22 Penis cancer

Penis cancer

12

THE GEC ESTROHANDBOOKOF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 15/07/2022

a manually afterloaded LDR technique. This may reduce toxicity in the future. HDR experience is a relatively recent development with smaller numbers reported but appears comparable and is certainly more widely available in modern radiotherapy departments. (Table 2)

a

b

13. ADVERSE SIDE EFFECTS

Acute adverse events are frequent, observed inmost patients treated with brachytherapy andmainly represented by acute radiomucositis/ epidermatitis and urethritis. Acute symptoms should be treatedwith symptomatic local and systemic treatments, including analgesics and antibiotics if necessary. With long-term follow-up, painful ulcerations and necroses may be observed, associated with higher volumes, higher dose rate, and higher total dose (14). Biopsies should be avoided. Painful necroses will respond well to a course of hyperbaric oxygen (40 dives breathing 100% oxygen at 2-2.5 atmospheres) and may eventually heal [37] (Figure 8) Distal urethral stenoses are also frequently seen, with a higher probability among patients having tumour infiltration of the distal meatus or with pre-existing symptoms. These rarely need surgical management, though urethral dilatations and, in severe cases, a meatotomy can be considered. In the largest series, 23% of patients required surgery for local relapse or toxicity, including 25 (12.4%) partial glansectomy, 14 (7.0%) total glansectomy, and 7 (3.5%) total penectomies (14). Early urethral adhesions should be separated by passing a catheter or urethral dilator and can be prevented by teaching the patient to self-dilate as required. Erectile dysfunction is another possible consequence but a survey has shown than 70% of men with baseline potency continued to be sexually active with only mild erectile dysfunction. Patient- assessed quality of life was considered good with a median score of 80/100 (IQR = 65-90) and was only impacted by pain. Overall, 57% and 39% declared having no or moderate pain or discomfort, respectively [38].

c

Figure 7: Radionecrosis after LDR brachytherapy for T3 SCC in a 48 year old man. Managed with Hyperbaric Oxygen. Figure 8: Radionecrosis after LDR brachytherapy for T3 SCC in a 48 year old man. Managed with Hyperbaric Oxygen. a) After first series of 40 dives b) After second series of 40 dives c) Long-term result at 8 years

a) After first series of 40 dives b) After second series of 40 dives c) Longterm result at 8 years

11. MONITORING

After treatment, follow-up is based on a consultation with clinical examination. The patients should be seen every 3-6 months for 2 years, then every 6 months for 3 years, then annually for life, given the risk of delayed local recurrence and late complications (> 10 years follow-up). This surveillance aims to detect isolated local relapses suitable for salvage penectomy, and also to monitor and treat delayed complications. For patients who did not undergo lymph node surgical staging despite risk factors for nodal relapse (e.g. high grade or deep infiltration), ultrasound of the bilateral groins is recommended every 6 months. Although data is lacking on when this could safely be discontinued, a minimumof 3 years is advisable. Other radiological examinations are ordered as necessary for symptoms. A chest/abdomen/pelvis computed tomography should be considered in patients with lymph node involvement.

12. RESULTS

Experience with LDR penile brachytherapy extends over four decades during which time staging systems and techniques have evolved. In general, penile preservation rate is approximately 85% at 5 years and 70% at 10 years (Table 1). The more recent reports show the evolution from classic LDR with manual afterloading to PDR.The results of these 2 techniques are combined in Table 1, but centres that include both techniques are indicated. Complications like meatal stenosis and ulceration/necrosis are seen consistently through the decades. PDR, however, allows the practitioner to address and modify issues such as meatal dose prior to treatment through dose optimization, something that was not possible with