PCT Penile Conservative Therapy

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PCT Penile Conservative Therapy Sexual
Functions in Penile Cancers

• Rajiv Sarin,
• Radiation Oncologist
• Tata Memorial Hospital
• ESTRO TMH EBM Course
• 2005

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Penile cancers The Facts

• Though rare in west, high prevalence in some
  developing countries (Brazil, India etc)
• Like cervical cancers, HPV is an important
  causative factor i.e. PREVENTABLE
• Amenable for early diagnosis.
• Glans ?infiltrate shaft ? nodes.
• In developing countries late presentation

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Penile cancers The Facts

• No consensus regarding optimal management
• Recent UK survey (Harden, Clin Oncol 2001)
• Irrespective of Stage
• Most Urologist preferred penectomy
• Most Clinical Oncologist preferred RT.
• Most Literature reports describe treatment and
  disease control but no formal evaluation of
  sexual dysfunction.
• No randomised trials ever conducted

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• Common in developing countries and rare in the
  affluent western countries.
• Doubtful patient compliance
• Remembering non compliant patients for whom PCT
  failed and they died unnecessarily by not
  undergoing curative amputative surgery initially.
• Partial Penectomy Procedure quick- can be done
  by General Surgeons even at small places.
  Radiotherapy not in all centres, acute reactions,
  higher risk of failure
• Urologists Prefer Penectomy
• Publications Bias
• Penectomy ? Urology Jr.
• PCT ? Radiotherapy / Cancer Jr.

No Advocates
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Forms of PCT

• Radiotherapy
• External Beam RT
• 50-55Gy in 3-4 weeks (accelerated)
• 60Gy in 6 weeks
• Brachytherapy
• Interstitial Iridium-192 Implant
• Surface Mould
• Mohs Microsurgical Technique
• LASER Excision / Wide Excision

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Advantages of RT

• Organ preservation of penis, without compromising
  the local control or survival.
• Retains erectile potency and sexual function.
• Eliminates psychological distress.

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Penile Conservation with Radiotherapy At what
cost?
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Not just the cosmetic outcome, It is the
function that matters Are functions retained
with PCT?
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Studies Assessing Quality of Life

• Opjordsmoen S et al
• Sexuality in patients treated for penile cancer
  patients experience and Doctors judgement. Br J
  of Urology (1994) 73, 554-560.
• Retrospective study

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TMH Prospective Study Aims

• Local control rate
• Survival
• To determine the psychosexual morbidity
• Physical morbidity
• Complications

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Pre-RT Evaluation of Sexual Functions

• Libido
• Quality of erection
• Frequency of intercourse
• Sexual satisfaction

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TMH Prospective study of PCT using accelerated
External RT1996-2003
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Dose and Treatment Delivery

• Dose- 54-55Gy/3weeks
• 3-3.3Gy/ Fraction
• 23-33 days
• Close follow up
• 1-2 monthly - first year
• 2-3 monthly-second yr
• 3-6 monthly after three years.

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Treatment and Acute Reactions

• Accelerated five days per week regimen of either
  55Gy/16 (n9) 54Gy /18 (n12 patients), or
  other regimens (n2)
• In all patients, acute radiation reactions over
  the glans and skin appeared 2-3 wks after
  starting RT and healed completely after a mean
  duration of 9 wks (range 3-28 wks)
• The mean healing time of 12 wks (range 3-28) with
  the radiobiologically more intense regimen of
  55Gy/ 16 used in the initial 9 patients was
  significantly reduced to 6 wks (3-14) after
  modifying the fractionation slightly to 54Gy /18
  in the subsequent 12 patients (p0.02).
• Symptoms of mild radiation urethritis were
  observed in 15 patients which resolved within 1-3
  wks and no patient required catheterization
  during / after RT.

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Other Late sequelae of RT

• Mild asymptomatic urethral maetus narrowing
  occurred in 2 men.
• Post radiation hypopigmentation with or without
  mild telengiectasia in the irradiated skin and
  glans was observed in all patients on long term
  follow up.
• All patients were well adapted in society and
  maintained their normal life style after
  treatment.
• None of these men had any obvious symptoms of
  anxiety or depression.

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TMH Prospective study of PCT Results
STAGE II Actuarial 5 year penile control rate
with penile preservation was 33 after RT and
100 after salvage penectomy
STAGE I Actuarial 5 year penile control rate with
penile preservation was 92 after RT and 100
after salvage penectomy
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Tata Memorial Hospital PCT Study Prospective
evaluation of Sexual Functions
5 patients who underwent penectomy for
residual / recurrent disease not included. 1
patient had loss of erectile function before
starting Radiotherapy 2 patients with
normal erection were not sexually active (single
and advanced age).
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Conclusion

• Radical radiotherapy is an effective means of
  achieving local tumor control and leads to
  preservation of a functioning penis.
• Surgery as salvage therapy after radical
  irradiation gives a high rate of long term
  survival in the early stage penile cancers.

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Conclusion

• It is unfortunate for men with early,
  radiocurable cancers subjected to unnecessary
  penectomy and hazardous for those with advanced
  cancers treated with primary radiotherapy.
• A randomised trial is unlikely to be ever
  conducted and may be even considered unethical by
  some.
• Thus, findings of our relatively small but
  prospective study evaluating tumour control and
  sexual functions could form the scientific basis
  for making treatment recommendations which would
  then need to be validated in larger prospective
  studies.

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Conclusion

• Radiotherapy is recommended for Stage-I cancers
  to avoid post penectomy sexual dysfunction and
  psychological morbidity but penectomy is often
  required for more advanced cancers.
• Accelerated RT Regimen have more acute toxicity
  but acceptable late sequelae and excellent local
  control rates.

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Partial Penectomy not affecting sexual quality of
life!
As hard to imagine as these flowers growing from
the wall- Is it the truth!
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Organ and Function Preservation