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