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Update on TNM Staging of Penile Cancer

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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 TNM Update on Penile Cancer TNM Update on Penile Cancer 1 3/22/2017 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 TNM Update on Penile Cancer TNM Update on Penile Cancer 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) TNM Update on Penile Cancer TNM Update on Penile Cancer 2 3/22/2017 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 TNM Update on Penile Cancer TNM Update on Penile Cancer 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]) TNM Update on Penile Cancer TNM Update on Penile Cancer S-13-017051 Dartos Dartos Muscle Muscle TNM Update on Penile Cancer TNM Update on Penile Cancer 3 3/22/2017 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 TNM Update on Penile Cancer TNM Update on Penile Cancer What Parts Are Involved In Stage pTa • Foreskin S-13-017051 • Glans penis • Skin of Penile Shaft TNM Update on Penile Cancer TNM Update on Penile Cancer S-13-017051 TNM Update on Penile Cancer TNM Update on Penile Cancer 4 3/22/2017 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 TNM Update on Penile Cancer TNM Update on Penile Cancer S-13-017051 S-13-017051 TNM Update on Penile Cancer TNM Update on Penile Cancer S-13-017051 S-13-017051 TNM Update on Penile Cancer TNM Update on Penile Cancer 5 3/22/2017 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 TNM Update on Penile Cancer TNM Update on Penile Cancer Skin Adnexa S-13-017051 S-13-017051 TNM Update on Penile Cancer TNM Update on Penile Cancer Lamina Propria Corpus Skin Buck’s Spongiosum Adnexa Fascia TNM Update on Penile Cancer TNM Update on Penile Cancer 6 3/22/2017 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 TNM Update on Penile Cancer TNM Update on Penile Cancer Dartos Fascia Foreskin Mucosa Lamina propria Lamina S-13-017051 Skin S-13-017051 propria Coronal Sulcus Dartos Fascia TNM Update on Penile Cancer TNM Update on Penile Cancer 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) TNM Update on Penile Cancer
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