Penile carcinoma in situ

Template:BalanitisV Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Vishal Devarkonda, M.B.B.S[2]

Overview

Balanitis is inflammation of glans penis. When inflammation involves foreskin and perpuce, it is termed as balanoposthitis. Bowenoid papulosis, Erythroplasia of Queyrat, and Bowen's disease are the three common penile carcinoma in situ causing balanitis. The exact pathogenesis for these conditions is not clearly known, but there is a strong association between Human papilloma virus and penile carcinoma in situ. Patients may be asymptomatic or symptomatic presentiing with pruritic, or painful lesions in the genital region. Diagnosis is based on the clinical features supported by biopsy. Transformation into invasive squamous cell carcinoma is the major complication associated with these conditions. Treatment for these conditions include both medical and surgical modalities.

Historical Perspective

Historical perspective of penile carcinoma in situ include:

Bowenoid papulosis

• In 1977, term Bowenoid papulosis was coined by Kopf and Bart and named after dermatologist John templeton Bowen

Erythroplasia of Queyrat

• In 1891, Tarnovsky for the first time described Erythroplasia of Queyrat
• In 1893, Fournier and Darier appreciated it as a penile disease
• in 1933, Sulzberger recognized it as carcinoma in situ

Bowen's disease

• In 1912, Bowen's Disease was described by American dermatologist John T. Bowen

Classification

There is no established classification for Balanitis caused by Penile carcinoma in situ

Pathophysiology

Pathophysiology of penile carcinoma in situ include:

Bowenoid papulosis

The exact pathogenesis of Bowenoid papulosis is unknown.

Some studies have shown, etiological role of HPV type 16, 31, and 39 in Bowenoid papulosis.

Associated conditions include:

• HIV
• Lymphopenia
• Depressed cell-mediated immunity

Histopathology

• The histopathology may reveal squamous cell carcinoma in situ, with widened spinous epidermal layer with proliferation of atypical basal cells, coilocytes, enlarged polimorfic and hyperchromatic nuclei as well as abnormal mitosis and hyperparakeratosis with collection of melanin of various amount seen.

Bowenoid papulosis histopathology

Erythroplasia of Queyrat

The exact pathogenesis of erythroplasia of Queyrat is unknown.

Some studies have shown that chronic irritation, inflammation, phimosis, smoking, smegma, poor hygiene, genital herpes simplex, HPV, heat, friction, maceration, trauma, perpuce dermatoses such as Lichen sclerosis or Lichen planus, may act as risk factors for developing Erythroplasia of Queyrat.

Associated conditions

• Epidermodysplasia verruciformis associated HPV-8
• Genital high-risk HPV-16

Histopathology

• Slight to moderate plaque-like acanthotic epidermis with focal parakeratosis and hypogranulosis with loss of epidermal cell polarity as evidenced by vacuolated cells, atypical mitoses, atypical epithelial cells with hyperchromatic nuclei, multinucleated cells, dyskeratotic cells, and mitotic figures in the upper Malpighian layers.
• The upper dermis is often edematous and densely invaded by a band-like plasma cell rich chronic round cell infiltrate.

Bowen's Disease

The exact pathogenesis of Bowen's disease is unknown.

Some studies have shown that lack of circumcision, HPV infection, phimosis, balanitis, or any chronic inflammation of the penile skin act as risk factors in developing Bowen's disease.

Associated conditions

• HPV types 16
• HPV type 33

Histopathology

Full-thickness epidermal atypia with disordered architecture, abnormal mitoses, dyskeratosis, and involvement of associated pilosebaceous apparatus with an intact epidermal junction.

Bowen's disease histopathology

Epidemiology and Demographics

There are no comprehensive studies reporting the incidence and prevalence of penile carcinoma in situ in general population. Some studies have reported the demographics of patients presenting with these conditions.

Bowenoid papulosis

Bowenoid papulosis usually occurs in sexually active men aged between 20 to 40 years, with a mean age of 31 years, it occurs slightly more common in women then men.

Erythroplasia of Queyrat

Erythroplasia of Queyrat is a rare condition usually affecting uncircumcised men in their third to sixth decades of life.

Bowen's Disease

Bowen's disease usually occurs equally in both men and women, with the highest incidence in patients older than age 60 years.

Screening

There are no established screening guidelines to screen patients for penile carcinoma in situ.

