Penile Carcinoma in Circumcised Males

New York State Journal of Medicine, Volume 79, Issue 12: Pages 1903-1904, November 1979.

STANLEY BOCZKO, M.D.
The Bronx, New York
SELWYN FREED, M.D., F.A.C.S.
The Bronx, New York

Note:

This historic article conclusively disproves the false claims made by circumcision promoter Abraham Wolbarst in 1932 that circumcision prevents penile cancer. This article probably accurately reflects the state of medical knowledge at the time. The most important risk factors for penile cancer, which are the presence of human papilloma virus and use of tobacco, had not yet been discovered at the time this article was written. See Carcinoma in Situ of the Penis in a 76-Year-Old Circumcised Man for a more recent report on cancer in circumcised males.

In Wolbarst's¹ extensive review of 1,103 case of penile carcinoma he was unable to find even a single patient who had been circumcised in infancy. Since then there have been only eight documented cases of penile carcinoma in an individual circumcised in infancy. The following is the ninth reported case and the first since 1968.

Case report

A 78-year-old Jewish male appeared in the emergency room of Montefiore Hospital with fungating and purulent penile lesion in the region of the frenulum. The patient claimed that the lesion had been present for nearly three years and had failed to respond to various topical medications prescribed by numerous physicians. He maintained that he had been ritually circumcised at eight days of age, and this was corroborated by family members.

Significant history included an open prostatectomy nine years earlier. The old chart was reviewed and described a normal circumcised penis without abnormalities.

A biopsy of the penile lesion revealed squamous cell carcinoma. No metastases were found, and the patient underwent a partial penectomy. Histologic examination showed a well-differentiated squamous cell carcinoma with extensive zones of invasion into the spongiosum; the margins of resection were free of tumor.

The patient recovered uneventually and was well one year postoperatively, after which he was lost to followup.

Comment

Circumcision is the oldest known surgical procedure, dating back more than 6,000 years according to Herodotus. Certain tribes with mother goddess figures, such as Ishtar and Cybele, in the ancient matriarchal religions, required the sacrificial offering of external male genitalia. As castration would have inevitably led to extinction of the tribe, it gave way to circumcision. The Hittites and the Amorites were also practicing this procedure when Abraham introduced mandatory ritual circumcision, in 1813 B.C. for all Hebrew males at the age of eight days. The ancient Hindus regarded the genitalia as the center of life and sacrificed the prepuce as a valuable offering to the gods. However, they no longer practice routine circumcision. Moslems continue to circumciseall males between 4 and 10 years of age.

There have been a number of articles published on the high incidence of penile carcinoma in Hindus who do not practice routine circumcision as compared with the Moslems who do.² During the Roman period, certain religious activities could only be performed by circumcised priests, but the general population was not circumcised.

Circumcision arose independently in the ancient Orient, Africa, and Polynesia as a pubertal or premarital rite, as well as a test of a man's ability to withstand pain. The females of certain African tribes are said to have demanded circumcision of their husbands, believeing that it decreased the sensitivity of the glans and, as a result, prolonged coitus. The practice gradually spread westward, and by the nineteenth century was well established on the European continent. In 1891 Remondino³ devoted an entire book to the various aspects of circumcision and described the prepuce as "tight constricted, glans deforming, onanism producing, and cancer generating."³

Cancer of the penis has also been recognized for thousands of years. Celsus recommended amputation for penile carcinoma with cauterization of the raw stump to control bleeding. In the seventeenth century, Scultetus used fire to destroy the tumor. The morbidity of the surgery in those days probably approached that for the disease itself.

In this country, the incidence of penile carcinoma is about 1 percent of male cancers.⁴ However, in countries where routine circumcision is not practiced, its incidence has been reported as high as 18 percent.⁵ While numerous reviews since Wolbarst¹ have confirmed his observation and corroborated the protective effect of circumcision, it has become apparent that this protection decreases if the circumcision is performed in later life. Lenowitz and Graham studied this group and found penile carcinoma occurring on an average of 22 years after the circumcision.⁶ A chronic irritative state, resulting from years of phimosis and balanoposthitis prior to the circumcision, has been postulated to explain this long latent period.

The incidence of phimosis in reviews of penile carcinoma ranges from 40 to 70 percent.^7,8 Smegma, a sterol, produced by Tyson's glands in the epithelium of the retroglandular sulcus, has been implicated as the causative agent. It may be converted to a carcinogen by the action of the Mycobacterium smegmatis. Plaut and Kohn-Speyer⁹ weer able to produce malignant skin lesions in mice, using smegma, but other investigators have been unsuccessful in confirming its carcinogenicity.

In 1936, the first case of penile carcinoma in a circumcised Jewish male was reported by Dean.¹⁰ In this patient the neoplasm developed in an old scar resulting rom cautery for a venereal wart. Four more cases in circumcised Jewish males have been reported.^11-14 There have also been three cases of penile carcinoma in gentiles who were reportedly circumcised in infancy.^15,16 In four of these eight cases there was a history of trauma to the penis preceding the development of cancer.

The diagnosis in our patient was made late, as in the other cases reported, perhaps because the disease was presumed not to occur in those circumcised in infancy. This is clearly not so. Although rare, the diagnosis must be considered when evaluating a penile lesion even in a circumcised individual.

Circumcision originated with the ancient tribes, and its basis can hardly be considered scientific. Nonetheless, performing it in infancy continues to be the most effective prophylactic measure against penile carcinoma.

Summary

The ninth case of squamous cell carcinoma of the penis in an individual circumcised in infancy is reported. The history of circumcision and its relationship to penile carcinoma is reviewed.

References

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