PREMALIGNANT LESIONS AND NONSQUAMOUS MALIGNANCY OF THE PENIS AND CARCINOMA OF THE SCROTUM

Necrotising granulomatous mass of the foreskin with inguinal lymphadenopathy: a rare presentation of syphilis

We report the case of a 24-year-old man who presented with a 5-week history of painful right inguinal lymphadenopathy, weight loss and non-ulcerative foreskin mass. The patient’s symptoms progressed despite initial antibiotic therapy. The foreskin mass was clinically suspicious for squamous cell carcinoma; however, histopathology of both the foreskin mass and inguinal lymph node showed necrotising granulomatous inflammation. Extensive immunohistochemistry testing was inconclusive and could not identify a causative microorganism. Ultimately, serology was positive for Treponema pallidum and he was treated with intramuscular benzathine penicillin. This is an unusual case, which highlights the importance of extensive investigation for differential diagnoses of penile mass and exemplifies the resurgence of syphilis in developed countries.

Progression of penile cutaneous horn to squamous cell carcinoma: A case report

The current report presents the case of a 43-year-old male suffering from a penile cutaneous horn. A surgical excision of the lesion was performed and histopathology demonstrated hyperkeratosis, dyskeratosis and epithelial hyperplasia. The cutaneous horn progressed to squamous cell carcinoma <1.5 months following surgery and a partial penectomy was conducted. The International Index of Erectile Function 5 questionnaire was used to assess the patient and the score had decreased in the one-month postoperative follow-up compared with that of the preoperative period. These findings indicate that undergoing a partial penectomy on initial diagnosis of a penile cutaneous horn should be considered in order to conserve a greater quantity of the penile tissue and improve the postoperative quality of life.

2013 European guideline for the management of balanoposthitis

Balanoposthitis can be caused by a disparate range of conditions affecting the penile skin. This guideline concentrates on a selected group of conditions and offers recommendations on the diagnostic tests and treatment regimens needed for the effective management of balanoposthitis.

Epigenetic mechanisms in penile carcinoma

Penile carcinoma (PeCa) represents an important public health problem in poor and developing countries. Despite its unpredictable behavior and aggressive treatment, there have only been a few reports regarding its molecular data, especially epigenetic mechanisms. The functional diversity in different cell types is acquired by chromatin modifications, which are established by epigenetic regulatory mechanisms involving DNA methylation, histone acetylation, and miRNAs. Recent evidence indicates that the dysregulation in these processes can result in the development of several diseases, including cancer. Epigenetic alterations, such as the methylation of CpGs islands, may reveal candidates for the development of specific markers for cancer detection, diagnosis and prognosis. There are a few reports on the epigenetic alterations in PeCa, and most of these studies have only focused on alterations in specific genes in a limited number of cases. This review aims to provide an overview of the current knowledge of the epigenetic alterations in PeCa and the promising results in this field. The identification of epigenetically altered genes in PeCa is an important step in understanding the mechanisms involved in this unexplored disease.

Cutaneous scrotal metastasis: origins and clinical characteristics of visceral malignancies that metastasize to the scrotum

Cutaneous metastases occur in about 10% of patients with cancer, occasionally presenting as the initial sign of internal malignancy. Most often cutaneous metastases are an indicator of advanced cancer and are associated with a poor prognosis. The scrotum is a rare site of cutaneous metastasis, and metastatic tumor to the scrotum can be mistaken for other skin lesions. We reviewed the published literature regarding patients who developed cutaneous metastasis to the scrotum. We summarized the clinical characteristics of these men, including primary tumor sites, age at diagnosis, treatment regimens, interval between diagnosis of primary tumor and subsequent metastasis, and outcomes. We extensively searched the PubMed medical database for papers on visceral malignancies with metastasis to the scrotum. We limited our definition to solid organ tumors; thus lymphomas, sarcomas, and melanomas of the scrotum were excluded. We identified 29 patients who developed scrotal metastases from visceral cancers. The colon/rectum (34%), prostate (28%), and lung (14%) were the most frequent sites of tumor origin. The prognosis for these patients is poor: mean patient survival was only four months after diagnosis of metastatic skin lesions. Cutaneous metastasis to the scrotum is a rare manifestation of internal malignancies that most often represents an advanced and/or progressive cancer associated with a poor prognosis. Treatment is often unsuccessful, and the mean patient survival following scrotal metastasis is <4 months.

