- UBC Urology Rounds

5/12/15
SCC Penis – a review of
diagnosis and management
and the impact of “supraregional” networks in the
UK
Dr. James Douglas
Aims
! Comprehensive overview of the diagnosis and
management of all stages of penile cancer
! Focus on surgical techniques including reconstruction
! Contemporary view of penile cancer management in
the UK
! Discuss the aims of “Supra-regional Networks” in the
UK
1
5/12/15
Penile Cancer
! Can be cured in over 80% of cases but has an exceedingly
poor prognosis once metastatic spread has occurred.
! Local treatment is potentially life saving but can be
devastating for the psychological well being of the pt.
! Careful diagnosis and accurate staging essential.
! No randomised trials
! No studies to compare different techniques
Changing practices in the UK
!
Large shift in management over last 10 years
!
Previously treatments comprised of:
!
Radiotherapy for small distal tumours
!
Partial or radical amputation
!
!
Decision based upon the principle of a 2cm macroscopic clear margin and whether guided
micturition through the stump possible after resection
Now aim for penile preservation wherever possible
!
Suitable for over 90% of cases
!
EAU guidelines are generally followed closely
!
Supra-regional networks:
!
High volume centres
!
Increased volume and analysis of outcomes should improve pt care.
!
Thanks to Mr N Watkins from St Georges, London
!
Thanks to Mr S Minhas from UCL, London
2
5/12/15
Incidence and demographics
! 1 in 100,000 per population: 400 cases per yr in the
UK
! 2 or 3 cases per year per UK hospital
! Median age 61 (wide range)
! High incidence in some developing countries
! 8 per100,000 in Brazil
! Higher in Uganda (most commonly diagnosed cancer)
Penile cancer
3
5/12/15
Risk Factors
! Phimosis
- 11X risk
! Chronic inflammation
- increased risk
! BXO
- increased risk
! Smoking
- 5X risk
! HPV infection (types 16 and 18)
! Condylomata acuminata
SCC
- 22.4% in verrucous SCC
- up to 66% in basaloid-warty
! Multiple sexual partners at a young age – 5X increased risk
Pre-invasive Conditions of the Penis
Buschke Lowenstein Tumour
Severe%dysplasia
Carcinoma%in%Situ
Severe%dysplasia
Widespread%
Widespread%
hyperkeratosis
hyperkeratosis
Carcinoma%in%Situ
Buschke Lowenstein
Tumour
4
5/12/15
HPV infection
!
Higher incidence of penile cancer in areas of high prevalence of HPV (Stankiewicz et al.)
!
HPV DNA in 70-100% of intraepitheial neoplasias (Kayes et al.)
!
HPV DNA in 30-40% of invasive SCC penis (Kayes et al.)
!
Role in oncogenesis through interaction with P53 and Rb genes (Kayes et al.)
!
HPV positivity varies between histological subtypes
!
!
!
22.4% of verrucous
!
36-66% of basaloid warty
Possibly effects prognosis (Lont et al.)
!
HPV +ve – 93% 5yr DFS
!
HPV –ve - 78% 5yr DFS
Another study showed no difference in lymph node mets or OS at 10yrs (Bezerra et al.)
Stankiewicz E et al. HPV infection and immunochemical detection of cell- cycle markers in verrucous carcinoma of the penis.
Mod Pathol 2009 Sep;22:1160-8.
Kayes O, et al. Molecular and genetic pathways in penile cancer. Lancet Oncol 2007 May;8(5):420-9.
Lont AP,, et al. Presence of high risk human papilllomavirus DNA in penile carcinoma predicts favorable outcome in survival.
Int J Cancer 2006 Sep;119(5):1078-81.
Bezerra AL, Lopes A, Santiago GH, et al. Human papillomavirus as a prognostic factor in carcinoma of
the penis: analysis of 82 patients reated with amputation and bilateral lymphadenectomy. Cancer 2001 Jun;15;91(12):5-21.
Phimosis
! 11x greater risk in non-circumcised men (Maden et
al.)
! Neonatal circumcission reduces the incidence of
penile cancer (Tsen et al.)
