Scrotal skin cancer is a malignancy that originates in the skin of the scrotal sac, distinct from testicular cancer, which forms inside the testicle itself. This form of cancer is extremely rare, with an estimated incidence of about one case per one million males annually. Squamous cell carcinoma (SCC) is the most frequently identified type, representing the majority of primary scrotal skin tumors. Understanding the specific signs of this uncommon skin cancer is important for early detection and successful management.
Recognizing the Signs
The presentation of scrotal skin cancer often begins as a small, isolated change on the skin surface. Early manifestations typically appear as a reddish, firm, raised area, described as an erythematous nodule or plaque. This initial lesion may be painless, often leading to a delay in seeking medical attention.
As the condition progresses, the lesion’s texture often becomes noticeable, sometimes feeling scaly, crusty, or wart-like. Ulceration is a frequent development, forming a persistent sore that does not heal. This open sore may bleed or produce a discharge, and patients often experience persistent itching (pruritus) in the affected area.
The lesion is often located on the anterior or lower aspects of the scrotum. In advanced stages, the cancer may spread to the lymphatic system, manifesting as enlarged, firm lymph nodes in the groin. Any persistent or changing lesion on the scrotal skin warrants prompt medical evaluation.
Identifying Risk Factors
Historically, scrotal skin cancer gained notoriety due to its strong association with occupational exposure to specific carcinogens. It was known as “chimney sweep’s carcinoma,” linked to chronic contact with soot containing polycyclic aromatic hydrocarbons. While occupational exposure has significantly decreased, modern risk factors now play a greater role in disease development.
One modern factor involves chronic inflammation and iatrogenic conditions, particularly Psoralen and Ultraviolet A radiation (PUVA) therapy used to treat severe psoriasis. The thin scrotal skin is susceptible to the carcinogenic effects of this radiation, making genital protection during treatment advisable. Another significant risk is infection with high-risk subtypes of the Human Papillomavirus (HPV). Studies suggest HPV may be present in many scrotal SCC cases, indicating a similar pathogenic pathway seen in other anogenital cancers.
The majority of men diagnosed with this cancer are older, typically in their sixties or later. Chronic irritation from poor hygiene or pre-existing dermatological conditions may also contribute to the risk profile. These factors highlight a shift in the disease’s epidemiology from industrial agents to viral and therapeutic exposures.
Diagnostic Procedures
Confirming scrotal skin cancer requires a systematic approach, beginning with a thorough physical examination by a specialist, such as a urologist or dermatologist. The doctor will inspect the lesion and palpate the scrotal sac and groin lymph nodes to detect enlargement or firmness. Since the appearance can mimic other benign skin conditions, a visual assessment alone is not sufficient for a definitive diagnosis.
Diagnosis is confirmed through a biopsy, where a small tissue sample is surgically removed for histopathology. Depending on the lesion’s size, this may be a punch biopsy (removing a cylinder of tissue) or an excisional biopsy (removing the entire growth). The tissue is analyzed under a microscope to determine the exact cancer type and assess its depth of invasion.
If the biopsy confirms malignancy, further imaging tests are necessary for staging the disease. A Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) of the abdomen and pelvis checks for spread to regional lymph nodes or distant organs. Positron Emission Tomography (PET)/CT scans may also be employed in high-risk cases to identify potential metastatic sites, guiding the treatment strategy.
Treatment Approaches
The primary treatment for localized scrotal skin cancer is surgical removal of the tumor. This procedure involves a wide local excision, where the surgeon removes the visible lesion along with a margin of surrounding healthy tissue. The goal is to ensure the surgical margins are clear of cancer cells, confirmed by pathological analysis.
Depending on the size of the excision, the resulting defect may be closed directly or require reconstructive techniques. Due to the elasticity of the scrotal skin, primary closure is often possible. However, larger excisions may necessitate a skin graft or local tissue flaps to cover the exposed area and protect the underlying testicles.
For patients with enlarged or suspicious groin lymph nodes, a complete lymphadenectomy (surgical removal of the lymph nodes) is necessary. If the lymph nodes appear negative but the primary tumor has high-risk features, a sentinel lymph node biopsy (SLNB) may be performed. This technique identifies the first lymph node draining the tumor, allowing for targeted removal and analysis.
Adjuvant therapies, such as radiation or chemotherapy, are reserved for more advanced cases. Radiation may be used with surgery if the tumor has high-risk features or if the surgical margins are not clear. Systemic chemotherapy is employed when the cancer has spread to distant sites. The multidisciplinary team collaborates to tailor the treatment plan based on the specific stage and characteristics of the cancer.