carcinoma penis

2.  Age: 55 years
 Sex: Male
 Address: Chipalli, East Godavari district
 Marital status : married
 Occupation: Driver
 Socioeconomic status: Upper lower Socioeconomic
class (IV) [Modified Kuppuswamy]
 Religion: Hindu

3.  Ulcer on Penis since 1 year.
 Bilateral Swelling and pain in groin region
since 8 months
 Enlargement of scrotum since 6 months.

4.  Patient was apparently normal 1 year ago
when he developed ulcer on Penis.
 H/o on & off fever present.
 No H/o Trauma. No H/o discharge.
 No H/o associated diseases.
 Later he developed B/L swellings in groin
associated with pain 8 months ago.

5.  The pain originated in groin.
 Insidious in origin, continuous, non
progressive and moderate severity.
 the patient was unable to describe the nature
of pain, relieved on self-medication.
 swelling was noticed due to pain.
 No aggravating factors, periodicity, special
times of occurrence and associated
symptoms.

6.  I&D by local surgeon. swellings
recurred.
 2 swellings –B/L and inguinal.
 recurred swellings associated with
similar pain & scrotal enlargement.
They were ulcerated in the due course.
 No H/o other lumps, weight loss.
 No H/o sudden increase in size of
swellings

7.  2 ulcers developed over swellings 5 months
ago in addition to previous ulcer on Penis.
 No H/o Trauma. Ulcers associated with
similar pain and foul smelling, Greenish,
discharge.
 No H/o associated diseases.

8.  No similar complaints in the past.
 No H/o T.B., Filariasis, STDs.
 No H/o any surgeries in the past. No H/o
Circumcision.
 No H/o Phimosis ,balanoposthitis.

9.  Married
 mixed diet
 non-smoker and non-alcoholic. Chews
Tobacco.
 Bladder and bowel habits are normal. Sleep
pattern and appetite are normal. No weight
loss.
 No H/o D.M.,HTN,CVD.
 H/o multiple sexual partners & unsafe sex
present.

10.  No relevant drug history
 No similar complaints in family
 No H/o allergies.

11.  Conscious, coherent and well oriented with time
and place.
 Moderately built and mild pallor is present
 Right pedal oedema of pitting type is present.
 B/L Inguinal Lymphadenopathy is present. No
Lymphadenopathy in other regions

13.  No Icterus ,Koilonychia
 No evidence of Syphilitic stigmas.
 No palpable Parotid & Lacrimal glands

14.  Pulse : 78 beats/min , with regular rhythm,
normal flow. Arterial wall just palpable, no
Radio-radial & Radio-femoral delay.
 B.P: 120/80 mm of Hg at right Brachial artery
in supine position.
 Temperature: 99*F
 Respiration : 18 breaths/min,
abdomino-thoracic type

15. INSPECTION :
 One ulcer on Penis.
 oval in shape and approximately 2-3cm*1 cm
in size
 rolled out edge and floor is sloughy.
 Discharge Green and the surrounding area
Red and oedematous.

17.  2 swellings B/L in groin.
 Red colour, oval shape. 7-8 cm horizontally
and 3-4 cm vertically with clearly defined
edges.
 Skin over the swollen lymph nodes is
oedematous, reddish and ulcerated.

19.  Ulcers-2, B/L, Oval in shape, 5-7*2-3cm in
size, 1 on each swelling, Rolled out edges,
sloughy floors, Purulent, Foul smelling,
Greenish discharge, Surrounding areas red &
oedematous.

20.  Oedema and thickening of scrotal skin .
 Scrotal rugae absent.
 Scrotum swollen, extends up to 2/3rds of
thigh.

22. PALPATION :
 Ulcer is tender.
 Edge rolled out, indurated.
 Base markedly indurated.
 No bleeding on touch.

23.  Local rise of temperature on all swellings.
 swellings tender and oval in shape.
 Swelling on right groin 7.5*4 cm*1mm , left
groin is 8*5cm*2mm.
 swellings have nodular surface, well-defined
edges, indistinct margins and stony hard
consistency and ulcerated.
 negative for fluctuation, reducibility, fluid
thrill, compressibility and pulsatility.

