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Penile Horn: Review of Literature With 3 Case Reports
THE JO"GRKAL OF UROLOGY
Vol. 97, Feb.
Copyright© 1967 by The Williams & Wilkins Co.
Pritded 'in U.S . .!i.
PE:NILE HORN: REVIEW OF LITERATURE WITH 3 CASE REPORTS ABDUL A. HASSAN, ARSENIO M. ORTEZA
AND
D. FRANKLIN rdILAl\I
From the Department of Surgery, Division of Urolo({Y, West Virginia University Jl1edical Center, JV1organtown, West Virginia
Cutaneous horns are peculiar forms of cutaneous warts characterized by excessive and increasing keratosis or over-growth of cornified epithelium which develops from a wart or acanthosis. 1 The rate of growth is often rapid and the horn can become quite large in a short period of time. Taylor reported a penile horn 3 inches long 1Yhich was formed in 6 months. 2 The most common site of cutaneous horns is the scalp. In a review of the literature ,rn found 28 cases reported in Europe; 3 - 16 and 10 cases reported in America. The first ca,c;e was reported by P. A. Jewett in 185417 and subsequently 9 cases have been reported.1 8 - 26 VVe have seen three of these cutaneous penile lesions.
CASE REPORTS
Case 1. A 28-year-old white man ,ms admitted to the West Virginia University Hospital 50-33) on February 8, 1966 for treatment of complications of cerebral palsy. There waN a cornified, slightly tender and fixed ulcerative lesion 2 by 2 cm. on the anterior .,nrfaee of the glans penis which had been present for 13 yea.rn (fig. 1). Inguinal lymph nodes were not All laboratory studies 1vere normal and the ehm,t.
Accepted for publicat1011 April 15, 1966. 1 Ewing, J.E.: Neoplastic Disease. Philadelphia: W. B. Saunders Co., 1940. 2 Taylor, J. A.: Penile horn. J, Urol., 52: 611, 1944, 3 Committee Report. Memoires de l'Academie Royale de Medicine, Juin, 1830, 4 Wilson, E.: Diseases of the Skin, pp. 79, 799. Med, Chir. Transac. 1867. 5 Lebert, H.: Ueber Keratose, Breslau, 1864, 6 Hessberg, L.: Beitrag zur· Kentniss der Hauthorner am Menschen u. Thieren. Gottingen, 1868. 7 Hebra, F.: On Diseases of the Skin. New Sydenham Soc,, Vol. III. 8 Bergh, R.: Arch. f. Derm. u. Syph., 1873. 9 Pick, F. ,L: Viertelj, £, Dermat. u. Syph., p.
315, 1875, 10 Gould, A. P,: Trans. Path. Soc., London, 38: 355-357, 1886-87,
11
Chauffard, M.A.· Bull, Mem. Soc. Hosp., 5:
434-436, 1888. 12
Fm. l. Case 1. Comified ulcerated lesion on glans penis before excision.
Ossola, S.: Boll. Soc. Med. Chir., 24: 127-131,
1910. 13
Hamonic, P.: Rev. cl.in. d'Androl. Gynec., 5:
x-ray was normal. There was minimal trophy of the hip joint margins and bilateral ilial exostoses. There was no urethral disdmrge, bleeding or urinary disturbance.
257-264. 1899.
Sic11ia: Papilomas Corneos o Cuernos de la Mucosa glands prepucial. Med. ibera, 6: 132, 1919. 15 Th,fuckai, T. and Funabashi, T.: Cutaneous horns of glans penis. Acta Dermat., 16: 88, 1930. 16 Muckai, T. and Morimoto, S.: Cutaneous horns of glans penis. Acta Dermat., 15: 595, 1930. 17 Jewett, P.A.: Case of horn on the glans penis New York Med. Times, 3: 79-81, 1854. 18 Brinton: J. Cutan. G. U. Dis,, July, 1887. 19 Young, H. H, and Davis, D, M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926. 20 Van Der Velde, 0.: J. lVlich. St. Med, Soc,, 35: 317-319, 1936. 21 Goldstein, H. H.: J. Urol., 30: 367, 1933. 14
22 Taylor, J. A.: Trans. American Assoc. ( ;enit;oUrin. Surg., 37: 101, 1944. 23 O'Crowley, C. R.: Discussion, Trnns. Am, Assoc. of Genito-Urin. Surg., 37: 107, 194+. 24 Winterhoff, E. and Sparks, A. J : Penile horn, J. UroL, 66: 704, 1951. 25 Lillie, G. V, and Guin, J, D,: Penile horn, a case report. Arch. Derm., 84: 322-324, 1961. 26 Presman, D., Rolnick, D. and Turbow, B. Penile horn, Amer. J. Snrg., 104: 040-641, 1962.