! Lowest incidence in Israeli Jews – 0.3:100,000
! Presumably more chronic inflammation in a non-
circumcised man (Van Howe et al.)
! Smegma has been shown not to be a carcinogen
! ? Thinner, moister epithelium that may allow easier
transfection of HPV virus.
Maden C, Sherman KJ, Beckmann AM, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst
1993 Jan;85(1):19-24.
Tsen HF, Morgenstern H, Mack T, et al. Risk factors for penile cancer: results of a population-based case-control study in Los Angeles County
(United States). Cancer Causes Control 2001 Apr;12(3): 267-77.
Van Howe RS, Hodges FM. The carcinogenicity of smegma: debunking a myth. Eur Acad Dermatol Venereol 2006 Oct;20(9):1046-54.
5
5/12/15
BXO
! 30% of penile CIS and malignancy associated with
BXO
! Have a high index of suspicion of abnormal areas
Diagnosis and staging
! Primary lesion
!
Often clinically obvious but may be hidden under a phimosis.
! Palpate the lesion and the whole shaft to get an idea of the
extent of the lesion.
! US and/or MRI can give information about invasion into
the corpora but not recommended in guidelines
! Almost always used in more advanced penile preserving surgery
! Regional lymph nodes
!
Palpate both groins carefully looking for enlarged nodes
!
Make a note of number, size, side and fixed or mobile
6
5/12/15
Regional nodes
!
!
Non-palpable nodes
!
Micro-metastatic disease in 25%
!
US, CT and MRI cannot reliably detect micro-metastatic disease
!
FDG PET CT can not reliably detect <10mm nodes
!
Therefore imaging not clinically useful
!
Diagnostic management therefore depends upon local risk factors such as
!
Stage
!
Grade
!
LVI
Palpable nodes
!
Highly suspicious for metastasis
!
Imaging of inguinal nodes does not effect management
!
Imaging of pelvic nodes may be helpful
!
FDG PET has a sensitivity of 88-100% and a specificity of 98-100% for
confirming metastatic pelvic nodes in pts with palpable inguinal nodes
7
5/12/15
Pathology
! 93% Squamous carcinoma
! 4% verrucous carcinoma
! 2% melanoma
! 1% sarcoma and other rarities
Of the squames:
Usual type
Basaloid
! Verruciform
! sarcomatoid
!
!
8
5/12/15
Histological Subtypes of Ca penis
Staging – TNM classification
9
5/12/15
TNM controversies
!
T2 does not differentiate between carvernosal invasion versus
spongiosum invasion
! Studies (Rees et al.) have shown that prognosis for spongiosum
invasion is better than cavernosal invasion
! Spongiosum invasion – 17% local recurrence and 21% mortality at
3yrs
! Cavernosal invasion – 35% local reurrence and 30% mortality at
3yrs.
!
T3 does not take into account the proximity of the invasion.
Invasion into the distal urethra does not infer a worse outcome.
Also N1 and N2 pts with T2 or T3 disease have the same
prognosis.
!
pN3 is a positive pelvic node OR extra-nodal extension in any
regional node
Outcome of 100 prospective cases of penile cancer
stratified according to the European Associaton of
Urology (EAU) guidelines (Hegarty, BJUI 2006)
!
Between 2002 and 2005, 100 consecutive cases (mean age 60
years) were prospectively analysed.
!
The EAU guidelines strictly applied in all cases.
!
Follow-up was up to 42 months.
!
36 men prophylactic ILND.
10
5/12/15
Age at presentation
30
25
20
15
10
5
0
30
40
50
60
70
80
Risk of N+ vs primary stage &
grade
100%
80%
60%
40%
20%
0%
G1
G2
G3
Tis
T1
T2
T3
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5/12/15
Survival%by%Stage
100%
90%
80%
70%
60%
T1
50%
40%
T2
T3
30%
20%
10%
0%
0
6
12
18
24
30
36
42
Survival by Grade
100%
90%
80%
70%
60%
G1
50%
40%
G2
G3
30%
20%
10%
0%
0
6
12
18
24
30
36
42
12
5/12/15
Survival by nodal stage
100%
90%
80%
70%
60%
N0,.N1
50%
40%
N2
N3
30%
20%
10%
0%
0
6
12
18
24
30
36
42
Survival with metastases
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
M0
M1
0
6
12
18
24
30
36
42
13
5/12/15
Treatment
! Aims
Complete tumour removal
! Maximal organ preservation
!
