Dr. Ye Shengwei: First, let’s introduce the patient’s condition. A male patient, 52 years old, was admitted to the hospital with “a lump on the glans penis that had been aggravated for one year and bleeding for one month”. The patient had no sexual life for one year due to a lump in the penis and painful intercourse, but urination was normal, and the lump increased to cauliflower shape and bleeding one month ago. Laboratory tests: routine blood test showed PLT51G/L, hemoglobin, red blood cells and white blood cells were in normal range; biochemical complete set showed: blood phosphorus 2.14mmol/L, serum total cholesterol 6.32mmol/L, triglycerides 18.87mmol/L (reference value <1.71mmol/L); coagulation function test could not be detected due to high blood lipids; ultrasound showed: bilateral Ultrasound showed bilateral inguinal lymph nodes enlargement, the largest being on the right side, about 1.8×1.07 cm; CT showed no enlargement of pelvic lymph nodes. Chest X-ray and ultrasound showed no liver and lung metastasis. Preliminary diagnosis: penile cancer? ;hypertension; hyperlipidemia; thrombocytopenia to be investigated. Dr. Xiong Zhiguo: According to the patient's symptoms and signs, the clinical consideration is penile cancer. In order to improve the patient's quality of life and reduce the pain, surgery can be considered after the patient's blood pressure is stabilized, and a rapid pathological section can be performed during surgery. Dr. Qin Jing: According to the patient's condition, there is no objection to the diagnosis, should total penile excision be performed? At present, the cause of thrombocytopenia is unknown, and since the tumor is considered to be malignant, is there a possibility of tumor bone marrow metastasis? If a full set of hematological examination is performed, it will take a long time, and the current patient has unbearable local pain. After full communication with the patient, surgery can be performed first to solve the pain problem. In view of the patient's wish to retain sexual function in the future, partial penile resection can also be performed, but the patient should be informed of the possibility of recurrence, and bilateral inguinal lymph node dissection needs to be communicated with the patient because about 50% of the patients may have postoperative complications such as scrotal and lower limb edema and non-healing wounds. Dr. Xiong Zhiguo: After communicating with the patient and knowing his condition, he was very worried about the possibility of malignant tumor and wished to operate as soon as possible and to preserve part of the penis. The scrotal edema gradually increased on the third day after surgery. Postoperative pathological examination: squamous carcinoma of the penis (sarcoma-like carcinoma), invading the urethral spongy body, no carcinoma was seen in the cut edge of the severed end, cancer metastasis was seen in 1/5 of the right inguinal lymph nodes, and there was no lymph node metastasis in the left groin. Dr. Ye Shengwei: I will introduce the postoperative treatment. The catheter was removed twelve days after surgery, and three days later, due to difficulty in urination, catheterization was performed again, and poor tissue healing was seen at the severed end of the penis. Half a month after surgery, due to pain at the penis and highly swollen scrotum, the granulation tissue at the severed end of the penis was hard and flesh-like, so biopsy was taken, and the pathology report showed: recurrent squamous carcinoma, and immunohistochemical examination supported sarcoma-like carcinoma. The patient was considered to have residual penile cancer and scrotal infection because of obvious pain symptoms and persistent scrotal swelling, combined with fever and elevated leukocytes, so a suprapubic cystostomy with scrotal drainage and biopsy of the right inguinal granulation tissue was performed 20 days after surgery. See figure). In view of the rapid development of the patient's condition, we would like to ask the physicians to discuss the lessons of diagnosis and treatment. Dr. Xia Heshun: Combining with the patient's clinical manifestations and pathological section results (Figure), the pathological diagnosis was penile cancer. Because of the atypical cell morphology of this case, further immunohistochemistry showed PCK(+), Vim(+), while CD68(─), CD34(─), Melan A(─), excluding lymphoma and malignant melanoma, considering the staging as sarcomatoid squamous carcinoma, which is rare and has poor prognosis. Dr. K.L. Chang: The patient was diagnosed with penile cancer and the pathological type was sarcomatoid squamous carcinoma, which is highly malignant, and the tumor invaded more than 1/2 of the glans and the depth of invasion to the urethral corpus cavernosum, which is T2. However, the patient had severe edema of the scrotum and it could not be ruled out that the tumor had invaded the scrotum and urethra, and it was impossible to separate the urethra. 2. The routine blood test showed that the platelets were 500,000, and later the test was progressively decreasing. However, bilateral inguinal lymph node dissection during the initial surgery could improve the patient's quality of life. Dr. Wei Shaozhong: The patient was admitted with thrombocytopenia, the cause of which was not further identified and analyzed retrospectively, and the possibility of bone marrow metastasis could not be ruled out. Therefore, the patient was probably admitted with advanced penile cancer and the pathological type of the tumor was sarcoma-like squamous carcinoma with extremely poor prognosis. Dr. Ye Zhangqun: The patient's diagnosis is clear and there is no obvious sign of distant metastasis at the time of admission in terms of staging, but the chest X-ray after one month shows the presence of lung metastasis, which indicates that there may be potential metastases that have not been detected. In view of the late stage of the patient's disease, it is better to perform total penile resection to minimize the possibility of local recurrence and to relieve the patient's pain. As for whether to do inguinal lymph node dissection, the current view is that preoperative lymph node dissection is not possible without palpable lymph node enlargement, and even if the patient has lymph node enlargement, it is possible to perform second-stage surgery, because some patients with lymph node enlargement may be caused by inflammation, and these lymph nodes can subside after the primary site surgery, while patients who do not subside may have real lymph node metastasis, and then perform lymph node dissection 1-2 months after the primary site surgery. inguinal lymph node dissection with rapid intraoperative pathology, and then ipsilateral pelvic lymph node dissection if there are more than 2 metastatic lymph nodes. Specifically for this patient, bilateral inguinal lymph node dissection was not possible during the first surgery, so that scrotal edema, swelling and pain would not occur after surgery and thus affect the patient's quality of life. At present, penile cancer is a rare disease, and sarcomatoid carcinoma only accounts for 1-2% of penile cancer, which is highly malignant, while this patient has been sick for one year and has a late stage, so the prognosis is definitely not good. This patient taught us the following lessons: we should clarify the pathological type and more accurate stage of the patient's tumor before surgery, and it is important to communicate with the pathologist so that the patient can be fully informed of the disease; we can also consider induction chemotherapy before surgery, the purpose of surgery is to solve the patient's pain, palliative is the main focus, and we should choose as much as possible the less invasive and less complicating surgery, such as not inguinal lymph node dissection.