2. Most common malignant tumor of penis –
squamous cell carcinoma (SCC)
42% of patients with SCC had a history of
preexisting penile lesion
All have been associated with SCC
3. Two broad categories, according to etiology
1. Non-HPV related (inflammatory)
2. Virus related
6. Rare
Develops over a preexisting skin lesion
Overgrowth and cornification of the epithelium
HPE : extreme hyperkeratosis,
dyskeratosis
acanthosis
HPV 16 associated
7. Lesions may recur
Lesions may undergo malignant change
Treatment consists of surgical excision with a
margin of normal tissue about the base of the
horn
Close follow up is necessary
9. White keratotic plaque
On glans penis
Exclusively in older men
Most cases appear following circumcision late
in life
May progress to verrucous carcinoma or SCC
10. Treatment – excision
laser ablation
cryosurgery
Relapse not infrequent
Close follow up needed
Fibrosarcoma of the glans after treatment of a
pseudoepitheliomatous micaceous and
keratotic balanitis lesion with cryotherapy has
been reported
12. Genital variation of lichen sclerosus et
atrophicus
Middle aged men
Uncircumcised / late-circumcised (after13 yrs of
age) men
Can also occur in boys
13. Exact etiology unknown
Postulated: genetic factor,
hormonal factor,
autoimmune condition
koebner phenomenon
Borrelia burgdorferi recently been identified in
early stage of the disease
14. Early stage: pain,
dyspareunia,
pruritus,
painful erections,
urinary obstruction
Late stage: phimosis
paraphimosis
Whitish patch on prepuce or glans
The meatus may appear white, indurated, and
edematous
Glanular erosions, fissures, and meatal stenosis
may occur
15. HPE: atrophic epidermis
loss of rete pegs
homogenization of collagen
in the upper third of dermis
zone of lymphocytic and histiocytic
infiltration
16. Male lichen sclerosus (LS) is frequently (28-
50%) found in conjuction with SCC penis
SCC is found subsequent to LS in 2.3-5.8%
cases
SCC can develop long after a lesion is treated
17. Medical care: for mild LS without scarring
topical clobetasol propionate
topical tacrolimus
topical acetretin
intralesional adalimumab
intralesional steroid (for stricture, stenosis)
Surgical care:
circumcision
foreskin preputioplasty+intralesional
triamcinolone
meatotomy
BMG urethroplasty
19. Human papilloma virus (HPV)
infection
HPV – principal causative agent in cervical
dysplasia and cervical cancer
HPV – one of the prime cause of premalignant
penile lesions
HPV – one of the causative agents of penile
cancers
23. Soft, friable, papillomatous growths typically
considered benign
Before puberty rare, may suggest sexual abuse
Found on glans, penile shaft, prepuce
Urethral involvement in 5%, may extend to
prostatic urethra. So inspect meatus
Bladder involvement rare
24. Also inspect base of shaft, scrotum, inguinal
fold.
5% acetic acid solution followed by magnifying
glass use for subclinical disease detection,
lesions will turn white
However, not all acetowhite lesions are HPV-
related, so biopsy must be done to confirm the
diagnosis
25. HPE: outer layer of keratinized tissue covering
papillary fronds, which are supported by
connective tissue stroma. The epithelial layer
consists of well-ordered rows of squamous
cells. A dermal lymphocytic infiltrate is usually
present.
Treatment of these lesions with podophyllin may
induce histologic changes suggestive of
carcinoma
Hence, biopsy of large lesions that appear to be
condylomata acuminata should be done before
any treatment with topical podophyllin
26. No proven treatment to reduce sexual
transmission or to prevent disease progression
Medical treatment options:
5% podophyllotoxin solution or gel
35-85% trichloroacetic acid
cryotherapy with liquid N2
electrofulguration
CO2 laser therapy
5% imiquimod cream
1% cidofovir gel
intralesional IFN α2b injection
5FU cream for urethral lesion
27. Circumcision
to remove prepucital lesion,
to gain exposure for treatment,
to allow post-treatment monitoring
Pediatric resectoscope for large intraurethral
lesion, to use lowest power and minimal use of
electrocautery
28. Prevention:
quadrivalent vaccine (Gardasil)
against HPV 6,11, 16 and 18,
approved for both males and females
in 9-26 years of age,
for prevention of both anal and genital lesions
65% efficacy in preventing genital lesion
consists of three injections over six months
30. Multiple papules on penile skin
Usually pigmented on penile skin
Glanular lesions tend to be flat papular
0.2-0.3 cm in diameter, similar lesions coalesce
In 2nd-3rd decade of life
31. Diagnosis is confirmed by biopsy
These lesions meet all the histologic criteria of
carcinoma in situ, but have a benign course,
display differing growth patterns relative to flat,
endomorphic, or exophytic clinical appearance
Causative role of HPV 16 is suspected
33. AKA Verrucous carcinoma, Giant condyloma
acuminatum
It differs from condyloma acuminata is that the
latter, regardless of size, always remain
superficial and never invade adjacent tissue,
while the former displaces, invades, and
destroys adjacent structures by compression
However, it does not show any sign of
malignant change on HPE, neither does it
metastasize
34. HPE: a luxuriant mass composed of broad
rounded rete pegs, often extending far into
underlying tissue. The pegs are composed of
well-differentiated squamous cells that show no
cellular anaplasia. These epithelial pegs are
characteristically surrounded by a dense band
of acute and chronic inflammatory cells
Excisional biopsy or multiple deep biopsies
required
HPV 6, 11 DNA found in tumors
35. Treatment is local excision
For larger lesions, total penectomy may be
needed
Bleomycin may be used
Systemic IFN therapy plus Nd:YAG laser
therapy
Cryotherapy
Recurrence is common, so close follow up
37. Tumor of reticuloendothelial system
It appears as a cutaneous neovascular lesion, a
raised, painful, bleeding papule or ulcer with
bluish discoloration
HPE: the tumor is vasoformative with
endothelial proliferation and spindle cell
formation
Etiology: HHV8
38. Four subtypes
1. Classic KS: in patients without known
immunodeficiency, indolent and rarely fatal
course
2. Immunosuppressive treatment-related KS: in
patients undergoing immunosuppressive
therapy, often reversed with dose modification
3. African KS: occurs in young men, have
indolent or aggressive course
4. Epidemic or HIV-related KS: occurs in patients
39. Nonepidemic forms:
classic and immunosuppressive forms
limited organ involvement
should be treated aggressively
Penile involvement more common in
homosexual men
Urethral obstruction in glans or corpus
spongiosum involvement
