penile squamous cell carcinoma ( pscc ) , the predominant histological type ( > 95% ) of penile cancer , is a relatively rare malignant tumor in western countries and japan .
pscc is a rare disease , making it difficult to establish a standard of care in any of the clinical stages , particularly in advanced disease .
multimodal treatments , including surgery , chemotherapy , and radiation therapy , should be considered for patients with advanced pscc . however , the optimal chemotherapeutic regimen is unknown , although cisplatin - containing chemotherapy is the mainstay of combination chemotherapy .
recent studies have suggested that taxanes in combination with cisplatin and fluorouracil ( 5-fu ) have a significant effect on unresectable and recurrent penile cancer .
malignant wound , results in a decline in the quality of life because of the presence of bleeding , exudates , and/or strong odor .
mohs chemosurgery is a technique of chemical fixation of a cutaneous tumor and subsequent excision .
several studies have shown the efficacy of mohs paste for maintaining malignant wounds in advanced squamous cell carcinoma of the breast , skin , head , and neck [ 4 , 5 ] .
we report a case of a pscc with advanced lymph node metastasis treated with combination therapy consisting of taxane - based chemotherapy , irradiation , and mohs paste .
an 80-year - old male presented to a community hospital with pain and redness in his left inguinal region .
he had undergone penectomy and bilateral inguinal lymphadenectomy 1 year ago because of primary pscc ( pt1pn0 ) .
a large solid mass with bleeding and a smelly exudate was observed in his left inguinal region .
macroscopically , the tumor mass of the left inguinal region was 7.0 cm in diameter with an ulcer , redness , and exudate ( fig .
a ct scan revealed a huge mass ( 5.9  5.8 cm ) in the left inguinal region along with his left femoral vessels ( fig .
he was administered combination therapy consisting of a taxane - based chemotherapy , irradiation , and mohs chemosurgery .
the chemotherapy regimen consisted of 60 mg / m docetaxel administered over 3 h on day 1 ; 750 mg / m 5-fu on days 15 ; and 70 mg / m cisplatin on day 4 .
the patient also received 50-gy external - beam radiation therapy to the left inguinal region , initiated on the same day of chemotherapy .
mohs paste was applied every morning with a surrounding gauze to avoid attaching with normal skin ( as previously reported ) .
mohs paste included 50 ml of zinc chloride - saturated aqueous solution , 10 g of zinc powder , and 15 ml of glycerin .
radiation therapy was temporarily deferred for 12 days beginning on day 9 because of neutropenia and general fatigue .
the necrotic tissue fell off and the wound flattened on day 20 after starting chemotherapy .
2b ) , and a ct scan showed that the tumor had decreased by 70% in diameter at 1 month after the first course of chemotherapy ( fig .
3b ) . because of socio - economic reasons , the patient declined additional treatment .
there was no progression or metastasis on the chest and abdominal ct for 8 months .
however , the wound grew and became erosive again 10 months after discharge , and the patient died because of the progression of local recurrence 1 year after chemotherapy treatment .
in our patient with inguinal recurrence of pscc , multimodal treatment , consisting of combination chemotherapy , irradiation , and mohs chemosurgery , was responsible for the tumor shrinkage and the successful local control of a malignant wound .
although this field is limited by a paucity of clinical trials or prospective data , the available single institutional retrospective reviews indicate that multiagent cisplatin - based chemotherapy regimens fight significantly against pscc . in 1991 , dexeus et al .  
reported a triple - drug chemotherapy regimen , which soon became a standard regimen for pscc with tolerable adverse effects .
the regimen consisted of 20 mg / m cisplatin on days 26 , 200 mg / m methotrexate on days 1 and 15 , and 10 mg / m bleomycin on days 26 .
they reported a response in 10 of 14 ( 71% ) patients ( with moderate side effects ) . in their follow - up studies ,
a lower rate of complete responses with severe toxicities was reported [ 8 , 9 ] . with respect to scc of the head and neck , in which pscc is historically similar
, a randomized trial revealed that the addition of docetaxel significantly improved progression - free , and overall survival in patients with unresectable scc compared to the standard regimen of cisplatin and 5-fu ; therefore , docetaxel , cisplatin and 5-fu have become the current standard induction regimen for advanced scc of the head and neck . in pscc , pizzocaro et al .  
