsy of suspicious nodes; (36,4) − for distant dissemination: chest radiograph, bone scan, liver CT, ultrasonography, as clinically indicated. General laboratory systematic studies: blood count and chemistry profile, urinary analysis. Different staging systems are used: the TNM classification (32) (see appendix 1) is the most common; many results are presented according to this classification, but for the indications of brachytherapy, Jackson’s staging is more appropriate (Table 21.1). Using the Jackson staging system, (18) in practice brachytherapy is indicated only for stage I tumours. Indications, Contra-indications Indications for brachytherapy alone are, in principle, all tumours, up to 4 cm, strictly limited to the glans and not extending beyond the balano-preputial sulcus. (10,11) The true problem is to detect extension in the corpus spongiosum towards the shaft. The balano- preputial sulcus is only an outer arbitrary and virtual limit between the glans and the shaft and does not represent a real anatomical barrier. (1,5,11,12,13,27) Moreover, the prepuce, particularly in cases of phimosis, often makes it difficult to evaluate the exact tumour extension. (5,10) Surgery is indicated for large tumours (e.g. >4 - 5 cm) exceeding beyond the glans, with partial or total amputation of the penis according to the infiltrating tumour size. (25,26,31) If there is any contraindication to brachytherapy and/or surgery, patients may also be treated by external beam radiotherapy. (23,25,28) In case of large tumours in which brachytherapy alone is not indicated, some patients do not accept any surgical removal of the penis. In these cases, a combination of external beam irradiation plus a brachytherapy boost may be indicated. (10,23,30) Treating lymph nodes by external beam therapy should follow certain principles. First of all, nodal involvement should be confirmed histologically. Inguinal nodal excision can be performed at the same time as circumcision: one involved node without capsular extension needs no further treatment. If there are several involved nodes or capsular extension, adjuvant treatment by external beam irradiation to the groin area ± the iliac nodes is indicated. (11,23) Target Volume The target volume (CTV) encompasses the tumour volume (GTV) plus a safety margin of 5 -10 mm. Since superinfection is very often associated with cancer of the penis, it is difficult to delineate the exact target volume. (11,12,13) The first step of treatment is to perform a wide circumcision, regardless of subsequent surgery or irradiation. This circumcision has two aims: first to allow optimal tumour assessment, and 5 6