0022-534 7/85/1332-0216$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1985 by The Williams & Wilkins Co. Vol. 133, February Printed in U.S.A. VERRUCOUS CARCINOMA OF THE PENIS DOUGLAS E. JOHNSON,* RICHARD K. LO,t JOHN SRIGLEY AND ALBERTO G. AYALA From the Departments of Urology and Pathology, University of Texas M. D. Anderson Hospital and Tumor Institute at Houston, Houston, Texas ABSTRACT We reviewed 13 cases of verrucous carcinoma, accounting for 5 per cent of the penile cancers seen during a 25-year interval. Although the typical verrucous pattern predominated minute foci of invasive squamous carcinoma were identified in 3 patients. All patients were followed for at least 6 years and none has died of the malignancy. Wide surgical excision, usually requiring partial or total penectomy, is the treatment of choice. Verrucous carcinoma, an uncommon variant of squamous cell carcinoma, accounts for only 8 to 16 per cent of the penile cancers. 1 - 3 Although verrucous carcinoma has been well ac- cepted as a distinct clinical and pathological entity in the oral cavity and larynx, where it first was characterized by Ackerman in 1948, 4 confusion persists when similar tumors on the penis are described. Consequently, we reviewed our experience with 13 cases of verrucous carcinoma of the penis in an attempt to define further the clinical and histological characteristics of this malignancy. MATERIAL AND METHODS The medical records of all patients with a diagnosis of penile carcinoma evaluated at our hospital between 1952 and 1976 were reviewed. Of 237 cases 13 (5 per cent) had verrucous carcinoma. The medical and histological findings of these 13 patients were reviewed in detail. The minimum followup for each patient was 6 years. RESULTS Clinical findings. Patient age ranged from 30 to 86 years, with a median age of 47 years. Although the lesion was described most frequently as warty or fungating the appearance of the malignancy at diagnosis varied widely, including ulceration, nodular, warty, giant condyloma and fungating (fig. 1). In 10 patients the tumor had been present for at least 12 months, including 5 who described its growth during intervals of 2, 2, 4, 8 and 17 years, respectively. Only 3 patients had noticed the tumor for less than 1 year (1, 2 and 4 months, respectively). Treatment consisted of partial penectomy in 9 patients, total penectomy in 3 and a circumcision in 1. Adjuvant therapy (4,000 rad external beam radiation delivered to the penis and both inguinal regions before total penectomy) was used in only 1 instance. No patient has died of this malignancy, while 5 died of other causes after 6, 13, 16, 16 and 18 years, respectively. Eight patients remain alive at 6, 8, 9, 10, 12, 12, 18 and 19 years, respectively. Disease has not recurred in any patient but is suspected after 9 years in the man who refused a partial penectomy and underwent circumcision only. However, this patient has refused biopsy and further evaluation. Pathological findings. Gross features: The major site of tumor development was the glans penis in 11 patients and the foreskin in 2. However, in 2 patients verrucous carcinoma had replaced the entire glans almost completely and extended proximally along the shaft (fig. 1). The tumors ranged from 1.0 to 8.0 cm. Accepted for publication October 10, 1984. * Requests for reprints: Department of Urology, Box 110, M. D. Anderson Hospital, 6723 Bertner Ave., Houston, Texas 77030. t Current address: Department of Surgery, University of Hong Kong, Hong Kong. and had a mean diameter of 3.6 cm. Multiple nodules were present in 7 instances. Microscopic features: All tumors had a prominent exophytic pattern characterized by papillomatosis and hyperkeratoses (fig. 2, A). The deep aspect of the tumor interfaced with the underlying stroma along a broad front that frequently had club- shaped extensions consisting of well differentiated squamous epithelium (fig. 2, B). Eight specimens contained modest to marked lymphocytic infiltration at the epithelial-submucosal junction; in the latter area the heavy lymphocytic infiltrate often obscured the basement membrane of the epithelium (fig. 2, C). The squamous epithelium was extremely well differen- tiated, and showed excellent maturation and keratinization from the basal level to the surface. Cellular anaplasia was absent and mitotic activity was confined to the basal region (fig. 2, B and C). Cytoplasmic vacuolization of the granular layer was noted in several specimens. Although the typical verrucous pattern predominated, min- ute foci of invasive squamous carcinoma were identified in the tumors of 3 patients (fig. 2, D). In these areas poorly defined extensions of the tumor infiltrated the stroma. These areas were associated with a greater degree of cellular anaplasia and a higher mitotic rate than occurs in typical verrucous carcino- mas. The lesions resembled the hybrid verrucous-squamous carcinomas that recently have been described in the oral cav- ity.5 DISCUSSION Verrucous carcinoma is a peculiarly slowly evolving but re- lentlessly expanding variant of squamous carcinoma that is extremely reluctant to metastasize. 6 Although the tumor most frequently has a long growth phase, averaging several years, growth occasionally is almost explosive or, alternatively, a period of relatively slow progression is followed by rapid growth. 7 • 8 In our series the lesion had been present for less than 5 months in only 3 patients, while the remaining 10 had noticed gradual growth for 1 to 17 years. V errucous carcinoma has been reported in almost all parts of the body, including the oral cavity, larynx, columella, nasal fossa, maxillary antrum, lacrimal duct, bronchi, esophagus, vulva, vagina, uterine cervix, perineum, anus, rectum, scrotal skin and leg. 7 • 9 Regardless of the location, these tumors have similar and well recognized histological characteristics, includ- ing 1) a warty, densely keratinized surface, 2) a sharply circum- scribed deep margin, 3) bulbous, well oriented rete ridges com- posed of well differentiated keratinizing squamous epithelium lacking anaplasia, 4) a pushing rather than an infiltrative type of advancing margin and 5) an associated inflammatory infil- trate in the adjacent stroma. 5 In addition, recent light and electron microscopic, and autoradiographic studies ofverrucous carcinomas from various sites have demonstrated the presence 216