PENILE SQUAMOUS CELL CARCINOMA , CASE REPORT AND REVIEW OF LITERATURES

Background Penile tumors represent a difficult diagnostic and therapeutic issue to solve, mainly because of their psychological implications. The diagnosis may be delayed because many patients tend to disregard early asymptomatic lesions. Circumcision soon after birth confers almost complete immunity against carcinoma of the penis. Later circumcision does not seem to have the same effect, and Moslems circumcised between the ages of 4 and 9 years are still liable to the disease 1 .


Background
Penile tumors represent a difficult diagnostic and therapeutic issue to solve, mainly because of their psychological implications.The diagnosis may be delayed because many patients tend to disregard early asymptomatic lesions.Circumcision soon after birth confers almost complete immunity against carcinoma of the penis.Later circumcision does not seem to have the same effect, and Moslems circumcised between the ages of 4 and 9 years are still liable to the disease 1 .

Case presentation
55 years old male patient presented with painful penile lesions since 6 months, associated with painful micturition and several attacks of retention of urine.He received irregular courses of different types of medical treatment without any improvement.On examination, there were two big ulcers, one anteriorly (2x3cm) and the other one (1x2cm) was laterally placed on the glans of the penis; both were irregular in shape with everted edges.The base was tender and indurated while the floor was covered by blood stained and seropurulant discharge.The bigger ulcer was reaching the urethra and invading it (Fig. 1-3 e x c e e d i n g l y r a r e i n m e n w h o a r e circumcised at birth.The prophylactic effect of circumcision on penile carcinoma is likely related to the lack of retained smegma that has been proven to be carcinogenic in animals.One study also demonstrated an increased risk of HPV infection in uncircumcised men (19.6%) compared with circumcised men (5.5%) 5 .Poor genital hygiene in uncircumcised males, even in the absence of phimosis, may also play a r o l e , l e a d i n g t o t h e r e t e n t i o n o f smegma 3 .5. Other factors: Occasional factors that have been reported in association with penile SCC include: • Prolonged exposure to different chemical compounds (e.g.insecticides, fertilizers) 6 .
• Late ritual circumcision followed by herbal treatments to control bleeding is associated with extensive scarring and may result in the development of invasive tumors 7 .
• Cigarette smoking, which has been found to show a clear-cut association with penile SCC related to the nicotine intake and independent of phimosis or balanitis 6 .
• UV radiation that may enhance the development of penile SCC 8 .

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Reconstructive surgery for sex reversal 9 .
Frequency: The incidence ranging from 1% in the Western countries to 10-20% in some parts of Asia, Africa, and South America 10 .I t i s r a r e a m o n g s o m e religious communities who practice circumcision, such as Jewish and Moslem groups 3 .The age at onset is 20-90 years, with a peak around the sixth and seventh decades 11 .
History: In most cases, the earliest symptoms are itching or a burning sensation under the foreskin, and ulceration of the glans or the prepuce.With time, the tumor destroys the glans a n d t h e p r e p u c e a n d i n f i l t r a t e s t h e corpora cavernosa 12 .It most often occurs on the glans (48%), prepuce (21%), both (9%), the coronal sulcus (6%), and the shaft (<2%) 10 .Lymphatic metastases first occur in the superficial or deep inguinal lymph nodes, then in the regional lymphatic of the pelvis.Distant metastases resulting from vascular dissemination (most commonly to the lungs and the liver) are rare and usually late 13 .Imaging techniques recommended for a more accurate staging include ultrasonography, CT scanning, and MRI 14 .Initial biopsy of the primary penile lesion is necessary to confirm the diagnosis and to assess the grade and the invasiveness of the tumor 3 .The staging systems currently used are the Jackson classification and the (TNM) system.

Medical Care:
The treatment of penile SCC varies according to the clinical stage.it includes radiation therapy, medical therapy, and surgery , alone or incombination 15 .1. Radiation therapy: Radiation therapy with external beams or mould techniques may be an option to treat small, superficial, exophytic lesions in young individuals, allowing for the preservation of sexual function with a high cure rate.In case of relapse, salvage surgery may be required.Circumcision before therapy is recommended.Major complications, such as urethral stenosis, fistulas, and penile necrosis, may occur 16 .
2. Medical treatment: local and systemic chemotherapy.Early premalignant and in situ changes can be treated with topical chemotherapy (5-FU) 17 .Systemic chemotherapy may be used according to the stage of the disease (3) .
Whereas partial penectomy is the procedure of choice for tumors at a low stage (stage I, T1-T2) that involves most of the glans or the distal third of the penis.Total penectomy is necessary when the lesion is in the proximal portion of the penis or when the tumor is at an advanced stage (stages II-III,T3-T4) 18 .Lymph node dissection: Because of the significant morbidity of inguinal and pelvic node dissection and because of the high incidence of reactive nodes, surgical dissection of the lymph nodes is necessary only if they are enlarged and do not regress after adequate antibiotic therapy 18 .
Prevention: Circumcision in infancy and a good standard of sexual hygiene are recognized as good prophylactic measures.Prognosis: In the absence of inguinal metastases, patients with invasive SCC of the penis involving the glans or the distal part of the shaft who undergo adequate partial amputation have a longterm survival rate of 70-80%.Of patients with involved lymph nodes, 40-50% can be cured with lymph node dissection, whereas untreated patients usually die within 2-3 years 18 .