Carcinoma Penis desk 27 May26

Added: 2026-05-27

[00:00:00]We we had a case today uh the patient with cancer penis who was operated earlier would like to can you tell us something about the case?

[00:00:10]>> Uh so patient is a 46 years old male a non-diabetic non-hypertensive uh few months back last year in 2025 around the month of May or June uh he was complaining of uh difficulty in maturation and feeling of ballooning at the anterior end of the penis. uh he visited a doctor who advised him for circumcision. He did not follow up for that. Later on he developed a lesion on that area which was passing uh which was discharging also and uh then he visited uh RGCI STAN hospital where uh he was named the >> he was um >> so he was treated >> he was treated for that initially he underwent circumcision in January uh 20th of January 2026 uh he was also complaining of presence of um some swellings in the bilateral al groin regions. Uh after evaluation of the lesion and the uh and the ulcer it was found out that it was moderately differentiated uh squam cell carcinoma according to the reports of the patient.

[00:01:16]Uh then for further evaluation he went to another hospital and uh there he underwent partial pnectomy. The bilateral u groin lesions they were not addressed at that moment and since two past two three months they have been discharging more on the right side are less actually the the this was a young man with cancer penis moderately differentiated cell carcinoma and as she mentioned many times and most of the time the presentation is firstly with inability to retract the prepus so fimosis which results and they have difficulty in passing urine also. So suppose they have difficulty in passing urine we we generally assume that ureiththra is also involved but in this case it was not involved it was just a mechanical uh reason no so with that background patient was taken up for surgery for cancer penis.

[00:02:12]Now this is where it starts and the lymph nodes in the groins were not addressed as a was mentioning. Uh if you are doing partial pnectomy what exactly would it mean to you? You taking out how much margin?

[00:02:29]>> So um least margin is 5 mm should be there.

[00:02:33]>> You know the earlier dictim of 2 cm margin and 2 cm stump is no longer valid. You basically need it to be R0 and you can go up to the the safer approach is to go for at least 1 cm gross margin so that you have 5 mm of >> at least this. So it's like scalar from other places but here margin is not such a problem and this margin should be from the induration. So it is the corpus cavalism and the deeper part of it which you should measure and urethra you know it suits the patient very much but leaving the groin >> especially in the positive nodes is a challenge and how do you address nodes if you were to manage this case from the very beginning you're managing it now when it is fungated >> the groin is fungated and do you know the very old teaching that most cancer penis They suffer from these nodes and their agony is relieved by one of these nodes eroding into the external eye vessel of femoral vessel and torrential embry and that relieves him of his agy because he dies.

[00:03:42]>> But that's not the right way to look at it. Right? So one is to prevent it from happening and the other is uh usually how do you address it if you were to >> uh sir on evaluation uh we examine the region as well as the presence of uh localized lymph nodes. If the lymph nodes are present uh we'll see the size of the lymph nodes the um the consistency of the lymph nodes and uh if the lymph nodes appear to be small we'll get a fine needle aspiration of them done and uh see if they are if they are metastatic nodes we have to address them along with the primary surgery. So the lymphrons are more than 2 cm lymphrons of more than 2 cm and in the lymphrons are significant and uh during the partialctomy surgery the liymph dissection >> how we approach the lymph nodes cancer the general approach >> we have to start with if it is a palpable in lymph nodes we have to give one week of antibiotic therapy followed by if they do not subside we have to go for dissection >> this something you read for a long time because very often the the uh the lymph nodes are uh you know reactionary due to inflammation right and uh that can um that can I mean they can confuse the picture to a degree that u uh you know the nodes are due to inflammation. So if you put the patient on antibiotics they it is believed that they will regress but they mostly don't right. So this concept was there not one week four weeks that's how much they wanted to wait nobody can wait for that long these lymph nodes are clinically and sonologically and then on FNAC you prove them to be positive and that's how you approach it with cancer penis and also with oral cancers the major problem is a lot of necrotic material a lot of secondary inflammation so you may get a false negative report therefore it's a good idea oral cavity you often get a negative report. So we put the patient on antibiotics, regular mouth, mouth washes and then repeat the biopsy. Often when I ask this question the students answer by saying we will repeat the biopsy from another side and we'll change possibly the pathologist also. Of course you should but then that is not a solution.

