Update on TNM Staging of Penile Cancer
3/22/2017
Update On TNM Staging of Penile Cancer
Pheroze Tamboli, MBBS MD Anderson Cancer Center
TNM Update on Penile Cancer
Disclosure of Relevant Disclosure of Relevant Financial Relationships Financial Relationships
USCAP requires that all planners (Education Committee) in a position to USCAP requires that all faculty in a position to influence or control the content of CME disclose any relevant financial influence or control the content of CME disclose any relevant financial relationship WITH COMMERCIAL INTERESTS which they or their relationship WITH COMMERCIAL INTERESTS which they or their spouse/partner have, or have had, within the past 12 months, which relates to spouse/partner have, or have had, within the past 12 months, which the content of this educational activity and creates a conflict of interest. relates to the content of this educational activity and creates a conflict of interest. Dr. PHEROZE TAMBOLI declares he has no conflict(s) of interest to disclose.
TNM Update on Penile Cancer
This Presentation Is Brought To You With th The Help of The Following Sponsors TNM Staging 8 Edition (2017) Penile Tumors
• Section of GU Pathology • Department of Urology • pTis: Carcinoma in-situ (PeIN) • Dr Bogdan Czerniak • Dr Curtis Pettaway • pTa: Non-invasive localized squamous cell carcinoma • Dr Patricia Troncoso • pT1: Invades lamina propria • Dr Charles Guo • pT1a: no lymphovascular or perineural invasion, or, G3 tumor • Dr Kanishka Sircar • pT1b: with lymphovascular and/or perineural invasion, and/or G3 tumor • Dr Priya Rao • Mentors in Penile Pathology • pT2: Invades corpus spongiosum with/without urethra invasion • Dr Miao Zhang • Dr Alberto Ayala • pT3: Invades corpora cavernosa (including tunica albuginea) • Dr Antonio Cubilla with/without urethra invasion • Dr Jae Ro • pT4: Invades into adjacent structures (scrotum, prostate, bone) • Dr Mahul Amin
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History Of TNM Staging For Penile Cancer History Of TNM Staging For Penile Cancer
• 1st and 2nd editions of TNM Cancer Staging Manual 3rd Through 6th Edition • No mention of Penile Cancer • “Second most important midline organ in GU pathology”. Colleague who must not be named • pTis: Carcinoma in-situ • pTa: Non-invasive verrucous carcinoma • 3rd edition of TNM Cancer Staging Manual (1988) • Penile Cancer finally has a staging system • pT1: Tumor invades subepithelial connective tissue • pT2: Tumor invades corpus spongiosum or cavernosum • 3rd through 6th editions of Cancer Staging Manuals • pT3: Tumor invades urethra or prostate • No change for 22 years (1988 to 2010) • pT4: Tumor invades other adjacent structures
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History Of TNM Staging For Penile Cancer Changes 3rd Ed. (1988) To 7th Ed. (2010)
3rd Through 6th Edition 3rd to 6th Edition 7th Edition • pTa • pTa • pN1: Metastasis in single superficial inguinal lymph • Non-invasive verrucous • Non-invasive verrucous node carcinoma carcinoma* • pN2: Metastasis in multiple or bilateral superficial • Broad pushing inguinal lymph nodes penetration/invasion • pN3: Metastasis in deep inguinal or pelvic lymph permitted node(s), unilateral or bilateral • Destructive invasion is pT1
TNM Update on Penile Cancer TNM Update on Penile Cancer
Changes 3rd Ed. (1988) To 7th Ed. (2010) Changes 3rd Ed. (1988) To 7th Ed. (2010)
3rd to 6th Edition 7th Edition 3rd to 6th Edition 7th Edition • pT1 • pT1: Lamina propria • pT3 • pT3 Invasion • Tumor invades • Tumor invades urethra or • Tumor invades urethra subepithelial connective • pT1a: no lymphovascular prostate tissue invasion, or, grade 3 carcinoma component • pT1b: with • pT4 • pT4 lymphovascular invasion • Invades other adjacent • Invades other adjacent and/or grade 3 structures structures (includes carcinoma component prostate gland)
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Changes 3rd Ed. (1988) To 7th Ed. (2010) Updates To 8th Edition From 7th Edition • Most significant updates 3rd to 6th Edition 7th Edition • pT2; pT3 • pN1 • pN1 • Single superficial inguinal • Single inguinal lymph node lymph node (both superficial and deep) • Less significant updates • pN2 • pN2 • pTa, pT1a, pT1b • Multiple or bilateral • Multiple or bilateral inguinal superficial inguinal lymph lymph nodes (both • pN1, pN2 nodes superficial and deep) • pN3 • pN3 • Change in wording • Deep inguinal or pelvic • Extra-nodal extension, or lymph node(s), unilateral or pelvic lymph node(s), • pTis, pT4 bilateral unilateral or bilateral
