Genital Squamous Cell CA In-Situ

presented by

David J Elpern MD (1), Williamstown, MA, USA

Jag Bhawan MD (2), Boston, MA, USA

April 8, 2007

(1) Dermatologist, The Skin Clinic, Williamstown, MA, USA

(2) Professor of Dermatology and Pathology, Boston University School of Medicine, Boston, Massachusetts, USA

Abstract 35 yo man with squamous cell carcinoma-in-situ of penis (bowenoid papulosis type)
35-year-old man
3 years
shaft penis

The patient is a healthy married 35-year-old truck driver who presents with a three year history of genital lesions. He was seen in April of 2004 with a papule on the shaft of the penis. Biopsy at the time was felt to be a condyloma or seborrheic keratosis. No cytopathologic effect. He returned in October 2006 for an unrelated problem and was found to now have discrete and confluent papules (forming plaques on the left side of the shaft of the penis). Biopsy now showed SCIN consistent with bowenoid papulosis. Treated with Aldara which he could not tolerate because of his driving schedule. Returned March 2007 with larger area involved. Bx again confirms SCIN.

Physical Examination
3 cm collection of papules and plaques on penile shaft


Laboratory Data

nil. Has not been tested for HIV


Fig. 1 Hyperplastic epidermis with transepidermal atypia. 10X

Fig. 2 Atypical epithelial cells with many mitotic figures in higher magnification. 40X

Microscopic Findings: Biopsies of the lesion (2006, 2007) show similar features. There is epidermal hyperplasia with transepidermal atypia. Many mitotic figures and individual dyskeratotic keratinocytes are seen. These changes are consistent with squamous cell carcinoma in situ. However, this diagnosis should be correlated with clinical findings as these changes can be seen in Bowenoid papulosis.


  1. Bhawan J. Multicentric pigmented Bowen’s disease: a clinically benign squamous cell carcinoma in situ. Gynecol Oncol 1980; 10:201-205.
  2. Bhawan J. Squamous cell carcinoma in situ in skin: what does it mean? J Cutan Pathol 2007; In press.
Diagnosis For discussion
Reasons Presented

1. Your thoughts on aetiology
2. Given the difficulty of using imiquimod in this patient -- what are your therapeutic suggestions?
3. Advice for patient's wife
4. Does this have a real risk for invasive SCC? If not, aggressive therapy is not indicated?

Questions and Teaching Points

See reasons presented


1. Gerber GS. Carcinoma in situ of the penis. J Urol. 1994 Apr;151(4):829-33. (see abstract)

2. Kessler GM, Ackerman AB. Nomenclature for very superficial squamous cell carcinoma of the skin and of the cervix: a critique in historical perspective. Am J Dermatopathol. 2006 Dec;28(6):537 - 45 ( see abstract )

3. Goorney BP, Polori R. A case of Bowenoid papulosis of the penis successfully treated with topical imiquimod cream 5%. Int J STD AIDS. 2004 Dec;15(12):833-5 ( see abstract )

4. Eisen R, Bhawan J, Cahn T. Spontaneous resolution of Bowenoid Papulosis of the penis. Cutis 1983; Vol 32: 269-73

Keywords squamous cell carcinoma, Bowen's Disease, HPV, imiquimod, bowenoid papulosis
Comments from Faculty and Members

Ted Rosen MD Professor of Dermatology, Baylor College of Medicine, Houston, TX, USA on Apr 8, 2007

Although some might like to "split" SCCIS based on morphology, the fact is that even Bowenoid papulosis should be considered potentially a source of invasive SCCA. Virtually all of these are due to oncogenic HPV (16,18,33,34 mostly) and his wife has been exposed. There are cases of VIN and CIN arising in the female partners of penile SCCIS patients, and therefore she needs to have the usual yearly (or perhaps twice yearly) gynecological exam with thin prep PAP smears. The real risk of conversion of SCCIS at ANY site into invasive disease actually is quite small, estimated at 3-10% (in the non-HIV+ and non-transplant patient). Nonetheless, this patient's disease is worsening, albeit slowly.

The therapeutic options include: fairly heavy cryo (favored by British standards), radiotherapy (probably overkill here), imiquimod and 5FU (both of which are hard due to truck driving, but could be "sold" to the patient by telling him he faces the possibility of penectomy!), PDT (nobody knows exactly the best regimen), surgery or Mohs surgery (big job with this extensive lesion).

Almost all Rx options have a downside, carry about the same cure (90%+) and some risk of recurrence (or appearance of invasive disease) over the ensuing five years. Frankly, I'd talk him into the imiquimod (or 5FU) and tell him he just needs to put up with the discomfort for a while to cure the problem. The other "best" option would be LN2, several sessions, with close follow-up.

Diane Taylor MD, on April 8, 2007

Why is it difficult to treat him with imiquimod?

Monroe Richman MD, Koloa, HI, USA on April 8, 2007

What an unusual case!!

John Kaiser MD, Austin, TX, USA on April 8, 2007

It is likely that this man's lesions are caused by oncogenic genotypes of HPV. Although the risk of invasive SCC is probably low, it is not non-existent.