[00:06:10]Practically even if everybody is doing his best there is a possibility of false negative on account of secondary uh infection secondary when that is inflammatory. So if it is inflammatory then you are basically wasting time changing places etc. Put the patient on antibiotics and repeat it by uh probably taking it from a couple of more sites.

[00:06:34]That's what you can do. That's one thing. Second is you have an ultrasound now which can help you guide the needle into the exact place. So it'll be more representative FNA and suppose it is positively not you are you have no business not to do a block dissection >> because if you don't they are going to fungate like we have in this case. So to stage it is not a good idea. Patient should be treated in one go with both aspects primary and then the nodes.

[00:07:07]>> The only situation is where it's a node negative disease. That's where you start thinking whether to do or not to do and in that case comes the question of central node biopsy cabana node dissection cabana node the picking up just a superficial group of nodes. I'm just quickly rushing through that. One can easily watch some of my old videos on cancer penis presentation and discussion. Now cabana node is based on the concept of a sentininal node only and in fact centin biopsy happened more often modern and others they did it most foretting the name of the chap specifically for this he they all that was melanoma so they did it for melanoma and then for this is this happened much cancer penis was not a very good organ where it could be done because of the bilateral lymphatic drainage sometimes you could get skip lesions so therefore cabana dissection is an option and even in that case personally I would like to generally do exhaustive imaging to rule out a little and I'll do a block dissection if required if you look at it from the point of view of uh you know a surgeon He would like to be done with a surgical job straight away. Do you know unlike what you would believe in a scam cell carcinoma? It is not radio sensitive is radioistant. Can you tell me why is cancer of the penis not so sensitive to radiations and therefore up front radiation zone although it can be used we are not getting into this very very early stages. You can offer radiation also. You can offer even local you know in a TIS you can offer even local chemotherapy. You can offer uh local radiation because you want to preserve the organ and the function all the such places where the organ and function is preserved. This is this is something very very common but generally speaking surgery is a standard of care.

[00:09:19]Most places radiation doesn't work here well because for radiation to be very effective.

[00:09:26]You need a very oxygenated blood. You need oxygen because free radicals have to be released from oxygen and most of these cancers have a lot of necrotic material. So the oxygenation is poor.

[00:09:37]Therefore radiation doesn't work very well. After surgery the blood supply improves. So the radiation is supposed to act well but although it may not be required in most cases. So doing block dissection can prevent the situation that we are in.

[00:09:56]What is the situation like now?

[00:09:59]So um there there is a risk of uh vascular exposure the vessels we uh can be seen in the uh deep depth of the wound. So there is a chance of the blowout of faval vessels if the necrosis happens at femoral vessels or external.

[00:10:17]>> So femoral vessels going into the external.

[00:10:23]So there is necrotic lymph node that is there in the wound and it is um exudative highly exudative with foul smelling that was controlled through table dressing and now also the on scanning we got to know that the beneath the blood vessels the femoral vessels there is uh no plane preserved between the negrotic lymph nodes and the blood vessels beneath it on both the sides.

[00:10:49]that >> you've been dressing regularly. So what is the dressing material of choice in these cases?