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Practical Anatomy & Gross Examination pTx to pTis 7th Edition Compared To 8th Edition
• Diagnosis is easy, but, staging is hard 7th Edition 8th Edition • “Diagnosing squamous cell carcinoma is so easy even a surgeon could do it” • pTx: • pTx: • Primary tumor cannot be • Primary tumor cannot be assessed • Accurate staging requires: assessed • pT0: • Understanding anatomy of the different penile components • pT0: • No evidence of tumor • Grossing appropriately according to specimen type • No evidence of tumor • pTis: • Carcinoma in-situ (Penile • Stage Dependent on penile component • pTis: intraepithelial neoplasia • Carcinoma in-situ [PeIN])
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S-13-017051
Dartos Dartos Muscle Muscle
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pTa 7th Edition Compared To 8th Edition pTa 7th Edition Compared To 8th Edition
7th Edition 8th Edition 7th Edition • Penetration/invasion by broad pushing front is pTa pTa pTa • Destructive invasion is pT1 • Non-invasive verrucous • Non-invasive localized 8th Edition carcinoma Squamous cell carcinoma • Term “Non-invasive verrucous carcinoma” assumed all verrucous • Broad pushing front • Verrucous Carcinoma, and, carcinomas are non-invasive Non-invasive Squamous • Rare verrucous carcinomas with overt destructive invasion are pT1 cell carcinoma • Projects above penile surface (carcinoma in-situ is a flat lesion) • Similar to urothelial cis (flat lesion) versus non-invasive papillary urothelial carcinoma of the urinary bladder
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What Parts Are Involved In Stage pTa
• Foreskin
• Skin of Penile Shaft
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S-13-017051
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pT1 7th Edition Compared To 8th Edition
7th Edition 8th Edition pT1: Tumor invasive into pT1: Tumor invasive into S-13-017051 lamina propria lamina propria pT1a pT1a • No lvi or grade 3 tumor • No pni, lvi or grade 3 pT1b tumor • With lvi and/or G3 tumor pT1b • With pni, lvi and/or G3 tumor
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S-13-017051 S-13-017051
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What Parts Are Involved In Stage pT1 Margin
Foreskin • Foreskin Skin Mucosa • Mucosal surface (more common), and, skin (less common) • Highest pT stage that can be assigned to foreskin tumors S-13-017051 • Glans penis • Mucosal surface: invasive into lamina propria • Coronal sulcus: invasive into lamina propria • Penile Shaft • Tumors most common on dorsal aspect of penile skin • From skin invades into lamina propria, dartos, Buck’s fascia
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Skin Adnexa
S-13-017051 S-13-017051
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Lamina Propria
Corpus Skin Buck’s Spongiosum Adnexa Fascia
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Foreskin Anatomy & Gross Examination Skin • Foreskin Coronal • Reflection of skin of penile shaft, attached at coronal sulcus Sulcus Lamina • Squamous mucosa (inner most) S-13-017051 • Non-keratinizing propria • No skin adnexa • Lamina propria • Loose connective tissue, blood vessels • Dartos muscle Foreskin • Irregular smooth muscle, loose connective tissue, blends with lamina propria Mucosa • Skin (outer most) • Dermis (skin adnexa, no hair follicles) Corpus Spongiosum Lamina • Epidermis Of Glans Penis Propria Of Glans
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Dartos Fascia Foreskin Mucosa Lamina propria Lamina S-13-017051 Skin S-13-017051 propria
Coronal Sulcus Dartos Fascia
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Foreskin Anatomy & Gross Examination Foreskin Anatomy & Gross Examination
