Lecture notes for medical students

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2. Introduction & History.

3. Introduction & History.
Uncommon disease of older uncircumcised
men.

4. Etiology

5. Etiology
• Idiopathic
• Congenital
• Traumatic
• Infections /Infestation HPV
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative

6. Etiology: Infections causing
malignancy
Viruses
– HPV Ca Cx, Penis , anus , vagina, vulva
– Hepatitis B-Liver
– Epstein-Barr virus (EBV)-nasopharyngeal cancer, Burkitt
lymphoma, Hodgkin lymphoma, Ca. Stomach
– HIV- Kaposi sarcoma cervical cancer,non-Hodgkin lymphoma, Anal
cancer,Hodgkin disease,Lung cancer,Cancers of the mouth and throat,skin
cancer,Liver cancer
• Human herpes virus 8 (HHV-8)
– Kaposi’s Sarcoma
• Human T-lymphotrophic virus-1 (HTLV-1)
– T-cell leukemia/lymphoma (ATL).
• Merkel cell polyomavirus (MCV) Merkel cell carcinoma

7. Etiology: Infections causing
malignancy
• Bacteria
– Helicobacter pylori- Ca. Stomach, Lymphoma
of stomach
• Parasites-
– Liver Fluke (Opisthorchis viverrini and Clonorchis sinensis)
- Cholangiocarcinoma
– Schistosoma haematobium -Bladder cancer

8. Etiology: premalignant lesions
AKA Penile intraepithelial neoplasia (PIN),
• Erythroplasia of Queyrat
• Bowen disease
• Bowenoid papulosis.

9. Erythroplasia of Queyrat
• Bright red, well-demarcated, velvety plaque or
plaques that involve the glans, coronal sulcus, or
prepuce.
• Risk for progression to invasive carcinoma- up to
10%.
• Predisposing factors-
– lack of circumcision,
– poor hygiene
– chronic infection.
• Several HPV serotypes have been isolated from
this disease, including HPV 8, 16, 18, 39, and 51.

10. Bowen disease

11. Bowen disease
• A sharply marginated, erythematous, scaly patch
or plaque on the shaft of the penis.
• A pigmented variant exists
• Risk for progression to invasive carcinoma- up to
10%.
• Ulceration may signal an invasive lesion
• Predisposing factors-
– Exposure to ultraviolet light,
– chemical carcinogens,
– arsenic.
– HPV types 16, 18, and 57b

12. Bowenoid Papulosis
• Seen predominantly in young, sexually active
males.
• solitary or multiple, rapidly growing, red-brown to
violaceous, flat-topped papules that may coalesce
into larger plaques on the penile shaft or the
perineum.
• The papules are nonpruritic, range in size from 2-
10 mm, and usually lack scale.
• Progression to squamous cell carcinoma, the rate
(2.6%) .

13. All three PINs
• Diagnosis-Biopsy .
• Treatment-removal or destruction of the lesion-
– topical therapy, cryotherapy, laser ablation,
radiotherapy, diathermy, surgical excision (including
partial penectomy), and Mohs micrographic surgery
– opical therapy with either 5-fluorouracil(5-FU)
or imiquimod
– photodynamic therapy

14. Other etiological factors
• Phimosis
• HPV infection
• associated with spousal cervical cancerassociated with
spousal cervical cancer
• poor hygiene.
• Smegma retention
• Chronic balanitis
• Ultraviolet light exposure
• Chemical carcinogen exposure
• Cigarette smoking
• HIV infection
• Immunosuppression.

15. Pathophysiology

16. Pathophysiology
• Invasive squamous cell carcinomas -well-
differentiated neoplasm
– Exophytic
– Verrucous
– Flat

17. Clinical Features

18. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

19. Demography

20. Demography
• In US 1% of all cancers in males.
• Higher incidence inUganda, Brazil,
Jamaica, Mexico, India, and Haiti.

21. Symptoms & Signs

22. Symptoms & Signs
• An ulcerated mass on glans .
• Followed by the prepuce, coronal sulcus,
and shaft.
• penile pain, malignant priapism, discharge,
and difficulty voiding.
• Lymphadenopathy Lymphadenopathy

23. Differential diagnoses

24. Differential diagnoses
• HPV infection
• Atypical herpes simplex infection
• Malignant cutaneous adnexal tumors
• Sarcomas
• Amelanotic melanoma

25. Prognosis

26. Prognosis
• Locally advanced, aggressive disease.
• Survival is most closely related to lymph
node status.
– 5-year survival rate is 93% for stage I,
– 55% for stage II,
– 30% for stage III disease.
– Involvement of the pelvic lymph nodes is
associated with a 5-year survival rate of less
than 5%.
– Death typically occurs within 2 years if tumors
are left untreated.

27. Investigations

28. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC of lymph nodes
• Imprint
– Histlogy

29. Classification

30. Classification
• Patients are staged
• Tumors are graded

31. TNM classification
• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ
• Ta: Noninvasive verrucous carcinoma
• T1: Tumor invades subepithelial connective tissue
• T2: Tumor invades the corpus spongiosum or
cavernosum
• T3: Tumor invades the urethra or prostate
• T4: Tumor invades other adjacent structures

32. TNM classification
Regional lymph nodes
• NX: Metastasis to regional lymph nodes is not
assessed or cannot be assessed
• N0: No regional lymph node metastasis
• N1: Metastasis to a single superficial inguinal
lymph node
• N2: Metastasis in multiple or bilateral superficial
inguinal lymph nodes
• N3: Metastasis to deep inguinal and/or pelvic
lymph nodes

33. TNM classification
Metastasis
• MX: Metastasis cannot be assessed
• M0: No suspicion or detection of metastasis
• M1: Metastasis
•

34. Grading

35. Grading
• Broders classification divides tumors into
four histologic grades ranging from well
differentiated to poorly differentiated.

36. Management

37. Management
• The primary treatment for penile carcinoma
is surgical
• Radiation, chemotherapy, or both adjunct.
• Chemo- cisplatin and bleomycin

38. Operative Therapy

39. Operative Therapy
• Wide excision, partial penectomy, or total
penectomy.
• Lymphadenectomy +- in second step.
• Laser therapy
• Mohs micrographic surgery (for verrucous
carcinoma)
• Photodynamic therapy (for superficial
lesions)

40. Prevention

41. Prevention
• Circumcision at early age.
• Personal hygiene
• HPV vaccination
• Avoid smoking

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