315
l
316
HASSAN, ORTEZA AND MILAM
FIG. 2. Case 1. Low power photomicrograph of tissue removed shows horny ulcerated lesion
FIG. 3. Case 2. Low power photomicrograph of tissue removed shows horny lesion
A wide local excision of the lesion with about 5 mm. of normal glans was performed. Closure was done with fine chromic catgut sutures. The wound healed per primam. The gross specimen "consists of a formalin fixed tissue mass, irregular in shape and measuring 2.2 by 1.7 by 0.5 cm. On the surface, 0.3 cm. from the margin of resection, there is an irregular ulcer 0.7 by 0.5 by 0.2 cm. in size. The edges are elevated and hyper-pigmented. The remaining surface is finely granular. The cut surface is yellowish-gray. "Microscopic sections of the penile skin show an area of marked hyperkeratosis and fairly regular acanthosis (fig. 2). The epithelial cells are mature and regular with no evidence of atypism. Mitotic activity is minimal. The subcutaneous tissue contains a lymphocytic and fibrocytic infiltrate. At one point the epidermis has been lost and the subcutaneous tissue shows superficial necrosis with a dense inflammatory infiltrate. In the deep
FIG. 4. Case 3. Penile lesion.
subcutaneous tissue there are numerous capillaries such as is seen in granulation tissue." The diagnosis was penile horn. Case 2. A 46-year-old white man was admitted
317
PENILE HORN
to West Virginia University Hospital (H15-55-10) on January 26, 1966 for treatment of penile wart. In 1963 a wart-like lesion on the glans penis was locally excised at another hospital. The histological diagnosis was condyloma acuminatum. The growth recurred and was again excised in November 1965. Histological diagnosis was pseudo-epitheliomatous hyperplasia with chronic inflammation. Three months later he was admitted to our hospital with a recurrent penile lesion. There was no pain, bleeding or discharge. An indurated, cornified non-tender lesion 1 cm. in diameter was located on the dorsal surface of the glans penis at its junction with the penile shaft. Regional lymph nodes were not palpable. All laboratory studies were within normal limits. An electrocardiogram and chest x-rays were normal. On January 27, 1966, under general anesthesia, the lesion was widely excised. Closure was with fine chromic catgut suture. The wound healed per primam. "The gross specimen consists of a formalin fixed tissue mass 0.3 by 1 by 0.5 cm. On one surface there is an oval, raised yellowish-gray, hard area measuring 0.7 by 0.4 cm. The remaining surface is smooth and pale pink. Other surfaces are rough and show punctate areas of hemorrhage. "A microscopic section of the epidermis shows an area of marked hyperkeratosis, focal parakeratosis, acanthosis and papillomatosis (fig. 3). The acanthosis is fairly regular. In the lower portions of the epidermis a few mitoses are seen but none are atypical. In this area there is some variation in nuclear size but polarity is retained throughout and intercellular bridges are well preserved. No mitoses or atypical cells are found in the upper layers. The upper dermis contains a focal lymphocytic infiltrate." The diagnosis was penile horn. Case 3. In 1948 at another hospital one of us
(D. F. M.) treated a similar case by local excision (fig. 4). Histological diagnosis was penile horn. DISCUSSION
The etiology of cutaneous horn is unknown although it has been stated that it may be a viral infection. 27 · 28 In many of the reported cases congen~tal phimosis had been a predisposing factor m the development of the horny lesion20 but in our 3 cases phimosis was not present. They are horn-like epidermal growths composed of cornified material originating from abnormal epidermis. Clinically these growths consist of a compact, tapered, keratinous mass surmounting a warty base. Microscopically they demonstrate extreme hyperkeratosis, acanthosis, dyskeratosis, papillomatosis and chronic inflammatory infiltration in the adjacent dermis. 1 These horns should probably be considered a tu~or of horny substance which can undergo malignant change and exhibit all the characteristics of a penile carcinoma. Lebert found that in 12 per cent of the 109 cases of the cutaneous horns he reported carcinoma developed. 5 In many of the reported cases the predominant symptoms were pain and tenderness with urinary obstruction. 2• 20 These symptoms were not noted in our cases. Ulceration of the lesion, which is uncommon, was seen in one patient. Wide excision with removal of a margin of normal tissue around the base is the treatment of choice.19 In large lesions with malignant change, amputation on the penis with inguinal lymph node dissection should be considered. 20 SUMMARY
Three cases of penile horn are reported. All were treated by local excision. A review of the literature revealed 38 cases previously reported. 27 Huggins, C. B.: Discussion of Taylor's paper. Trans. Amer. Assoc. Genito-urin. Surg., 37: 107-
108, 1944.
