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 glandsmay 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).

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

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

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

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

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

Balanitis Xerotica Obliterans This is a genital variation of lichen sclerosis et atrophicus, which presents as a whitish patch on the prepuce or glans, often involving the meatus and sometimes extending into the fossa navicularis. 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

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

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

Treatment involves elimination of chronic irritation, and circumcision may be indicated. Surgical excision and radiation have been used in the treatment of leukoplakia. This disorder has been associated with both in situ squamous cell cancer and verrucous cancer of the penis (Hanash et al, 1970; Reece & Koontz, 1975; Bain & Geronemus, 1989). 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. Condyloma acuminatum and bowenoid papulosis appear to be related to infection with human papillomavirus (HPV). Human herpesvirus 8 (HHV-8)also known as Kaposis sarcomaassociated herpesvirusis strongly suspected to be the etiologic agent of epidemic (AIDS-related) Kaposis sarcoma (Miller et al, 1996; Simpson et al, 1996; Jaffe & Pellett, 1999).

Condyloma AcuminatumCondylomata acuminata are soft, papillomatous growths generally considered to be benign. 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. These lesions are rare before puberty (Redman & Meachum, 1973; Copulsky et al, 1975) and when encountered may suggest sexual abuse (Handly et al, 1993).

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

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, prepuce, or penile shaft is called Bowen's disease if it involves the remainder of the genitalia or perineal region

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

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

Invasive Carcinoma

Incidence Penile carcinoma accounts for 0.4% to 0.6% of all malignancies among males up to 10% of malignancies in males in some Asian, African, and South American countries (Gloeckler-Ries et al, 1990; Vatanasapt et al, 1995). of older men, with an abrupt increase in incidence in the sixth decade of life and a peak around age 80 years (Persky, 1977). In two studies, the mean age was 58 years (Gursel et al, 1973) and 55 years (Derrick et al, 1973 younger men; in one large series, 22% of patients were younger than 40 years and 7% were younger than 30 years (Dean, 1935); the disease has also been reported in children (Kini, 1944; Narasimharao et al, 1985).

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

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, a byproduct of bacterial action on desquamated cells that are within the preputial sac, 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.

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

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

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

Metastases to the regional femoral and iliac nodes are the earliest route of dissemination from penile carcinoma. Metastatic enlargement of the regional nodes eventually leads to

skin necrosis, chronic infection, death from inanition, sepsis, or hemorrhage secondary to erosion into the femoral vessels. Clinically detectable distant metastatic lesions to the lung, liver, bone, or brain are uncommon

causing death for the majority of untreated patients within 2 years

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

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

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

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

Biopsy Confirmation of the diagnosis of carcinoma of the penis and assessment of the depth of invasion, 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

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

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

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

Radiologic study

cavernosography ultrasound magnetic resonance imaging (MRI).

MRI

Staging

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

TREATMENT

RPLND (retroperitoneal lymphnode desection) Chemotherapy Radiation Therapy

6000 rad) may cause urethral fistula, stricture, or stenosis, with or without penile necrosis, pain, and edema

TREATMENT

Partial penectomi Total penectomi COMBINATION

NONSQUAMOUS MALIGNANCY

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

Melanoma

Fewer Primary mesenchymal tumors of the penis are very rare

Sarcoma

Paget's DiseasePaget's disease of the penis is extremely rare. Surface Adenosquamous Carcinoma

This is a rare tumor characterized by the presence of both glandular and squamous

MATUR NUWUN NOPO WONTEN PITAKENAN..??