Verrucous carcinoma arising in pseudoepitheliomatous keratotic and micaceous balanitis, without evidence of human papillomavirus

Pseudoepitheliomatous keratotic and micaceous balanitis: a series of eight cases

BACKGROUND

Pseudoepitheliomatous keratotic and micaceous balanitis (PEKMB) is a clinicopathological entity characterized clinically by micaceous scale on the glans, and histologically by acanthosis, hyperkeratosis and pseudoepitheliomatous hyperplasia. We present a series of eight cases of this rare condition, the first series of more than two cases to be reported.

OBJECTIVES

To determine the clinical and histological characteristics of cases of PEKMB, and evaluate treatments used and clinical course.

METHODS

This monocentric case series was conducted at the University College London Hospitals tertiary male genital dermatology clinic between April 2018 and August 2020. Eight patients with PEKMB were evaluated. Data were collected on demographics, clinical presentation, histological features, presence of human papilloma virus (HPV), history of lichen sclerosus, treatment of PEKMB and subsequent response, and presence or development of squamous cell carcinoma (SCC) or penile intraepithelial neoplasia (PeIN) during follow-up.

RESULTS

Eight Caucasian males presented with clinical and histological evidence of PEKMB. Seven had a background of lichen sclerosus; two had failed treatment with superpotent topical steroids and four had symptoms for three or more years prior to circumcision. There was no clinical or histological relationship with HPV infection, and p16 staining was negative. HPV PCR, performed in two cases, was negative. Basal atypia, insufficient to amount to PeIN, was present in six patients. One patient progressed to PeIN during follow-up, and no patient progressed to invasive malignancy. Five patients were treated successfully with glans resurfacing and split skin graft reconstruction.

CONCLUSIONS

Our observations demonstrate that PEKMB represents a form of chronic, undiagnosed or misdiagnosed, inadequately treated or treatment refractory, unstable lichen sclerosus. The significant potential for squamous carcinogenesis (differentiated PeIN and verrucous carcinoma) can be mitigated by timely diagnosis and treatment. Glans resurfacing and split skin graft reconstruction appears to be a successful treatment modality in patients with refractory disease.

Penile Pseudoepitheliamatous Hyperkeratosis balanitis: A case report and review in Assiut university urology department 2021

A 35 years old man present with a skin lesion on his glans complaining of mild irritation. The condition began 3 years ago, he took wrong medication as he was diagnosed as psoriasis, mostly because the disease in it the beginning is very similar and could trick the dermatologist. He was diagnosed by the biopsy taken,Pseudo-epitheliomatous hyperkeratotic and micaceous balanitis. 5-Flouracil was given in combination with oral Acitretin, Dramatic improvement occurred in both the skin lesion and the symptoms associated.

Optimal treatment for penile verrucous carcinoma: a systematic literature review

BACKGROUND

Verrucous carcinoma, a rare low-grade well-differentiated squamous cell carcinoma, is known for its favorable biological behavior and lack of metastatic potential. However, aggressive resection is problematic in terms of compromised function and aesthetics. Hence, more conservative treatments are needed.

METHODS

To identify the up-to-date general biological behavior, diagnosis, and treatment trends, we searched PubMed using the keyword "penile verrucous carcinoma" without restrictions on publication date.

RESULTS

Current treatments for penile verrucous carcinoma include wide surgical excision, seldom preventive lymphadenectomy, and conservative chemotherapy without surgery or local excision with safe margins. Despite the advent of partial penectomy to minimally impact function and aesthetics, affected patients experience psychosexual problems. Local excision can be used to save the penile shaft and glans penis without preventive lymphadenectomy or adjuvant therapy and can achieve good clinical prognosis with rare recurrence.

CONCLUSIONS

To preserve the functional and cosmetic aspects, we recommend local excision, especially for tumors measuring < 3 cm and classified as stage T1 according to the 2016 tumor node metastasis clinical and pathological classification for penile cancer.

Pseudoepitheliomatous keratotic and micaceous balanitis: low-risk human papilloma virus detection in two further cases

We report two cases of histologically documented pseudoepitheliomatous keratotic and micaceous balanitis in middle-aged male patients, which showed positivity for low-risk serotype human papillomavirus DNA. To our knowledge, only one other case has been documented. Further immunohistochemical proliferative markers were performed and compared to literature findings in penile epithelial proliferations. Evolution to invasive verrucous carcinoma has been associated with absence of HPV DNA. Thus, if confirmed by further studies, HPV testing should be included in pseudoepitheliomatous keratotic and micaceous balanitis assessment to address prognosis, and management.

Pseudoepitheliomatous, keratotic, and micaceous balanitis

A 51-year-old circumcised male presented with hard, thick, keratotic, nail-like covering of the skin of his glans penis of 2 year duration. Histology showed acanthosis, papillomatosis, and elongated rete ridges into the dermis suggestive of pseudoepitheliomatous, keratotic, and micaceous balanitis with features of cellular atypia. Partial penile amputation was done. There was no recurrence after 6 months of follow up.

