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Carcinoma of the Penis, with a Report of Sixty-Seven Cases

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Carcinoma of the Penis, with a Report of Sixty-Seven Cases CARCINOMA OF THE PENIS, WITH A REPORT OF SIXTY-SEVEN CASES W. E. LEIGHTON, M.D. (From tha Bamrd Free Skin and Cancer Hospital, St. Louis) Jonathan Hutchinson, Jr. (I), lecturing before the London Hospital in 1899, opened with the following significant paragraph: "Epithelioma of the penis is, you may think, almost too rare a dis- ease to have devoted to it a whole lecture, but I can speak from experience on the subject and I wish to impress upon you that it is such rare affections as this which are worthy of your study, because it is their rarity which leads to mistakes in diagnosis at a time when treatment might be successful, and in epithelioma of the penis and the tongue there is much loss of life due' to such mistakes." The rarity of this disease is shown by the fact that it comprises only a small percentage of all carcinomata. Paget (2) says it forms but one per cent of all cases, while Billroth's estimate (3) is as high as three per cent. Barney (4)) in a study of the cases seen in the Massachusetts General Hospital for a period of thirty- three years, 1872-1905, found an average of about three cases per year. He found that many surgeons of large experience had had no cases of carcinoma of the penis in their practices. Sawtelle (5)) in an examination of 70,826 cases in the Marine Hospital service, during a space of five years, saw only 7 cases. At The Barnard Free Skin and Cancer Hospital 68 cases have been seen in the last twenty-six years. During the past five years, 1,364 males were admitted for cancer, 18 of whom had carcinoma of the penis, an average of over three cases a year, but a percentage of only 1.3 of all cancer in the male. Carcinoma of the penis as a rule arises from the epithelium covering the prepuce or glans penis. In rare instances it starts from the mucous membrane of the urethra. The actual cause of the disease, as of all carcinoma, is unknown. 261 252 W. E. LEIGHTON Various factors appear to contribute to the beginning of this disease. A common contributory condition is phimosis, which is found to be of frequent occurrence in those cases where careful histories have been taken. It was noted in 13 of our patients. Barney (4) found it present in 85 per cent of those cases in which inquiry was made as to its occurrence, and Martin (6) found it in 6 out of 7 cases. Irritation from smegma under the tight prepuce of elderly men is frequently the starting point of carcinoma. The importance of this condition is emphasized by the fact that among the Jews and the Mohammedan population of India, by whom circumcision has been practised for ages, carcinoma of the penis is almost unknown. There were no Jews in the present series. Greensfelder (7)) however, reported a case occurring in a circum- cised Mohammedan among 202 cases collected in India, and Pacha (8)) of Constantinople, saw 5 cases of carcinoma of the penis in circumcised Mussulmen, in four years. Syphilis at times seems to be of etiological significance, since it is not uncommon to find cancer developing upon the site of a chancre. Martin (6) thinks the ground for this supposition is not tenable, although he has seen such a case. Sheild (9) and Green (10) also each saw a case. Barney (4) reports 2 cases, and De- marquay (11) in an analysis of 59 cases found a history of syphilis in 10. In 2 of our cases carcinoma developed at-thesite of a chancre. Seven of the patients gave a history of syphilis, 4 of whom had received treatment. A positive Wassermann reaction was ob- tained in 4 cases. A history of gonorrhea was obtained in 11 cases. Trauma probably plays the same r61e as in the etiology of other cancer. Kronlein (14) reports such a case. In the series reported here two cases developed following a crushing injury (cases 12 and 38) and in another case the cancer developed on the scar of an old laceration (case 11). Rodman (15) and Whiteford (16) each saw a carcinoma which had developed upon an earlier circumcision, and Barney (4) reported 6 such cases. Sixteen of our patients had been circumcised in adult life; in 11 of these the wound did not heal and a carcinoma developed. Dormanns (17)) in a period of eighteen months in China, received for examination five specimens of cancer of the penis. Three had been removed from young men, twenty-four, twenty-six, and thirty-six years of age respectively. In all instances the skin was markedly inflamed and showed micro- scopic changes similar to those produced by tar. In seeking an explanation for this, it was found that