Penile intraepithelial neoplasia (erythroplasia of Queyrat / Bowen’s disease of the penis / bowenoid papulosis)

Penile intraepithelial carcinoma (PeIN) has three morphological entities; erythroplasia of Queyrat, Bowen's disease of the penis (BDP) and bowenoid papulosis (BP); and two histopathological entities of undifferentiated and differentiated. 

This chapter is set out as follows:

Erythroplasia of Queyrat

• Single or multiple, non-tender, red, shiny patches/plaques of the ‘mucosal’ penis ie the glans and prepuce (foreskin) of the uncircumcised. Lesions tend to be more palpable than the glistening erythema of lichen sclerosus; the two can co-exist 

Bowen's disease of the penis (BDP)

• Red, or sometimes hyperpigmented, scaly patches or plaques of the keratinised penis. Lesions can occasionally have a warty or crusty appearance 

Bowenoid papulosis (BP)

• Is associated with HPV (Human Papilloma Virus)
• Multiple warty lesions, which are often pigmented in keratinised sites, and more numerous and more inflamed at mucosal sites
• Tends to occur in younger sexually active men, as opposed to the lesions of erythroplasia of Queyrat and Bowen's disease that are usually seen in older men
• Lesions tend to be less papillomatous, flatter-topped, more polymorphic, and more coalescent than common genital viral warts (condylomata acuminata)

Squamous cell carcinoma

• There is often a long history of preceding pathology such as PeIN, lichen sclerosus, or ulcerative lichen planus (uncommon in men)
• Irregular nodular and ulcerative morphology is found on examination. There can be discharge and/or bleeding
• Unless treated promptly, the condition becomes mutilating and can metastasize

• Both erythroplasia of Queyrat and Bowen's disease require urgent biopsy to exclude invasive squamous cell carcinoma
• A biopsy is also needed to see if the changes are undifferentiated (HPV-related), or differentiated (lichen sclerosus-related)

Erythroplasia of Queyrat and Bowen's disease of the penis

• The risk of progression to invasive squamous cell carcinoma is cited at 10–33% with the risk being greatest for erythroplasia of Queyrat 

• First-line treatment is circumcision. Any remaining areas can be treated as per Bowen's disease at other sites

• In undifferentiated cases, the HPV vaccine is important aspect of management

• If invasive carcinoma is suspected then an urgent referral (two-week wait) is required
  

Bowenoid papulosis

• In the absence of other risk factors, especially immunosuppression, the risk of progression to invasive squamous carcinoma is believed to be very low 

• Management is generally the same as for viral warts with topical therapies, cryosurgery, or curettage & cautery