! Local recurrence has little effect on long term survival
! Excision of recurrence has similar outcomes
! Important considerations
!
No randomised studies comparing organ preservation versus
radical surgery only level 3 evidence or less
Histological diagnosis must be obtained if non-surgical
options being considered.
! Primary tumour and nodes can be dealt with in a stepwise
fashion with sequential surgeries
!
Treatment of superficial non-invasive (CIS)
! Topical chemotherapy
! Imiquimod or 5-FU have a 57% complete response rate
! Lasers - ideally not be used alone – need photodynamic
visualisation
! Glans resurfacing (partial or complete)
! Removal of glandular epithelium and covered by a split skin
graft.
! Superficial invasive disease in up to 20% of pts
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5/12/15
Treatment of invasive disease
confined to the glans (Ta/T1)
! Penis preservation surgery is recommended
! For all surgical options intra-operative frozen section is
recommended to ensure negative margins
! Tumours of prepuce can be cured by radical circumcision alone
as long as margins are negative at histology
! Decision on treatment choice depends on size, histology,
location and pt preference as no documented difference in long
term recurrence between surgery, laser and radiation therapy.
! All studies retrospective cases series
! Note that recurrence after total glansectomy is the lowest at 2-
8%
Treatment for Ta/T1 cont’d
! Lasers - Nd:YAG or CO2 with or without
photodynamic diagnosis to aid visualisation
! Mohs micrographic surgery
! Glans resurfacing
! Glansectomy
! Partial penectomy
! Brachytherapy
! Radiotherapy
15
5/12/15
Glans Resurfacing
! First described for the treatment of BXO
(Bracka et De Pasquale BJUI 2000)
2 weeks
(images courtesy of Mr Watkins)
4 weeks
Appearance at 3 months
16
5/12/15
T1 disease with glans involvement
circumcision, partial glansectomy and skin graft (NW)
T1 disease with glans involvement
circumcision, partial glansectomy and skin graft (NW)
17
5/12/15
T1 disease with glans involvement
circumcision, partial glansectomy and skin graft (NW)
Results of treatments for Ta/T1 lesions
18
5/12/15
T2 without cavernosum invasion
! Total glansectomy with or without re-surfacing of
corporeal heads.
! Evidence for a 2cm macroscopic margin is unproven
! Generally felt that 5mm enough and perhaps 1mm
! Partial amputation if pt not suitable/fit for
reconstructive surgery
What is a good enough margin?
!
Minhas S et al. BJU Int. 2005 Nov;96(7):1040-3.
!
51 patients. Between 2000 – 2004. Selected for conservative treatment (9
WLE, 26 glans excision, 16 partial penectomy)
! All staged with MRI pre operatively
! Mean range follow up 26 months
! Stage (Tis 3, T1 20, T2 26, T3 2)
!
Type – 8 basaloid, 4 verrucous, 26 not specified
!
Margins
! 48% within 10mm of tumor edge
! 90% within <20mm resection margin
! 6% had tumor at the margin (and had further surgery)
!
4% developed local tumour recurrence
!
Conclusion: 2cm margin NOT required
19
5/12/15
Total Glansectomy with Grafting
to corporal heads (NW)
Plane between glans and corpora developed
20
5/12/15
Glans disconnected from urethra
Skin graft quilted upon corporeal
heads
21
5/12/15
Appearance at 3 months
22
5/12/15
Treatment of T2 with cavernosum
or T3 with distal urethral invasion
! Up to 90% of tumours involve the distal penis
(including the corporeal heads)
! Partial amputation with penile reconstruction
recommended
! Resection margin of 5mm considered safe
! Some specialists argue 2mm (Mr Minhas/ Mr Watkins)
! Radiation (brachytherapy or ext. beam) if tumour
<4cm
23
5/12/15
The Role of Magnetic Resonance Imaging in
Staging Primary Penile Cancer
Kayes 2006
! 51 patients diagnosed with penile carcinoma
on biopsy
! Radiological staging was compared against the
final histopathological stage
! Sensitivity 93% for detecting T1 and T2
tumours, 80% for T3 tumours
! The relative specificities were: T1 (91%), T2
(91%) and T3 (97%).
