This document outlines pre-malignant conditions and management algorithms for cancer of the penis. It discusses various premalignant lesions like Bowen's disease, erythroplasia of Queyrat, lichen sclerosis, and their treatment options including topical therapies, ablation, excision and Mohs micrographic surgery. It also discusses staging and treatment options for primary penile cancer including organ-sparing surgeries and algorithms for managing inguinal lymph nodes depending on tumor characteristics and pathological findings. Radiation therapy has a role for small early-stage lesions or in patients who cannot undergo surgery. The goal of management is eradication of disease while preserving organ function.

1. PRE-MALIGNANT CONDITIONS
AND
MANAGEMENTALGORITHM
FOR
CA. PENIS
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D.Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,Chennai. 2

3. 3
Premalignant Lesions
HPV RELATED Related Lesions
Cutaneous horns
Bowenoid Papulosis
Bowen’s Disease
Erythroplasia of Queyrat
Giant Condylomata Acuminata
(Buschke-Lowenstein Tumour)
Dept of Urology, GRH and KMC,Chennai.

4. NON HPV RELATED
Leukoplakia
Pseudoepitheliomatous Micaceous Keratotic Balanitis (PMKB)
Balanitis Xerotica Obliterans (Lichen scleorus et Atrophicus)
4
Dept of Urology, GRH and KMC,Chennai.

5. 5
Penile Intraepithelial Neoplasia (PeIN)
 Precursor lesion of basaloid & warty penile cancer
 HPV infection asso. with all types of PeIN (70-100%)
 Basaloid cancer  strongest asso. with HPV (70-100%)
 PeIN in males whose female partner has CIN = 33%
 Time for malignant progression for low-grade PeIN = 20 yrs
World J Urol 2009;27(2):141–50
Urol Clin N Am 2010; 37: 335–32
Dept of Urology, GRH and KMC,Chennai.

6. 6
Bowenoid Papulosis
 HPV-related 16 & 18
 Average age 30 yrs
 Majority (73%) regress or do not recur
 Can recur, progress to EQ or BD,or become
malignant
 Strong relationship with CIN in female sexual
partners
 Microscopy:spotty distribution of atypical
cells & greater maturation of keratinocytes
 Risk factors for malignant progression
◦ Smoking, immune suppression, high-risk
HPV types, genetics
Dept of Urology, GRH and KMC,Chennai.

7. 7
Bowen’s Disease/Erythroplasia of Queyrat
 EQ= glans, prepuce
 BD= Hair bearing region of
genitalia/shaft of penis.
 Both histologically similar- correspond
toTis
 Clearly documented as precursors of
invasive penile carcinoma = 10% risk
Dept of Urology, GRH and KMC,Chennai.

8. 8
Lichen Sclerosis et Atrophicus (BXO)
 Whitish patch on prepuce/glans often
involving meatus
 Granular erosions,fissures, meatal
stenosis, painful erections, urinary
obstruction
 Uncircumcised middle age men
 Microscopy:
◦ Atrophy of squamous epithelium, loss of rete
pegs, homogenisation of collagen in upper 1/3rd
of dermis
 Clobetasol propionate (0.05% , 8–12 wks)
Dept of Urology, GRH and KMC,Chennai.

9. 9
Giant Condyloma Accuminata
 Buschke-LowensteinTumour
 Locally invasive; displaces, invades &
destroys adjacent structures by
compression
 No metastasis
 LN mets: Rare => malignant degn
 Excision/total Penectomy
 Topical 5FU, podophyllin, Bleomycin
 RT – ineffective & contraindicated 
Malignant Degeneration
Dept of Urology, GRH and KMC,Chennai.

10. 10
Verrucous Carcinoma
•Is an exuberant variant of sq. cell carcinoma
•Low malignant potential
•Rarely metastasize to lymphnode
•Good prognosis
Dept of Urology, GRH and KMC,Chennai.

