Radiation-Induced Vasculopathy Precipitating Penile Gangrene
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LETTER TO THE EDITOR
Radiation-Induced Vasculopathy Precipitating Penile Gangrene Aakanksha Singh 1 & Rahul Insa 2 & Nadeem Tanveer 1
&
Pankaj Kumar Garg 2
Received: 17 October 2019 / Accepted: 17 June 2020 # Indian Association of Surgical Oncology 2020
Sir, Anal carcinoma is a rare tumor with age-standardized incidence rates mostly between 1 and 2 per 100,000 per year [1]. Abdominoperineal resection of the rectum remained the mainstay of treatment until mid-1970s; however, with the introduction of Nigro protocol, definitive chemoradiotherapy became a popular modality and led to a paradigm shift in the management of anal carcinoma [2, 3]. However, radiotherapy has its own complications—both acute effects and long-term sequelae. Besides being tumoricidal, therapeutic radiation also damages normal tissues and has the potential to induce second malignancies. Known complications of anorectal irradiation were decreased sphincter competency, lumbosacral plexus toxicities, and radiodermatitis [4]. Meatal stenosis of penile urethra is a common late effect, but a tissue gangrene secondary to obliterative changes and radiation-induced vasculopathy is rarely reported. A 46-year-old gentleman presented with a 3-day history of painful swelling of scrotum and penis. He was a non-diabetic and non-hypertensive and denied any history of trauma or immunosuppressive therapy. He was an anal carcinoma survivor who had undergone definitive chemoradiation 10 years ago at a center with a cobalt-60 teletherapy unit. Though the exact details of the chemoradiotherapy could not be retrieved, * Nadeem Tanveer [email protected] Aakanksha Singh [email protected] Rahul Insa [email protected] Pankaj Kumar Garg [email protected] 1
Department of Pathology, University College of Medical Sciences and GTB Hospital, Delhi, India
2
Department of Surgery, University College of Medical Sciences and GTB Hospital, Delhi, India
he was treated with 30 fractions over a period of 6 weeks (likely 54 to 60 Gy) and weekly intravenous chemotherapy. The patient had erectile dysfunction subsequent to the radiation therapy. His physical examination revealed swelling of the penis and scrotum. The distal third of penis was dry, shriveled, and black in color (Fig. 1a). The patient was initially managed with broad-spectrum antibiotics and urinary diversion with percutaneous suprapubic cystostomy. Subsequently, color Doppler ultrasonography of the penis confirmed the absence of flow in the dorsal penile artery. Subsequently, he underwent partial penectomy and perineal urethrostomy in view of complete obliteration of anterior urethra. Gross examination of the partial penectomy specimen showed partly ulcerated, shriveled, and discolored skin. Cut surface showed fibrosed cavernosae with no identifiable meatus or urethra (Fig. 1b). On microscopy, areas of geographic, inhomogenous fibrosis were seen (Fig. 1 c and d). Fibrinous exudate was observed as a delicate network of acidophilic fibrils. Atypical fibroblasts were identified (hyperchromatic an
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