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

• Classified as HPV-related vs. non-HPV related§
  • HPV related (3): bowenoid papulosis, verrucous carcinoma, CIS
    1. Bowenoid papulosis
       • 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
    2. Verrucous carcinoma (also known as classic Buschke-Löwenstein Tumor and giant condyloma)
       • 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
    3. CIS
       • Erythroplasia of Queyrat
         • CIS of the glans or foreskin/span>
         • Progression rate to invasive cancer: 30%
       • Bowen’s disease
         • 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
  • Non-HPV related (5):
    1. Penile Kaposi sarcoma
       • Often associated with herpes-virus 8
       • 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):
         1. Classic: occurs in patients without known immunodeficiency and typically has an indolent course
         2. Immunosuppressive treatment-related: occurs in patients undergoing immunosuppression for organ transplantation or other reasons
         3. African Kaposi sarcoma: occurs in young men and can be indolent or aggressive
         4. 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.
    2. Penile cutaneous horn
       • 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
    3. Leucoplakia
    4. Lichen sclerosis (see Penis and Urethra Surgery Chapter Notes)
    5. Pseudoepitheliomatous micaceous and keratotic balanitis

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015