28 Rous, P.: The nearer causes of cancer. J.A.M.A., 122: 573-581, 1943.
Vol. 97, Feb.
Copyright© 1967 by The Williams & Wilkins Co.
Pritded 'in U.S . .!i.
PE:NILE HORN: REVIEW OF LITERATURE WITH 3 CASE REPORTS ABDUL A. HASSAN, ARSENIO M. ORTEZA
AND
D. FRANKLIN rdILAl\I
From the Department of Surgery, Division of Urolo({Y, West Virginia University Jl1edical Center, JV1organtown, West Virginia
Cutaneous horns are peculiar forms of cutaneous warts characterized by excessive and increasing keratosis or over-growth of cornified epithelium which develops from a wart or acanthosis. 1 The rate of growth is often rapid and the horn can become quite large in a short period of time. Taylor reported a penile horn 3 inches long 1Yhich was formed in 6 months. 2 The most common site of cutaneous horns is the scalp. In a review of the literature ,rn found 28 cases reported in Europe; 3 - 16 and 10 cases reported in America. The first ca,c;e was reported by P. A. Jewett in 185417 and subsequently 9 cases have been reported.1 8 - 26 VVe have seen three of these cutaneous penile lesions.
CASE REPORTS
Case 1. A 28-year-old white man ,ms admitted to the West Virginia University Hospital 50-33) on February 8, 1966 for treatment of complications of cerebral palsy. There waN a cornified, slightly tender and fixed ulcerative lesion 2 by 2 cm. on the anterior .,nrfaee of the glans penis which had been present for 13 yea.rn (fig. 1). Inguinal lymph nodes were not All laboratory studies 1vere normal and the ehm,t.
Accepted for publicat1011 April 15, 1966. 1 Ewing, J.E.: Neoplastic Disease. Philadelphia: W. B. Saunders Co., 1940. 2 Taylor, J. A.: Penile horn. J, Urol., 52: 611, 1944, 3 Committee Report. Memoires de l'Academie Royale de Medicine, Juin, 1830, 4 Wilson, E.: Diseases of the Skin, pp. 79, 799. Med, Chir. Transac. 1867. 5 Lebert, H.: Ueber Keratose, Breslau, 1864, 6 Hessberg, L.: Beitrag zur· Kentniss der Hauthorner am Menschen u. Thieren. Gottingen, 1868. 7 Hebra, F.: On Diseases of the Skin. New Sydenham Soc,, Vol. III. 8 Bergh, R.: Arch. f. Derm. u. Syph., 1873. 9 Pick, F. ,L: Viertelj, £, Dermat. u. Syph., p.
315, 1875, 10 Gould, A. P,: Trans. Path. Soc., London, 38: 355-357, 1886-87,
11
Chauffard, M.A.· Bull, Mem. Soc. Hosp., 5:
434-436, 1888. 12
Fm. l. Case 1. Comified ulcerated lesion on glans penis before excision.
Ossola, S.: Boll. Soc. Med. Chir., 24: 127-131,
1910. 13
Hamonic, P.: Rev. cl.in. d'Androl. Gynec., 5:
x-ray was normal. There was minimal trophy of the hip joint margins and bilateral ilial exostoses. There was no urethral disdmrge, bleeding or urinary disturbance.
257-264. 1899.
Sic11ia: Papilomas Corneos o Cuernos de la Mucosa glands prepucial. Med. ibera, 6: 132, 1919. 15 Th,fuckai, T. and Funabashi, T.: Cutaneous horns of glans penis. Acta Dermat., 16: 88, 1930. 16 Muckai, T. and Morimoto, S.: Cutaneous horns of glans penis. Acta Dermat., 15: 595, 1930. 17 Jewett, P.A.: Case of horn on the glans penis New York Med. Times, 3: 79-81, 1854. 18 Brinton: J. Cutan. G. U. Dis,, July, 1887. 19 Young, H. H, and Davis, D, M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926. 20 Van Der Velde, 0.: J. lVlich. St. Med, Soc,, 35: 317-319, 1936. 21 Goldstein, H. H.: J. Urol., 30: 367, 1933. 14
22 Taylor, J. A.: Trans. American Assoc. ( ;enit;oUrin. Surg., 37: 101, 1944. 23 O'Crowley, C. R.: Discussion, Trnns. Am, Assoc. of Genito-Urin. Surg., 37: 107, 194+. 24 Winterhoff, E. and Sparks, A. J : Penile horn, J. UroL, 66: 704, 1951. 25 Lillie, G. V, and Guin, J, D,: Penile horn, a case report. Arch. Derm., 84: 322-324, 1961. 26 Presman, D., Rolnick, D. and Turbow, B. Penile horn, Amer. J. Snrg., 104: 040-641, 1962.
