Open Journal of Urology, 2011, 1, 89-90
doi:10.4236/oju.2011.14019 Published Online November 2011 (http://www.SciRP.org/journal/oju)
Ulcerated Nodal Metastasis in Penile Carcinoma
Krishnamachar Harish*, Yagachikatte Chikkanarasaiah Madhu
Department Of Surgical Oncology, M S Ramaiah Curie Centre of Oncology,
M S Ramaiah Medical College, Bangalore, India
Received May 5, 2011; revised June 16, 2011; accepted June 26, 2011
Abstract
A 35 year old male patient presented with untreated ulcerative lesion over the penis of one year duration with
ulcerations over bilateral groin and suprapubic areas of three months duration. Biopsy was reported as
squamous cell carcinoma. Involvement of nodes along suprapubic area is rare and is found ulcerated in this
case. Ulceration of nodes and fixity occurs in the later stages of malignancy. Blowout of the underlying
femoral vessels is one of the terminal events in such cases. This patient underwent bilateral ilioinguinal node
dissection, total penoscrotal amputation and bilateral flap cover with tensor fascia lata flap.
Keywords: Penis, Carcinoma, Ulceration, Inguinal Nodes
1. Introduction
One of the most important determinants of outcome of
penile cancer is the nodal disease. Palpable groin nodes
are present in up to 60% of penile cancers and about 85%
of these actually harbor metastatic disease [1,2]. The
nodal disease progresses in a step wise manner from in-
guinal to pelvic and therapy of early nodal disease would
be aimed at cure. We present an image of a locally ad-
vanced penile and groin lesions of carcinoma penis.
Figure 1. Clinical photograph showing primary ulcero-
proliferative lesion over the penis and ulceration over bila-
teral groin regions. Note that ulceration over the pubic
symphysis area is the ulceration of rarely described nodes
by Bazy and Decloux.
2. Case Report
A 35 year old male patient presented with untreated ul-
cerative lesion over the penis of one year duration, ul-
cerations over bilateral groin and suprapubic areas of
three months duration. On examination, the ulcers have
raised and everted edges with indurated base (Figure 1).
Biopsy was reported as Grade 2 squamous cell carci-
noma. CT scan revealed no involvement of deeper mus-
cles or pelvic nodes (Figure 2). This patient underwent
bilateral ilioinguinal node dissection, total penoscrotal
Figure 2. CT scan of groin area showing extensive nodal
disease with skin involvement. Note that the deeper struc-
tures including vessels and muscles are free of disease.

K. HARISH ET AL.
90
amputation and bilateral flap cover with tensor fascia lata
flap for local control. He is being planned for adjuvant
chemoradiation.
3. Discussion
Ulceration of nodes and fixity occurs in the later stages
of malignancy. Blowout of the underlying femoral ves-
sels is one of the terminal events in such cases [3,4].
There are some peculiarities in this patient. Bilateral in-
guinal nodes are involved with cutaneous ulceration.
However neither underlying muscles nor pelvic nodes
are involved. In addition, aberrant lymph nodes interca-
lated in the course of lymphatic trunks efferent to the
inguinal nodes have been reported in the inguinal canal
and over the symphysis pubis and at the base of penis
[5,6]. Involvement of these nodes is extremely rare and is
found ulcerated in this case. Based on retrospective stud-
ies [3,7-9] use of neo-adjuvant chemotherapy appears
attractive. Increased disease control has been reported
with adjuvant radiation in patients with bulky nodal dis-
ease [10]. However, in this case since nodes were not
fixed to underlying structures and the fact that there were
no radiologically detectable pelvic nodes, we opted for
surgical resection with flap cover to be followed by
chemoradiation. In addition, there are no prospective
randomized trial results available at this time. Moreov er,
most of the studies address nodal disease after the pri-
mary has been treated. In this case, primary and nodal
diseases were addressed simultaneously.
4. References
[1] S. Misra, A. Chaturvedi and N. C. Misra, “Penile Carci-
noma: A Challenge for the Developing World,” Lancet
Oncology, Vol. 5, No. 4, 2004, pp. 240-247.
[2] V. Margulis and A. I. Sagalowsky, “Penile Cancer: Man-
agement of Regional Lymphatic Drainage,” Urologic Cli-
nics of North American, Vol. 37, No. 3, 2010, pp. 411-
419. doi:10.1016/j.ucl.2010.04.009
[3] D. J. Culkin and T. M. Beer, “Advanced Penile Carcino-
ma,” The Journal of Urology, Vol. 170, No. 2 Pt 1, 2003,
pp. 359-365.
[4] U. Ferreira, L. O. Reis, L. Y. Ikari, W. da Silva Jr., W. E.
Matheus, F. Denardi, R. M. Stopiglia and F. H. Menezes,
“Extra-Anatomical Transobturator Bypass Graft for Fe-
moral Artery Involvement by Metastatic Carcinoma of
the Penis: Report of Five Patients,” World Journal of
Urology, Vol. 26, No. 5, 2008, pp. 487-491.
doi:10.1007/s00345-008-0282-z
[5] P. Bazy, “Ganglions du Penis,” In Gerota: Sur les Gan-
glions Prevesicaux. The Bullein of the Memebers of Sur-
gical Society of Paris, Vol. 28, 1902, p. 538.
[6] L. Decloux, “Examen dún Ganglion Penien,” In Gerota:
Sur les Ganglions Prevesicaux. The Bullein of the Me-
mebers of Surgical Society of Paris, Vol. 28, 1902, p. 538.
[7] C. Bermejo, J. E. Busby, P. E. Spiess, L. Heller, L. C.
Pagliaro and C. A. Pettaway, “Neoadjuvant Chemother-
apy Followed by Aggressive Surgical Consolidation for
Metastatic Penile Squamous Cell Carcinoma,” The Jour-
nal of Urology, Vol. 177, No. 4, 2007, pp. 1335-1338.
doi:10.1016/j.juro.2006.11.038
[8] J. A. Leijte, J. M. Kerst, E. Bais, N. Antonini and S. Ho-
renblas, “Neoadjuvant Chemotherapy in Advanced Penile
Carcinoma,” European Urology, Vol. 52, No. 2, 2007, pp.
488-494. doi:10.1016/j.eururo.2007.02.006
[9] L. C. Pagliaro and J. Crook, “Multimodality Therapy in
Penile Cancer: When and Which Treatments?” The Jour-
nal of Urology, Vol. 27, No. 2, 2009, pp. 221-225.
doi:10.1007/s00345-008-0310-z
[10] M. F. Chen, W. C. Chen, C. T. Wu, C. K. Chuang, K. F.
Ng and J. T. Chang, “Contemporary Management of Pe-
nile Cancer Including Surgery and Adjuvant Radiother-
apy: An Experience in Taiwan,” The Journal of Urology,
Vol. 22, No. 1, 2004, pp. 60-66.
doi:10.1007/s00345-003-0383-7