Pseudoepitheliomatous, keratotic and micaceous balanitis after penile squamous cell carcinoma

Pseudoepitheliomatous keratotic and micaceous balanitis (PKMB) is a rare form of balanitis, with only a handful of cases reported since the disease was first described. Although the condition has been described as benign, there is increasing evidence of its premalignant potential, with several of the reported cases progressing to verrucous or squamous cell carcinoma (SCC). We report a case of PKMB following penile SCC and discuss the literature on this rare condition.

[Balanitis: diagnosis and treatment]

Balanitis refers to a variety of unrelated conditions. It results from infective, irritative, allergic, traumatic, or inflammatory causes; pre-malignant lesions have been also identified. All these causes are successively reviewed regarding their positive diagnosis and their treatment. Normal aspects of the balanopreputial area will be explained because they may cause some anxiety in certain patients. The difference between the circumcised and uncircumcised penile skin that cause differences in the incidence and appearance of dermatoses of the glans and corona will be studied. Pre-malignant lesions of the balanopreputial area, although not frequent, represent a difficult diagnosis and therapeutic challenge. The major problem is the earliness of the diagnosis that may avoid the occurrence of squamous cell carcinoma. Moreover, lichen sclerosus may develop into squamous cell carcinoma and therefore a lifelong follow-up must be implemented. Thus, any fixed, chronic or suspicious Lesion must be rapidly assessed by a biopsy.

Penile cancer

Penile cancer, while relatively rare in the western world, remains a disease with severe morbidity and mortality, not to mention significant psychological ramifications. Furthermore, the disease is observed with dramatically increased incidence in other parts of the world. A review of the literature has shown that the overwhelming majority of penile cancers are in situ or invasive squamous cell carcinomas, including a well-differentiated variant, verrucous carcinoma. Important predisposing factors are lack of circumcision, human papillomavirus infections, and penile lichen sclerosus, although other factors have occasionally been reported as well. Prevention, careful monitoring of patients at risk, and early diagnosis are essential to reduce the incidence of penile carcinoma and to provide a definitive cure. Public health measures, such as prophylactic use of circumcision, have proved successful but are controversial. Also, no standard therapeutic guidelines as to the best treatment strategy according to different stages, including efficacy of conservative nonsurgical modalities and indications for lymph nodal dissection, are available so far. It is common opinion that penile cancer is an emerging problem that deserves further investigations, and physicians, especially dermatologists, should be aware of this issue.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with penile carcinoma, its risk factors, its clinical and histologic presentation, and the treatments currently available for its management.

Role of human papillomavirus in penile cancer, penile intraepithelial squamous cell neoplasias and in genital warts

Using PCR, the overall prevalence of human papillomavirus (HPV) DNA in penile carcinoma is about 40-45%, which is similar to the detection rate of HPV-DNA in vulvar carcinoma (50%). In analogy to vulvar cancer two different pathways of penile carcinogenesis seem to exist. In contrast to basaloid and warty penile cancers which are regularly HPV-associated (about 80-100%), only a part of keratinizing and verrucous penile carcinomas appear to be related with HPV (33-35%). Penile intraepithelial neoplasias comprising Bowen's disease, erythroplasia of Queyrat and bowenoid papulosis are precursor lesions of basaloid and warty carcinomas of the penis. Precursors of keratinizing carcinomas and verrucous carcinomas are not established. Whether lichen sclerosus and squamous-cell hyperplasia precede penile keratinizing carcinoma is a matter of discussion. Giant condylomata acuminata may precede the development of verrucous carcinomas in some cases. Since high risk HPVs are more frequently found in verrucous carcinomas than in giant condylomas, HPV typing may be a helpful diagnostic step to differentiate giant condyloma from verrucous carcinoma.

Invasive Penile Carcinoma: A Review

BACKGROUND

Penile carcinoma is an invasive epithelial tumor that may arise from penile skin or mucosa.

OBJECTIVE

To review the pathogenesis and the clinical and histopathologic features of invasive penile carcinomas, with emphasis on current guidelines for their diagnosis and treatment.

METHODS

Information available from the authors' clinical experience, review articles, case reports, clinical trials, and in vitro research studies identified from a computerized literature search on MEDLINE database and from Meetings' Abstract Books, including those from non-English literature, was considered.

RESULTS

Penile cancer may develop de novo or in association with underlying factors. Conditions predisposing to the development of penile cancer are delineated. The diagnosis should be suspected by clinical findings and must be confirmed histologically. Imaging techniques may be useful for staging and planning therapy. Therapeutic options include excisional surgery, laser destruction, cryosurgery, radiotherapy, immunotherapy, and chemotherapy.

CONCLUSIONS

Although there are no current guidelines for the treatment of penile carcinoma, surgical ablation probably represents the best option, as conservative treatments still deserve cautious evaluation because of the relatively small number of treated patients and the lack of good-quality comparative data. Regarding indications for lymph nodal dissection in patients showing no inguinal node enlargement, sentinel node mapping with targeted lymph node dissection is recommended for those with deeply invasive, high-grade tumors, whereas a watchful waiting may be advised for those with superficially invasive, low-grade tumors.