Male genital premalignant dermatoses

The spectrum of conditions affecting the penile skin is varied and ranges from simple, benign dermatoses to premalignant and malignant conditions. Recently, improved understanding of the aetiology and natural history of these conditions has shaped new treatment paradigms and a functional knowledge of dermatology, urology and genitourinary medicine is required to successfully diagnose and treat these men. In this article, we explore the common precancerous states that can lead to penile carcinoma and review the recent advances with regards to the molecular basis for these dermatoses and the treatments that may be most effective for these men.

Basal cell carcinoma of the scrotum: clinicopathologic analysis of 10 cases

BACKGROUND

Basal cell carcinoma (BCC) located on the scrotum is rare.

OBJECTIVE

To analyze clinical and pathologic features, discuss therapeutic strategies, and identify prognostic factors of scrotal BCC in Chinese patients.

MATERIALS AND METHODS

Between 2000 and 2010, 10 patients with scrotal BCC were diagnosed and treated at our institution. A review was performed using the clinical records and dermatopathologic slides of these patients.

RESULTS

The median patient age was 70. Skin lesions presented as red nodules and brownish plaques. All patients were treated using wide excision without adjuvant therapy. After an average follow-up of 47 months, eight patients were in good health without any relapse. One patient developed left inguinal lymph node metastasis at 21 months that was successfully treated using bilateral inguinal lymphadenectomy. One patient developed bilateral pulmonary metastasis at 48 months and was palliatively treated with chemotherapy. The clinical and histopathologic risk factors predisposing to metastasis were large primary neoplasms; a long period of misdiagnosis; and infiltrating, morpheaform, spiky, irregular outline pathologic patterns.

CONCLUSIONS

BCC of the scrotum is rare. It can metastasize after a long period of initial therapy. Long-term surveillance including a complete metastatic examination is recommended for these patients.

Primary large-cell neuroendocrine carcinoma of the scrotum

Neuroendocrine tumors (NETs) mostly develop from the neural crest cells but a few arise from neuroectoderm. They are common in the lungs and gastrointestinal tract but rare in the genitourinary tract. A 78-year-old man with no family history of malignant or hereditary diseases presented with a 3-month history of a rapidly growing asymptomatic scrotal nodule and swelling in the groin. He had a negative history of sexually transmitted disease and of trauma, fungal infection or chronic irritation in the scrotal area; there was no history of radiotherapy or exposure to chemicals or arsenic. Both the scrotal and groin lesions were excised with a minimum of 1.2 cm of normal skin. Examination of the specimen revealed a confined poorly differentiated large-cell neuroendocrine carcinoma with a metastasis to the inguinal lymph nodes. Three months after the excision we found a local recurrence. The recurrent tumor revealed tumor tissue concurrent with the primary lesion. To the best of our knowledge, there have been no previously published case reports on neuroendocrine tumor of the scrotum.

The usefulness of a diagnostic biopsy clinic in a genitourinary medicine setting: recent experience and a review of the literature

Genital diseases include a wide range of lesions e.g. infectious and inflammatory. In most cases a clinical diagnosis is reached without the need for a biopsy. Nonetheless, a genital biopsy is safe and may help to confirm the diagnosis. We established a dedicated diagnostic biopsy clinic in 2003. Our objective was to evaluate the effectiveness of our diagnostic biopsy clinic and compare it with other Genitourinary medicine (GUM) clinics in the UK. A retrospective case-note study was performed on 71 patients referred to the biopsy clinic with persistent genital lesions over a 12-month period. Forty-seven biopsies were performed (71% biopsy rate). 43 specimens (92%) were appropriate for histopathological diagnosis. Of these 15% were lichen planus, 15% lichen sclerosis, 10% psoriasis, 7.5% each: eczema, Zoon's and non-specific balanitis. The remainder represented a variety of other conditions. In 27 cases (68%) the clinical diagnosis was consistent with the histological result. The possibility of self-referral and walk-in nature of our GUM service substantially decrease the waiting times for assessment of anogenital disorders. We had a lower biopsy rate for the diagnosis of non-specific balanitis (7.5%) compared with the average rate (21.5%) in 14 UK GUM clinics and good agreement between clinical and histological diagnosis. An empirical first treatment, with simple emollients before biopsy, appears to be a safe clinical approach for the treatment of non-specific balanitis. A multidisciplinary approach (GUM physicians, dermatologists and urologists/gynaecologists) could help prevent unnecessary biopsies and improve correlation between clinical and histological diagnosis.