• Circumcision Specimen for foreskin tumors Lamina Distal End • Rectangular fragment of skin and squamous mucosa Not a Margin • Surgical margin along proximal long axis (resected at coronal sulcus) Propria, • Opposite to the surgical margin, skin folds over to the squamous mucosal surface of the (Transition of foreskin, and is not considered a margin • Cut surface along the short axis is not a margin either Dartos Skin Skin to • incised to remove the foreskin after it is excised off the coronal sulcus and skin of the penile shaft Squamous • For gross exam • Ink surgical margin Mucosa) • Stretch out specimen and fixe overnight in formalin • Slice perpendicular to the long axis of surgical margin • Each section demonstrates the skin, lamina propria, dartos muscle and the squamous mucosa Squamous Not a Margin • Most invasive tumors arising from the foreskin are pT1; unless they extend along the (Surgical Incision surface of the glans penis and invade into the corpus spongiosum of the glans penis Mucosa Surgical Margin Line)
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Foreskin Stage pT2 7th Edition Compared To 8th Edition
• pT0 7th Edition 8th Edition • No evidence of primary tumor • pTis: Carcinoma in-situ (PeIN) pT2 pT2 • pTa: Non-invasive localized squamous cell carcinoma • Corpus spongiosum • Corpus spongiosum invasion invasion ONLY. With or • pT1: Invades lamina propria • Corpus without urethral invasion • pT1a: no LVI or PNI, or, G3 tumor cavernosum/Corpora • pT1b: with LVI and/or PNI, and/or G3 tumor • Tunica albuginea, is thick cavernosa invasion and dense, ensheathes • No pT2, pT3 or pT4 in tumors involving foreskin only C. cavernosa. Acts as barrier to tumor spread
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Tumor In What Parts Are Involved In Stage pT2 Corpus Spongiosum Glans penis • Most common location for pT2 tumors • Mucosal surface and coronal sulcus: invasive into corpus spongiosum
Penile Shaft • Uncommon, but most arise on ventral aspect Coronal • Dorsal tumors would have to grow along skin or Buck’s Sulcus fascia to invade corpus spongiosum Tumor
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S-13-017051
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Corpus Spongiosum Practical Anatomy & Gross Examination Tumor Glans penis Penile Skin • Distal most end of penis S-13-017051 • Squamous mucosa (keratinized in circumcised penis) Buck’s • Lamina propria Fascia • Conical expansion of corpus spongiosum forms most of Tunica the glans Albuginea • Corpora cavernosa and tunica albuginea are variable Corpus • Urethra on ventral aspect Cavernosum
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Coronal Corpus Ridge Spongiosum
Corpus Lamina Cavernosum Propria Corpus Lamina Spongios Propria um
Urethral Meatus
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Lamina Propria
Corpus Spongios um
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SMA
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SMA SMA
Corpus Lamina Spongio Propria sum
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Corpus Spongios um
Corpus Lamina Spongios Propria um Lamina Propria
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Corpus Lamina Spongios Propria um
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Lamina Propria
Corpus Spongios um
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Specimen Types & Gross Examination Specimen Types & Gross Examination
Glans penis resection specimens Glans penis resection specimens (cont’d) • Surgical Goal • Partial penectomy without corpus cavernosum excision • Maximal functional preservation • Glans penis excised without opening tunica albuginea or • Local excision excising corpora cavernosa • Small fragment of mucosa with underlying corpus spongiosum • Glans sparing partial penectomy • Partial penectomy specimen includes the entire glans • Larger surface of glans along with some (not all) of the superficial corpus spongiosum is excised penis and a short segment of the penile shaft, including • Coronal sulcus and/or a short segment of urethra may also be skin of penile shaft excised
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Gross Examination & Margin Evaluation Gross Examination & Margin Evaluation
