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Penile Horns: Report of 2 Cases
0022-534 7/84/1326-1192$02.00/0 Vol. 132, December
THE JOURNAL OF UROLOGY
Copyright© 1984 by The Williams & Wilkins Co.
Printed in U.S.A.
PENILE HORNS: REPORT OF 2 CASES MAX K. WILLSCHER, KENNETH J. DALY, JAMES F. CONWAY, JR. MICHAEL A. MITTELMAN
AND
From the Departments of Surgery (Urology) and Medicine (Dermatology), Elliot Hospital and Catholic Medical Center, Manchester, New Hampshire
ABSTRACT
We report 2 cases of penile horns, including 1 in which verruca carcinoma developed in the base. Treatment of this disease and its potential malignant degeneration are discussed. A cutaneous horn is a cohesive mass of cornified material protruding from the surface of the skin. It usually is found on the scalp and rarely is found on the glans penis. In the combined urological literature of the United States, Europe and Japan <100 cases of penile horns have been reported. 1 While most cutaneous horns are benign one must consider that roughly 25 per cent of them have a premalignant disposition. 2 CASE REPORTS
Case 1. A 45-year-old white man presented with penile horns that grew 1.5 cm. within 3 months. Because the horns involved part of the coronal edge of the glans penis they were treated initially by superficial resection (fig. 1). Deeper biopsy of the base of these lesions was consistent with dysplasia. The glans healed but 2 months later the lesion recurred. In <4 weeks the horns grew again and were 2 cm. long. The lesions were removed superficially and similar histological findings were obtained. Surgical removal was followed by topical application of 5fluorouracil cream daily for 2 weeks. The penis healed and no recurrence was noted 12 months later. In the interim several small condylomata acuminata developed on the shaft of the penis, which were treated locally with podophyllum. Case 2. A 65-year-old white man had a 2-year history of balanitis xerotica obliterans. As in case 1 he also presented with the rapid growth of a penile horn. The horn grew to 3 cm. and was removed by excision (fig. 2). The horn grew again within 6 weeks of initial healing to its original length. Initial pathological evaluation of the first specimen revealed dysplasia at the base of the horn. Upon subsequent removal of the second horn pathological diagnosis was consistent with verrucous carcinoma as well as balanitis xerotica obliterans. A partial penile amputation was performed. Pathological evaluation of the amputated glans penis revealed locally invasive verrucous carcinoma as well as balanitis xerotica obliterans (fig. 3). Convalescence was uneventful and the patient has done well. Clinically, the inguinal lymph nodes have remained negative.
FIG. 1. Case 1. Multiple penile horns
FIG. 2. Case 2. Large penile horn with balanitis xerotica obliterans
DISCUSSION
Penile horns are composed of heaped up keratin and the histological appearance primarily is that of hyperkeratosis. They usually are considered benign epidermoid outgrowths. However, when all body locations are considered roughly 25 per cent of these lesions may have a malignant base. 2 Histologically, one may find actinic keratosis, verruca vulgaris (warts), seborrheic keratosis, squamous cell carcinoma as well as several less common entities in the base of these lesions. To obtain an adequate diagnosis one cannot simply break off the horn or shave it at its base. Deep biopsies must be obtained to establish an accurate diagnosis. While penile horns are benign, malignant degenerative changes in the base have been reported. 3 The rate of growth of these penile horns is variable but rapid recurrent growth should suggest the possibility of a malignant base. In Accepted for publication August 6, 1984.