T2 disease involving corpora cavernosa
24
5/12/15
Appearance at 3 months
Tunical reconstruction
! Tunical invasion of penile shaft tumours
! Allows preservation of penile length/function
! Biomaterials- Tutoplast
Saphenous vein
Pelvicol
25
5/12/15
Coutesy of Mr S Minhas
Penile lengthening
! Penile de-gloving
! Division of suspensory ligament
! Tunical fixation to pubis
! Full thickness skin grafts
26
5/12/15
T2 with corporal invasion
Courtesy of Mr S Minhas
Courtesy of Mr S Minhas
27
5/12/15
28
5/12/15
29
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30
5/12/15
Local recurrence after organ
preservation surgery
! If still no cavernosum invasion then repeat organ
preservation surgery may be attempted
! Eg: glans re-surfacing to total glansectomy.
! Large or high stage recurrence – partial or total
penectomy.
! Total phallic reconstruction may be offered
31
5/12/15
Radiotherapy
! Not recommended in UK supra-network currently
! EBR, Brachy
! 30-40% failure
! Only suitable for small distal tumours
! Long term penile problems
! Srictures
! Pain/burns
! Fibrosis
Interstitial brachytherapy
Hypodermic needles are manually after loaded with iridium wires
32
5/12/15
Treatment of locally
advanced T3/4
! Relatively rare (5% in Europe, 13% in Brazil)
! Total penectomy with perineal urethrostomy for T4
! Multi-modal therapy
! Consider neoadjuvant chemotherapy for T4 or fixed
enlarged inguinal nodes
! Surgery for the responders
! Palliative radiotherapy may be an option
33
5/12/15
Type of Patient
! Well motivated
! Good performance status
! Intent to cure- locally advanced
! Understands the limitations of surgery
! Intent to improve quality of life- metastatic
disease
Locally advanced disease
34
5/12/15
T4 (scrotal invasion) but NO
tunical invasion
35
5/12/15
36
5/12/15
Extensive cutaneous spread but
NO deep invasion
37
5/12/15
38
5/12/15
Total Penectomy and Perineal Urethrostomy
- Should phalic reconstruction should be
considered
39
5/12/15
40
5/12/15
Lymphatic Drainage of Penis
glans
Superficial inguinal nodes
corpora
¯
skin
Deep inguinal nodes
¯
Pelvic nodes
Lymphatic drainage of penis
! Anatomic rules
! Penis lymphatics drain sequentially from penis to
superficial inguinal lymph nodes to deep inguinal
lymph nodes and then ipsilateral pelvic nodes and then
para-aortic/para-caval nodes
! There is no direct spread to pelvis nodes
!
There is no cross over spread from single sided
inguinal nodes to contra-lateral pelvic nodes
41
5/12/15
Early lymphadenectomy
Ornellas 1991 200 patients
! 5 year disease free survival 62% for those undergoing
primary surgery and lymphadenectomy versus 8%
undergoing delayed nodal treatment
Lymphadenectomy- Controversial
! Prophylactic
! Unilateral/Bilateral
! Pelvic
42
5/12/15
Radical inguinal
lymphadenectomy
! Significant morbidity in up to 50% of pts
!
Risk factors
! Obesity
! Sartorious muscle transposition
! Technique should be meticulous as lymphatic walls don’t
contain smooth muscle and can’t be closed with
electrocoagulation.
!
Liberal use of ligation or clips
!
Post-operative stockings/compression bandages
!
Vacuum suction to drains
!
Prophylactic anti-biotics
Management of clinically normal regional
nodes (cN0) depends on primary tumour
!
pTa, pTis and low grade tumours have a low chance of nodal involvement
!