Natural History, Complications, and Prognosis

Natural history

Bowenoid papulosis

If left untreated, papules may increase, or decrease, or disappear with time, or progress into squamous cell carcinoma(Studies have reported risk of progression of bowenoid papulosis to squamous cell carcinoma at 2.6%).

Erythroplasia of Queyrat

If left untreated, Erythroplasia of Queyrat may progress into invasive Squamous cell carcinoma, with an incidence ranging from 10% to 33%.

Bowen's Disease

If left untreated, Bowen's disease may progress into invasive Squamous cell carcinoma(Incidence of Bowen's disease to develop into invasive squamous cell carcinoma is 3% to 5% for cutaneous and 10% for genital lesions). The malignant potential of Bowen's disease is increased when its existence is compounded by concomitant disease such as HPV infection, Lichen sclerosis or Lichen planus, or in patients with poor genital hygiene and smokers.

Complications

Complication of penile carcinoma in situ include:

• Pain
• Transformation into invasive squamous cell carcinoma

Prognosis

The prognosis is usually good with treatment.

Diagnosis

History and symptoms

History and symptoms of penile carcinoma in situ include:

Bowenoid papulosis

• Patients may be asymptomatic or present with pruritic, or painful lesions in the genital region.

Erythroplasia of Queyrat

• Patients may present with non-healing lesions in the genital region, which could also be associated with scaling, crusting, and bleeding.

Bowen's Disease

• Patient may be asymptomatic or present with pruritic, or painful lesions in the genital region.

Physical examination

Physical examination findings of penile carcinoma in situ include:

Physical examination findings of penile carcinoma in situ
Bowenoid papulosis	Erythroplasia of Queyrat	Bowen's Disease
Multiple, small, well-demarcated, grey-brown, red, pink, or skin-colored papillomatous papules or small patches on the penile shaft, glans, or foreskin, vulva, and perianal area.The papules are nonpruritic, range in size from 2 to 10 mm, and usually lack scales.	Single or multiple red, shiny, slightly raised, sharply demarcated, velvety, non-healing plaques associated with scaling, crusting, and sometimes bleeding, affecting the mucosal surfaces of the penis. Inguinal nodes should be examined(Several studies have reported,the tendency of Erythroplasia of Queyrat to metastasize to local lymph nodes)	Red, sometimes slightly pigmented, scaly, moist, velvety patches and plaques of keratinization on penis.

Bowen's Disease

Laboratory findings

Definite diagnosis is made by biopsy showing typical histologic picture of intraepidermal carcinoma in situ.

Treatment

Choice of treatment in penile carcinoma in situ depends after careful analysis of lesion size, number, site, degree of functional impairment, modality availability and cost.

Modalities for treating penile carcinoma in situ include:

Bowenoid papulosis

Conservative treatment

• Topical 5-FU,or podophyllin, or retinoic acid, or cidofovir; only moderate effects have been reported.
• Imiquimod cream 5% reported successful clearance of bowenoid papulosis

Surgical treatment

Surgical modalities in treating bowenoid papulosis include:

Cryosurgery, electrodessication, laser vaporization (Nd:YAG, argon, and carbon dioxide lasers), and surgical excision. All these modalities are found to associated with scarring

Erythroplasia of Queyrat

Conservative treatment Imiquimod and Topical 5-FU application, help in minimizing the risk for scarring, poor wound healing, and functional impairment

Surgical treatment

Surgical modalities in treating Erythroplasia of Queyrat include: mohs micrographic surgery, cryotherapy, electrodesiccation and curettage, and laser ablation

Bowen's Disease

Conservative treatment

• Photodynamic therapy and Topical 5-FU application, help in minimizing the risk for scarring, poor wound healing, and functional impairment
• Recent studies have found that topical application of Imiquimod cream 5% once daily for 16 weeks was effective in treating Bowen's disease

Surgical treatment

Surgical modalities in treating bowen's disease include: Local excision, mohs micrographic surgery, cryotherapy, curettage with cautery/electrocautery, laser therapy with carbon dioxide, argon, and Nd:YAG lasers

Prevention

Primary Prevention

There are no established primary preventive measures for preventing penile carcinoma in situ.

Secondary prevention

There are no established secondary preventive measures for penile carcinoma in situ.