Intra-op margin evaluation is urologist dependent Glans penis resection margins Intra-op • Local excision • Partial penectomy without corpus cavernosum • Ink deep margin, section perpendicular to mucosa • Margins: Urethra, Corpus spongiosum of glans, Coronal sulcus • Partial penectomy with corpus cavernosum • Glans sparing partial penectomy • Margins: Urethra, Corpus spongiosum of glans, Penile skin, • Ink deep margin, and other margins indicated by Urologist Corpora cavernosa • Section perpendicular to mucosa (dependant on orientation) • Submit urethra margin en face if present • Freeze separately: Urethra, Corpus spongiosum, Corpus • Coronal sulcus inked similar to glans penis cavernosum, Penile skin
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Gross Examination & Margin Evaluation Gross Examination & Block Selection
Glans penis resection margins Intra-op Glans penis gross examination • Partial penectomy without corpus cavernosum • Fix overnight in formalin • Margins: Urethra, Corpus spongiosum of glans, Coronal sulcus • Slice through sagittal plane (mid-line), dividing the urethra and glans penis into two halves (right and left) • Partial penectomy with corpus cavernosum • Margins: Urethra, Corpus spongiosum of glans, Penile skin, • Subsequent sections are taken parallel to the first cut Corpora cavernosa (para-sagittal sections) • Lateral most ends are sliced as coronal sections • Freeze separately: Urethra, Corpus spongiosum, Corpus • This easily allows evaluation of tumor and invasion of cavernosum, Penile skin penile structures important for pT stage
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Dorsal Dorsal
Left Distal Right Proximal
Ventral Ventral TNM Update on Penile Cancer TNM Update on Penile Cancer
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Dorsal Dorsal Corpus Coronal Spongio Ridge sum
Proximal Left Right Distal
Ventral
Urethra
Ventral Ventral
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Coronal Corpus Ridge Spongiosum
Tunica Albuginea & Corpus Cavernosum Lamina Propria
Urethral Meatus
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Corpus Spongiosum
Tumor in Lamina Coronal Propria Sulcus
Tunica Albuginea & Corpus Urethra Cavernosum
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Gross Examination & Block Selection
Glans penis gross examination (cont’d) • Submit sagittal sections entirely to visualize tumor with glans penis and urethra • Can be in two cassettes (mention dorsal and ventral sections) • Submit entire parasagittal sections with tumor • Can be in multiple blocks (mention dorsal and ventral sections) • Gross photos to show each section submitted • Easier to reconstruct tumor on slides to allow evaluation of tumor and invasion of penile structures important for pT stage
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Coronal Ridge Lamina Propria
Corpus Spongiosum S-13-017051
Tunica Albuginea & Corpus Cavernosum
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7th Edition Compared To 8th Edition Corpus 7th Edition 8th Edition Cavernosum Tunica • pT3 • pT3 S-13-017051 Albuginea • Tumor invades urethra • Tumor invades corpus cavernosum (including Corpus tunica albuginea), with or Spongiosum Buck’s without urethral invasion Urethrae Fascia
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Corpus Cavernosum
S-13-017051 Corpus S-13-017051 Spongiosum Urethrae
Tunica Albuginea
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Practical Anatomy & Gross Examination Corpus Buck’s Spongiosum Fascia
Penile Shaft • Skin (epidermis and dermis) • Dartos muscle S-13-017051 Corpus • Buck’s fascia Cavernosum • Paired corpora cavernosa (dorsal aspect) • Urethra surrounded by corpus spongiosum (ventral aspect) Buck’s Tunica Fascia Albuginea
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Corpus Spongiosum Corpus Cavernosum Tunica Albuginea Tunica Albuginea
S-13-017051 S-13-017051
Corpus Spongiosum Corpus Urethrae Cavernosum
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Urethral Corpus Mucosa Spongiosum Urethrae Corpus Peri- Cavernosum urethral Glands S-13-017051 Peri- S-13-017051 urethral Glands
Corpus Tunica Urethral Spongiosum Albuginea Mucosa Urethrae
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Corpus Cavernos um
Tunica Buck’s Albuginea Fascia
Urethra
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Corpus Cavernosum Corpus Corpus Spongiosum Tunica Cavernosum Albuginea
S-13-017051
Tunica Albuginea
