Recurrent paraphimosis. 1. First secondary care specialty seen. Urology. 23. Dermatology. 9. Genitourinary Medicine. 5. Plastic Surgery. 1. Symptoms reported ...
MANAGEMENT OF PENILE INTRAEPITHELIAL NEOPLASIA:
A RETROSPECTIVE OBSERVATIONAL STUDY H. Naasan1, L. Long1, S. Allstaff2, P. Halliday3, A. Affleck1 Departments of Dermatology1, Genitourinary medicine2, and Urology3 Ninewells Hospital and Medical School, Dundee Introduction: Penile intraepithelial neoplasia (PIN) encompasses a spectrum of clinical diagnoses, including penile Bowen’s disease, bowenoid papulosis and erythroplasia of Queyrat (EQ). These 3 clinical subtypes can be differentiated as Bowen’s disease presents as a red scaly plaque on the keratinised penis, EQ presents with a red shiny plaque on the mucosal glans and / or foreskin (Fig. 1,2), while bowenoid papulosis presents as multiple warty banal-looking lesions in younger men on the glans, shaft, prepuce and groin areas.1 However, clinical presentation is variable and there may be diagnostic difficulty especially in differentiating from an inflammatory balanoposthitis in which case a biopsy is useful. Histological features of PIN are of squamous cell carcinoma in situ. There are no definite histological features to distinguish between the 3 clinical subtypes of PIN so careful clinicohistopathological correlation is desirable to optimise treatment choice. Risk factors for PIN include previous or current HPV infection with types 16, 18, 33, chronic inflammatory penile dermatoses eg. lichen sclerosus, intact prepuce, ultraviolet light exposure, radiation, smoking, poor gentital hygiene and previous arsenic ingestion. 1,2 We present a case series of PIN identified from our pathology database over a 20 year period. Our patients: 38 cases 13-85 years old (average 49, median 51.5)
Previous Penile Skin Problems
8 Patients
Genital warts
5
Lichen sclerosus
1
Penile cancer
1
Recurrent paraphimosis
1
First secondary care specialty seen
Urology
23
Dermatology
9
Genitourinary Medicine
5
Plastic Surgery
1
Figure 1 EQ with predominant white velvety plaques
Symptoms reported (number of patients): Redness (15), foreskin tightness (11), tearing/bleeding foreskin (5), warts (4), spot (4), itch (2), ulcer (1), mass (1), poor flow (1), pus (1)
Signs (number of patients): Erythema (11), phimosis (9), nodules/plaque (4), scarring (4), warts (2), ulcer (2), balanitis (2), mass (1), telangectasia (1)
Figure 2 EQ as a shiny red plaque Discussion: PIN has a spectrum of clinical presentations. A high index of suspicion and a low threshold for biopsy is desirable to achieve an early accurate diagnosis and facilitate timely optimal treatment. In our series 10 patients had symptoms for > 2 years before referral to secondary care. Only 5 patients had the correct clinical diagnosis pre-biopsy. Treatments included circumcision (11 patients), 5% imiquimod cream(8 patients), 5-fluorouracil cream (3 patients), surgical excision (5 patients), radiotherapy (3 patients), and cryotherapy (1 patient). We suggest that management in a joint dermatology / urology male genital skin clinic with close links to genito-urinary medicine is desirable to optimise patient outcomes. A national interspecialty guideline for PIN is needed (there is only a small section in the existing BAD guideline on SCC in situ).3 Further research is desirable as clinical practice appears to be variable including choice of treatment modality, threshold for circumcision, length of follow-up, HPV subtyping, HIV testing, role of condoms, vaccination with gardasil, full STD screen, partner screening for cervical and anal intraepithelial neoplasia (personal communication). References: 1. Porter WM, Francis N, Hawkins D, Dinneen M, Bunker CB Penile and intraepithelial neoplasia: clinical specrum and treatment inn 35 cases. Br J Dermatol 2002; 147: 1159-1165. 2. Wade TR, Kopf AW, Ackerman AB. Bowenoid papulosis of the penis. Cancer 1978; 42: 1890-1903. 3. British Association of Dermatologists’ guidelines for the management of squamous cell carcinoma in situ. . Br J Dermatol 2014; 170 :245-260.
