penile cancers comprised 2% of all cancers in our institution in 1968 . despite the high frequency of penile squamous carcinomas ( sc ) in india , there is no published literature on the frequency of its histologic types . among the various subtypes , warty or condylomatous type of squamous cancer ( wc ) of the penis is a relatively recently described entity and , barring a few studies from paraguay and brazil , very little has been published on this pathology . we reviewed our institutional database of penile cancers to assess the frequency of wc , its clinicopathological characteristics , and identify any differences between wc and squamous carcinoma - not otherwise specified ( sc - nos ) . 103 cases of penile carcinoma , who underwent total or partial penectomy between september 2001 and august 2007 at our institution were studies . after treatment of the primary tumor , all patients were advised inguinal lymphadenectomy ( lad ) irrespective of inguinal nodal status and primary tumor histology . patients who refused to undergo lad were advised to come for regular follow - up . patients with pathologically positive inguinal node either on frozen or routine histopathological examination were subjected to pelvic lad . the specimen were grossed and the location , size , anatomic compartment , and maximum depth of invasion were noted . sections were taken from area of maximum invasion . the number of blocks of tumor taken per case ranged from two to four . microscopic features studied for all 103 cases included grade of tumor , presence of lymphovascular tumor emboli , level of invasion ( t stage ) , and maximum depth of invasion ( measured from basement membrane of adjacent normal squamous epithelium to the point of maximum invasion ) . of the 103 cases , 24 tumors with exophytic papillary architecture ( verruciform tumors of cubilla ) were studied in detail . in all 24 cases , additional features including the presence of papillae , degree of hyperkeratosis and parakeratosis , keratin cysts , intraepidermal abscesses , presence of koilocytosis , degree of nuclear atypia , and type of tumor - stromal interface ( pushing versus irregular , infiltrative ) were noted . adjuvant treatment if any , lymph node ( ln ) status at the time of presentation and disease free survival in months whenever available were noted . the different subtypes were compared for ln status and depth of invasion and lymphovascular tumor emboli . although follow - up was not available for all cases , disease free survival in months wc was diagnosed when typical features like papillomatous exophytic growth with rounded or spiky papillae with prominent fibrovascular cores [ figure 1a ] and irregular , infiltrative tumor stromal interface [ figure 1b ] , and conspicuous koilocytosis [ figure 1c ] , were present throughout the tumor . koilocytosis was defined as clear perinuclear cytoplasmic haloes , wrinkled , enlarged nuclei , bi or multinucleated cells , and dyskeratosis . when these features were not uniformly present , it was called mixed subtype with components listed in order of predominance . ( a ) rounded and spiky papillae of warty carcinoma ( h and e , 100 ) ( b ) irregularly infi ltrating downgrowths ( h and e , 200 ) ( c ) conspicuous koilocytosis ( h and e , 400 ) there were ten pure wc ( 9.70% of the total cases ) , and seven cases with warty and nos components . four of these seven had predominant warty component and three of the tumors had predominant nos component and only focal warty areas . the single case of mixed verrucous and nos was included under nos category for purposes of comparison . among the nonverruciform tumors we did not have any rare variants such as sarcomatoid , pseudohyperplastic type , or cuniculatum . frequency of histological subtypes of penile squamous carcinoma the clinicopathologic features are summarized in table 2 . of the 79 cases , 67 had involvement of the glans penis with or without extension into the prepuce and shaft and six cases had only prepucial involvement . in three cases the tumor was mainly in the prepuce with extension into the glans , four cases were in the shaft without involvement of glans . partial amputation was done in 55 cases , total amputation was done in 21 cases , and two cases underwent circumcision . eleven cases with ln metastases received chemotherapy . in one case of mixed verrucous and nos subtypes , one patient had ln metastasis proven by fine needle aspiration cytology ( fnac ) , but refused surgery . of the 21 cases with ln metastases , lymphovascular tumor emboli were detected in the penile resection specimen in 71.42% . the average depth of invasion in those cases with ln metastases was 7.33 mm versus 6.04 mm in those cases with negative ln on dissection . follow - up of 6 months or more was available only in 41 cases and the average follow - up after the diagnosis of disease was 38.6 months with a range of 6 - 87 months . of the 41 patients , one developed local recurrence and ln metastases after 33 months of partial amputation , while another developed ln metastases 14 months after total penectomy . one patient who had t4 disease developed local recurrence involving perineal skin and soft tissues 2 months after total penectomy . comparison of clinicopathological features of the different subtypes 24 patients had verruciform tumors [ table 3 ] ; partial amputation was done in 18 patients and total amputation in four . one patient had wide local excision as part of penile conservation and one was lost to follow - up after the diagnosis was made on wide local excision of the lesion . comparison of microscopic features of the different histologic subtypes under verruciform category clinicopathologic features of the 10 patients with warty carcinoma ( wc ) are given in table 2 . the rest were advised close follow - up . follow up of 6 months or