315
l
316
HASSAN, ORTEZA AND MILAM
FIG. 2. Case 1. Low power photomicrograph of tissue removed shows horny ulcerated lesion
FIG. 3. Case 2. Low power photomicrograph of tissue removed shows horny lesion
A wide local excision of the lesion with about 5 mm. of normal glans was performed. Closure was done with fine chromic catgut sutures. The wound healed per primam. The gross specimen "consists of a formalin fixed tissue mass, irregular in shape and measuring 2.2 by 1.7 by 0.5 cm. On the surface, 0.3 cm. from the margin of resection, there is an irregular ulcer 0.7 by 0.5 by 0.2 cm. in size. The edges are elevated and hyper-pigmented. The remaining surface is finely granular. The cut surface is yellowish-gray. "Microscopic sections of the penile skin show an area of marked hyperkeratosis and fairly regular acanthosis (fig. 2). The epithelial cells are mature and regular with no evidence of atypism. Mitotic activity is minimal. The subcutaneous tissue contains a lymphocytic and fibrocytic infiltrate. At one point the epidermis has been lost and the subcutaneous tissue shows superficial necrosis with a dense inflammatory infiltrate. In the deep
FIG. 4. Case 3. Penile lesion.
subcutaneous tissue there are numerous capillaries such as is seen in granulation tissue." The diagnosis was penile horn. Case 2. A 46-year-old white man was admitted
317
PENILE HORN
to West Virginia University Hospital (H15-55-10) on January 26, 1966 for treatment of penile wart. In 1963 a wart-like lesion on the glans penis was locally excised at another hospital. The histological diagnosis was condyloma acuminatum. The growth recurred and was again excised in November 1965. Histological diagnosis was pseudo-epitheliomatous hyperplasia with chronic inflammation. Three months later he was admitted to our hospital with a recurrent penile lesion. There was no pain, bleeding or discharge. An indurated, cornified non-tender lesion 1 cm. in diameter was located on the dorsal surface of the glans penis at its junction with the penile shaft. Regional lymph nodes were not palpable. All laboratory studies were within normal limits. An electrocardiogram and chest x-rays were normal. On January 27, 1966, under general anesthesia, the lesion was widely excised. Closure was with fine chromic catgut suture. The wound healed per primam. "The gross specimen consists of a formalin fixed tissue mass 0.3 by 1 by 0.5 cm. On one surface there is an oval, raised yellowish-gray, hard area measuring 0.7 by 0.4 cm. The remaining surface is smooth and pale pink. Other surfaces are rough and show punctate areas of hemorrhage. "A microscopic section of the epidermis shows an area of marked hyperkeratosis, focal parakeratosis, acanthosis and papillomatosis (fig. 3). The acanthosis is fairly regular. In the lower portions of the epidermis a few mitoses are seen but none are atypical. In this area there is some variation in nuclear size but polarity is retained throughout and intercellular bridges are well preserved. No mitoses or atypical cells are found in the upper layers. The upper dermis contains a focal lymphocytic infiltrate." The diagnosis was penile horn. Case 3. In 1948 at another hospital one of us
(D. F. M.) treated a similar case by local excision (fig. 4). Histological diagnosis was penile horn. DISCUSSION
The etiology of cutaneous horn is unknown although it has been stated that it may be a viral infection. 27 · 28 In many of the reported cases congen~tal phimosis had been a predisposing factor m the development of the horny lesion20 but in our 3 cases phimosis was not present. They are horn-like epidermal growths composed of cornified material originating from abnormal epidermis. Clinically these growths consist of a compact, tapered, keratinous mass surmounting a warty base. Microscopically they demonstrate extreme hyperkeratosis, acanthosis, dyskeratosis, papillomatosis and chronic inflammatory infiltration in the adjacent dermis. 1 These horns should probably be considered a tu~or of horny substance which can undergo malignant change and exhibit all the characteristics of a penile carcinoma. Lebert found that in 12 per cent of the 109 cases of the cutaneous horns he reported carcinoma developed. 5 In many of the reported cases the predominant symptoms were pain and tenderness with urinary obstruction. 2• 20 These symptoms were not noted in our cases. Ulceration of the lesion, which is uncommon, was seen in one patient. Wide excision with removal of a margin of normal tissue around the base is the treatment of choice.19 In large lesions with malignant change, amputation on the penis with inguinal lymph node dissection should be considered. 20 SUMMARY
Three cases of penile horn are reported. All were treated by local excision. A review of the literature revealed 38 cases previously reported. 27 Huggins, C. B.: Discussion of Taylor's paper. Trans. Amer. Assoc. Genito-urin. Surg., 37: 107-
108, 1944.
28 Rous, P.: The nearer causes of cancer. J.A.M.A., 122: 573-581, 1943.