I wonder in what way his driving schedule caused him to not tolerate imiquimod treatment. It would seem that this would be the least invasive, least intrusive form of therapy for his disease. In my opinion, imiquimod would be the treatment of choice. Alternatives would include: 5-fluorouracil cream, which would be even less well tolerated, or destructive modalities, such as, electrosurgery, cryosurgery, TCA or laser ablation, all with varying risks of scarring.

I would make certain the patient understands the fact that he likely is infected with a cancer-causing virus that he may pass to his wife, possibly placing her at risk for cervical cancer, and that imiquimod may facilitate his immune system's elimination of this virus, with the least risk of scarring. Regardless of the intervention pursued, he needs regular follow-up. Although the HPV vaccine may not be of benefit to his wife if she already has contracted HPV, it should be discussed with her. She definitely needs regular gynecologic exams and Pap smears.

Amanda Oakley FRACP, Clinical Associate Professor of Dermatology, University of Auckland, Hamilton, New Zealand on April 8 2007

Photodynamic therapy may be better tolerated than imiquimod or fluorouracil because recovery time is shorter.

Anthony Benedetto MD, Clin Assist Prof Dermatol, University of PA, Philadelphia, PA, USA on April 8, 2007

Mohs micrographic surgery is the only treatment that will give the best results for a complete removal of the lesion. Otherwise in time it will become invasive and life threatening. Wife should use protection during sexual intercourse and insist that her husband have a complete extirpation of the lesion.

Khalifa Shaquie MD, PhD, Professor of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq on April 9, 2007

According to my experience, I will call this case as ordinary genital viral warts although the border of distinction between bowenoid papulosis and ordinary genital warts is very thin and similarly applied to the histopathology of both conditions. But often dermatologists are obssesive in this regard and searching fo complex things to highlight their images in front of themselves and to their patients. Still this behaviour is for the benefit of patients. If this patient belongs to me, I will treat him with 25% podophyllin in benzoin co applied every 5 days until full clearance. Imiquimod is also a good choice although I have no experience with it as it is not available because of occupation of Iraq and very bad health situations. Regarding wife should be examined well and managed accordingly.

Ian McColl FRACP, Consultant Dermatologist, John Flynn Medical Centre
Tugun, Gold Coast, Australia
on April 9, 2007

This is multifocal viral disease. Mohs would be a waste of time and money. You could never be sure you were clear. Imiquimod is the only rational treatment. You would have fun and games trying to apply Metvix PDT cream to this extensive area on the shaft of the penis extending down to the scrotum and apparently up into the pubic area. You could CO2 laser off what you can see and apply Imiquimod afterwards to clean up what was left. This should make the inflammatory reaction less and allow him to work with less discomfort.

Khaled el-hoshy MD, USA on April 9, 2007

Mohs surgery 1st option. RadioRx is another option. Had similar case that recurred after urologist did primary excision. Doing well after Mohs 22 months f/up so far.

Carlos Garcia MD, Associate Professor, Department of Dermatology at the University of Oklahoma, Oklahoma City, OK, USA on April 9, 2007

  1. Etiology: HPV-16 and others
  2. Therapeutic suggestions: TCA 25-50%, podophyllin, cryotherapy alone or in combination with TCA or podophyllin
  3. Advice: Intercourse using condom, gynecologic evaluation for wife, pap smear
  4. Risk for invasive SCC: Minimal. Aggressive therapy is not indicated.

Doug Johnson MD, Assoc Prof Dermatol, Department of Medicine, University of Hawaii School of Medicine, Honolulu, HI, USA on April 9, 2007

Xylocaine with epinephrine and desiccate. Should be cleared with one treatment.

Samer Ghosn MD Assistant Professor, Department of Dermatology, American University of Beirut Medical Center, Riad El Solh, Beirut, Lebanon on April 12, 2007

Clearly, the histology is that of SCCIS, full thickness epidermal atypia type and the differential diagnosis in this case includes both Bowen's disease and bowenoid papulosis (BP). Differentiation between the two can be made only on clinical basis and is important for management. The first entity is presumably not virally induced and has a high risk of invasion. BP, on the other hand, is caused by HPV, particularly HPV 16, but also other HPV types such as 18, 31, 32, 33, 34, 35, 39, 42, 48, 51, 52, 53, and 54.

Given the clinical picture, especially the multicentricity and the warty look of the lesion, our case is most likely a case of BP rather than Bowen's disease. Although BP runs a benign self limited course in young immunocompetent individuals, a chronic course complicated in 2.6% of cases by malignant invasive transformation is the rule in elderly and immunosuppresed patients.

As part of management, aldara sounds to be the best management and I cannot understand why the patient could not tolerate it. White vinegar (5% acetic acid) application may make subclinical lesions visible within 5-10 minutes. This is a simple test that may be used on follow-up visits to estimate the progression of the disease during and after therapy.

Female sexual partner(s)should be seen for a thorough cervical examination because of the increased risk of malignancy.

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