Editing Penile Cancer: Benign & Premalignant Penile Tumors

==Benign Penile Tumors==
===Pearly penile papules===
*'''Also known as papillomas'''
*'''Normal and generally found on the glans penis or corona'''
*Insert figure
===Zoon balanitis===
*'''Also called plasma cell balanitis''' and balanitis plasmacellularis

*'''Occurs in uncircumcised men from the 3rd decade onward'''
*'''Appearance: smooth, moist, erythematous, well-circumscribed plaques on the glans penis; shallow erosions are often present and lesions can be quite large (up to 2cm); difficult to distinguish from carcinoma in situ'''
**See Figure
*'''Pathology:'''
**Angiofibromas, similar to the lesions seen on the face in tuberous sclerosis
**'''Plasma cell infiltrate'''
*'''Diagnosis and evaluation: biopsy'''
**'''Malignancy and extra-mammary Paget’s disease must be excluded'''
*'''Management'''
**'''Circumcision'''
***Curative in the majority of cases
***Prevents against development of the disease
***'''For patients wanting to avoid circumcision, topical corticosteroids may provide symptomatic relief'''; topical calcineurin inhibitors (tacrolimus or pimecrolimus) and laser therapy may also play a role
==Premalignant Cutaneous Penile Lesions==
*'''<span style="color:#ff0000">Classified as HPV-related vs. non-HPV related</span>§'''
**'''<span style="color:#ff0000">HPV related (3): bowenoid papulosis, verrucous carcinoma, CIS</span>'''
**#'''<span style="color:#ff0000">Bowenoid papulosis</span>'''
**#*Appearance: multiple reddish-brown verrucous papules on the penile skin; occurs on the shaft of young men in most cases
**#**See Figure
**#*'''Histologically similar to low-grade carcinoma in situ [Bowen’s disease]'''
**#*'''HPV 16 has been suspected as a cause'''
**#*'''Progression rate to invasive cancer: 1%'''
**#*Diagnosis: biopsy (gold standard)
**#*Management: options include excision, electrocautery, cryotherapy, laser, or 5-fluorouracil topical therapy
**#'''<span style="color:#ff0000">Verrucous carcinoma (also known as classic Buschke-Löwenstein Tumor and giant condyloma)</span>'''
**#*'''DNA from HPV types 6 and 11 has been identified in these tumors'''
**#*'''Progression rate to invasive cancer: 30%'''
**#**'''Exhibits progressive local growth but does not metastasize'''
**#**Results in invasion and destruction of adjacent tissues by compression
**#***Buschke-Löwenstein tumor differs from condyloma acuminatum in that condylomata, regardless of size, always remain superficial and never invade adjacent tissue.
**#*'''Management: often requires surgical excision for definitive treatment; radiation is ineffective'''
**#*INSERT FIGURE
**#'''<span style="color:#ff0000">CIS</span>'''
**#*'''<span style="color:#ff0000">Erythroplasia of Queyrat</span>'''
**#**'''<span style="color:#ff0000">CIS of the glans or foreskin/span>'''
**#**'''Progression rate to invasive cancer: 30%'''
**#*'''<span style="color:#ff0000">Bowen’s disease</span>'''
**#**'''<span style="color:#ff0000">CIS the penile shaft or the remainder of the genitalia or perineal region/span>'''
**#**'''Progression rate to invasive cancer: 5%'''
**#**See Figure
**#*Metastasis extremely rare
**#*Not associated with visceral malignancies
**'''<span style="color:#ff0000">Non-HPV related (5):</span>'''
**#'''<span style="color:#ff0000">Penile Kaposi sarcoma</span>'''
**#*'''<span style="color:#ff0000">Often associated with herpes-virus 8</span>'''
**#*'''Should prompt an investigation into whether patient is also infected with HIV or otherwise immunosuppressed'''
**#*'''Appears as a raised, painful, bleeding papule or ulcer with bluish discolouration'''
**#**See Figure
**#*Categories of Kaposi sarcoma (4):
**#*#Classic: occurs in patients without known immunodeficiency and typically has an indolent course
**#*#Immunosuppressive treatment-related: occurs in patients undergoing immunosuppression for organ transplantation or other reasons
**#*#African Kaposi sarcoma: occurs in young men and can be indolent or aggressive
**#*#Epidemic or HIV-related: occurs in patients with AIDS
**#**'''The classic and immunosuppressive forms of the disease are considered non-epidemic'''
**#***'''Non-epidemic Kaposi sarcoma limited to penile involvement should be aggressively treated''' because it is rarely associated with diffuse organ involvement
**#*Management
**#**The first step in treatment of Kaposi's sarcoma in patients with HIV is to initiate HAART or to optimize the HAART regimen, which generally results in remission of Kaposi's sarcoma.
**#**Local treatment can include laser therapy, cryotherapy, surgical excision, application of topical retinoids.
**#**Disseminated or visceral Kaposi's sarcoma is treated with combination chemotherapy.
**#'''<span style="color:#ff0000">Penile cutaneous horn</span>'''
**#*Rare
**#*Usually develops over a pre-existing skin lesion (wart, nevus, traumatic abrasion, or malignant neoplasm)
**#*Characterized by overgrowth and cornification of the epithelium, which forms a solid protuberance
**#**See Figure
**#*'''May recur and may demonstrate malignant change on subsequent biopsy, even when initial histological appearance is benign. As a result, careful histological evaluation of the base and close follow-up of the excision site are essential'''
**#'''<span style="color:#ff0000">Leucoplakia</span>'''
**#'''<span style="color:#ff0000">Lichen sclerosis</span>''' (see Penis and Urethra Surgery Chapter Notes)
**#'''<span style="color:#ff0000">Pseudoepitheliomatous micaceous and keratotic balanitis</span>'''
==References==
*Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015