Karsinoma Penis | Circumcision | Metastasis

Karsinoma penis

Reports have confirmed the importance of tumor grade, depth of invasion, and tumor configuration with respect to both prognosis and treatment planning in the management of penile squamous carcinoma (McDougal, 1995)

BENIGN LESIONS Noncutaneous Lesions Benign tumors of the penile shaft skin include congenital and acquired inclusion cysts, retention cysts, syringomas, and neurilemomas. Congenital inclusion cysts have occurred in the penoscrotal raphe (Cole & Helwig, 1976). Acquired inclusion cysts from circumcision or trauma are more common. Retention cysts arise from the sebaceous glands located on the mucosal surface of the prepuce and on the skin of the penile shaft. Retention cysts may arise in the parameatal area as a result of obstruction of the urethral glands (Shiraki, 1975). Syringomas— benign tumors of the sweat glands—may become large and symptomatic (Lipshutz et al, 1991; Sola Casas et al, 1993). Neurilemomas have been reported in the frenulum and the prepuce (Chan et al, 1993; Hamilton et al, 1996).

Benign tumors of the supporting structures include angiomas, fibromas, neuromas, lipomas, and myomas. Angiomas are usually superficial and appear most frequently as punctate reddish papules or macules on the corona. They resemble the small angiokeratomas found on the scrotum. Neuromas present as firm, whitish papules at the corona or frenulum (Montgomery et al, 1990).


as well as other common oils (Engleman et al. or pseudotumors. 1990). Pyogenic granuloma may arise at the site of self-injection in impotence therapy (Summers. 1974). may develop after self-administered injections or implantation of foreign bodies (Nitidandhaprabhas. have been applied to or injected into the penis. 1969). 1975). producing a destructive lipogranulomatous process that may grossly mimic carcinoma. Early or atypical Peyronie's plaques may present as masses within the shaft and base of the penis. . Penile masses and deformities. Testosterone in oil (Zalar et al.

all benign lesions are best treated with local excision and thorough histologic evaluation to rule out malignancy. When a diagnosis is in question. .

 PREMALIGNANT CUTANEOUS LESIONS Some histologically benign penile lesions have been recognized as having malignant potential or close association with the development of squamous carcinoma .


nevus. Cutaneous Horn The penile cutaneous horn is a rare lesion. Microscopically extreme hyperkeratosis. and acanthosis are noted. traumatic abrasion. even when initial histology is benign (Fields et al. or malignancy—and is characterized by overgrowth and cornification of the epithelium that forms a solid protuberance. These lesions may recur and demonstrate malignant change on subsequent biopsy. Treatment consists of surgical excision with a margin of normal tissue around the base of the horn. dyskeratosis. 1987 . It usually develops over a preexisting skin lesion—wart.

1967). careful histologic evaluation of the base and close follow-up of the excision site are essential (Pressman et al. Hassan et al. Because this tumor may evolve into carcinoma or may develop as a result of underlying carcinoma. . 1962.

which presents as a whitish patch on the prepuce or glans.  Balanitis Xerotica Obliterans This is a genital variation of lichen sclerosis et atrophicus. There are reports documenting the association of balanitis xerotica obliterans with squamous cell carcinoma and the development of carcinoma long after a lesion of balanitis xerotica obliterans has been treated . often involving the meatus and sometimes extending into the fossa navicularis.


steroid injection. 1967). Meatal stenosis is a common problem that often requires repeated dilations. or even formal meatoplasty (Poynter & Levy. and surgical excision. . injectable steroids. with biopsy if a change in appearance or behavior occurs.   Treatment consists of topical steroid cream. Close follow-up is essential.

. there are hyperkeratosis. Leukoplakia These lesions present as solitary or multiple whitish plaques that often involve the meatus. parakeratosis. and hypertrophy of the rete pegs with dermal edema and lymphocytic infiltration. Careful microscopic examination is necessary to determine the presence of malignancy. Histologically.

    Treatment involves elimination of chronic irritation. Bain & Geronemus. 1975. This disorder has been associated with both in situ squamous cell cancer and verrucous cancer of the penis (Hanash et al. 1989). Surgical excision and radiation have been used in the treatment of leukoplakia. 1970. and circumcision may be indicated. Reece & Koontz. Because of this close relationship with carcinoma. meticulous follow-up of the excision site with periodic biopsy of incompletely excised lesions is necessary to detect early malignant change .

