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An Unusual Case of Penile Carcinoma
THE JOURNAL OF l.JROT,OGY
Vol. 69, No. 4, April Hl53 Printed in L".S.A.
A~ t:>JUSUAL CASE OF PENILE CARCINOMA PAUL H. REITMAN
From the T11rnor Clinic, Michael Reese Hospital, Chica.go, Ill.
Carcinoma of the penis, though not uncommon, is a relatively infrequent leRiori in the United States. Approximately 2.5 per cent, of all carcinomas in the males of thiR country are found on the penis. A slightly lower incidence exists in England, while that for Europe as a whole is about 5 per cent. Carcinoma of the penis reaches its highest incidence in certain Asiatic countries: Siam, Tonkin, Ja,·a, 19 per cent.; China 18 per cent; non-Moslem India, 10 per cent. 1 It is relatively infrequent among the l\fohammedans of India and in the other Mmdern nations. Dean has reported the only case of penile carcinoma in a Jewish male, and this had itfi origin in the scar of a previously cauteriied luetic lesion. 2 HmYeYer infrequent the lesio11, the subject of carcinoma of the penis has been adequately c-oYered and reYie1Yed many times in medical literature and from all viewpoints, etiology, 3 racial immunity,4 the prophylaxis of eireumcision, 5 earc-inogenicity of smegma, 6 significance of pre-existing lues,7 methods of t.herapy.8· 9 · rn It would be redundant to repeat such an accounting. However, since there has been only one reported. ease of carcinoma of the penis in a circumcized Je,Yish male, we helie-ve that the report of a sernnd case 1nmld be of inter-est. CASE REPORT
A 73 year old .Je,,ish male had undergone a ritual circumcision on the eighth day after birth. He was first see11 in the Tumor Clinic of Michael Reese Hospital on December 5, 1951, eighteen months after the onset, of his disease. The leRion had its origi11 as a small red papule on the shaft of the penis, near the glans. H gradually ukerated and increased in size until it involved the entire don,um and lateral ,mrfaces of the shaft, of the penis. All this time the patient had been under care of ,.;everal dermatologists ,Yho had made a variety of diagnoses and. had instituted a nl,riety of therapeutics. The lesion had been considered a dermatitis ,•eneuata, au eczematoid dermatitis, a chronic granuloma. Physical examination revealed an extensive, red, weeping, crusted lesion on the dorsum of the penis measuring ;-3 by-± cm. (fig. l, A_ and B). The lesion appeared Accepted for publication J\Tay D, 1952. 1 Ackerman, L. V cleJ Regn.to, J A.· Cancer, Diagnosis, Treatment, Prognosis. Sr,. Louis: C \' :\Iosl,y , 1948 2 Dean, A. L. Jr.: Epithelion:m of the penis in a Jew who was circumcized in early !Il·· fancy. Tr. Arn. A. Ge11ito-Urin. Surg., 29: 493, 1936. 3 Schrek, R. aml Linowitz, I-I.: Etiologic factors in carcinoma of Llw penis. Cancer Resca.rch, 7: 180, 1D47. 4 Cnck, Sir Standford· The naturnl history of malignant clise[1Sc. Brit. J. Rad., 22: :-n, 1949.