!
pT1G1 are well differentiated and have a low risk
!
!
Lymphadenectomy recommended or DSLNB
pT1G3/4 are at high risk of nodal involvement
!
!
Surveillance recommended or DSLNB
pT1G2 with LVI at intermediate or high risk of nodal involvement
!
!
Surveillance recommended
pT1G2 without LVI considered low to intermediate risk
!
!
Surveillance recommended
Lymphadenectomy recommended or DSLNB
pT2 or greater – bilateral lymphadenectomy
43
5/12/15
Surveillance
! Involves regular physical examination and the role of
imaging has not be proven
! EAU guidelines say 3 monthly physical examination
for 2yrs then 6 monthly till 5yrs
! Also regular self exam by pt.
! Overall lymph node positive pts have over a 90%
overall survival with an early lymphadenectomy
compared to below 40% with a later regional
recurrence.
Disadvantages
Surveillance
! Potential to miss at least 20% who have micro
metastasis who benefit from early
lymphadenectomy
! Long term patient compliance for surveillance is
poor
! Unreliable screening tools
False positive for clinical examination 50%
Sensitivity for CT/MRI 50% (Kayes 2005)
44
5/12/15
Complications of lymphadenectomy (%)
Number
870
Overall
Infection
50%
26%
(24-87)
(3-70)
Necrosis
41%
(8-54%)
lymphocele
21%
(9-87)
lymphoedema
55%
(27-100)
Modified from Horenblas 2001
45
5/12/15
Modified groin dissection
! 10cm sub-inguinal
incision
! Preservation of Scarpa’s
fascia
! Dissection medial to
femoral artery
! Preservation of long
saphenous vein
! No sartorius flap
46
5/12/15
Modified Inguinal
lymphadenectomy
! If positive node then needs ipsilateral radical lymph
node dissection
! Intra-operative frozen section useful. If positive then
can continue to radical LND
! False negative rate unknown
47
5/12/15
Sentinel lymph node concept
! Cabanas 1977- anatomical only
! Lymphangiograms in 100 anatomical dissections
! Assumed embolisation to lymphatics
! Stepwise/predictable drainage
! First lymph node in chain acts like a filter
! If sentinel node clear the rest of basin is clear
Daseler’s Zones
Sentinel node usually in superior medial or central groups and never seen to
drain to either inferior zones. – Single photon emission computed tomography
(SPECT) study
48
5/12/15
Dynamic sentinel lymph node
biopsy (DSLNB)
! Tc99m nanocolloid injected around base of penis
! Lymphoscintigraphy +/- FNA
! Additional patent blue inject prior to surgery
! If positive node needs ipsilateral radical inguinal lymph node
dissection
! Sensitivity of 90-94%
! False negative rate reported to be as high as 12% (Neto et al.)
Neto AS,, et al. Dynamic sentinel node biopsy for inguinal lymph node staging in patients with penile cancer:
a systematic review and cumulative analysis of the literature. Ann Surg Oncol 2011 Jul;18(7):2026-34.
Lymphoscintigraphy
49
5/12/15
! Patent blue dye
injected
intradermally
around the penile
shaft 10 minutes
before surgery.
50
5/12/15
Courtesy of Mr Watkins
Courtesy of Mr Watkins
51
5/12/15
Mr N Watkins results 2004 - 2006
! 61 patients (50% of referrals)
! > or = pT1G2/clinically negative groins
! 121 groins examined
! 5.7% non-visualised
Results cont’d
! All positive nodes were radioactive and blue
! 26% of patients had a positive lymph node
! 16% of groins examined were positive
! In 16 of 18 groins the SLN was the only positive
node
! No false negatives at 20 months (median 8.5months)
! 6% minor complications
52
5/12/15
Management of palpable inguinal
nodes (cN1/2)
! If palpable the risk of node positive disease is >75%
! Old clinical advice of antibiotics should not be used
! Prompt treatment important
! CT/MRI only used to assess pelvic nodes
! No role for DSLNB
• Bilateral Radical Inguinal Lymph Node dissection
• Role for Frozen section as if more than 2 positive nodes
or Cloquet’s node positive then pt will need concurrent
PLND
• ? Laparosocpic
53
5/12/15
Management of N3 disease
! Metastatic disease assumed
!
