Pathology > Study Images > Male Genitals > Penis > Premalignant and Malignant Neoplasms
Objectives Anat & Hist Congenital Infectious Benign Malignant

V. Premalignant and Malignant Neoplasms

Objectives:

After completing this section you will know:

  • the definition of carcinoma-in-situ
  • the various types of carcinoma-in-situ of the penis, their locations and malignant potential
  • the most important factors in the development of carcinoma of the penis
  • the clinical and histologic features of carcinoma of the penis
  • the natural course and prognosis of carcinoma of the penis

Carcinomas of the penis are exclusively of the squamous cell type.

  1. Squamous Cell Carcinoma-In-Situ

This is a pre-cancerous lesion in which the epithelium has all the cytological features of malignancy but is confined to the epithelium without penetration of the basement membrane. Carcinoma-in-situ of the penis and surrounding genital region is also called erythroplasia of Queyrat or Bowen's disease. Lesions involving the shaft of the penis are referred to as Bowen's disease while those affecting the glans and prepuce are called erythroplasia.

Clinically, these lesions present as erythematous plaques. Erythroplasia of Queyrat occurs almost exclusively in uncircumcised males and, on the average, in men slightly younger than those with Bowen's disease.


Erythroplasia of Queyrat presenting as an erythematous lesion involving the ventral aspect and tip of the glans.


Erythroplasia of Queyrat. Erythematous lesions on the glans and neck of the penis.


Bowen’s disease. Erythempatous lesion involving the distal shaft and groins.

The histologic picture of carcinoma-in-situ is that of a thickened epithelium with complete architectural disorganization, enlarged, hyperchromatic nuclei and atypical mitotic figures. A chronic inflammatory infiltrate in the subjacent dermis is typically present.


Bowen’s disease. Thickened squamous epithelium (acanthosis) with irregular elongation of the papillae (papillomatosis), cytologic atypia and many mitoses, some abnormal.


Bowen’s disease. High power photomicrograph showing complete architectural disorganization with loss of polarity, nuclear pleomorphism and mitotic figures.

Another condition called Bowenoid papulosis occurs in younger patients on the shaft of the penis. They are smaller, often multiple and histologically are no different from Bowen's disease. HPV 16 antigens have been demonstrated in most cases of Bowenoid papulosis.

In spite of the different names, they are variants of the same disease and some prefer to call all three lesions intraepithelial neoplasia. If left untreated, some carcinoma-in-situ of the penis will regress and others will progress to invade underlying stroma. The frequency with which progression to full-fledged squamous cell carcinomas occurs is uncertain. Bowenoid papulosis has not been clearly documented to progress.

  1. Verrucous carcinoma (Giant condyloma of Buschke - Löwenstein)

This is an extensive, exophytic, warty or cauliflower-like tumor of the penis that involves and, often, destroys the glans and the prepuce.

The lesion shows the histologic features of condyloma accuminatum. However, in addition to the upward growth of the epithelium, there is downward proliferation of the epithelium with the papillae forming broad, compressive fronts into the underlying tissue, which is destroyed. Focal cytologic atypia may be seen in the epithelium.

Although the histologic picture appears benign, the lesion behaves as a low-grade squamous cell carcinoma with true invasion through the basement membrane occurring late in its evolution. Surgical removal of the tumor is usually curative.

  1. Squamous cell carcinoma

Epidemiology

In countries with high circumcision rates the incidence of squamous cell carcinoma of the penis is very low and correspondingly more common in countries where the practice is not routine. The tumor is rare in men circumcised at birth and occurs with higher frequency in uncircumcised individuals with congenital phimosis. No single etiologic agent has been identified but the association with phimosis and the protection afforded by circumcision is thought to be due an unidentified carcinogen in smegma, which accumulates under the prepuce in uncircumcised males. HPV 16, and to a lesser extent 18, has been suggested as causal factors.

Question: In what other genital cancers do HPV subtypes play a role.

Early lesions present as an ulcer, nodule or warty growth on the glans or inner surface of the prepuce. More advanced tumors are usually large, ulcerated and fungating. The presence of a prepuce may obscure the tumor until it is well advanced. Most patients are reluctant to seek early medical attention, and tumors are often advanced at the time of presentation with extensive destruction of the organ.


Squamous cell carcinoma of the penis. Fungating lesion with complete destruction of the glans.

The tumor may invade deeply and extend along the shaft, destroying portions of it.


Squamous cell carcinoma. Serial blocks of the penile shaft showing extensive involvement.

Histologically, the tumors are usually well to moderately differentiated squamous cell carcinomas with focal keratinization and rarely poorly differentiated. Invasion of the dermis is in the form of irregular cords or small clumps.

Because of late presentation approximately 20% of patients will have lymph node involvement at presentation. The prognosis of disease limited to the penis is quite good with 90 to 95% 5-year survival. With lymph node metastases 5-year survival is reduced to less than 50%. Systemic spread is rare.

Question: What lymph node groups do carcinomas of the penis spread to?

Objectives Anat & Hist Congenital Infectious Benign Malignant