11. 11
Cutaneous Horn
- Overgrowth & Cornification over
preexisting skin lesions
- Asso with HPV 16
-May evolve into Cancer or develop in an
underlying Cancer
- Surgical Excision
Pseudo epitheliomatous keratotic
& micaceous balanitis (PKMB)
- Microscopically mimics verrucous Cancer
- Cryotherapy,laser, excision
- Fibro sarcoma of glans post Cryotherapy
Dept of Urology, GRH and KMC,Chennai.

12. Leukoplakia
•Solitary or multiple whitish plaques
•Involving glans, prepuce, meatus
•Asso.withTis and Ta
- Surgical Excision
12
Dept of Urology, GRH and KMC,Chennai.

13. 13
Lesions with No malignant Potential
 Pearly penile papules
 Hirsute papillomas
 Coronal Papillae
 Zoon’s Balanitis
 Benign pigmented warts
 Seborrheic keratosis
 Lichen planus
 Psoriasis
 Eczema
 Contact dermatitis
Dept of Urology, GRH and KMC,Chennai.

14. 14
Treatment of Premalignant lesions
eradicate disease while limiting penile mutilation
 TopicalTreatment: (Recurrence:13–19%)
◦ Podophyllotoxin, 5 - FU,Imiquimod, Corticosteroids,Trichloracetic
acid
 Ablative treatments:
◦ Cryosurgery (Recurrence:21%)
◦ Electro surgery
◦ Laser - Nd-YAG, KTP 532, CO2 Lasers (Recurrence:0 -33%)
Dept of Urology, GRH and KMC,Chennai.

15. ExcisionalTreatments: (Recurrence 13-33%)
Excision Biopsy
Moh’s Micrographic Surgery
Excision + total glans resurfacing
Radiotherapy/ IFNs
15
Dept of Urology, GRH and KMC,Chennai.

16. 16
Treatment of Premalignant lesions
Urology 2010;76 (Suppl 2A): S24 –S35
Dept of Urology, GRH and KMC,Chennai.

17. 17
Histopathology
 Histologic evaluation – “ is Must”
 Wedge biopsy is preferable for diagnosis
◦ Histologic type & grade
◦ Depth of invasion
◦ Vascular invasion
◦ Treatment decisions & Prognosis - preferably based on resected specimen
 Good pathology report
◦ Anatomic site, tumor size, histologic type or subtype
◦ Grade, growth pattern
◦ Depth of invasion, tumor thickness, resection margins
◦ Lympho vascular invasion, perineural invasion
Dept of Urology, GRH and KMC,Chennai.

18. 18
Ca. Penis
Management of Primary
Organ Conservation
Standard Surgical Procedures
Partial penectomy
Total penectomy
Emasculation
Dept of Urology, GRH and KMC,Chennai.

19. Organ Conserving Surgical Approach
 LaserTherapy
 Mohs Micrographic Surgery
 Conservative Local Surgical Excision
◦ Circumcision
◦ Local excision
◦ Total glansectomy
19
Dept of Urology, GRH and KMC,Chennai.

20. LaserTherapy
 Lasers used 
 carbon dioxide (CO2),
 neodymium:yttrium-aluminum-garnet (Nd:YAG)
 potassium titanyl phosphate (KTP)
 Drawbacks
◦ Healing time - 5 to 8 weeks for CO2 laser (8 to 12
weeks for the Nd :YAG and KTP lasers)
◦ local recurrence rate – 20%
◦ difficulty in determining depth of laser coagulation
◦ inability to treat larger lesions
◦ careful long-term surveillance
20
Dept of Urology, GRH and KMC,Chennai.

21. Mohs Micrographic Surgery
 removal of cancer by excision of tissue in
thin layers
 Local control rate - 94%
 Best suited in- Ca.in situ, smallT1
21
Dept of Urology, GRH and KMC,Chennai.

22. Local excision
 excision of lesion with negative margin
 Reconstruction
 primary closure,
 preputial skin flap,
 full-thickness graft of penile skin ,
 SSG
 local recurrence - 8% to 11%
22
Dept of Urology, GRH and KMC,Chennai.

23. Treatment of Primary lesion-Ta
 Laser Excision
 Mohs
Micrographic
Surgery
 RT
-
contraindicated
23
Dept of Urology, GRH and KMC,Chennai.