CT chest/abdo/pelvis
! Neo-adjuvant chemotherapy with surgery for the
responders
! If responder then long term survival in up to 37% of
cases
! Role of adjuvant or neo-adjuvant radiation not
recommended as no evidence but role established in
head and neck SCC therefore used by some centres
Adjuvant Radiotherapy
! Tumours are radiosensitive
! Aim to reduce the regional recurrence rate
! In UK offered when 2 or more positive nodes or extra-
capsular spread
! Incorporate ipsilateral pelvic nodes
! May be better with combined chemotherapy
54
5/12/15
Flap Reconstruction
• For large volume disease
• Allows for adjuvant DXT
55
5/12/15
56
5/12/15
Pelvic Lymphadenectomy
! In pts with 2 or more positive nodes or Cloquets node
an ipsilateral Pelvic LND is recommended
! More than 2 nodes positive then a 23% chance of
positive pelvic nodes
! More than 3 nodes or extra-capsular involvement in at
least 1 node then a 56% chance of positive pelvic
nodes.
! 5yr CSS 71% if pelvic nodes negative or 33.2% if
pelvic nodes positive
57
5/12/15
Chemotherapy
! No randomised data
! Treatment based on results with anal and head and neck
squamous cancers
! Cis-platinum, 5- Fluoro-uracil, Taxanes
! May prolong survival
Chemotherapy for Nodal disease
!
Adjuvant Chemotherapy
! All evidence from a single Italian group (Barmejo 2007)
! Benefit from Vincristine, Bleomycin and Methotrxate in 25pts compared
to a historical control of 38pts
! Since 2004 the group started to use Taxanes due to success in head and
neck SCC
! 19 N2/3 pts had cisplatin, 5-FU and Paclitaxel (TPF)
! 52.5% disease free after median 42month follow up
!
!
EAU guidelines recommend – 3-4 cycles of TPF for pN2/3
Neo-adjuvant Chemotherapy
! Considered for N3 disease (small non-significant studies)
!
4 cycles of a cisplatin and taxane regime
! Surgery reserved for the responders
58
5/12/15
Metastatic disease
! Survival with metastasis (Hegarty 2006 – Guy’s
Hospital)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
M0
M1
0
6
12
18
24
30
36
42
! Treatment is palliative
59
5/12/15
60
5/12/15
Contemporary practice in the UK
!
Increasing incidence with more than a doubling in the last decade
!
now 400 cases a year in the UK
!
Due to low incidence of disease most hospitals would only see 1-2
cases per year
!
Historically a varied standard of care and minimal penile
preservation surgery
!
Richie et al. looked at a snap shot of practice in the UK over an 18month period from 1999-2000
!
!
!
!
!
BAUS national audit database
243 pts with penile cancer – 194 responses
Most in a single hospital was 8 cases in 18 months
Most by a single surgeon was 5 cases in 18 months
Variation in surgical technique
61
5/12/15
Ritchie et al. Penile cancer in the UK: clinical presentation and outcome. BJUI 94 (9) 1248-1252
!
!
!
CIS/Ta
!
13- local excision
!
1- local excision and radiation
!
1- local excision and chemotherapy
!
1- radiotherapy
!
6- partial penectomies
!
1- (5%) lymph node dissection
!
T1
T2
!
2- local excision
!
2- local excision and radiation
!
9- radiotherapy
!
32- partial penectomies
!
8 -total penectomies
!
21- (36%) lymph node dissection
T3
!
1- local excision
!
2- Radiation
!
23- local excision
!
8- partial penectomy
!
11- local excision and radiation
!
7- total penectomy
!
4- Radiotherapy
!
8- (42%) Lymph node dissection
!
3- Glansectomies
!
30- partial penectomy
!
2- total penectomy
!
10- (13%) Lymph node dissections
!
T4
!
3- local excisison
!
1- radiotherapy
!
