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Penile Cancer TOC Discussion ® NCCN NCCN Guidelines Index Penile Cancer TOC Discussion NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines® ) Penile Cancer Version 1.2012 NCCN.org Continue Version 1.2012, 04/03/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ® NCCN NCCN Guidelines Version 1.2012 Panel Members NCCN Guidelines Index Penile Cancer TOC Penile Cancer Discussion * Peter E. Clark, MD w Chair Timothy M. Kuzel, MD ‡ Michael P. Porter, MD, MS w Vanderbilt-Ingram Cancer Center Robert H. Lurie Comprehensive Cancer Fred Hutchinson Cancer Research Center/ Seattle Center of Northwestern University Cancer Care Alliance * Philippe E. Spiess, MD, MS w Penile Cancer Subcommittee Lead Subodh M. Lele, MD ¹ Jerome P. Richie, MD w H. Lee Moffitt Cancer Center & UNMC Eppley Cancer Center at Dana-Farber/Brigham and Women’s Research Institute The Nebraska Medical Center Cancer Center Neeraj Agarwal, MD ‡ Jeffrey Michalski, MD, MBA § Wade J. Sexton, MD w Huntsman Cancer Institute Siteman Cancer Center at Barnes- H. Lee Moffitt Cancer Center & Research Institute at the University of Utah Jewish Hospital and Washington University School of Medicine William U. Shipley, MD § w * Matthew C. Biagioli, MD, MS § Massachusetts General Hospital Cancer Center H. Lee Moffitt Cancer Center & James E. Montie, MD w Research Institute w University of Michigan Eric J. Small, MD † Comprehensive Cancer Center UCSF Helen Diller Family J. Erik Busby, MD Comprehensive Cancer Center University of Alabama at Birmingham Comprehensive Cancer Center * Lance Pagliaro, MD † The University of Texas Donald L. Trump, MD † Roswell Park Cancer Institute Mario A. Eisenberger, MD † w MD Anderson Cancer Center The Sidney Kimmel Comprehensive Geoffrey Wile, MD Cancer Center at Johns Hopkins Sumanta K. Pal, MD † Vanderbilt-Ingram Cancer Center City of Hope Comprehensive Cancer Center Richard E. Greenberg, MD w Timothy G. Wilson, MD w * w Fox Chase Cancer Center Anthony Patterson, MD City of Hope Comprehensive Cancer Center St. Jude Children’s Research Hospital/ Harry W. Herr, MD w University of Tennessee Cancer Institute NCCN Memorial Sloan-Kettering Cancer Center Kamal S. Pohar, MD w Mary Dwyer, MS Maria Ho, PhD Gary R. Hudes, MD † ‡ The Ohio State University Comprehensive Fox Chase Cancer Center Cancer Center - James Cancer Hospital and NCCN gratefully acknowledges the review of Solove Research Institute the Penile Cancer Guidelines by: * Brant A. Inman, MD, MSc w Juanita M. Crook, MD Duke Cancer Institute * Cesar E. Ercole, MD Simon Horenblas, MD Deborah A. Kuban, MD § Curtis A. Pettaway, MD The University of Texas Continue MD Anderson Cancer Center w Urology § Radiotherapy/Radiation oncology † Medical oncology ¹ Pathology NCCN Guidelines Panel Disclosures ‡ Hematology/Hematology oncology * Development/writing subcommittee Version 1.2012, 04/03/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ® NCCN NCCN Guidelines Index NCCN Guidelines Version 1.2012 Table of Contents Penile Cancer TOC Penile Cancer Discussion NCCN Penile Cancer Panel Members Clinical Trials: NCCN believes that the best management for any cancer Primary Evaluation, Pathologic Diagnosis, and Primary Treatment Tis, Ta (PN-1) patient is in a clinical trial. Participation in clinical trials is especially encouraged. Primary Treatment T1, T2 or greater (PN-2) To find clinical trials online at NCCN Member Institutions, click here: Management of Non-Palpable Inguinal Lymph Nodes (PN-3) nccn.org/clinical_trials/physician.html. NCCN Categories of Evidence and Management of Palpable Inguinal Lymph Nodes (PN-4) Consensus: All recommendations are Category 2A unless otherwise Management of Bulky/Unresectable Inguinal Lymph Nodes (PN-5) specified. See NCCN Categories of Evidence Surveillance (PN-6) and Consensus. Management of Recurrent Disease (PN-7) Staging (ST-1) Management of Metastatic Disease (PN-8) See Principles of Surgery (PN-A) See Principles of Radiotherapy (PN-B) See Principles of Chemotherapy (PN-C) The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network®® (NCCN ) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network® . All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2012. Version 1.2012, 04/03/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ® NCCN NCCN Guidelines Version 1.2012 NCCN Guidelines Index Penile Cancer TOC Penile Cancer Discussion PRIMARY EVALUATION PATHOLOGIC PRIMARY TREATMENT DIAGNOSIS Topical therapyb See or Management of H&P Wide local excision including Non-Palpable · Risk factors circumcision Inguinal Lymph > Tis or Ta balanitis, chronic inflammation, or Nodes (PN-3) or penile trauma, lack of neonatal Laser therapy (category 2B) Palpable circumcision, tobacco use, or Inguinal Lymph lichen sclerosus, poor hygiene, Complete glansectomy (category 2B) Nodes (PN-4) sexually transmitted disease · Lesion characteristics > diameter > location Grade 1-2 Suspicious > number of lesions penile lesion > morphology (papillary, nodular, T1 ulcerous, or flat) > relationship to other structures Grade 3-4 See Primary Treatment (PN-2) (submucosal, corpora spongiosa and/or cavernosa, urethra) Cytology or histological diagnosis · Punch, excisional, or incisional biopsy Imaginga T2 or greater · MRI or ultrasound If recurrent disease,see PN-7 or if metastatic disease, see PN-8 aMRI or ultrasound are optional studies based on clinical suspicion and to further define concerning physical exam findings. bTopical therapy may include topical imiquimod (5%) or 5-fluorouracil (5-FU) cream. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. PN-1 Version 1.2012, 04/03/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ® NCCN NCCN Guidelines Version 1.2012 NCCN Guidelines Index Penile Cancer TOC Penile Cancer Discussion PATHOLOGIC DIAGNOSIS PRIMARY TREATMENTc Wide local excision; possible STSG or FTSGd or Grade 1-2 Laser therapy (category 2B) or Radiotherapye (category 2B) T1 Wide local excisiond,f or Glansectomyg or See Management of Partial penectomyf,h Grade 3-4 Non-Palpable Inguinal Lymph or Nodes (PN-3) or Palpable Total penectomyf,h Inguinal Lymph Nodes (PN-4) or Radiotherapye ± concurrent chemotherapy (category 2B) Partial penectomyf,h or Total penectomyf,h T2 or greater or Radiotherapye ± concurrent chemotherapy (category 2B) fIf positive or close margins and/orlymphovascular invasion ( LVI), consider radiotherapy (category 2B). gAppropriate with proven negative margins. For tumors involving the glans only: glansectomy or radiotherapy (interstitial brachytherapy at experienced centers) c See Principles of Surgery (PN-A). with prior circumcision. d Complete excision of skin with a wide negative margin with skin grafting needed. hWhen it is necessary to dissect into the corpora cavernosum to achieve a STSG = split-thickness skin grafts; FTSG= full-thickness skin grafts. negative margin, a partial penectomy is performed. Total penectomy is required eSee Principles of Radiotherapy (PN-B). for lesions extending into the corpora cavernosum. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. PN-2 Version 1.2012, 04/03/12 © National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®. ® NCCN NCCN Guidelines Version 1.2012 NCCN Guidelines Index Penile Cancer TOC Penile Cancer Discussion MANAGEMENT OF NON-PALPABLE INGUINAL LYMPH NODES NODAL RISK STRATIFICATION TREATMENT STATUS BASED ON PRIMARY LESION Low risk (Tis, TaG1-2, T1G1) Surveillance ()See PN-6 or Dynamic sentinel node biopsy (DSNB)i (category 2B) Absent Non-palpable Intermediate risk Lymphovascular inguinal See Surveillance (T1G2) invasion lymph nodes (PN-6) Present Inguinal lymph node dissection (ILND) or High risk DSNBi (category 2B) (Any T2 or G3) iDSNB is recommended provided the treating physician has experience with this modality. If positive lymph nodes are found on DSNB, ILND is recommended. Note: All recommendations are category 2A unless otherwise indicated.
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