Premalignant lesions of penis Penile premalignant lesions Premalignant conditions of penis Penile lesions Premalignant lesions Human papilloma virus related penile premalignant lesions

1. Premalignant penile lesions
Dr. Rabindra Tamang
MCh Resident
Department of Urology and Kidney Transplant Surgery
MMC, TUTH

2. Contents
• Introduction
• Types
• Clinical presentation
• Differential diagnosis
• Treatment

3. Introduction
• A morphologically altered tissue in which cancer
is more likely to occur than in its apparently
normal counterpart 1
• 42% with preexisting lesions 2
1 World Health Organization. Geneva: World Health
Organization 1973
2 Bouchet et al, 1989

4. Types
• Carcinoma in situ (CIS)
• New classification 1
▫ Human papilloma virus (HPV) related penile
premalignant lesions
▫ Non – HPV related penile premalignant lesions
1 Shabbir et al, 2011b

5. Penile Intrepithelial Neoplasia (PIN)
• Queyrat -1911
• Types 1:
1. Erythroplasia of Queyrat (EQ)
2. Bowen disease (BD)
3. Bowenoid papulosis (BP)
1 Potter et al, 2002

6. Erythroplasia of Queyrat (EQ)
• Lesion 1:
▫ Glans or prepuce
▫ Red, velvety lesions, ulcerations
• Discharge and pain
• Progression to invasive carcinoma: 10 - 33% 2
1 Arogana et al, 1985
2 Bleeker et al, 2009

7. Bowen Disease (BD)
• Lesion 1:
▫ Penile shaft or remainder
▫ Sharply defined plaques of scaly erythema
▫ Crusted or ulcerated variants
• Progression to invasive carcinoma: 5% 2
1 Graham and Welwig, 1973
2 Buechner, 2002

8. Microscopic findings of CIS 1
• Atypical hyperplastic cells
• Extension of rete pegs
• Capillary proliferation and ectasia with
surrounding inflammatory infiltrate
1 Buechner, 2002

9. Management
• Biopsy – multiple
• Treatment:
▫ Circumcision 1
▫ Glans resurfacing 2
• Alternative strategies 3:
• 5 FU cream
• 5% imiquimod cream
• Laser therapy:
Nd: YAG, KTP, CO2
1 Bissada, 1992
2 Hadway et al, 2006
3 Danielson et al, 2003

10. Bowenoid Papulosis (BP)
• Lesion 1:
▫ Multiple papules or pigmented lesions
▫ Penile shaft or glans
• Second or third decade 1
• HPV 16 linkage 2
• Invariably benign 3
1 Patterson et al, 1986
2 Endo et al, 2003
3 Su and Shipley, 1997

11. Treatment of BP 1
• Electrodessication
• Cryotherapy
• Laser fulguration
• Topical 5 FU cream
• Excision 1 Campbell 12th edition

12. Non HPV penile premalignant lesions
1. Cutaneous horn
2. Pseudoepitheliomatous keratotic and
micaceous balanitis (PKMB)
3. Male lichen sclerosus

13. Cutaneous horn
• Rare – solid protuberance
• Predisposing factors 1:
▫ Inflammation
▫ Poor hygiene
▫ Trauma
▫ Tumor
1 Gupta et al, 2014

14. Cutaneous horn
• Clinical significance 1:
▫ Underlying lesion:
 Benign:
 Seborrheic keratitis
 Viral warts
1 Gupta et al, 2014

15. Cutaneous horn
Premalignant
 Solar keratitis
 Bowen disease
Malignant
 Squamous cell cancer (SCC)
 Basal cell cancer (BCC)
 Kaposi sarcoma
1 Gupta et al, 2014

16. Cutaneous horn
• Treatment:
▫ Excision
▫ Issue:
 Recurrence 1
1 Fields et al, 1987

17. Pseudoepitheliomatous keratotic and
micaceous balanitis (PKMB)
• Scaly and micaceous growth
• 4 stages 1:
▫ Initial plaque
▫ Late tumor stage
▫ Verrucous carcinoma
▫ Invasive SCC
1 Krunic et al, 1996