 VIRAL-RELATED DERMATOLOGIC LESIONS Increasing evidence suggests that a number of penile lesions share viral etiologies. 1996. 1999). Human herpesvirus 8 (HHV-8)—also known as Kaposi’s sarcoma–associated herpesvirus—is strongly suspected to be the etiologic agent of epidemic (AIDS-related) Kaposi’s sarcoma (Miller et al. 1996. Simpson et al. Condyloma acuminatum and bowenoid papulosis appear to be related to infection with human papillomavirus (HPV). . Jaffe & Pellett.

These lesions are rare before puberty (Redman & Meachum. 1993). papillomatous growths generally considered to be benign.   Condyloma AcuminatumCondylomata acuminata are soft. 1973. Copulsky et al. Also known as genital warts or venereal warts. The lesions are soft and friable and may occur singly on a pedicle or in a moruloid cluster on a broad base. 1975) and when encountered may suggest sexual abuse (Handly et al. .

.  Treatment of these lesions with podophyllin may induce histologic changes suggestive of carcinoma (King & Sullivan. preliminary biopsy of large lesions that appear to be condylomata acuminata should precede any treatment with topical podophyllin. Consequently. 1947).

prepuce.SQUAMOUS CELL CARCINOMA  Carcinoma in SituCarcinoma in situ of the penis is called erythroplasia of Queyrat by urologists and dermatologists if it involves the glans penis. or penile shaft is called Bowen's disease if it involves the remainder of the genitalia or perineal region .

appropriately delivered radiation results in minimal morbidity (Kelley et al. Radiation therapy has successfully eradicated these tumors. 1974. When lesions are small and noninvasive.    Treatment is based on proper histopathologic confirmation of malignancy with multiple biopsies of adequate depth to determine the presence of invasion. local excision that spares penile anatomy and function is satisfactory. Circumcision adequately treats preputial lesions. 1980 . Fulguration may be successful but often results in recurrences. Grabstald & Kelley. well-planned.

CO2 laser (Rosemberg & Fuller. 1986). Graham & Helwig. 1974). 1971. 1973. 1965. 1980). 1982. There are also reports of successful treatment with Nd:YAG laser (Landthaler et al. Goette. 1969.     Topical 5-fluorouracil as the 5% base causes denudation of malignant and premalignant areas while preserving normal skin. Lewis & Bendl. . Systemic absorption of 5-fluorouracil is minimal. 1983) with excellent control and cosmetic outcome. liquid nitrogen (Madej & Meyza. Mortimer et al. Cosmetic results are excellent (Dillaha et al. Hueser & Pugh.

1990. African. 22% of patients were younger than 40 years and 7% were younger than 30 years (Dean. with an abrupt increase in incidence in the sixth decade of life and a peak around age 80 years (Persky. 1935).4% to 0. 1985).6% of all malignancies among males up to 10% of malignancies in males in some Asian. the disease has also been reported in children (Kini. In two studies. in one large series. 1973) and 55 years (Derrick et al. . 1977). 1973 younger men. Vatanasapt et al. Narasimharao et al. and South American countries (Gloeckler-Ries et al. 1944. 1995). of older men.Invasive Carcinoma      Incidence Penile carcinoma accounts for 0. the mean age was 58 years (Gursel et al.

Maiche.  phimosis.  hygienic standard.  exposure to tobacco products.  number of sexual partners. 1992.Etiology  The incidence of carcinoma of the penis varies according to  circumcision practice.  HPV infection. 1987. 1993). Maden et al. . and other factors (Barrasso et al.

a byproduct of bacterial action on desquamated cells that are within the preputial sac.   Neonatal circumcision has been well established as a prophylactic measure that virtually eliminates the occurrence of penile carcinoma. because it eliminates the closed preputial environment where penile carcinoma develops. The chronic irritative effects of smegma. have been proposed as an etiologic agent incidence of HPV infection directly correlated with number of lifetime sexual partners and that the latter was also related to risk of penile cancer. .

 Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks.Prevention  Routine neonatal circumcision has been. When circumcision is being considered. a controversial topic over time. the benefits and risks should be explained to the parents and informed consent obtained." .

 if it is untreated. penile autoamputation may occur as a late result. which gradually extends to involve the entire glans. .  The lesion may be papillary and exophytic or flat and ulcerative. and corpora. shaft.  The rates of growth of the papillary and ulcerative lesions are quite similar.Natural History  Carcinoma of the penis usually begins with a small lesion.