1- partial penectomy
!
1- total penectomy
!
3- (33% Lymph node dissections
! 2002 - National Institute of Clinical Excellence (NICE)
Published the Improving Outcomes Guidance (IOG) :
Urological Cancer
! “Specialised penis cancer multidisciplinary teams (MDTs) should be
established jointly by two to four neighbouring networks. Each of these
teams should serve a population base of four million or more and expect
to manage a minimum of 25 new patients pet year”
! Access to plastic surgery
! BAUS envisaged 10 such networks
! Currently 9 spread across the country
! 2003-2005 - Supra-regional penile cancer networks formed
! 2011 – Department of health published –
! Improving Outcomes; a strategy for cancer
! Endorsed the Supra-regional networks and introduced targets for
the pt. pathway
62
5/12/15
Aims of supra-regional networks
! Guidance from NHS England
! A service to deliver high quality holistic care so as to increase
survival whilst maximising a patient’s functional capabilities
and quality of life.
! Ensure ready and timely access to appropriate supportive care
for patients, their relatives and carers
! Regular MDT meetings
! Undertake research
! Regular Audit
! Meet necessary national targets
Targets
! 100% pts discussed at MDT
! Core members of MDT must attend 67% of meetings
! 100% of team must attend an advanced communication skills course
! 86% compliant with 62 day wait
! 62 days from GP referral to treatment
! 93% compliant with 2 week cancer wait
!
2 weeks from GP referral to seeing a specialist
! 100% participation in national audits
! 75% of pt satisfaction questionnaires expressing satisfaction or better
with their service
! And more….!
63
5/12/15
East Midlands Network
Structure and function of the network
!
“Hub and spoke” with Leicester as centre
!
Serves a population of 6 million
!
MDT team consists of 14 people and meets every 2 weeks (videoconference to “referring hospitals”)
! 3 urologists with special interest in penile surgery
! 3 uropathologists
! Medical and clinical oncologists with specialist interest
!
!
!
!
!
!
!
Uro-radiologist with specialist interest
Dermatologist
2 specialist uro-oncology nurses
1 plastic surgeon
MDT co-ordinator
Ability to call a psychiatrist and psycho-oncological counselor
Results of MDT sent to referring hospital within 24hrs
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5/12/15
Results
! Increasing trend in referrals and activity
! 2009-2010 there were 56 new referrals and 81 surgical
procedures
Results – cont’d
!
Research – recruiting for a national phase 2 trial of docetaxel,
cisplatin and 5-FU for locally advanced and metastatic disease
!
Regular Audit
!
Regular pt satisfaction questionnaires
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5/12/15
Results cont’d
!
2 pts received radiation from 2005-2010
!
Treatments for penile cancer 2009-2010
!
20-biopsies
!
30 - penile preserving surgeries
!
1-primary excission
!
3-circumcission
!
16-glansectomies
!
9-partial penectomies
!
5 - total penectomies
!
Management of regional nodes
!
18-DSLNB
!
7-superficial bilateral ILND
!
3-superfical unilateral ILND
!
2-PLND
! Supra-regional networks are now well established
! Workloads have increased 10 fold in coordinating
centre
! DSLNB is now the standard of care for eligible pts
! Penile preserving surgery is performed whenever
possible
! Now possible to recruit to meaningful trials
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5/12/15
Summary
! Penile cancer is curable in the majority of cases
! Penile preserving techniques can be used even for more
advanced lesions
! Genital/abdominal reconstruction is possible in most
patients with advanced genital tumours with good
cosmesis and improvement in quality of life.
! Primary chemotherapy followed by surgical consolidation
appears to be a promising treatment for advanced penile
cancer conferring survival benefit.
The Future - Multi-modality
therapy
! Survival for N+ disease is poor-
Neo-adjuvant/adjuvant therapies in the trial setting
! Survival for metastatic disease poor-
Neo-adjuvant/adjuvant therapies in the trial setting
! TPF chemo therapy appears a promising treatment
regimen for advanced penile cancer
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5/12/15
Thanks
! For listening
! Mr S Minhas
! Mr N Watkins
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