Guys I need your opinion on this case
72/Male,
Previous Intermediate risk ca. prostate treated with hormones + RT in 2006, now PSA undetectable.
January 2010 patient noticed a small superficial growth on dorsal surface of glans.
Excision biopsy March 2010: Specimen size 1x1x0.8 cm superficial invasive squamous cell cancer, margin not commented.
History of phimosis since birth, circumcision done during childhood.
July 2010 has a 5-6 mm clinical recc just beside the biopsy site, its very close to the coronal sulcus on the right later side, urethral meatus normal, no pain/bleeding or urinary complaints. No groin nodes palpable. CT pelvis is scheduled to be done in few weeks time.
Patient does not want surgery.
What are the treatment options? If Radiation then dose fractionation ?
Nikhilesh
In our setup, these patients would have a MRI , which provides supplementary information regarding the depth / invasion into corpora cavernosa and in addition the nodal regions. In addition, if clinical or radiological suspicion of groin nodes, these pts would have US scan of groins +/- FNA.
I believe this pt has T1 No Mx SCC Penis at least, unless proved otherwise based on further staging.
Interesting to see, that only a Excision biopsy was performed in march 2010, and despite the questionable margin status, a wide local excision was not perfomed and i presume a wrong decision of observation my have been made resuling in this so called recurrent disease.
Treatment of Choice for such a small lesion is gonna be Wide Local excision that too under Local Anaesthesia. I would insist a surgical consultation at least, to ensure this patient has not been misguided or he has nt been given some wrong messages regards surgery (miscommunication by oncologists, at times — does happen believe me).
The second best treatment option is gonna be either Brachytherapy or External RT .
Now if this patent has refused Surgery, i find it really hard to beleive he will accept Brachytherapy so easily.
Only option left is External RT. I d use 140-160 KV giving a 1 cm margin all around this 5-6 mm recurrence.
(If orthovoltage not available, use 6 MeV Electrons with bolus). In case of electrons use 1.5 cm margin
Dose: 55 Gy / 20 # / 4 weeks or 64 Gy / 32 # / 6.5 weeks.
I do not think Previous RT to the prostate in 2006 would in any way influence this treatment for penile cancer, as only the base of the penile shaft would have received some RT in the region of 74 Gy presumably.
I would ensure on patient setup, there is no potential overlap which i might be under-estimating.
Hi Rohit,
We are planning brachytherapy for this man. I was waiting for some opinions from the surgical side. My plan is to deliver 3.5 - 3.75 Gy HDR x 10-12 fractions. The dose is as per my mentor Dr.J Crook's experience. We do not have a lot of HDR Penile Brachy experience, we did 4 HDR cases in last year and all are doing well till date. http://www.ncbi.nlm.nih.gov/pubmed/19854685 this article describes the technique in detail for those who may be interested.
Thanks
Nikhilesh
Nikhilesh,
Could you ask Dr Crook, whether he has ever used Plesiobrachytherapy (Surface / Mould Brachytherapy) on patients with Penile cancer.
If this is a 5-6 mm recurrence, could this Mould be theoritically possible to use.
Of course, we could use HDR in this setting.
My advice to you, is read this ESTRO Brachytherapy Chapter on Penile cancer, before you enter in any discussion with your boss.
For the benefit of other busy isocentre members,the conclusion is that:
This chapter mentions it can be used for lesions no more than 5 mm thick. Hence you definitely need to know the thickness of this lesion either via MRI or via US scan. There are some good black & white images for your understanding.
Take a printout and show the relevant pages to your boss. (Section 7)
The beauty of this treatment is of course its Non-invasive for the patient, but the problem most oncologists face is No clinical experience and you should be having a "Good dedicated Mould room" who can make you this silicone mould.
For other member of isocentre, if you ever have a case of Penile Brachy in your OT, this should be your bible before you enter the OT.
Thanks Rohit, yet another excellent article.
In our patient we did discuss surface mould since we have a dedicated mould room however the staff uro-oncologist and RO were not happy. The lesion itself is semi-circular, nearly 50% of the right lateral surface is involved and the previous excision biopsy was 1x1cms which will be included in our target volume. So we thought surface mould would be too risk in this case.
Dr.Crook is a she and her data is published, she has been doing this for last 20 years now. I dont remember seeing any penile case treated with surface mould. The main reason is we never saw them early enough, most of them come with some sort of excision and recc or positive margins.
http://www.ncbi.nlm.nih.gov/pubmed/18682961
http://www.ncbi.nlm.nih.gov/pubmed/18636264
http://www.ncbi.nlm.nih.gov/pubmed/15890588
http://www.ncbi.nlm.nih.gov/pubmed/12803712
Followup of this case.
The patient did not come for implant and landed up with surgeon again.
CT abdo+pelvis = Normal.
Bone Scan: Single focus of SCLEROTIC met in left sacrum (asymptomatic). PSA still low. Most recent 2.34. It has always been in that range of 2'ish. Never became zero/undetectable.
I want to know from the house, how common is bone mets from Penile Ca and what would be the radiological appearance of one ?
Right boss, firstly Nikhilesh initially you mentioned in your post on 24th July 2010 that PSA was undetectable which to me means (PSA <0.1). Now you say its 2.34, but appears to be stable.
To the little knowledge i posess about penile cancers, i remember a rule saying in the absence of Groin nodes, the incidence of distant mets is rare and hence the diagnostic yield of any staging procedure is going to be low. So to answer your question, for r T1 N o Mx Penile cancer, the incidence of any distant mets is gonna be < 3 % and the incidence of Bone mets i gonna be < 1%.
The sclerotic mets in the Lt sacrum is much more highly likely going to be due to his prostate cancer and at times we have been caught up with another differential called sacral insufficiency fractures (post RT seen 3-5 years postRx) which at times are indistinguishable radiologically and may require biopsy if this is going to influence any management decision.
Penile cancers are predominantly squamous cancers and the Bone mets are mostly lytic 50%, but can be sclerotic (25%) or mixed (25%).