CYSTS AND CANCER OF THE SCROTUM
Sebaceous cysts (epidermoid, epidermal cysts) of the scrotal wall are not uncommon. Derived from sebaceous glands in the skin, cysts form either from over-production of secretions or as a result of obstruction of the gland outlet. These cysts, usually scrotal, appear as smooth, round cystic tumors, varying in size from a few millimeters to, in rare instances, 8 to 12 cm. Although usually solitary or few in number, the occurrence of several hundred cysts has been described. The secretions contain cholesterol crystals and degenerated epithelial cells, and the ﬁbrous cyst capsule is lined by stratiﬁed squamous epithelium with varying degrees of atrophy. Trichilemmal cysts (pilar cysts) are clinically indistinguishable from sebaceous cysts but contain keratinous rather than sebaceous material. Regarding the cyst type, inﬂammation is common in the obstructed duct and can lead to infection and pain. Sebaceous cysts are not precancerous but have been known to calcify. Deﬁnitive treatment is surgical excision, best performed after infection has been quelled with antibiotics. With excision, the entire epithelial sac that lines the cyst must be removed to avoid recurrence.
Angiokeratoma is a skin disorder characterized by the presence of multiple, small, punctate, violaceous (purple) lesions on the scrotal, and occasionally penile, skin. There can be hundreds of lesions present, but they are generally asymptomatic. They represent slightly elevated areas of venous ectasia and appear similar to punctate angiomas. As they are benign, treatment is usually unnecessary. However, if they bleed, local fulguration is effective.
Carcinoma of the scrotum is a rare cancer and for the most part an occupational disease conﬁned to men exposed to petroleum and its products. It was the ﬁrst cancer shown to be caused by an environmental carcinogen, and was named chimney-sweep’s cancer in 1775 after its association with soot by Sir Percival Pott. It also occurs in men chronically exposed to tar, pitch, parafﬁn, shale, creosote, and crude wool. It has been observed in weavers who lean across machinery, and whose clothes become impregnated with oil, which then contacts the scrotum. It has also been described after x-ray therapy to the scrotum or following the chronic use of local treatments (PUVA [psoralen and ultraviolet A]) for scrotal psoriasis. An occasional case is observed without a history of occupational contact, and there may be an association with HPV type 18 virus. The malignancy appears after two or three decades of exposure, usually between the ages of 45 and 70 years. The early lesion may be a small pimple or warty tumor that ulcerates, or the lesion may begin as an ulcer and develop into a large fungating mass.
Most carcinomas of the scrotum are squamous in type, but melanomas, basal cell carcinomas, and sarcomas have also been observed. Local remedies are usually applied without beneﬁt before clinical presentation with pain. In about 50% of cases, metastases to inguinal lymph nodes are present when the patient is ﬁrst seen. Metastatic spread occurs relatively quickly as the thin scrotal wall lacks natural barriers that tend to wall off neoplasia. Consistent with other squamous cancers, dissemination occurs chieﬂy by lymphatic rather than hematogenous spread. If the malignancy has invaded the scrotal contents, metastases may spread directly to the peri-aortic nodes. Possibly due to its rarity or to the nature of scrotal cancers, there is little relation between the duration of the cancer diagnosis, the grade of malignancy, and the prevalence of lymph node involvement. In very early, localized cases, a 75% cure rate is possible, with wide scrotal excision. Among those with lymph node involvement, 25% of patients are cured with bilateral inguinal and femoral lymphadenectomy. Bilateral excision of draining lymph nodes is necessary, as the lymphatic channels in the scrotum are richly interconnected. The prognosis in metastatic cases is poor, and treatment can be quite morbid. Direct extension of tumor to deep femoral, external iliac, and hypogastric lymph nodes can occur, requiring dismemberment, lower limb removal, and hemipelvectomy. Chemotherapy and radiotherapy can be considered for downsizing tumors before resection but rarely result in cure when used as classic adjuvant therapy.