24. Treatment of Primary lesion- Options
 T1,T2,T3 
◦ Partial penectomy
◦ Total penectomy
◦ Emasculation
24
Dept of Urology, GRH and KMC,Chennai.

25. Treatment of Primary lesion- Options
 T4
◦ Emasculation
◦ Hemipelvectomy
25
Dept of Urology, GRH and KMC,Chennai.

26. Penile Cancer
Predictors of lymph node metastases
 Tumour histology
 Corporal invasion
 Urethral involvement
 Tumour grade
 Lymphatic & vascular invasion
 DNA ploidy
26
Dept of Urology, GRH and KMC,Chennai.

27. MANAGEMENT OF INGUINAL NODES
CA.PENIS
SURGERY
IF PALPABLE NODES
ANTIBIOTICS
(4-6WEEKS)
27
Dept of Urology, GRH and KMC,Chennai.

28. NODES NOT PALPABLE NODES PALPABLE
PRIMARY – WELL-DIFF NODAL METS
OBSERVE ILIO-INGUINAL BLOCK
DISSECTION
IF PRIMARY MOD/POOR DIFF
SUPERFICIAL LND
NODE NEG – OBSERVE
IF NODE POSITIVE
28
Dept of Urology, GRH and KMC,Chennai.

29. Radiation Therapy for
the Primary Lesion
 Indications
◦ young patients with small (2- to 4-cm)
superficial lesions of distal penis, not willing
for amputation
◦ patients who refuse surgery
◦ patients with inoperable cancer
◦ Patients unsuitable for major surgery.
29
Dept of Urology, GRH and KMC,Chennai.

30. Radiation Therapy for
the Primary Lesion
 EBRT 
◦ direct field method - only for very superficial
tumors (Tis ,T1)
◦ parallel opposed field method - T2,T3 (penis
irradiated by encasing the lesion in a wax
mold)
 Brachytherapy 
◦ Interstitial brachytherapy - placement of
radioactive material within the tumor
◦ Plesiobrachytherapy- placement of
radioactive material molded around the
tumor
30
Dept of Urology, GRH and KMC,Chennai.

31. Brachytherapy not suitable
 bulky tumors
 obese patients with short penis
 deeply infiltrating tumors
31
Dept of Urology, GRH and KMC,Chennai.

32. Radiation Therapy for
the Primary Lesion
 60 Gy to 74 Gy
 Salvage penectomy
◦ persistent or recurrent disease after RT
◦ radiation necrosis
32
Dept of Urology, GRH and KMC,Chennai.

33. Although cosmetically attractive, disadvantages
are
◦ Useful only in early stage (T1,T2)
◦ Only 65-80% success rate even in early stage
◦ Penile necrosis - 0% to 23%
◦ High chance for stricture urethra
◦ Penectomy required for recurrence and necrosis
33
Dept of Urology, GRH and KMC,Chennai.

34. Role of radiotherapy
 Radiation to the inguinal area is not as effective as
surgery for treatment of the inguinal nodes.
 Prophylactic radiation therapy has not been shown to
alter the natural history of inguinal metastases and
is not recommended.
 Integration of radiation therapy with surgery and
chemotherapy in advanced disease requires further
study.
 Palliative radiation therapy among patients with
inoperable
inguinal nodes may provide some benefit.
34
Dept of Urology, GRH and KMC,Chennai.

35. Relative Indications for adjuvant
therapy- Chemotherapy, RT
 >2 metastatic inguinal nodes
 Extranodal extension of disease
 Pelvic lymph node metastases
35
Dept of Urology, GRH and KMC,Chennai.

36. 36
Inguinal Nodes- Surgical Staging
Nomograms to predict inguinal LNM
KATTAN, FICCARO ETAL.
◦ tumor thickness,
◦ microscopic growth pattern,
◦ histologic grade,
◦ Vascular embolization,
◦ lymphatic embolization,
◦ infiltration of corpora cavernosa,
◦ corpus spongiosum, or urethra,&
◦ clinical stage of inguinal lymph nodes
Dept of Urology, GRH and KMC,Chennai.

37. ThankYou
37
Dept of Urology, GRH and KMC,Chennai.