Management of Circumscribed Lesions
The appropriate management of a circumscribed lesion requires biopsy for histologic diagnosis before initiating any treatment, as this will determine the specific approach based on pathologic findings. 1
Initial Evaluation
- A thorough physical examination of the lesion should document diameter, location, number of lesions, morphology (papillary, nodular, ulcerous, or flat), and relationship with surrounding structures 1
- Histologic diagnosis with punch, excisional, or incisional biopsy is essential to determine the treatment algorithm 1
- MRI or ultrasound can be used to evaluate the depth of tumor invasion if malignancy is suspected 1
Management Based on Histologic Diagnosis
For Penile Carcinoma In Situ (Tis) or Noninvasive Verrucous Carcinoma (Ta)
- Penile-preserving techniques may be used, including: 1
- Topical therapy with imiquimod (5%) or 5-FU cream
- Circumcision and wide local excision (such as Mohs surgery)
- Laser therapy using carbon dioxide or neodynium:yttrium-aluminum-garnet (category 2B)
- Complete glansectomy (category 2B)
For T1, G1-2 Penile Carcinoma
- Penile-preserving techniques if patient is reliable for follow-up: 1
- Wide local excision and Mohs surgery with reconstructive surgery
- Laser therapy (category 2B)
- Radiotherapy delivered as external-beam RT or brachytherapy (category 2B)
- Surgical margins of 5-10 mm are as safe as 2-cm margins 1
- Circumcision should precede radiotherapy to prevent radiation-related complications 1
For T1, G3-4 or T≥2 Penile Carcinoma
- More extensive surgical intervention with partial or total penectomy depending on tumor characteristics and depth of invasion 1
- Intraoperative frozen sectioning is recommended to achieve negative margins 1
- For tumors <50% of glans and patient agreeable to close observation, more conservative approaches may be considered 1
For Lichen Sclerosus
- Biopsy of the initial lesion before treatment is necessary to confirm diagnosis and rule out squamous cell carcinoma 1
- Treatment goals: alleviate symptoms, prevent anatomical changes, and prevent malignant transformation 1
- Medical management: 1
- Topical steroids (clobetasol propionate 0.05% twice daily for 2-3 months with gradual dose reduction)
- Topical emollients
- Surgical management (if disease progresses despite medical treatment): 1
- Circumcision for early lichen sclerosus (96% success rate when limited to glans and foreskin)
- Meatoplasty for meatal stenosis
Follow-up Recommendations
For Penile Carcinoma
- Clinical examination schedule depends on treatment type: 1
- After topical therapy, laser therapy, radiation therapy, or wide local excision: every 3 months in year 1-2, then every 6 months in years 3-5
- After partial or total penectomy: every 6 months in years 1-2, then annually in years 3-5
For Lichen Sclerosus
- Follow-up at 3 months after initial consultation and treatment 1
- Further review at 6 months later 1
- Long-term follow-up for patients with ongoing active disease 1
- Written instructions for self-monitoring and when to seek medical attention 1
Important Considerations
- Malignancy risk must be assessed in all circumscribed lesions, particularly in patients with risk factors such as chronic inflammation, trauma, tobacco use, or history of sexually transmitted diseases 1
- Tissue removed during procedures should be sent for pathological review, especially in pediatric cases 1
- Patients with urinary symptoms should be referred to a urologist for further evaluation 1
- Any change in symptoms, lack of response to treatment, new areas of erosion, ulceration, or development of lumps must prompt immediate medical attention 1
Pitfalls to Avoid
- Failing to obtain histologic diagnosis before initiating treatment 1
- Inadequate surgical margins leading to recurrence 1
- Missing underlying malignancy in chronic inflammatory conditions 1
- Neglecting long-term follow-up in high-risk patients 1
- Overlooking the need for multidisciplinary care in complex cases 1