Malignant transformation of penile lichen sclerosus: exactly how common is it?

A comprehensive review of current knowledge on penile squamous cell carcinoma

Neoplasm of the penis is relatively rare in most regions representing 0-2% of cancers worldwide. While the penis can be affected by sarcomas, basal cell carcinomas or even melanoma, Penile Squamous Cell Carcinoma (PSCC) represents approximately 95% of all penile neoplasms. Despite its rarity and most common presentation at later decades of life most individuals diagnosed with PSCC are faced with significant decrease in quality of life. The prevalence and incidence vary among different regions and populations, but a common trend is for diagnosis to occur late (stage 4). Underdeveloped countries are traditionally reported to have higher incidence rates; however, rates may vary significantly between urban and rural areas even in developed countries. Age adjusted rates are on the rise in some countries that used to have incidence rates of 1:100 000 or less. The list of associated risk factors is long and includes among others, lack of neonatal circumcision, poor genital hygiene, socioeconomic status, history of human papillomavirus (HPV) infection and penile intraepithelial neoplasia (PeIN). Many risk factors are widely debated among experts however HPV and PeIN are indisputable risk factors, and both also form part of the classification system for PSCC. Both conditions may have occurred in the past or be present at the time of diagnosis and identifying them plays a major role in management strategies. For such a rare condition PSCC can present in many different forms clinically making diagnosis no easy feat. Diagnosis of PSCC is done through clinical examination, including lymph node palpation, followed by a biopsy, which is essential for the classification. Lymph node involvement is a common finding at first presentation and investigation of spread to deep nodes is important and can be done with the aid of PET-CT. Treatment options for PSCC include surgery, chemotherapy, and radiation therapy. Surgical removal of the tumor is considered the most effective however can lead to severe decrease of quality of life. Chemotherapy is used in the case of fixed or bulky lymph nodes, where surgery is not indicated, and for distant metastasis. Radiation therapy is particularly effective in the case of HPV-positive PSCC.

Lichen Sclerosus and Phimosis - Discrepancies Between Clinical and Pathological Diagnosis and Its Consequences

OBJECTIVE

To assess the accuracy of clinical diagnoses and the true incidence of lichen sclerosus (LS) in patients with phimosis.

MATERIALS AND METHODS

The 92 adult male patients who were qualified for circumcision due to phimosis, were included in the study. The patients were diagnosed clinically by a urologist and dermatologist before the surgical procedure. After the circumcision, the resected foreskins were examined by 2 independent uropathologists.

RESULTS

Preoperative clinical diagnosis of LS was established in 54 patients (58.7%); healthy-looking skin in 26 (28.3%) and other penile diseases in 12 (13.1%) patients. After histopathological examination, the diagnosis of LS was established in 62 patients (67.4%), but only in 44 patients with previous LS clinical diagnosis. LS was histopathologically confirmed in 18 other patients with clinically diagnosed healthy skin (n = 17) or lichen planus (n = 1). Healthy skin was histopathologically confirmed in 10 cases in patients diagnosed clinically before as LS. Other 15 histopathological diagnoses were Zoon balanitis (n = 3), nonspecific balanitis (n = 5), lichen planus (n = 1), psoriasis (n = 1), invasive penile cancer (n = 3), Bowen's disease (n = 1), penile intraepithelial neoplasia 2 usual type (n = 1).

CONCLUSION

LS has been revealed as the most common histopathological diagnosis in patients undergoing circumcision in our study. Histopathological examination seems to be necessary to exclude this disease.

Balanitis xerotica obliterans: a review of diagnosis and management

Balanitis xerotica obliterans (BXO), or penile lichen sclerosus, is a progressive sclerosing inflammatory dermatosis of the glans penis and foreskin. It is associated with significant morbidity and may result in impaired urinary and sexual function. It was initially described by Stuhmer in 1928, named after its pathological features, and is considered the male equivalent of vulvar lichen sclerosis (LS).^3,40 The etiology of BXO is uncertain; however, autoimmune disease, local trauma, and genetic and infective causes have been proposed. BXO occurs most commonly on the prepuce and glans penis. It is considered to have premalignant potential to transform into squamous neoplasia. This postulation rests on retrospective studies and parallels drawn with vulvar LS and squamous cell carcinoma (SCC) development. Histologically, BXO and vulvar LS are considered the same disease.⁴¹ There is a paucity of evidence-based guidelines to assist with appropriate follow-up for patients with BXO.

Perineostomy: the last oportunity

Objective

To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure.

Material and methods

We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression.

Results

The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21).

Conclusions

The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis.

Squamous cell carcinoma of the penis: clinicopathologic study of 34 cases

BACKGROUND

In Brazil, the incidence of penile cancer is 8.3 cases per 100,000 population, in contrast to 0.7 in Europe and the United States. 95% of these cases correspond to squamous cell carcinoma (SCC). It is usually diagnosed late.

OBJECTIVES

To describe the clinicopathologic features of squamous cell carcinoma of the penis registered at the Hospital between 1978 and 2004.

METHODS

A cross-sectional observational study. We included cases of squamous cell carcinoma of the penis that were histologically confirmed. Those patients who responded to the study call were evaluated in person, while others had their data researched in medical records.

RESULTS

34 patients with squamous cell carcinoma of the penis were registered: 8 in situ and 26 invasive, with a mean age of 54.7 ± 22.4 and 64,7 ± 12.5 years, respectively. Glans cancer was involved in 91.1% of the cases and the foreskin in 41.1%. SCC in situ exhibited papules or erythema and erosion, usually smaller than 2 cm. Invasive SCC was characterized by ulcers and/or vegetation, usually single and bigger than 2 cm. Of the invasive cases, 80.8% were well differentiated; half was in the TNM stage I and the remaining in stages II to IV. 16 patients had their penis amputated, and 3 died.

CONCLUSIONS

Cancer of the penis is rare and affects adults of all ages and treatment can be aggressive. The nonspecific clinical appearance of early lesions, insufficient medical training in skin lesions and lack of routine diagnostic investigation, treatment and follow up of these cases contribute to the poor prognosis of this neoplasm.

The Strong Protective Effect of Circumcision against Cancer of the Penis

Male circumcision protects against cancer of the penis, the invasive form of which is a devastating disease confined almost exclusively to uncircumcised men. Major etiological factors are phimosis, balanitis, and high-risk types of human papillomavirus (HPV), which are more prevalent in the glans penis and coronal sulcus covered by the foreskin, as well as on the penile shaft, of uncircumcised men. Circumcised men clear HPV infections more quickly. Phimosis (a constricted foreskin opening impeding the passage of urine) is confined to uncircumcised men, in whom balanitis (affecting 10%) is more common than in circumcised men. Each is strongly associated with risk of penile cancer. These findings have led to calls for promotion of male circumcision, especially in infancy, to help reduce the global burden of penile cancer. Even more relevant globally is protection from cervical cancer, which is 10-times more common, being much higher in women with uncircumcised male partners. Male circumcision also provides indirect protection against various other infections in women, along with direct protection for men from a number of genital tract infections, including HIV. Given that adverse consequences of medical male circumcision, especially when performed in infancy, are rare, this simple prophylactic procedure should be promoted.