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Recurrent penile squamous cell carcinoma in an elderly circumcised man

A 76-year-old Bangladeshi man presented with a long-history of penile irritation and a newly discovered penile lesion. He was a nonsmoker, and his medical history included diabetes mellitus type 2, ischaemic heart disease, cerebrovascular disease, hypertension, hypercholesterolaemia and benign prostatic hypertrophy. His medications included finasteride, aspirin, bisoprolol, bumetanide, candesartan, gliclazide and atorvastatin. He was a Muslim and had undergone circumcision in early childhood. On examination, the patient was found to be lean in stature and had a pseudo-foreskin with signs of male genital lichen sclerosus (MGLSc), and an additional suspicious lesion on the glans penis. Histological examination of a biopsy revealed a moderately differentiated, squamous cell carcinoma (SCC) that was treated by local excision. Histology showed a completely excised tumour with no evidence of lymphovascular invasion (stage G2 pT1). Over the following 2 years, the patient was seen occasionally with pseudo-foreskin inflammation and secondary superinfections. Each time he was treated successfully with antibiotics and potent topical corticosteroids. Four years after his initial diagnosis, he represented with a papular lesion, 6 mm in size, on the glans, close to the urethral meatus. Recurrent or new SCC was suspected, and a biopsy was arranged. Unfortunately, the patient was hospitalized elsewhere with severe cardiac disease, delaying investigations by 3 months. By this time he had developed an ulcerated lesion on the glans, adjacent to the meatus and extending to the coronal sulcus (Fig. 1). Histological examination confirmed the presence of a moderately differentiated SCC with 2.5 mm invasion (stage G2–3 pT2a) surrounded by differentiated penile intraepithelial neoplasia (PeIN1–2) and MGLSc (Fig. 2). Computed tomography did not show any evidence of metastatic disease. Because of the patient’s multiple comorbidities he underwent glansectomy without sentinel node biopsy. Since then he has remained asymptomatic with no evidence of recurrence at the 1-year follow-up. Penile cancer has an annual incidence of < 1 case/ 100 000 person-years in Western countries, and the predominant type is SCC. In the UK, approximately 550 men are diagnosed with penile cancer each year, most commonly those over the age of 60 years. In contemporary practice, penile cancer in a male patient circumcised at birth or during childhood is exceedingly rare. Risk factors for penile cancer include human papillomavirus (HPV) infection, MGLSc, lichen planus, human immunodeficiency virus infection, smoking, poor penile hygiene and low socioeconomic status. None of these except MGLSc were present in our case. MGLSc is caused by chronic, intermittent, occluded exposure of susceptible epithelium to urine. Additionally, it has been correlated with genetic predisposition, autoimmunity, infections, medications, physical trauma and metabolic syndrome. The carcinogenic pathway from MGLSc to penile SCC is obscure, but appears to be HPV-independent, and related to chronic inflammation and scarring, possibly analogous to Marjolin ulcer. A means by which MGLSc can develop in a circumcised man is by the formation of a pseudoor neoforeskin as a consequence of the ‘vanishing penis syndrome’. This is often encountered in obese patients, where increased suprapubic and lateral thigh fat pads facilitate burying of the penis within the surrounding Correspondence: Dr Georgios Kravvas, Department of Dermatology, University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK E-mail: kravvas@hotmail.com