9
ESSM
Today
Key from Kols:
Penile Cancer
by Giorgio Bozzini
dr. giorgio bozzini, Md
Urology Consultant
Assistant Professor
School of Urology
Academic Division of Urology
IRCCS Policlinico San Donato,
Italy
Is there a wider space for
Doppler US in the Penile Cancer
diagnostic pathway?
Penile Cancer is mostly a Squamous Cell Car-
cinoma (that accounts for more than 95% of
cases of malignant diseases of the penis) and
has an incidence of less than 1 per 100.000
males in Europe.
Currently, as EAU Guidelines stated, the diag-
nostic pathway to be followed before the surgi-
cal procedure, requires a careful diagnosis and
adequate staging. A greater role is played by
Magnetic Resonance Imaging (MRI) in combina-
tion with artificial erection obtained with pros-
taglandin E 1. This is done to achieve better
preoperative informations to exclude (or confirm)
corpora cavernosa infiltration and to better plan
an organ sparing surgical approach.
Nodal involvement although can be assessed with
clinical examination and US help is described
(as CT and PET), but not for micro-metastasis.
Each of this statements has a level C of rec-
ommendation so they are made despite the
absence of directly applicable clinical studies
of good quality.
Doppler US of the penis can play a wider role in
this diagnostic field?
Almost ten years ago Bertolotto and Lont with
their papers started to empathized this concept.
Doppler US could be a feasible diagnostic tool to
evidence a corpora cavernosa malignant involve-
ment as it is already for lymphnodes.
The YAUWP (Young Academic Urologist Working
Party of the EAU) Men’s Health expertise group
is drawing up a study to assess what could be
the correct role of Penile Doppler US and even if
this role can be similar to the one played by MRI.
What can be the points that strengthen this
thesis?
Doppler US is easier and faster to be done if
we compare it to MRI. Not all hospitals have
the same possibilities to get an early MRI for
our patients. Also, not all the radiologists are
properly trained to perform a good test that will
drive the next surgical procedure. Despite this
prostaglandin E 1 injection is similarly performed
in the two tests.
MRI is surely more expensive than Doppler US.
The cost of the two devices are so different and
the time exploited is much more for MRI. MRI
also needs at least one technician to be per-
formed and one radiologist to be read. Doppler
US has not the same need.
A well trained urologist on Penile Cancer and
on Doppler US of the penis can be the correct
answer. He will be the one who get the informa-
tion from the US to drive his surgical strategy.
Not all the patients that has a penile cancer can
at least perform an MRI investigation. An objec-
tive contraindication is represented by claustro-
phobia. Another can be found in a patient who
previously has done hip prosthesis surgery or a
patient that had a pacemaker implant (actually
new generation devices will allow MRI).
This is to underline that some problems can
come out if, following guidelines, we need to
perform an MRI.
It will be interesting, as we are currently doing,
to better understand the role of Frozen Section
Examination (FSE) during the surgical procedure
planned on the evidences got from the imaging.
Is its role important? It will be important with a
new US role in Penile Cancer?
A urologist who had previously done by himself
the Doppler US study will be more or less con-
fident on a procedure, on the other hand, driven
by an MRI? Will his FSE, performed to exclude
corpora malignant involvement, be done with
more or less consciousness?
Currently there are no sure answers to that ques-
tions but it is interesting that they are rising.
A new role for Doppler US in discovering malig-
nant infiltration could come out, but not only. The
new 3D imaging for US device can play a role to
plan the correct surgical strategy. Intraoperative
use of US is already a fact, and can be used to
amend the surgical strategy if needed. With a
previous Doppler US and a planned sparing-sur-
gery it will be easier to assess a postoperative or
preoperative presence of an Erectile Dysfunction.
This possibilities confirm how wide can be the
applications of the Penile US and how valuable
could be his help.
To achieve this goal another key point should be
reached. This key point is the centralization of
the procedures and of the diseases as it is done
already done in some countries. As we know the
penile cancer incidence is not high, and even
with a good knowledge of the subject a urologist
needs cases to still offer to his patients the gold
standard treatment for this disease. Numbers
also guarantee good clinical and research out-
comes thus lowering the costs.
I hope that this approach may fuel inter-
est among urologist to integrate clinical best
practice and scientific research in the field of
penile cancer.