more was available in eight cases . mean follow - up was 40.63 months with a range of 7 - 67 months in these 8 patients . one patient who had an initial wide local excision had recurrence after 6 months , at which point , partial amputation was done . the tumor was located on the glans in all of the cases and it involved the prepuce in three cases . partial amputation was done in five cases , total amputation in one case and wide local excision in one case as part of penile conservation . mean follow - up was 41.8 months with a range of 15 - 89 months . mean age of presentation , tumor size , and depth of invasion is given in table 2 . the tumors were located in the glans with involvement of corona in all the four cases and prepucial involvement was additionally noted in two cases . one patient who underwent a wide local excision of the tumor for confirmation of diagnosis was lost to follow - up . only one of the four cases had superficial inguinal lad and the nodes were negative for tumor . of the four cases , three had follow - up of 22 , 24 , and 65 months . one patient , who was seropositive for human immunodeficiency virus ( hiv ) , was found to have metastatic squamous cancer deposits in the inguinal ln by fnac , 65 months after partial penectomy . the maximum tumor size was 2.5 cm and the depth of invasion was 8 mm . the maximum tumor dimension was 7 cm and the depth of invasion was 12 mm . 67 had involvement of the glans penis with or without extension into the prepuce and shaft and six cases had only prepucial involvement . in three cases the tumor was mainly in the prepuce with extension into the glans , four cases were in the shaft without involvement of glans . partial amputation was done in 55 cases , total amputation was done in 21 cases , and two cases underwent circumcision . eleven cases with ln metastases received chemotherapy . in one case of mixed verrucous and nos subtypes , one patient had ln metastasis proven by fine needle aspiration cytology ( fnac ) , but refused surgery . of the 21 cases with ln metastases , lymphovascular tumor emboli were detected in the penile resection specimen in 71.42% . the average depth of invasion in those cases with ln metastases was 7.33 mm versus 6.04 mm in those cases with negative ln on dissection . follow - up of 6 months or more was available only in 41 cases and the average follow - up after the diagnosis of disease was 38.6 months with a range of 6 - 87 months . of the 41 patients , one developed local recurrence and ln metastases after 33 months of partial amputation , while another developed ln metastases 14 months after total penectomy . one patient who had t4 disease developed local recurrence involving perineal skin and soft tissues 2 months after total penectomy . comparison of clinicopathological features of the different subtypes 24 patients had verruciform tumors [ table 3 ] ; partial amputation was done in 18 patients and total amputation in four . one patient had wide local excision as part of penile conservation and one was lost to follow - up after the diagnosis was made on wide local excision of the lesion . clinicopathologic features of the 10 patients with warty carcinoma ( wc ) are given in table 2 . the rest were advised close follow - up . follow up of 6 months or more was available in eight cases . mean follow - up was 40.63 months with a range of 7 - 67 months in these 8 patients . one patient who had an initial wide local excision had recurrence after 6 months , at which point , partial amputation was done . the tumor was located on the glans in all of the cases and it involved the prepuce in three cases . partial amputation was done in five cases , total amputation in one case and wide local excision in one case as part of penile conservation . mean follow - up was 41.8 months with a range of 15 - 89 months . mean age of presentation , tumor size , and depth of invasion is given in table 2 . the tumors were located in the glans with involvement of corona in all the four cases and prepucial involvement was additionally noted in two cases . one patient who underwent a wide local excision of the tumor for confirmation of diagnosis was lost to follow - up . only one of the four cases had superficial inguinal lad and the nodes were negative for tumor . of the four cases , three had follow - up of 22 , 24 , and 65 months . one patient , who was seropositive for human immunodeficiency virus ( hiv ) , was found to have metastatic squamous cancer deposits in the inguinal ln by fnac , 65 months after partial penectomy . the maximum tumor size was 2.5 cm and the depth of invasion was 8 mm . the maximum tumor dimension was 7 cm and the depth of invasion was 12 mm . the frequency of subtypes of penile cancers in our study is similar to those previously published by guimares et al [ table 1 ] . only one case of pure basaloid carcinoma was seen in our series of 103 cases ( 0.97% ) . this was much lower when compared to previous data where its incidence varied from 4% to 8% . we thus found a higher frequency of warty type and much lower frequency of basaloid type when compared to the studies from paraguay . this is interesting because both the subtypes are preferentially associated with human papilloma virus ( hpv)-16 infection and a possible relation between the two entities has been proposed with the description and characterization of a mixed warty - basaloid variant . there is significant variability in the frequency of sub - types of penile cancer geographically . rare subtypes like adenosquamous , pseudohyperplastic sc , and carcinoma cuniculatum were not seen in our series . geographic variations in the prevalence of different hpv subtypes and conditions like lichen sclerosus et atrophicus and phimosis could be some of the reasons for these differences . the first description of wc of the penis in english medical