Penile cancer

Penile cancer, while relatively rare in the western world, remains a disease with severe morbidity and mortality, not to mention significant psychological ramifications. Furthermore, the disease is observed with dramatically increased incidence in other parts of the world. A review of the literature has shown that the overwhelming majority of penile cancers are in situ or invasive squamous cell carcinomas, including a well-differentiated variant, verrucous carcinoma. Important predisposing factors are lack of circumcision, human papillomavirus infections, and penile lichen sclerosus, although other factors have occasionally been reported as well. Prevention, careful monitoring of patients at risk, and early diagnosis are essential to reduce the incidence of penile carcinoma and to provide a definitive cure. Public health measures, such as prophylactic use of circumcision, have proved successful but are controversial. Also, no standard therapeutic guidelines as to the best treatment strategy according to different stages, including efficacy of conservative nonsurgical modalities and indications for lymph nodal dissection, are available so far. It is common opinion that penile cancer is an emerging problem that deserves further investigations, and physicians, especially dermatologists, should be aware of this issue.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with penile carcinoma, its risk factors, its clinical and histologic presentation, and the treatments currently available for its management.

Cancer of the penis

Cancer of the penis is rare in Europe, accounting for less than 0.5% of all cancers. Phimosis and poor hygiene are strong risk factors whereas neonatal circumcision is a contributing factor in the prevention of this disease. More than 95% of penile carcinomas are squamous cell carcinomas. Early disease (stage I-II) is curable in most patients, who can be treated by conventional penile amputation or, in selected cases, by organ preserving techniques, including Moh's micrographic surgery, laser ablation or radiation therapy (external-beam, brachytherapy). For more advanced primary tumours, penile amputation is required. Survival of patients with penile cancer is strongly related to the presence and extent of nodal metastases. Bilateral inguinal lymphadenectomy is recommended for palpable lymph nodes that persist 3 or more weeks after removal of the primary tumour and a course of antibiotic therapy. In patients with proven inguinal lymph node metastases, bilateral ileoinguinal dissection should be performed. When the nodes are clinically negative, "prophylactic" inguinal lymphadenectomy may be a reasonable approach in patients with invasive tumours (T2 or greater), high grade tumours, or tumours exhibiting vascular invasion. The role of chemotherapy, as adjuvant and neoadjuvant or primary treatment in metastatic disease, needs to be further explored in prospective clinical trials.

Invasive Penile Carcinoma: A Review

BACKGROUND

Penile carcinoma is an invasive epithelial tumor that may arise from penile skin or mucosa.

OBJECTIVE

To review the pathogenesis and the clinical and histopathologic features of invasive penile carcinomas, with emphasis on current guidelines for their diagnosis and treatment.

METHODS

Information available from the authors' clinical experience, review articles, case reports, clinical trials, and in vitro research studies identified from a computerized literature search on MEDLINE database and from Meetings' Abstract Books, including those from non-English literature, was considered.

RESULTS

Penile cancer may develop de novo or in association with underlying factors. Conditions predisposing to the development of penile cancer are delineated. The diagnosis should be suspected by clinical findings and must be confirmed histologically. Imaging techniques may be useful for staging and planning therapy. Therapeutic options include excisional surgery, laser destruction, cryosurgery, radiotherapy, immunotherapy, and chemotherapy.

CONCLUSIONS

Although there are no current guidelines for the treatment of penile carcinoma, surgical ablation probably represents the best option, as conservative treatments still deserve cautious evaluation because of the relatively small number of treated patients and the lack of good-quality comparative data. Regarding indications for lymph nodal dissection in patients showing no inguinal node enlargement, sentinel node mapping with targeted lymph node dissection is recommended for those with deeply invasive, high-grade tumors, whereas a watchful waiting may be advised for those with superficially invasive, low-grade tumors.

A rare case of primary malignant melanoma of the scrotum diagnosed by fine-needle aspiration

We report a case of a 55-yr-old man with malignant melanoma of scrotum. He was referred to our Hospital with a complaint of gradual focal enlargement of the scrotum in a period of 3 yr. On physical examination, a pigmented, poorly marginated mass, with central necrosis was observed. A fine-needle aspiration (FNA) of the lesion was performed. Cytological examination revealed highly cellular smears, containing malignant cells, dispersed or arranged in loose aggregates. Cellular morphology and characteristics were identical to those of malignant melanoma arising elsewhere in the skin. The immunocytochemical study revealed positivity of neoplastic cells for anti-melanoma monoclonal antibody (HMB-45) antigen. Histological confirmation finally was provided after wide excision of the lesion. We emphasize the difficulties in differential diagnosis considerations and diagnostic pitfalls of scrotal lesions.

Cancer of the penis

BACKGROUND

Cancer of the penis is an uncommon malignancy in developed countries, but the incidence is as high as 17% of all male cancers in some undeveloped countries. The surgical management of this disease has improved due to better knowledge of risk for metastasis and newer imaging technologies to assess the regional lymph nodes.