[00:10:56]>> So earlier due to filling and uh we started with antibiotic u oils uh like antibiotic only. Yes. Uh sir uh we started with the cleaning the wound the skin >> no cleaning and any specific uh dressings that you use to prevent mouth smell. Uh so see line dressings and uh then >> the line dressing don't work is not a dressing washing material >> which which dressing is used to take care of anorobes nitrogen >> or you can do put charcoal dressings to take away the which dissolves the bad odor. The bad order is on account of anes. So it would nothing of this obviously in dressing has got to be there is nothing like saline dressing anymore today I I you mentioned I'm clarifying because basically it used to be dry on dry on wet dressing saline was a dry on wet dressing you know it is wet and then it dries up and it sticks and you peel it off the sluff comes out but along with slough even the granulation tissue comes off so it'll bleed you must have seen and it will not heal that was the problem so it is replaced by moisture wound therapy and the dry therapy. Your wound should neither be a desert nor it should be a tsunami. So you need to balance it out. It should be moist and optimally. It should not be very dry. It won't heal. And the dressing should not stick because sticking dressing is going to cause pain and it's going to peel off the >> granulation tissue. And for malignant wounds, there's a presentation of mine on YouTube. You can watch it. Do that sometimes. go through that lecture. It's on malignant wounds, dressings only in malignant wounds. How to manage malignant wounds? Because they are foul smelling, fungating, they can erode into vessels. Do you know even radiation has a role in very small wounds which are malignant because it leads to you know drying of the wound and healing improves. But by and large there is no way you can stop this from carrying on because it is not the slough. It's a necrotic material from within the node that is coming out.

[00:13:14]Sooner or later the patient is going to get really surgery and there is a risk of the vessels getting you know eroded.

[00:13:21]The PET CT showed very little as she mentioned very little space and no space no fat planes between the external and the nodes both both the sides and you're paying for the not done node dissection.

[00:13:38]Okay, there is a clause where people want to avoid or do staged dissection in view of the nodes not becoming positive in most cases. But if the patient presented with positive nodes, you got no business to leave it. Most people avoid islanding block dissection on account of the mobility of flap failure, floating flaps, lympadema mobility is there. Nobody denies it. Therefore we do staged one on one one at a time block dissection and when we do block dissection today you watch tomorrow we'll discuss as a short discussion on alumal block dissection you'll watch my how I do it video on the YouTube which has got and others can also watch I mean what surgery how do we do it what are the boundaries of it and watch that video along with the model that it shows we'll discuss the steps >> the you know The usual limits we have I think discussed the upper limit is last time I discussed last time >> superior limit >> superior limit is inguinal ligament and for the inguinal li >> u the common the space between the common where the common divides into u external sorry the it is between the the upper limit is between the two common ids I'm >> so it is like this ran just So the aota by getting into common eyelid then external eye internal eyelid. So the superior limit is the bifocation of common eyelid.

[00:15:31]Lateral limit is general nerve.

[00:15:36]This is one ligament maybe higher sorry our bladder here. The medial limit is the bladder.

[00:15:45]The depth is the opterator nerve which lies in between goes into the opterator fossa here and this continues down as femoral artery >> artery and both sides you having ligaments buna and this is where the nodes are and one is not surprised because they're going to be it's a pongating node similarly here you'll be a rock trader the limit as you go down into The thigh are different. Medially it's the adductor longus laterally it's arttorious outer border or lateral border medial border here and they cross and then from here to lateral to medial what was I what was the what was the formula I taught you? Naval. No.

[00:16:36]>> Nerve which is femoral. Nerve artery.

[00:16:39]Fmormoral.

[00:16:41]>> Fmormor lateral to >> medial >> medial.

[00:16:58]So this is how and now this is the zone of dissection and what is the depth of it? I specifically asked you that question that we operate enough in the >> No, this is opt here.

[00:17:15]>> So here we u uh the uh so alio soass and the pectinius muscle they are the depth.

[00:17:27]Thank god you remember pectinius and swat asthma sir >> and we take the sheath off complete sheath is dissected and this is your mouth dection but read about it and we'll discuss the nuances of it any anything that you should do more for this patient what what have we done regarding the planning >> we have patient is already received chemotherapy >> in three cycles three cycles and is u been advised imunotherapy now based on the NGS. What is NGS?

[00:18:05]>> So uh next generation u sequencing >> what is that?