Bleich, A. R.: Prophyla:l\.is of penile c:ucinoma. J. A. :vi A., 143: 1054, Hl50. Blaut, A. and Kohn-Spevcr, A. C.: The cn.rcinogenic action of smegma. Scie11ce, 104: 3\l, 1D4\l. 'Willis, R. A .. Pathology of Tumors, St. Louis: C. V. l\fosby Co., 1948. 8 Zausncr, J .. Penile ca.reinorna. Radiol., 50: 786, Hls18. " Engelstad, R. B.: Treatment of cancer of the penis at the Norwegian Radium Hospital. Arn. J. Roentg1,noL arnl R:id. Therapy, 60: 801, 1948. 10 LinmYit,z, H., Grab<1m, A. D.: Carcinoma oI the pe11is. J. Crol., 56: 458. Hl46. 547 5
0
548
PA UL H. REITMAN
Fm. 1
Fw.2
to be superficial and there was no induration of its edges or of the underlying tissues. The patient complained of severe itching and pain in the involved area. There was no evidence of regional lymphadenopathy. Because of the progressive
PENILE CARCINOMA
549
nature of the lesion and its failure to respond to the previously administered medications such as boric acid soaks, calamine lotion, zinc oxide, aqua calcis, tyrothricin, we suspected malignancy and a biopsy was taken. lV[icroscopic sections showed a markedly thickened squamous epithelium covering a vascularized fibrous tissue densely infiltrated with round cells. The epithelial cells differed markedly in size and were in disorderly arrangement ,vithin the epidermis. Mitotic figures were present in the corneum and basalis stratum. Basal cells penetrated the underlying tissues in several foci. The microscopic diagnosis was squamous cell carcinoma (figs. 2 and 3). Radium was chosen as t,he therapy of choice because of the extreme superficial nature of the lesion. Amputation was deemed too drastic for such a locally limited lesion as described. A special radium mold was constructed to adequately cover the involved area and a margin of 1 cm. around all borders. The radium
FIG. 3
content of the plaque was 100 mg., consisting of twenty 5-mg. tubes of radium distributed uniformly over the convex surface of the mold made to fit the dorsum and lateral surfaces of the penile shaft. A dose of 3000 mgh, equivalent to 6000 gamma roentgen, was administered to the base of the lesion in seven treatments over a period of 8 days, from December 10 through December 17, 1951. The treatment periods to achieve such a dose were 3~5 hours daily. A uniform radiation reaction appeared ,Yithin 2 weeks, covering the whole dorsum with a moisi, epidermite. This regressed gradually until on January 29, 1952, the lesion was 90 per cent healed, and only a small area of residual epidermite remained (fig, 1, By February 19, 1952, two months after the treatment had been completed, the radiation reaction had completely subsided and the lesion healed (fig. 1, . The patient was asymptomatic. The patient remained free of disease when last seen December 1952. In summary, an unusual case of penile carcinoma has been presented. The lesion is of interest since it is doubly rare, occurring as it did, localized to the shaft of the penis, of a cireumcized Jewish male.
Vol. 69, No. 4, April Hl53 Printed in L".S.A.
A~ t:>JUSUAL CASE OF PENILE CARCINOMA PAUL H. REITMAN
From the T11rnor Clinic, Michael Reese Hospital, Chica.go, Ill.
Carcinoma of the penis, though not uncommon, is a relatively infrequent leRiori in the United States. Approximately 2.5 per cent, of all carcinomas in the males of thiR country are found on the penis. A slightly lower incidence exists in England, while that for Europe as a whole is about 5 per cent. Carcinoma of the penis reaches its highest incidence in certain Asiatic countries: Siam, Tonkin, Ja,·a, 19 per cent.; China 18 per cent; non-Moslem India, 10 per cent. 1 It is relatively infrequent among the l\fohammedans of India and in the other Mmdern nations. Dean has reported the only case of penile carcinoma in a Jewish male, and this had itfi origin in the scar of a previously cauteriied luetic lesion. 2 HmYeYer infrequent the lesio11, the subject of carcinoma of the penis has been adequately c-oYered and reYie1Yed many times in medical literature and from all viewpoints, etiology, 3 racial immunity,4 the prophylaxis of eireumcision, 5 earc-inogenicity of smegma, 6 significance of pre-existing lues,7 methods of t.herapy.8· 9 · rn It would be redundant to repeat such an accounting. However, since there has been only one reported. ease of carcinoma of the penis in a circumcized Je,Yish male, we helie-ve that the report of a sernnd case 1nmld be of inter-est. CASE REPORT
A 73 year old .Je,,ish male had undergone a ritual circumcision on the eighth day after birth. He was first see11 in the Tumor Clinic of Michael Reese Hospital on December 5, 1951, eighteen months after the onset, of his disease. The leRion had its origi11 as a small red papule on the shaft of the penis, near the glans. H gradually ukerated and increased in size until it involved the entire don,um and lateral ,mrfaces of the shaft, of the penis. All this time the patient had been under care of ,.;everal dermatologists ,Yho had made a variety of diagnoses and. had instituted a nl,riety of therapeutics. The lesion had been considered a dermatitis ,•eneuata, au eczematoid dermatitis, a chronic granuloma. Physical examination revealed an extensive, red, weeping, crusted lesion on the dorsum of the penis measuring ;-3 by-± cm. (fig. l, A_ and B). The lesion appeared Accepted for publication J\Tay D, 1952. 1 Ackerman, L. V cleJ Regn.to, J A.· Cancer, Diagnosis, Treatment, Prognosis. Sr,. Louis: C \' :\Iosl,y , 1948 2 Dean, A. L. Jr.: Epithelion:m of the penis in a Jew who was circumcized in early !Il·· fancy. Tr. Arn. A. Ge11ito-Urin. Surg., 29: 493, 1936. 3 Schrek, R. aml Linowitz, I-I.: Etiologic factors in carcinoma of Llw penis. Cancer Resca.rch, 7: 180, 1D47. 4 Cnck, Sir Standford· The naturnl history of malignant clise[1Sc. Brit. J. Rad., 22: :-n, 1949.
