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Penis auto-amputation and chasm of the lower abdominal wall due to advanced penile carcinoma: a case report
© Baltogiannis et al; licensee BioMed Central Ltd. 2011
Received: 5 May 2011
Accepted: 12 December 2011
Published: 12 December 2011
Penile cancer is uncommon. When penile cancer is left untreated, at an advanced stage it can have tragic consequences for the patient.
Our case report does not concern a new manifestation of penile cancer, but an interesting presentation with clinical significance that emphasizes the need to diagnose and treat penile cancer early. It is an unusual case of a neglected penile cancer in a 57-year-old Greek man that led to auto-amputation of the penis and a large chasm in the lower abdominal wall. The clinical staging was T4N3M0 and our patient was treated with a bilateral cutaneous ureterostomy, chemotherapy and radiotherapy. Our patient died 18 months after his first admission in our clinic.
Emphasis must be placed on early diagnosis and treatment of penile cancer, so further development of the disease can be prevented.
Penile cancer accounts for less than 1% of all cancers in men . It is a relatively rare squamous cell carcinoma (SCC), which usually originates in the epithelium of the inner prepuce and glans. Invasive carcinoma of the penis begins as an ulcerative or papillary lesion, which may gradually grow to involve the entire glans or shaft of the penis . Primary dissemination is via lymphatic channels to the femoral and iliac nodes. Distant metastases are clinically apparent in less than 10% of cases, and may involve the lungs, liver, brain or bones. With regard to the diagnosis and staging, for penile cancer assessment of the primary lesion, regional lymph node disease and the possibility of distant metastases are all required . The assessment is based on physical examination results, a lesion biopsy, ultrasound and ultrasound-guided fine-needle aspiration biopsy (FNAB) for non-palpable nodes, an abdominal computed tomography (CT) scan, a chest X-ray and additionally a bone scan in symptomatic patients who are classed as M1.
Treatment depends on the staging and varies from laser surgery (Tis and Ta) to partial or total penis amputation (T2, T3, T4) with or without inguinal lymphadenectomy (nodal metastases or not) and radiotherapy/chemotherapy if needed [3–6]. Although it is considered to be one of the few solid tumors that have a high curative rate, patients tend to delay seeking medical attention; this is mostly due to embarrassment, fear of emasculation, ignorance and personal neglect. A search through the literature revealed only seven other cases, none as severe as the one presented below [7, 8].
Carcinoma of the penis in developed countries accounts for about 0.4% of all malignancies in men. Penile carcinoma occurs most commonly in the sixth decade of life .
The risk factors are phimosis, chronic inflammatory conditions (for example, balanoposthitis) and treatment with sporalene and ultraviolet photochemotherapy . The most common issue at presentation is the lesion itself. It may appear as an area of induration or erythema, ulceration, a small nodule, or an exophytic growth. Phimosis may obscure the lesion and result in a delay in seeking medical attention. In fact, 15% to 50% of patients delay seeking medical attention for at least a year . Delays in diagnosis and initiation of therapy can affect survival and may lead to tragic and unusual cases of total penis auto-destruction [3, 8].
Careful palpation of the inguinal area is mandatory because more than 50% of patients show enlarged inguinal nodes. Anemia and leukocytosis may be present in patients with a long-standing disease or an extensive local infection. A biopsy of the primary lesion is mandatory to establish the diagnosis of malignancy. Treatment varies depending on the pathology as well as the location of the primary lesion and the positive or negative nodal metastases [3, 4, 12, 13].
Patients who have an inoperable disease and bulky inguinal metastases are often treated with chemotherapy. The four chemotherapeutic agents that have demonstrated activity against penile carcinoma are: bleomycin, methotrexate, cisplatin and 5-fluorouracil [14, 15].
The percentage of five-year survival rates for patients with node-negative disease ranges from 65% to 90%. For patients with positive inguinal nodes this rate decreases to 30% to 50%, and for patients with positive iliac nodes it decreases to less than 20%. In the presence of soft-tissue or bony metastases, no five-year survivors have been reported. Squamous cell carcinoma accounts for 98% of all penile cancers. Sporadic cases of melanoma, basal cell carcinoma, and Paget's disease have all been reported. These lesions tend to be radiosensitive [3–5, 7].
We consider this case to be an interesting one with clinical significance, emphasizing the need to diagnose and treat penile cancer early so that further development of the disease is prevented.
The person described in the case report has died. Written informed consent for publication from the patient's next-of-kin could not be obtained despite all reasonable attempts. The case is important to public health and every effort has been made to protect the identity of our patient. There is no reason to believe that our patient's next-of-kin would object to publication.
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