[00:18:10]>> Uh we uh uh in this test we uh do do the genomic study of the patient uh checking all the genes which could be positive or the uh which could be abnormal in this patient. for that. Uh so it was done to assess for the newer target therap target targeted drugs whether one could work with the specific genomic sequencing of first >> and what are the various options have you heard of anywhere that NGS is so it'll help you provide imunotherapy >> and imunotherapy can be a gamecher in a lot of these fungating masses it can be a game changer because you can have a very good and the tumor may actually disappear. Are there any metastatic lesions?

[00:18:57]>> So the only metastasis to the bilateral >> no besides the nodes at the top M distant metastasis not there no other.

[00:19:04]>> So it's a still a local regional disease and we should be able to provide you may not get an R0 dissection but at least R1 and then patient can have a lower burden of disease. Presently what is our priority? What should be our priority oncologically?

[00:19:23]You can't get an R0. Patient is on systemic therapy. So we are going to do salvage surgery. It is a salvage after systemic therapy that these nodes are the bunch of nodes can are making his quality of life extremely poor on account of fungation. A wound that is never going to heal. Malignant wounds don't heal with dressings. Dressings are only letting it work. They what is the best receive?

[00:19:51]>> Skin.

[00:19:52]>> Skin. Who said it?

[00:20:01]A thing which start in MBBS, MS all through Joseph Listister.

[00:20:10]Skin is the best dressing. So you wait till you have removed the tumor and you put a flap there. That is what is the plan. So for that we are optimizing the patient.

[00:20:21]>> He's probably going to get his next dose very soon. When is the due date?

[00:20:25]>> So he'll start with the imunotherapy.

[00:20:27]>> Imunotherapy. No he's taken two two targeted therapy already. That is what and it's now continuing beyond one more gene has been hit.

[00:20:37]>> So they're trying to add one >> add to what is the concept of imunotherapy if you can answer.

[00:20:46]Sir um these uh imunotherapies targets a specific gene uh drug which uh targets the specific uh abnormal gene of the patient >> cases of that that is leading around bush.

[00:21:01]>> So the uh imunotherapy is given to patient when the cancer is already there. uh it provides the immunity around the cancer cells and it tries to >> no actually uh it is have you heard of carti cell therapy in leukemia and it was a game changer the person was awarded the Nobel prize cartis cell therapy came in children were dying of leukemia so what they did was it was found out that you have tea cells T- helpper and T suppressor all those cells they prevent your foreign body or cancer related uh issues. So most of the time tea cells are not functioning to their capability and the cancer happens. So this therapy is to you know either provide you with the tea cells that act like in cartisel what did they do? They derived the blood took it from the leukemia patients children and into another individual or or as you know uh they created an invio cells in response and those were injected back into these patients and they started having an absolute response. The carti cell is a very basic thing. Now imunotherapy requires a tumor micro environment to be present to be able to react you know. So if you do it post surgery it's not going to work. It will work in a neoadent setting only when the tumor is still there.

[00:22:38]And therefore when in the discussion MDT when they when the medical oncologist was asking whether you would operate first or I should give you know imunino I said it's not going to work in your case if I remove it. So you give whatever you have to give, let the tumor shrink to reectable levels and then we can plan a surgery and uh and we can try to clear the tumor and if we can get an R0 resection because many of times the dead tissue has no cancer in it. It's just necrotic material then they sometimes end up doing better than they are. So again he's a young man. So you will put in the pictures and the clips of this patient so that it can add to the discussion that we can have. Any questions pertaining to this?

[00:23:30]Right. So cancer penis has been discussed. You're also encouraged to go back and watch uh my videos on cancer penis case discussion then surgery. Case discussion is very old. Many things have changed now. Management has changed with case discussion remains just the same.

[00:23:49]We have moved on from just surgery being one treatment multimodality therapies now but importantly lymph nodes are in very very very fundamental parts to be addressed and you could see you can see in this case typically this case exemplify is not doing the block dissection can leave it for the future a fungating you know wound can happen and then you find it difficult to manage.