Lesions otherwise suited to brachytherapy for management of the primary tumor may present with early adenopathy or require sentinel lymph node evaluation or inguinal node dissection. A combined approach of brachytherapy for the primary and surgical evaluation of lymph nodes can be considered. T3 tumors with extension into the penile www.selleckchem.com/products/azd-1208.html urethra are

generally not optimal candidates for brachytherapy, although those cases where urethroscopy reveals submucosal deformity without mucosal disruption may still be treated with success, although there is however an increased risk of meatal stenosis that should be explained and understood by the patient. If a locally advanced primary tumor presents with concomitant adenopathy, brachytherapy is unlikely to play a role in management and combinations of external beam radiotherapy (EBRT) with chemotherapy ± surgery should be considered (18). Tumor grade is not an exclusion factor for brachytherapy (19). In the 74 cases treated by Crook et al. (19) between 1989 and 2007, half had well-differentiated and the other half had moderately or poorly differentiated cancer. Moderately and poorly differentiated tumors responded as well as those that were well differentiated. Local recurrences occurred in six well-differentiated

and two moderate-to-poorly differentiated cases. Penile check details brachytherapy is not a treatment modality that needs to be available in every radiotherapy department. A high volume and varied brachytherapy practice that undertakes interstitial next brachytherapy for other tumor sites may wish to provide this treatment as the basic principles are not dissimilar to those for other interstitial implants. As this is an uncommon tumor, three to six cases per year are sufficient to justify a program. Collaboration

with a penile carcinoma center of excellence is recommended. Penile brachytherapy can be performed under general anesthesia or penile block with systemic sedation. Antibiotic prophylaxis is optional. Low-dose-rate (LDR) brachytherapy consists of either manually afterloaded 192Ir or pulse-dose-rate (PDR) brachytherapy. The latter uses automated afterloading with a high-intensity 192Ir source to deliver hourly pulses. The two are similar in implant principles and total dose. These implants should be clinically designed according to the anatomic extent of tumor. Knowledge of the Paris system of dosimetry (20) as shown in Fig. 1 is a helpful guide for placement of sources so that the prescription isodoses will encompass the visible and palpable tumor with an appropriate margin. Because the depth of invasion is often underappreciated, margins should be generous and of 10 mm or greater in all directions around the gross tumor volume to delineate the clinical target volume.