METHODS

We review the literature on incidence, etiology, pathology, clinical presentation, staging, and management of penile cancer. We present our institutional experience with 160 patients who underwent extended ilioinguinal lymph node dissection, as well as with 7 patients who underwent a modified lymph node dissection.

RESULTS

Better understanding of pathologic features allow for stratification of patients into low, intermediate, or high risk for lymph node involvement. Lymphatic mapping to this stratification improves selection of patients who might benefit from lymph node dissection after excision of the primary lesion. Our experience with lymph node dissection yielded a high incidence of positive lymph nodes when lymphadenopathy was present. The recent use of a modified lymph node dissection has minimized morbidity. Current chemotherapy agents are ineffective in this disease.

CONCLUSIONS

Pathologic features of the primary lesion and the incorporation of lymphatic mapping have improved the selection of patients who might benefit from lymph node dissection. The use of a modified lymph node dissection in selected patients has decreased morbidity. Effective chemotherapy agents are needed in the management of advanced penile cancer.

Diagnosis and clinical presentation of premalignant lesions of the penis

Although a considerable number of penile cancers may arise de novo, certain potentially premalignant conditions do exist. We account in some detail for precancerous growths, which may initially be misclassified and not submitted to proper therapy and follow-up. At one end of the spectrum disorders exist that are generally considered as medically benign, such as warty tumors; at the other end growths occur that are highly indicative of being potentially invasive, i.e. giant condylomas, bowenoid papulosis, eythroplasia of Queyrat and Bowen's disease. We also focus on elucidating the clinical behavior of some inflammatory conditions, which may either be of pathogenic significance for squamous cell carcinoma development or give rise to differential diagnostic problems, most importantly lichen sclerosus et atrophicus (balanitis xerotica obliterans). We advocate a vigilant approach for histopathological evaluation whenever any clinical diagnostic uncertainty or therapeutic recalcitrance exists. We also favor the administration of highly active topical therapy against penile chronic inflammatory conditions such as lichen sclerosus et atrophicus, careful clinical follow-up of these cases and surgical treatment of phimosis.

Clinicopathologic variants of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinomas (SCC) are one of the most common malignancies, which, with early recognition, may be curable. These tumors represent a broad spectrum of disorders with many significant clinical, morphologic, and etiologic distinctions. The objective of this article is to review the important clinicopathologic features of SCC with particular emphasis on important recent developments, practical application, and their relevance to the practice of pathology. The most pertinent literature of the last 5 years was reviewed and capsulized. Appropriate histologic interpretation and clinical management of patients with cutaneous SCC requires a comprehensive understanding of the latest advances in the broad field of dermatopathology. Squamous cell carcinoma of the skin represents a complex group of disease subtypes, each with its own characteristics, which may influence morphologic diagnosis as well as treatment and clinical management.

Basal cell carcinoma of the scrotum

An 80-year-old man with a 7 year history of a slowly enlarging, asymptomatic scrotal nodule is presented. He had a negative history for sexually transmitted disease, trauma to the area, radiotherapy and chemical or arsenic exposure. The lesion was excised with a margin of 0.8 cm of normal skin. Examination of the specimen revealed a basal cell carcinoma.

Erythroplasia of Queyrat treated by topical aminolaevulinic acid photodynamic therapy

Erythroplasia of Queyrat (EQ) is an intraepithelial carcinoma in situ affecting the mucosal surfaces of the penis, with a significant risk of invasion and metastasis. Treatment is often difficult and is associated with significant recurrence rates. Topical 5-aminolaevulinic acid (ALA) photodynamic therapy (PDT) combines a photosensitizer precursor and visible light to produce a photodynamic effect. It has been used successfully to treat benign, premalignant and malignant skin diseases. We present four patients with EQ who have been treated by topical ALA PDT. Of two patients with limited disease one has achieved a long-term complete response (36 months) and the other developed a recurrence at 18 months after a complete response. Two further patients with more extensive disease achieved a significant improvement, allowing easier treatment by laser vaporization. Although topical ALA PDT offers the advantages of tumour specificity, preservation of function and a good cosmetic result, more extensive EQ appears less responsive to this new therapeutic modality using current treatment parameters.