fact, it was the rapid recurrent growth in case 2 that, despite its initial histologically benign appearance, eventually prompted the diagnosis of verruca carcinoma. Balanitis xerotica obliterans is a chronic sclerosing atrophic process of the glans penis that may often result in meatal stenosis. Presently, the consensus is that balanitis xerotica obliterans, kraurosis penis, kraurosis vulva and lichen sclerosus et atrophicus are identical, since the first 3 entities are localized forms of the last. While lichen sclerosus et atrophicus of the skin never undergoes malignant degeneration, lichen sclerosus et atrophicus of the vulva can progress to squamous cell carcinoma in 3 to 6 per cent of the cases. 4• 5 Similarly, balanitis xerotica obliterans of the glans penis rarely degenerates into squamous carcinoma but this occurrence has been reported in
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PENILE fiORNS
usually are not required for dissection and radiation radiation therapy has been control of this neoplasm. In implicated in causing anaplastic transformation of verrucous carcinoma and should not be used as primary therapy for the local lesion. 8 Carbon dioxide or neodymium-YAG laser radiation may be a good alternative mode of treatment. While topical treatment with 5-fluorouracil cream, as in case 1, or bleomycin may be useful for dysplastic elements in the base of these lesions, such therapy must be reserved for those cases when biopsy of the base shows no malignancy. Accurate histological diagnosis must be established by deep biopsies of the circumferential skin surrounding the base of these lesions. If malignant degeneration to frank squamous cell carcinoma is found, regional lymph node dissection should be considered. REFERENCES
1. Sugiura, H., Otaguro, K. and Tsugaya, M.: Penile horn: verruca
FIG. 3. Case 2. Histological confirmation of verrucous carcinoma
2 of 44 patients in 1 study but in none of 77 patients in another study. 5 •6 Verrucous carcinoma represents a highly differentiated squamous cell carcinoma of the skin and mucous membrane that is locally aggressive and destructive but only rarely metastasizes. Classically, it may occur in varying anatomical locations, such as the mouth (oral verrucous carcinoma), genital area (giant condyloma acuminatum) and extremities (carcinoma cuniculatum). The latter usually appears as a progressive locally invasive lesion of the skin of the anterior foot. 7 Since regional lymph nodes rarely if ever metastasize treatment consists of local wide excision. Regional lymph node
vulgaris. Urology, 13: 548, 1979. 2. Schosser, R. H., Hodge, S. J., Gaba, C. R. and Owen, L. G,: Cutaneous horns: a histopathological study. South. Med. J., 72: 1129, 1979. 3. Raghavaiah, N. V., Soloway, M. S. and Murphy, W. M.: Malignant penile horn. J. Ural., :U8: 1068, 1977. 4. Hart, W. R., Norris, H. J. and Helwig, E. B.: Relation of lichen sclerosus et atrophicus of the vulva to development of carcinoma. Obst. Gynec., 45: 369, 1975. 5. Wallace, H. J.: Lichen sclerosus et atrophicus. Trans. St. John's Hosp. Dermatol. Soc., 57: 9, 1971. 6. Post, B. and Janner, M.: Lichen sclerosus et atrophicus penis. Z. Hautkr., 50: 675, 1975. 7. Headington, J. T.: Verrucous carcinoma. Cutis, 21: 207, 1978. 8. Perez, C. A., Kraus, F. T., Evans, J. C. and Powers, W. E.: Anaplastic transformation in verrucous carcinoma of the oral cavity after radiation therapy. Radiology, 86: 108, 1966.
THE JOURNAL OF UROLOGY
Copyright© 1984 by The Williams & Wilkins Co.
Printed in U.S.A.
PENILE HORNS: REPORT OF 2 CASES MAX K. WILLSCHER, KENNETH J. DALY, JAMES F. CONWAY, JR. MICHAEL A. MITTELMAN
AND
From the Departments of Surgery (Urology) and Medicine (Dermatology), Elliot Hospital and Catholic Medical Center, Manchester, New Hampshire
ABSTRACT
We report 2 cases of penile horns, including 1 in which verruca carcinoma developed in the base. Treatment of this disease and its potential malignant degeneration are discussed. A cutaneous horn is a cohesive mass of cornified material protruding from the surface of the skin. It usually is found on the scalp and rarely is found on the glans penis. In the combined urological literature of the United States, Europe and Japan <100 cases of penile horns have been reported. 1 While most cutaneous horns are benign one must consider that roughly 25 per cent of them have a premalignant disposition. 2 CASE REPORTS
Case 1. A 45-year-old white man presented with penile horns that grew 1.5 cm. within 3 months. Because the horns involved part of the coronal edge of the glans penis they were treated initially by superficial resection (fig. 1). Deeper biopsy of the base of these lesions was consistent with dysplasia. The glans healed but 2 months later the lesion recurred. In <4 weeks the horns grew again and were 2 cm. long. The lesions were removed superficially and similar histological findings were obtained. Surgical removal was followed by topical application of 5fluorouracil cream daily for 2 weeks. The penis healed and no recurrence was noted 12 months later. In the interim several small condylomata acuminata developed on the shaft of the penis, which were treated locally with podophyllum. Case 2. A 65-year-old white man had a 2-year history of balanitis xerotica obliterans. As in case 1 he also presented with the rapid growth of a penile horn. The horn grew to 3 cm. and was removed by excision (fig. 2). The horn grew again within 6 weeks of initial healing to its original length. Initial pathological evaluation of the first specimen revealed dysplasia at the base of the horn. Upon subsequent removal of the second horn pathological diagnosis was consistent with verrucous carcinoma as well as balanitis xerotica obliterans. A partial penile amputation was performed. Pathological evaluation of the amputated glans penis revealed locally invasive verrucous carcinoma as well as balanitis xerotica obliterans (fig. 3). Convalescence was uneventful and the patient has done well. Clinically, the inguinal lymph nodes have remained negative.