literature could be found in the article by davies et al . similar carcinoma has been described much earlier in the vulva by rastkar et al . , in 1982 . the type of papillae and degree of hyperkeratosis and parakeratosis did not help in differentiating the different types . the presence of koilocytosis and type of tumor - stromal interface were the important features differentiating warty subtype from other verruciform tumors . there are only a few published series on wc of the penis and most of them are from paraguay and brazil . our data on these cases is similar to theirs . these patients are generally in their sixth decade and , pathologically , the majority are grade 2 with less than 20% incidence of ln metastasis . in comparison with other subtypes , the mean age of presentation of wc was slightly higher but the average size of the tumor or depth of invasion did not differ significantly . the incidence of lymphovascular tumor emboli and ln metastasis was lower in wc cases ( 30% and 10% ) than in the sc - nos category ( 49.4% and 26.6% ) respectively . table 4 show the percentage of cases with lymphovascular tumor emboli in each category with the tumor stage . tumor stage for stage comparison of lymphovascular invasion in the different subtypes in a study on the relation between histologic subtypes of penile sc and outcome , cubilla et al . the verruciform tumors had a better prognosis than sc of the usual type which in turn had a better prognosis than the basaloid - sarcomatoid group . the authors stated that this could be due to the inherent invasive characteristics of the different subtypes , that is , verruciform tumors had lesser depth of invasion than usual type sc . in our series , the average depth of invasion of the wc cases and the sc - nos were identical , but wc displayed lesser degree of lymphovascular embolization and inguinal ln metastases . guimares et al . , have documented a 10% recurrence rate for wc when compared to 28% for sc - nos . hence , an exact comparison of disease free survival between the different groups is not possible . however , in the wc cases with follow - up , recurrence was seen in only one case that had only an excision of the tumor . in the sc - nos group , three had recurrence / metastases , even after total / partial penectomy . of the six wc cases with clinically palpable inguinal ln , only one had metastasis ; while in the mixed ( warty and nos ) category , only one of the four cases with enlarged inguinal ln had metastasis . low recurrence rate and low rate of inguinal ln metastasis necessitates the question whether a conservative surgery without ln dissections would suffice in at least a subset of patients with wc subtype . in a study published earlier by bhagat et al . , on the same cohort of patients regardless of histological subtype , strongest predictors of inguinal ln metastasis were presence of high grade and lymphovascular invasion in the penile resection specimen and clinically palpable ln . more cases of wc have to be studied to assess whether the predictors are different for this subtype . pathologic factors predicting the likelihood of nodal metastases include histological grade of the tumor , level of infiltration , and perineural invasion . the importance of histological subtype in triggering a prophylactic inguinal lad is not established . however , in a study by chaux et al . , warty , papillary , and verrucous histological types of penile cancers were associated with significantly lower rates of recurrence and inguinal ln metastases . although there seems to be a case for conservative management for these subtypes , larger studies with longer follow - up are necessary before this can be adopted as routine . in summary , we have studied the frequency of the different subtypes of penile squamous carcinoma in india and compared it to published literature from paraguay and brazil . in india , the frequency of wc appears almost slightly higher . the wc cases in our series , did not differ significantly in mean size or depth of invasion from sc - nos . similar to studies from south america , wc cases were found to have lower frequency of lymphovascular invasion and ln metastasis when compared to sc - nos .
aims : there are few studies on the pathology of warty carcinoma ( wc ) of the penis and these have been from south america . 
 penile cancers are not uncommon in india . 
 we reviewed the frequency of subtypes of penile squamous carcinoma ( sc ) and the pathological features and outcome of wc when compared to squamous carcinoma - not otherwise specified ( sc - nos ) . 
 we also compared the clinicopathological features of wc in our series with those published earlier.materials and methods : we studied 103 cases of penile cancers over 6 years . 
 cases were classified into different subtypes according to established histologic criteria . 
 clinicopathologic features were studied in detail and compared among the different subtypes , especially between wc and sc - nos . 
 the patients were followed - up and disease free survival in months was noted.results:sc-nos constituted 75.7% of all penile cancer cases in our series . 
 the frequency of other subtypes was wc : 9.7% , verrucous : 3.9% , basaloid type and papillary type : 0.97% each , and mixed types 8.7% . 
 the average tumor size and depth of invasion did not differ significantly between the two subtypes . 
 frequency of lymphovascular emboli and percentage of lymph node metastasis in wc ( 30 and 10% ) were lesser than in sc - nos ( 49.37 and 26.58% ) , respectively . 
 there were no recurrences after partial penectomy in the wc subtype . in the sc - nos type , three cases 
 had recurrence after partial / total penectomy.conclusion:warty carcinoma constitutes nearly 10% of all penile squamous cell cancers . 
 these patients seem to have a less aggressive behavior than sc - nos .