Bleich, A. R.: Prophyla:l\.is of penile c:ucinoma. J. A. :vi A., 143: 1054, Hl50. Blaut, A. and Kohn-Spevcr, A. C.: The cn.rcinogenic action of smegma. Scie11ce, 104: 3\l, 1D4\l. 'Willis, R. A .. Pathology of Tumors, St. Louis: C. V. l\fosby Co., 1948. 8 Zausncr, J .. Penile ca.reinorna. Radiol., 50: 786, Hls18. " Engelstad, R. B.: Treatment of cancer of the penis at the Norwegian Radium Hospital. Arn. J. Roentg1,noL arnl R:id. Therapy, 60: 801, 1948. 10 LinmYit,z, H., Grab<1m, A. D.: Carcinoma oI the pe11is. J. Crol., 56: 458. Hl46. 547 5
0
548
PA UL H. REITMAN
Fm. 1
Fw.2
to be superficial and there was no induration of its edges or of the underlying tissues. The patient complained of severe itching and pain in the involved area. There was no evidence of regional lymphadenopathy. Because of the progressive
PENILE CARCINOMA
549
nature of the lesion and its failure to respond to the previously administered medications such as boric acid soaks, calamine lotion, zinc oxide, aqua calcis, tyrothricin, we suspected malignancy and a biopsy was taken. lV[icroscopic sections showed a markedly thickened squamous epithelium covering a vascularized fibrous tissue densely infiltrated with round cells. The epithelial cells differed markedly in size and were in disorderly arrangement ,vithin the epidermis. Mitotic figures were present in the corneum and basalis stratum. Basal cells penetrated the underlying tissues in several foci. The microscopic diagnosis was squamous cell carcinoma (figs. 2 and 3). Radium was chosen as t,he therapy of choice because of the extreme superficial nature of the lesion. Amputation was deemed too drastic for such a locally limited lesion as described. A special radium mold was constructed to adequately cover the involved area and a margin of 1 cm. around all borders. The radium
FIG. 3
content of the plaque was 100 mg., consisting of twenty 5-mg. tubes of radium distributed uniformly over the convex surface of the mold made to fit the dorsum and lateral surfaces of the penile shaft. A dose of 3000 mgh, equivalent to 6000 gamma roentgen, was administered to the base of the lesion in seven treatments over a period of 8 days, from December 10 through December 17, 1951. The treatment periods to achieve such a dose were 3~5 hours daily. A uniform radiation reaction appeared ,Yithin 2 weeks, covering the whole dorsum with a moisi, epidermite. This regressed gradually until on January 29, 1952, the lesion was 90 per cent healed, and only a small area of residual epidermite remained (fig, 1, By February 19, 1952, two months after the treatment had been completed, the radiation reaction had completely subsided and the lesion healed (fig. 1, . The patient was asymptomatic. The patient remained free of disease when last seen December 1952. In summary, an unusual case of penile carcinoma has been presented. The lesion is of interest since it is doubly rare, occurring as it did, localized to the shaft of the penis, of a cireumcized Jewish male.