24.  negative for translucency and impulse on
coughing.
 Not fixed to surrounding structures
 Pitting right pedal oedema and thickened
scrotal skin
 Epididymis and Spermatic cord normal
 Testis not palpable
 Translucency of scrotum negative

25.  Non-metastatic Jacksonian stage III, TNM
stage T4 N2 M0 primary ulcerative carcinoma
of penis(suspected to be of Squamous cell
origin)complicated with secondary infection
and scrotal elephantiasis.

26.  Lymphogranuloma Venerum.
 Filariasis
 Tuberculosis
 Syphilis
 Chromoblastomycosis
 Co-existing Lymphogranuloma Venerum and
HPV infection leading to carcinoma penis
complicated by secondary infection(suspected
to be by Pseudomonas sp) and scrotal
elephantiasis.

27. GENERAL INVESTIGATIONS
 The general investigations to help in planning
therapy.
BIOCHEMISTRY :
 Random blood sugar(RBS),blood urea, Creatinine,
Sodium and Potassium levels normal.
PATHOLOGY :
 Bleeding time(B.T) and Clotting time(C.T) normal.
 Haemoglobin concentration low(6.3 g/dl)-Anaemia.
 Total Leucocyte count(T.L.C) elevated (19,200
cells/cu.mm) - immune response to secondary
infection and malignancy.
 Blood group-B +.

28. SPECIAL INVESTIGATIONS :
PATHOLOGY
 The investigation of choice in a suspected
case of Penile carcinoma is Histopathological
examination of edge biopsy specimen of
ulcer.

30. RESULT :
Well differentiated squamous cell carcinoma

31. RADIOLOGY :
 The other investigation is ultrasonography.
 This is done to assess the condition of Testis
and to confirm Scrotal elephantiasis.

34.  RESULT :
 Normal Testis with bilateral Hydrocele and
thickened scrotal skin(Scrotal Elephantiasis).

35. MICROBIOLOGY
 The discharge from ulcer was sent to Culture
and sensitivity test.

37.  Tests for Syphilis, Hepatitis and H.I.V were
negative.

38. RESULT :
 secondary infection organism- Pseudomonas sp.
 sensitive to
1. Amikacin
2. Piperacillin
3. Gentamycin
4. Imipinem
5. Levofloxacin
6. Tobramycin
7. Azetreonam
8. Mefzocillin

39.  Advanced well differentiated non-metastatic
Jacksonian stage III, TNM stage T4 N2 M0
ulcerative primary Squamous cell carcinoma
of Penis complicated with secondary
Pseudomonas infection and scrotal
elephantiasis.

40. MANAGEMENT OF PRIMARY TUMOUR :
 As tumour involves entire shaft of the penis,
total penectomy must be done with perineal
urethrostomy.
COMPLICATIONS :
 Scrotal Ammonical dermatitis.
 Stricture at urethrostomy site.
 Ammonical dermatitis can be prevented by
asking the patient to urinate in sitting
position.

41.  Alternatively Total scrotectomy with
orchidectomy can be done along with total
amputation of penis (Sir Piersey Gold
operation).
 This procedure also reduces sexual desire.

42. MANAGEMENT OF SWOLLEN LYMPH NODES :
 Swelling of lymph nodes due to secondary
carcinomatous deposits .
 However as the tumour is of T4 stage
prophylactic inguinal block dissection can be
done.
COMPLICATIONS :
 Flap necrosis is the most common complication.
Other complications are :
1. Haemorrhage
2. Lymphorrhea
3. Lymphoedema
4. Infection.

43. THANKS TO
Dr.Swaroop sir
AND
Dr.DILIP sir
Of Department of Surgery
And to
My friends

44. THANK
YOU