FIG. 1. Case 1. Multiple penile horns
FIG. 2. Case 2. Large penile horn with balanitis xerotica obliterans
DISCUSSION
Penile horns are composed of heaped up keratin and the histological appearance primarily is that of hyperkeratosis. They usually are considered benign epidermoid outgrowths. However, when all body locations are considered roughly 25 per cent of these lesions may have a malignant base. 2 Histologically, one may find actinic keratosis, verruca vulgaris (warts), seborrheic keratosis, squamous cell carcinoma as well as several less common entities in the base of these lesions. To obtain an adequate diagnosis one cannot simply break off the horn or shave it at its base. Deep biopsies must be obtained to establish an accurate diagnosis. While penile horns are benign, malignant degenerative changes in the base have been reported. 3 The rate of growth of these penile horns is variable but rapid recurrent growth should suggest the possibility of a malignant base. In Accepted for publication August 6, 1984.
fact, it was the rapid recurrent growth in case 2 that, despite its initial histologically benign appearance, eventually prompted the diagnosis of verruca carcinoma. Balanitis xerotica obliterans is a chronic sclerosing atrophic process of the glans penis that may often result in meatal stenosis. Presently, the consensus is that balanitis xerotica obliterans, kraurosis penis, kraurosis vulva and lichen sclerosus et atrophicus are identical, since the first 3 entities are localized forms of the last. While lichen sclerosus et atrophicus of the skin never undergoes malignant degeneration, lichen sclerosus et atrophicus of the vulva can progress to squamous cell carcinoma in 3 to 6 per cent of the cases. 4• 5 Similarly, balanitis xerotica obliterans of the glans penis rarely degenerates into squamous carcinoma but this occurrence has been reported in
1192
1193
PENILE fiORNS
usually are not required for dissection and radiation radiation therapy has been control of this neoplasm. In implicated in causing anaplastic transformation of verrucous carcinoma and should not be used as primary therapy for the local lesion. 8 Carbon dioxide or neodymium-YAG laser radiation may be a good alternative mode of treatment. While topical treatment with 5-fluorouracil cream, as in case 1, or bleomycin may be useful for dysplastic elements in the base of these lesions, such therapy must be reserved for those cases when biopsy of the base shows no malignancy. Accurate histological diagnosis must be established by deep biopsies of the circumferential skin surrounding the base of these lesions. If malignant degeneration to frank squamous cell carcinoma is found, regional lymph node dissection should be considered. REFERENCES
1. Sugiura, H., Otaguro, K. and Tsugaya, M.: Penile horn: verruca
FIG. 3. Case 2. Histological confirmation of verrucous carcinoma
2 of 44 patients in 1 study but in none of 77 patients in another study. 5 •6 Verrucous carcinoma represents a highly differentiated squamous cell carcinoma of the skin and mucous membrane that is locally aggressive and destructive but only rarely metastasizes. Classically, it may occur in varying anatomical locations, such as the mouth (oral verrucous carcinoma), genital area (giant condyloma acuminatum) and extremities (carcinoma cuniculatum). The latter usually appears as a progressive locally invasive lesion of the skin of the anterior foot. 7 Since regional lymph nodes rarely if ever metastasize treatment consists of local wide excision. Regional lymph node
vulgaris. Urology, 13: 548, 1979. 2. Schosser, R. H., Hodge, S. J., Gaba, C. R. and Owen, L. G,: Cutaneous horns: a histopathological study. South. Med. J., 72: 1129, 1979. 3. Raghavaiah, N. V., Soloway, M. S. and Murphy, W. M.: Malignant penile horn. J. Ural., :U8: 1068, 1977. 4. Hart, W. R., Norris, H. J. and Helwig, E. B.: Relation of lichen sclerosus et atrophicus of the vulva to development of carcinoma. Obst. Gynec., 45: 369, 1975. 5. Wallace, H. J.: Lichen sclerosus et atrophicus. Trans. St. John's Hosp. Dermatol. Soc., 57: 9, 1971. 6. Post, B. and Janner, M.: Lichen sclerosus et atrophicus penis. Z. Hautkr., 50: 675, 1975. 7. Headington, J. T.: Verrucous carcinoma. Cutis, 21: 207, 1978. 8. Perez, C. A., Kraus, F. T., Evans, J. C. and Powers, W. E.: Anaplastic transformation in verrucous carcinoma of the oral cavity after radiation therapy. Radiology, 86: 108, 1966.