Penetration of Buck's fascia and the tunica albuginea permits invasion of the vascular corpora and establishes the potential for vascular dissemination . protecting the corporal bodies from invasion.  Buck's fascia acts as a temporary natural barrier to local extension of the tumor.

liver. death from inanition.  Metastases to the regional femoral and iliac nodes are the earliest route of dissemination from penile carcinoma. chronic infection. or brain are uncommon  causing death for the majority of untreated patients within 2 years . Clinically detectable distant metastatic lesions to the lung. bone. Metastatic enlargement of the regional nodes eventually leads to     skin necrosis. or hemorrhage secondary to erosion into the femoral vessels. sepsis.


warty growth or a more luxuriant exophytic lesion  on the glans (48%) and prepuce (21%). suppuration. . Other tumors involve both the glans and prepuce (9%).  Urinary retention or urethral fistula owing to local corporal involvement are rare presenting signs. pustule.  mass. ulceration.  The presentation ranges from relatively subtle induration or small excrescence to a small papule. or hemorrhage may present in the inguinal area owing to the presence of nodal metastases from a lesion concealed within a phimotic foreskin. the coronal sulcus (6%).Signs  It is the penile lesion itself that usually alerts the patient to the presence of penile cancer. 1991). or the shaft (less than 2%) (Sufrin & Huben.

. fatigue. and systemic malaise occur secondary to chronic suppuration.Symptoms  Pain does not develop in proportion to the extent of the local destructive process and usually is not a presenting complaint. weight loss. Weakness.

guilt. fear.  This level of denial is substantial. 1963. 1969). given that the penis is observed and handled on a daily basis. . Hardner et al.  15% to 50% of patients delayed medical care for more than a year (Dean. 1935. seem to delay seeking medical attention (Lynch & Krush. Buddington et al. 1973). ignorance. more than patients with other types of cancer. Explanations include embarrassment.Diagnosis  Delay  Patients with cancer of the penis. 1972. Gursel et al. and personal neglect.

 The penile lesion is assessed with regard to size. location. 1973). Johnson et al. 1973. and involvement of the corporal bodies. .Examination  At presentation. most lesions are confined to the penis (Skinner et al. Derrick et al. Inspection of the base of the penis  Careful bilateral palpation of the inguinal area for adenopathy is extremely important. 1972. fixation.

the presence of vascular invasion  the histologic grade of the lesion by microscopic examination of a biopsy specimen is mandatory before the initiation of any therapy .Biopsy  Confirmation of the diagnosis of carcinoma of the penis and assessment of the depth of invasion.

and various degrees of mitotic activity  Broders' classification to define the level of differentiation based on keratinization. number of mitoses .Histologic Features  Most tumors of the penis are squamous cell carcinomas demonstrating keratinization. nuclear pleomorphism. epithelial pearl formation.

depending on scale). whereas only 10% of tumors located in the prepuce are high-grade tumors .  Low-grade lesions (grades 1 and 2) constitute 70% to 80% of the reported cases poorly differentiated (grades 3 and 4.

Anemia. and extensive suppuration at the area of the primary and inguinal metastatic sites.Laboratory  Studies Laboratory tests in patients with penile cancer are often normal. . leukocytosis. and hypoalbuminemia may be present in patients with chronic illness. malnutrition. Azotemia may develop secondary to urethral or ureteral obstruction.

Radiologic study    cavernosography ultrasound magnetic resonance imaging (MRI). .


Staging .



 Buschke-Löwenstein tumor.  tuberculosis.  herpes.  granuloma inguinale.Differential Diagnosis  A number of penile lesions must be considered in the differential diagnosis of penile carcinoma.  condyloma acuminatum.  balanitis xerotica obliterans  chancroid.  lymphopathia venereum. .

with or without penile necrosis.TREATMENT    RPLND (retroperitoneal lymphnode desection) Chemotherapy Radiation Therapy  6000 rad) may cause urethral fistula. and edema . stricture. or stenosis. pain.

TREATMENT    Partial penectomi Total penectomi COMBINATION .

Fewer than 15 cases have been well documented (Goldminz et al.NONSQUAMOUS MALIGNANCY   Basal Cell CarcinomaAlthough basal cell carcinoma is frequently encountered on other cutaneous surfaces. 1998). 1989. Ladocsi et al. it is rare on the penis. Treatment is by local excision. which is virtually always curative .

Surface Adenosquamous Carcinoma  This is a rare tumor characterized by the presence of both glandular and squamous . Melanoma  Fewer Primary mesenchymal tumors of the penis are very rare  Sarcoma    Paget's DiseasePaget's disease of the penis is extremely rare.


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