18. PKMB
• Treatment 1:
▫ Topical 5 FU
▫ Excision
▫ Laser therapy
▫ Cryotherapy
• Issue:
▫ Recurrence 1 Gray and Ansell, 1990

19. Male lichen sclerosus
• Balanitis xerotica obliterans (BXO)
• Genital variant
• Etiology 1,2:
▫ Unknown
▫ Borrelia
▫ Autoimmunity
▫ Genetics
1 Esendle et al, 2008
2 Fistaro et al, 2014

20. BXO
• Clinical features 1:
▫ Multiple whitish patches
▫ Mosaic appearance
▫ Glans, prepuce, meatus
▫ Dyspareunia, painful erection, urinary obstruction
• Association 2:
▫ SCC 1 McKay et al, 1975
2 Velazquez and Cubilla, 2003

21. BXO
• Treatment 1, 2:
▫ Clobetasol
▫ Meatal stenosis:
 Dilatation
 Corticosteroid injection
 Surgery 1 Pugliese et al, 2007
2 Pounter and Levy, 1967

22. HPV related penile lesions
• HPV in malignant transformation
• Buschke Lowenstein tumor
• Kaposi sarcoma

23. HPV in malignant transformation
• Condyloma accuminata
• Genital warts
• Site: glans, prepuce, shaft, urethra
• Lesions 1:
▫ Soft, friable
▫ Single
▫ Moruloid cluster
1 Copulsky et al, 1975

24. Condyloma acuminata
• Risk factors 1:
▫ Foreskin
▫ Multiple sexual partners
▫ No condom
▫ Smoking
1 Guiliano et al, 2009

25. Condyloma acuminata
• HPV genotypes 1
▫ 6, 11, 40, 44 : low grade
▫ 16, 18, 31, 33, 35, 39, 45, 51, 52, 58, 59 : malignant
disease
• Pathogenesis 2:
▫ E7 proteins  pRB  p16 INK4a
1 de Sanjose et al, 2010
2 Doorbar, 2006

26. Condyloma acuminata
• Diagnosis:
▫ Examination
▫ Androscopy
• Treatment 1:
▫ Podophyllotoxin
▫ TCA
▫ Cryotherapy
•Electrofulguration
•CO2 laser
•Imiquimod 5% cream
1 Dupin, 2004

27. Condyloma
• Surgery 1:
▫ Circumcision
▫ Fulguration and excision
▫ Intraurethral lesions:
 Resectoscope
1 Buechner, 2002

28. Condyloma
• Newer treatments 1,2:
▫ Intralesional IFN alfa 2b
▫ Cidofovir
1 Eron et al, 1986
2 Snoeck et al, 2001

29. Buschke Lowenstein tumor
• Buschke and Lowenstein - 1925
• Unlike condyloma 1:
▫ Invasive
▫ Topical therapy ineffective
• Like condyloma:
▫ HPV 6, 11 linkage
1 Braga et al, 2012

30. • Diagnosis:
▫ Biopsy
• Treatment 1,2:
▫ Surgery +/- skin graft
▫ Systemic IFN therapy
• Vaccination:
Quadrivalent
Nanovalent
1 Hasid and Papadopoulos, 2017
2 Petrosky et al, 2015

31. Kaposi sarcoma KS
• Dr. Mortiz Kaposi 1972
• 4 categories 1:
▫ Classic KS
▫ Immunosuppressive treatment related KS
▫ African KS
▫ Epidemic / AIDS related KS
1 Campbell 12th edition

32. KS
• Raised, painful, bleeding papule or ulcer with bluish
discoloration
• Non epidemic KS
• Human Herpes Virus 8 (HHV-8) 1
• KS and AIDS 2:
▫ 7000 factor
▫ Homosexuals: 44% 1 Sitas et al, 1999
2 Miles, 1994

33. KS
• Treatment 1
▫ Localised surgical excision
▫ Small field external beam or electron beam
radiation
▫ Partial penectomy
▫ Systemic therapy:
 IFN therapy 1 Lowe et al, 1989

34. Thank you