A 38-year-old man presented with a fleshy lesion beneath the tip of his penis. He had discovered it about 18 months before the initial evaluation. A second similar lesion resembling a “cauliflower” had appeared several weeks after the first. Both lesions had grown and had begun to bleed during intercourse.
A 38-year-old man presented with a fleshy lesion beneath the tip of his penis. He had discovered it about 18 months before the initial evaluation. A second similar lesion resembling a “cauliflower” had appeared several weeks after the first. Both lesions had grown and had begun to bleed during intercourse. The patient had been circumcised in infancy and underwent a meatotomy for correction of hypospadias. He denied any history of sexually transmitted diseases. The lesions measured 2.8 and 0.8 cm and had a verrucous appearance. No bleeding, excoriation, or lymphadenopathy (A and B) were noted. The remainder of the physical examination was unremarkable. The patient was referred to a urologist. A biopsy of a penile lesion confirmed the diagnosis of carcinoma of the squamous cell type. Fewer than 1% of malignancies that affect men in the western hemisphere are penile cancers1; the vast majority of those that do occur (over 95%) are squamous cell carcinomas.2 Their cause remains unclear; some investigators suggest an association with the human papillomavirus (HPV) type 16.3 Two recent studies found that late circumcision, multiple sex partners, a history of HPV infection, and smoking are epidemiologic risk factors.3,4 Squamous cell carcinoma of the penis usually appears as a fleshy growth with an area of erythema. In another patient, a squamous cell carcinoma of the penis manifested as a verrucoid red plaque on the proximal shaft (C). As the lesion enlarges, an itching or burning sensation can evolve into pain, and a nodule or mass that often becomes verrucous may develop along with a foulsmelling discharge. With neoplastic extension, bleeding, fistulization, and lymphagenous dissemination can occur. Enlarged inguinal lymph nodes may be a clue to the diagnosis. Ultrasonography or MRI can help delineate the degree of disease infiltration. CT scans of the abdomen and pelvis can help detect pelvic lymphatic involvement. A chest film and a bone scan may be required to determine the extent of malignancy.5 The Table outlines the staging of penile carcinoma, which can influence treatment choice. The staging system is not correlated with prognosis; the single best prognostic indicator of survival is the degree of lymph node involvement.6,7 Local excision and circumcision are appropriate for patients with lesions smaller than 2 cm, which are usually less invasive. About 90% of such patients remain alive at 5 years. Penectomy and urethrostomy are performed on those whose lesion is at least 2 cm and who have no nodal involvement. The 5-year survival for these patients is between 80% and 90%. Radiation therapy and chemotherapy have limited success in patients with advanced disease. Chemotherapeutic agents include cisplatin, bleomycin, methotrexate, vincristine, and 5-fluorouracil. Despite treatment, fewer than 50% of patients with involved lymph nodes survive for 5 years.8 This patient underwent a radical penectomy immediately after the disease was confirmed. Postoperative care and emotional support and guidance were given. The patient died 6 weeks after surgery. (Case and photographs A and B courtesy of Dr Steven N. Glavas; photograph C courtesy of Dr Reynold C. Wong.)