gonorrhea, syphilis, and CARCINOMA OF THE PENIS 253 chancroid are treated by the local application of a highly irritating substance, the nature of which, however, Dormanns was unable to ascertain. Contagion, or rather implantation, has been suggested. In 1895, MacFarland (18), searching the literature, found eight cases of "contagion from wife to husband." Bernstien (19) reported a case of possible contagion from husband to wife. Bruce (20) saw a patient who developed cancer of the penis one year after his wife died from carcinoma of the uterus. Outland (21) reports a similar case, and Cornil (22) reports two cases which he thinks confirm the direct contagion of carcinoma. Frank (23) cites the case of a man of thirty-nine developing carcinoma of the penis five years after his wife died of carcinoma of the uterus. His case, however, is similar to case 9 of the present series, which would seem to be purely coincidental. Barney (4) reports a case of auto-im- plantation on the scrotum due to contact with cancer on the penis. Origin of the Growth: In 30 of our cases the disease began on the glans penis, and in 13 the first appearance was on the prepuce, while a few have thought that the growth began in the sulcus. Only 2 cases were recorded as beginning on the frenum. Barney (4) noted that in a few cases the growth waa limited to the point of origin but in most it had spread so as to involve both glans and prepuce. Our experience was similar. Demarquay (11) and Thomsen (12) state that the lesion occurs more frequently on the glans penis, while Kaufmann (13) reported 20 of 33 cases observed by him as occurring primarily on the prepuce, and only 13 on the glans. The origin of one of our cases, No. 62, was in the urethra at the peno-scrota1 junction. Age: The age at which carcinoma of the penis develops corre- sponds with that in carcinoma of other organs. Creite (24) re- ports a carcinoma of the penis in a boy of two years, Freyer (25) in a boy of fifteen years, Ralph (26) in a young man of twenty-two years, and Fielewicz (27) in a young man of twenty-six years. While a few cases occur in the twenties, the condition is most common between fifty and sixty. Forty-five of our cases occurred after fifty. The age of the patient on admission ranged from thirty to seventy-seven years. Seven patients were between thirty and forty; 12 between forty and fifty; 21 between fifty and sixty; 14 between sixty and seventy, and 2 between seventy and eighty. 254 W. 1. LEIGHTON Nationality: Fifty-four of the patients were born in America, 8 in Germany, and one each in Ireland, Holland, and Switzerland. In 2 cases the nationality was not recorded. Sixty-two patients were white, and 5 colored. No race is exempt from this affliction unless it be the Jews. Contrary to the experience of Rodman (15) and Barney (4)) who never saw a carcinoma of the penis in a negro, Thomas (28) and McCoy (29) each report a case occurring in a negro. Four out of five patients treated by Shivers (30) at his clinic at Atlantic City were colored, and Howze (31) reported six negroes in seventeen cases. There are five colored patients in the present series. PATHOLOGY Carcinoma of the penis develops from the epithelium of the prepuce or glans penis, occasionally from the urethra. It corre- sponds with the epithelial type of carcinoma found elsewhere. Microscopically it begins either as an ulcer or as a warty excres- pence, which proliferates rapidly, forming a cauliflower mass, which in time may involve the whole organ. Extensive ulceration may take place, and the whole penis become destroyed. Fre- quently the tumor persists for many years without causing much discomfort. The growth is more or less superficial, extension to the corpus cavernmum being prevented by its fibrous sheath. Hutchinson (1) was able to find only one pathological specimen in which extension to the corpus cavernosum had taken place. That this may occur, however, has been shown by Thomsen (12)) Kuttner (32), Pelagatti (33)) Oraison (34)) Bergeret (35), and others. The growth extends by means of the lymphatic channels which are superficially situated, involvement of the inguinal nodes occurring early. Kiittner (32)) in a study of 60 cases, found the inguinal glands enlarged in 71 per cent, although in only 32 per cent were they cancerous. While the inguinal nodes are often enlarged from inflammatory causes, as shown by these examina- tions and also by subsidence after operation without dissection of the groin, many authorities find a much larger percentage involved by cancer, notably Gussenbauer (36)) who states that the microscope will reveal carcinoma even though palpation fails to reveal enlarged glands.
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