cancer is a significant cause of morbidity and mortality in human immunodeficiency virus ( hiv)-infected subjects . verrucous carcinoma refers to a clinicopathologic concept implying a locally aggressive , clinically exophytic , low - grade , slow - growing , well - differentiated squamous cell carcinoma ( scc ) with minimal metastatic potential . there are very few cases of verrucous carcinoma of penis in hiv - positive patients reported in the literature . we report a case of verrucous carcinoma of penis in an hiv - positive patient which was treated with partial penectomy . a 60-year - old unmarried male patient presented with complaint of urethral discharge of 3 weeks duration which was yellowish , copious and non - foul smelling . he was being treated for multiple pruritic lesions over both upper and lower limbs for 7 months prior to onset of his present complaint . the patient was referred to urology where a dorsal slit of the prepuce was done which revealed an ulceroproliferative growth measuring 3 cm  3 cm arising from prepuce and involving glans [ figure 1 ] . venereal disease research laboratory was nonreactive and enzyme linked immunosorbent assay for hiv was positive . biopsy from the growth in the prepuce showed ulcerated dysplastic keratinized stratified squamous epithelium with hyperkeratosis , acanthosis , and papillomatosis . the base of the tumor was broad and had pushing border infiltrating the subepithelial stroma and showed dense lymphoplasmacytic infiltrate [ figure 2b ] . features were suggestive of verrucous carcinoma of penis ( prepuce ) infiltrating the subepithelial connective tissue . fine needle aspiration cytology of the inguinal lymph nodes showed features consistent with reactive lymphadenitis . dorsal slit of the prepuce showing an ulceroproliferative growth arising from prepuce and involving glans ( a ) histopathology of tumor in the prepuce showing dysplastic keratinized stratified squamous epithelium with hyperkeratosis , acanthosis and papillomatosis . tumor cells are well - differentiated with numerous keratin pearls ( h and e , 100 ) . ( b ) higher magnification showing broad tumor base with a pushing border infiltrating the subepithelial stroma ( h and e , 400 ) scc of the penis is itself rare and represents 0.3 - 0.5% of male malignancies in europe and the united states of america . verrucous carcinoma is a slow - growing variant of epidermoid carcinoma with low incidence of metastasis . the reported frequency of penile verrucous carcinoma is low and accounts for 3 - 20% of all penile cancers . the verrucous carcinoma lesion manifests as a verrucous , exophytic , or endophytic mass that typically develops at sites of chronic irritation and inflammation . it may be locally destructive and can penetrate deeply into the skin , fascia , and even bone . pai et al reported a case of verrucous carcinoma over the penis presenting as a nail - like cutaneous horn in an immunocompetent patient . the majority of cancers affecting hiv - infected subjects are those established as acquired immunodeficiency syndrome ( aids)-defining : kaposi 's sarcoma , non - hodgkin 's lymphoma , and invasive cervical cancer . however , other types of cancer , such as hodgkin 's disease , anal cancer , lung cancer and testicular germ cell tumors appear to be more common among hiv - infected subjects compared to the general population . many hiv - associated malignancies affect sites that are in contact with the outside environment ( e.g. , cervix , lung , oral cavity , skin , and anus ) . the increased density of immune cells and coincident elevated concentration of hiv-1 at these sites could lead to local compromised immune defenses and the subsequent development of malignancies at these sites . risk factors for penile verrucous carcinoma seem to be similar as for penile cancer in general , which are poor hygiene , phimosis and chronic inflammation . there seems to be a striking relationship between lack of circumcision and verrucous carcinoma of the glans penis . lack of circumcision and poor hygiene along with compromised local immunity could have been the risk factors in our patient . guiguet et al investigated the incidence of both aids - defining cancers and non - aids - defining cancers in 52,278 patients and found that the risk of both aids - defining cancers and non - aids - defining cancers increased with decreasing cd4 cell counts . our patient also had low absolute cd4 t helper cell count ( 29 cells / mm ) . absolute lymphocyte count in our patient was 800 cells / mm . in a study of the spectrum of mucocutaneous manifestations in hiv - infected patients conducted by fernandes and verrucous carcinoma is generally managed with wide surgical excision and glansectomy for carcinoma limited to the glans , with or without adjunctive chemotherapy , and tissue - sparing options such as mohs surgery , co2 laser surgery , liquid nitrogen cryosurgery for smaller lesions , either alone or in combination with topical 5-fu , and systemic or intralesional interferon- therapy in combination with surgical shaving . a surgical approach is usually preferred , as it shows excellent treatment outcomes and allows thorough histologic sampling and search for focal scc . thodore et al reported a case of a 37-year - old man who was hiv 1 positive who earlier was treated for condylomatous balanitis and subsequently developed scc of the glans penis which despite surgical excision metastasized to bilateral inguinal lymph nodes and lungs . patient is on regular follow - up with no evidence of local recurrence or inguinal lymph node metastasis 2 years postsurgery . there are very few cases of verrucous carcinoma of penis in hiv - positive patients reported in the literature . hence this case is being reported . as the number of hiv - infected patients continues to increase a high index of suspicion and early biopsy are crucial in the management of penile malignancies . managing hiv - positive patients with malignancy remains a challenge because of drug interactions , potential effect of chemotherapy on cd4 count and hiv-1 viral load . moreover , treatment compliance by hiv - infected patients with cancer may be poor , possibly because of the increased responsibility of taking drugs for both diseases with associated increased rate of compounded side effects .
cancer is a significant cause of morbidity and mortality in human immunodeficiency virus - infected subjects . 
 verrucous carcinoma is a peculiarly slow evolving , but relentlessly expanding variant of epidermoid carcinoma that is extremely reluctant to metastasize . a 60-year - old unmarried male patient presented with urethral discharge of 3 weeks duration . 
 dorsal slit of the prepuce revealed an ulceroproliferative growth measuring 3 cm  3 cm arising from prepuce and involving glans . 
 biopsy from the growth in the prepuce showed histopathological features of verrucous carcinoma . 
 partial amputation of the penis was done . 
 human papillomavirus dna by polymerase chain reaction was negative . 
 the patient was started on antiretroviral therapy .