they reported a high activity of this regimen , with 5 of 6 treated patients showing a response .
based on these findings , we chose docetaxel for taxane - based combination therapy for the patient , although there are few reports demonstrating its efficacy against pscc .
further studies are needed to determine which taxane has a better response and less toxicity in patients with pscc .
radiation therapy has been used for many years in the treatment of pscc for the primary tumor , inguinal metastases and distal metastases .
it may also play a role in the treatment of locally advanced penile cancer , particularly when inguinal adenopathy is initially unresectable .
there are no randomized trials that have evaluated the impact of radiation on the prognosis and the local control of patients with inguinal metastasis originating from pscc .
however , ravi et al .   revealed that palliative radiation therapy showed an amelioration of symptoms in 56% of patients with inguinal metastasis in growing pscc .
in addition , the radiosensitizing effect of cisplatin , 5-fu , and docetaxel has been demonstrated in several types of cancers [ 13 , 14 , 15 ] .
therefore , it is plausible that radiation in combination with cisplatin , 5-fu , and the docetaxel regimen is a promising option for multimodal treatment of pscc .
malignant wounds from primary or metastatic carcinoma are generally incurable , and palliative methods to manage the wounds are needed .
frederic e. mohs developed and published a technique for the chemical fixation of a cutaneous tumor in 1941 .
mohs paste is effective for the hemostasis of bleeding , odors , and exudates , thereby contributing to the patient 's quality of life . in japan , kakimoto et al
.   reported on 5 patients with breast cancer who were successfully treated with mohs paste .
showed the efficacy of radical surgery followed by systematic therapy and mohs paste in patients with breast cancer . in our case ,
the tumor started to decrease in size after treatment and the necrotic tumor fell off by day 20 , without any resection . to the best of our knowledge ,
this is the first report demonstrating the advantage of mohs paste for inguinal recurrence of pscc .
our result shows that mohs paste may be an effective and reliable option for multimodal treatment of inguinal recurrence .
it is difficult to define which treatment modality was the most effective for the patient , because we used a combination of 3 different modalities .
although our result suggests that each treatment was synergistically effective , it is also important to delineate which modality is the most effective and then choose a suitable modality for each patient with pscc .
secondly , the socio - economic background of the patient did not allow him to continue systemic treatment and/or maintenance therapy .
the study showed that paclitaxel was well tolerated , with a moderate activity against pscc .
therefore , the patient may have been able to avoid cancer progression for a much longer time if he had received additional maintenance chemotherapy . in conclusion , we report a case of successful local control of a recurrent inguinal mass of pscc treated with multimodal therapy . to the best of our knowledge ,
combination treatment with taxane - based chemotherapy , external beam radiation therapy , and mohs paste is a reliable option for the induction therapy for recurrent pscc .
further studies are needed to investigate maintenance treatment after effective induction therapy for recurrent pscc .
 abstractpenile squamous cell carcinoma ( pscc ) is a rare disease , making it difficult to establish a standard of care , particularly in the advanced stage . 
 we report a case of pscc with advanced lymph node metastasis treated with multimodal therapy consisting of combination chemotherapy , irradiation , and chemosurgery using mohs zinc chloride - containing paste . 
 an 80-year - old male with a past history of local treatment for penile cancer presented with a large painful inguinal mass with an ulcer and exudates . 
 the patient underwent multimodal treatment with combination chemotherapy , irradiation , and mohs paste . the combination chemotherapy consisted of cisplatin , 5-fluorouracil , and docetaxel . 
 the patient received 50-gy external - beam radiation therapy to the left inguinal region along with daily local treatment with mohs paste . 
 after the initiation of treatment , the pain and bleeding in the inguinal region considerably ameliorated . the wound became dry and flattened 20 days after the initiation of chemotherapy . 
 a ct scan showed that the tumor had decreased 70% in diameter 1 month after the initiation of chemotherapy . 
 after the first course of chemotherapy , the patient and his family decided not to continue treatment because of socio - economic reasons . 
 the patient underwent no additional treatments ; nevertheless , he had no local progression of the inguinal tumors for 8 months . 
 we report a case of successful local control of recurrent inguinal pscc treated with multimodal therapy . 
 combination treatment with taxane - based chemotherapy , external - beam radiation therapy , and mohs paste is an option for the management of recurrent pscc . 
Introduction
Case Report
Discussion
Disclosure Statement