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Corpus SMA Cavernosum
Corpus Spongiosum
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Corpus SMA Cavernosum
Corpus Cavernos um
Tunica Albuginea Corpus Spongiosum
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Corpus Buck’s Spongiosum Fascia
Buck’s Fascia
Tunica Albuginea Corpus Cavernos um Tunica Corpus Albuginea Cavernosum
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Corpus Cavernos um
Corpus Buck’s Cavernos Fascia um
Tunica Buck’s Tunica Albuginea Fascia Albuginea
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Tunica Corpus Albuginea Cavernosum Specimen Types & Gross Examination
Penile shaft resection specimens • Partial penectomy: • With a short segment of the penile shaft, including skin of penile shaft
• Total penectomy: • Entire penis removed, except for penile root (attached to pubic bones) • Variable length of urethra (for perineal urethrostomy) Buck’s Corpus • Variable length of skin (for reconstruction) Fascia Spongiosum
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Gross Examination & Margin Evaluation Gross Examination & Block Selection
Total Penectomy resection margins Intra-op Total penectomy gross examination • Similar to partial penectomy with penile shaft excision • Fix overnight in formalin as layers fix at different rates (skin vs corpus spongiosum vs corpus cavernosum) • Margins: Urethra with surrounding corpus spongiosum, • Penile shaft is amputated a few centimeters proximal to Penile skin, Corpora cavernosa the glans penis • Penile shaft is serially cross-sectioned from distal to proximal, so each cross section shows all the structures of the shaft • Freeze separately: Urethra, Corpus spongiosum, Corpus (skin, Buck’s fascia, corpus spongiosum and corpora cavernosum, Penile skin cavernosa) • Glans penis grossed same as in partial penectomies
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Coronal Penile Skin Sulcus Buck’s Fascia
Corpus Corpus Cavernosum Spongiosum
Tunica Albuginea
Foreskin Urethra
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Corpus Foreskin Urethra Spongiosum Coronal Sulcus Foreskin With Tumor Growing Along Mucosa
Corpus Buck’s Cavernosum Fascia
Tunica Albuginea
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Gross Examination & Block Selection
Total penectomy gross examination (cont’d) • Submit sagittal/parasagittal sections entirely to visualize tumor with urethra, glans penis, coronal sulcus and shaft • Submitted in multiple blocks • Map sections (easier to figure out block location) • Gross photos to show each section submitted • Easier to reconstruct tumor on slides to allow evaluation of tumor and invasion of penile structures important for pT stage
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Dartos Foreskin Muscle With Tumor Coronal Growing Coronal Sulcus Along Sulcus Mucosa Corpus Spongiosum
S-13-017051
Foreskin Corpus Foreskin Dartos Spongiosum With Tumor Fscia Growing Along Mucosa
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7th Edition Compared To 8th Edition 7th Edition Compared To 8th Edition
7th Edition 8th Edition 7th Edition 8th Edition • pT4 • pT4 • pN0 • pN0 • Tumor invades other • Tumor invades into • No regional lymph node • No lymph node metastasis adjacent structures adjacent structures (i.e., metastasis • pN1 scrotum, prostate, pubic • pN1 • <2 unilateral inguinal bone) • Metastasis in a single metastases, no extra-nodal inguinal lymph node extension
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7th Edition Compared To 8th Edition Important Information Regarding CME/SAMs 7th Edition 8th Edition The Online CME/Evaluations/SAMs claim process will only be • pN2 • pN2 available on the USCAP website until September 30, 2017. • Metastasis in multiple or • >3 unilateral metastases or bilateral inguinal lymph bilateral metastases No claims can be processed after that date! nodes • pN3 • pN3 • Extra-nodal extension of After September 30, 2017 you will NOT be able to obtain any • Extra-nodal extension of lymph node metastases or CME or SAMs credits for attending this meeting. lymph node metastasis or pelvic lymph node pelvic lymph node(s) metastases unilateral or bilateral
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