Squamous cell carcinoma of the scrotum: A look beyond the chimneystacks

Table 1 Risk factors associated with scrotal squamous cell carcinoma

Occupations

Chimney sweepers, tar and paraffin workers, occupations with exposure to mineral and cutting oils, printing, metal working, car and aeroplane manufacture, car mechanics, commercial printing, aluminum worker, shale oil workers, pitch workers, engineering, steel production, cavalrymen

Carcinogenic metals

Arsenic, nickel, chromium

Chronic mechanical irritation

Chronic inflammatory states

Chronic lymphedema, infective and surgical scars

Lifestyle

Poor personal hygiene, smoking

Viruses

HPV

Ionizing Radiation

Iatrogenic

Coal tar, PUVA, radiotherapy, nitrogen mustard, Fowler’s solution

Immunosuppression

Acquired and inherited immunodeficiency, post transplant immunosuppression

HPV: Human papilloma virus; PUVA: Psoralens and ultraviolet A radiation.

Table 2 Lowe’s staging of scrotal squamous cell carcinoma

A1	Disease localized to scrotum
A2	Locally extensive disease involving adjacent structures (penis, perineum, testis or cord, and pubic bone) by continuity but without evident metastasis
B	Superficial lymph node metastasis, resectable
C	Pelvic lymph node metastasis or any unresectable metastasis
D	Distant metastasis beyond regional nodes

Table 3 TNM staging system for squamous cell carcinoma

Stage	Primary tumour	Regional lymph nodes	Distant metastasis
Stage 0	Tis = carcinoma in situ	N0 = no regional lymph node involvement	M0
Stage I	T1 = tumour 2 cm or less	N0	M0
Stage II	T2 = tumour > 2 cm but < 5 cm	N0	M0
	T3 = tumour > 5 cm	N0	M0
Stage III	T4 = Invasion of deeper extradermal structures	N0	M0
	Any T	N1 = regional lymph node spread.	M0
Stage IV	Any T	Any N	M1 = distant metastasis.

Table 4 Case series with epidemiology, management and outcomes of scrotal squamous cell carcinoma published after 2000

Ref.	n	Design	Cohort characteristics	Summary
Stern et al[17], 2002	17	Prospective multi-institutional cohort study	892 men first treated with PUVA	Dose-dependent increase in the risk of genital tumors in men treated with PUVA
Seabra et al[19], 2007	6	Retrospective single institution	Age: 52 (31-89) Race: Ca: 2; Bl: 2; Oth: 1; Unknown: 1 Staging: LC: 4, RL: 1, DD: 1	4/6 WLE; 1/6 WLE + SLNB; 1/6 was unresectable: 1 developed LN metastasis and was treated with chemo/radiation Patient with unresectable disease and was treated with chemotherapy and subsequently died
Wright et al[2], 2008	151	SEER (1973-2002)	Age: 682 Race: Ca 117 (77.5); Bl 24 (15.9); Oth 10 (6.6)	SCC had the worse survival compared to other histological subtypes
Verhoeven et al[1], 2010	53	NCR (1989-2006)	Age: 56.5 Staging: Stg 0: 1 (1.9), Stg 1: 22 (41.5), Stg 2: 18 (34), Stg 3: 2 (3.8), Stg 4: 0, Unk: 10 (18.9)	SCC had the worse survival compared to other histological subtypes: 1 yr relative survival 93% 3 yr relative survival 80% 5 yr relative survival 77%
Johnson et al[16], 2013	269	SEER (1973-2006)	Age: 65.42± 14.9 Race: Ca 206 (76.6%), Bl 43 (16.0%), As 12 (4.5%), Hi 18 (6.7%), Oth 8 (3.0%) Staging: LC 205 (76.2%), RL 54 (20.1%), DD 10 (3.7%)	The median OS for patients with SCC was 115 (95%CI: 97-133) mo
Matoso et al[18], 2014	29	Retrospective multi-institutional	Age: 55 (30-74) Race: Ca 19 (65.5%), Bl 10 (34.5%) Follow up: 37 mo	25/29 WLE; 1/29 WLE + LND; 3/29 imiquimod post WLE: 13 (45%) with1 margins required re-excision1 3/29 local recurrence: 2 WLE; 1 WLE/RT 3 /29 with lymphadenopathy lost to follow-up

¹Positive;

²Mean. As: Asian; Bl: Black; Ca: Caucasians; DD: Distant disease; Hi: Hispanics; LC: Local disease; NCR: Netherlands Cancer Registry; OS: Overall survival; Oth: Other; PUVA: Psoralens and ultraviolet A radiation; RL: Regional lymph node; SCC: Squamous cell carcinoma; SEER: Surveillance, Epidemiology and end results; SLNB: Sentinel lymph node biopsy; Stg: Stage; WLE: Wide local excision.