Cumulation of TP53 mutations and p16INK4A/p15INK4B homozygous deletions in human papilloma virus type 16 positive scrotal cancer

Scrotal cancer is the first described occupational cancer. The frequency of occupation-related scrotal cancer is very rare because of better hygiene and protective clothing. Human papilloma viruses (oncogenic types 16 and 18) were reported as the causative agents in the pathogenesis of scrotal cancers. E5, E6, and E7 proteins, expressed by human papilloma virus type 16, affect the cell cycle at the G1 checkpoint. TP53, p16INK4A, and p15INK4B were reported as the transcription factors that regulate the cell cycle on the same pathway. Here, the mutation pattern of TP53, p16INK4A, and p15INK4B genes and the homo/hemizygous deletion patterns of p16INK4A/p15INK4B genes are presented in four scrotal carcinoma cases. The results were correlated with the findings of oncogenic human papilloma viruses (types 16 and 18) in this panel. In two of four case, human papilloma virus type 16 was observed. Homozygous deletion in p16INK4A/p15INK4B genes and a codon 259 missense point mutation (GAC-->TAC; Asp-->Tyr) in the TP53 gene were observed in one human papilloma positive scrotal carcinoma case. The homozygous deletion in p16INK4A/p15INK4B genes was observed in another human papilloma positive scrotal carcinoma case. The cumulation of TP53 mutations and p16INK4A/p15INK4B homozygous deletions in human papilloma virus type 16 positive scrotal carcinoma cases indicate that the alterations of TP53, p16INK4A, and p15INK4B genes have an important role in the progression of scrotal cancers, as well as other factors. The survival rate for the two human papilloma virus type 16 positive patients who had a TP53 mutation or p16INK4A/p15INK4B homozygous deletion or both was lower than that for the human papilloma virus type 16 negative cases who had no TP53, p16INK4A, and p15INK4B mutation. The molecular alteration of TP53, p16INK4A, and p15INK4B genes may be useful as a prognostic marker in scrotal cancer.

Male genital cancers

Each type of male genital cancer has features that are unique in diagnosis and treatment. The incidences of these cancers are related to age, race, and environment. Early diagnosis and treatment are documented as important for all male genital cancers except prostate cancer, where this remains a subject of controversy.

Squamous cell carcinoma of the penis

Penile tumors, although not frequent, represent a difficult diagnostic and therapeutic challenge. Of the malignant penile neoplasms, the most frequent is penile carcinoma, which includes squamous cell carcinoma and its well-differentiated variant, verrucous carcinoma. Current concepts about classification, epidemiology, pathogenesis, histopathology, diagnosis, staging, prognosis, and treatment are presented.

Carcinoma in situ of the penis

Bowen's disease, erythroplasia of Queyrat and bowenoid papulosis are uncommon disorders of the anogenital skin that may be confused with a variety of other lesions. While all appear histologically as carcinoma in situ and are strongly associated with human papillomavirus infection, only Bowen's disease and erythroplasia of Queyrat have been demonstrated to lead to the development of invasive squamous cell carcinoma. In contrast, bowenoid papulosis has a completely benign course with no present evidence suggesting the potential for malignant degeneration. The standard treatment for all 3 lesions in surgical excision, although use of the carbon dioxide or neodymium:YAG laser appears to be effective at obtaining local control of disease while achieving an excellent cosmetic result. Alternative treatments with micrographic surgery, topical 5-fluorouracil or radiotherapy have a more limited role. It is important to remember that adequate biopsies are always necessary to ensure a complete and accurate diagnosis, and allow for proper treatment and followup, as well as appropriate counseling of sexual partners.

Composition of the inflammatory infiltrate in pediatric penile lichen sclerosus et atrophicus (balanitis xerotica obliterans): a prospective, comparative immunophenotyping study

Dermatopathological evaluation of pediatric preputial inflammatory disease rarely allows for specific diagnosis other than pediatric penile lichen sclerosus et atrophicus (balanitis xerotica obliterans, LSA/BXO). A prospective immunopathological study was performed on 20 consecutive, unselected, clinically and histopathologically confirmed LSA/BXO cases to determine the relative presence of T and B lymphocytes. There were seven cases with early stages of disease, eight with florid disease, and five with later stages of disease. Two ritual circumcision specimens and 12 specimens with non-LSA/BXO balanitis, collected during the same period, were used as controls. The infiltrate in LSA/BXO patients was wholly composed of T cells (positive with UCLH-1 antibody) in all cases. B cells (positive with L-26 antibody) were found only focally in small, discreet, easily recognizable (follicular or early follicle-like) aggregates, positioned slightly deeper than the band-like infiltrate of T cells. T cells were inconspicuous in 9 of the 12 control specimens. In the three other controls, T cells were much more obvious and these patients showed clinical features possibly suggestive of LSA/BXO in early, prediagnosable phases of development. We conclude that limited immunophenotyping may be a useful adjunct to diagnosis in pediatric cases in which only limited tissue is available or the disease may be more difficult to classify with confidence.