Penis & scrotum

Dysplasia / carcinoma in situ

Bowenoid papulosis


Editorial Board Member: Debra L. Zynger, M.D.
Deputy Editor-in-Chief: Maria Tretiakova, M.D., Ph.D.
Heather Jones, M.D.
Liwei Jia, M.D., Ph.D.

Last author update: 15 June 2022
Last staff update: 15 June 2022

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PubMed Search: Bowenoid papulosis penis

Heather Jones, M.D.
Liwei Jia, M.D., Ph.D.
Page views in 2021: 4,644
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Cite this page: Jones H, Jia L. Bowenoid papulosis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/penscrotumbowenoid.html. Accessed December 9th, 2022.
Definition / general
  • Human papillomavirus (HPV) related proliferation of atypical basaloid and koilocytic cells; characteristically involves the anogenital skin and mucosa
Essential features
  • Characterized by the presence of atypical basaloid and koilocytic cells in squamous epithelium above the basement membrane
  • Typically presents as solitary or multiple small pink, brown or violaceous papules or plaques on the penis or other sites
  • Diagnosis requires both characteristic clinical and microscopic findings
  • Usually caused by HPV 16 infection or (less commonly) other HPV strains
Terminology
  • Penile intraepithelial neoplasia (PeIN) is the standardized terminology for pathologic reporting, which may be integrated with clinical presentation for diagnosis of bowenoid papulosis (Eur Urol 2016;70:93)
  • Bowenoid papulosis is no longer a term used by pathologists in the World Health Organization (WHO) Classification of Tumors, 5th edition
  • First reported as multicentric pigmented Bowen disease (historical, not recommended) (Arch Dermatol 1970;101:48)
ICD coding
  • ICD-10:
    • D07.4 - carcinoma in situ of penis
    • D01.3 - carcinoma in situ of anus and anal canal
    • D04.9 - carcinoma in situ of skin, unspecified
    • B97.7 - papillomavirus as the cause of diseases classified elsewhere
  • ICD-11: 2E67.4 - carcinoma in situ of penis
Epidemiology
  • Young, sexually active males (on average, late 20s to early 30s)
Sites
Pathophysiology
  • Persistent infection with high risk HPV leads to expression of oncoproteins E6 and E7, which inactivate p53 and Rb tumor suppressors, leading to dysregulation of cell division and apoptosis (World J Urol 2009;27:141)
Etiology
Clinical features
Diagnosis
  • Diagnosis requires characteristic clinical findings in conjunction with pathologic features from biopsy
Prognostic factors
Case reports
Treatment
  • Conservative treatment modalities include carbon dioxide laser vaporization, cryotherapy, electrocoagulation, 5-aminolevulinic acid mediated photodynamic therapy, excisional surgery, 5-fluorouracil and topical imiquimod cream 5% (Australas J Dermatol 2017;58:86)
  • Female partners are at increased risk for cervical dysplasia and should be monitored (Ther Adv Urol 2011;3:151)
Clinical images

AFIP images

2 small papules with irregular margins



Images hosted on other servers:

Penile lesions

Typical appearance in female


Gross description
  • Skin / mucosal punch or shave biopsy with superficial surface demonstrating papule(s), plaque or papillomatous lesion(s) that may be skin toned, violaceous or red-brown
Microscopic (histologic) description
  • Dysplastic changes with intact basement membrane, consistent with squamous cell carcinoma in situ (Eur Urol 2016;70:93)
  • Proliferation of atypical basaloid and koilocytic cells in squamous epithelium may range from scattered cells to full thickness involvement
  • Often accompanied by acanthosis, parakeratosis and mitotic figures above the basal layer
  • May demonstrate hyperkeratosis, dyskeratosis, lymphocytic infiltrate, loss of polarity and dilated, tortuous capillaries in dermal papillae (Arch Dermatol 1970;101:48, J Am Acad Dermatol 1986;14:433)
  • Cannot definitively be distinguished from other forms of carcinoma in situ, Bowen disease and erythroplasia of Queyrat, based on histology alone (Cancer 1986;57:823, Australas J Dermatol 2019;60:e201)
Microscopic (histologic) images

Contributed by Liwei Jia, M.D., Ph.D.

Intact basement membrane

Mitotic figures

Proliferation


AFIP images

Acanthosis and spotty distribution of atypical cells

Positive stains
Electron microscopy description
Molecular / cytogenetics description
Videos

Microscopic findings of bowenoid papulosis / HSIL

Gross and microscopic findings of bowenoid papulosis, ruling out differential diagnoses

Sample pathology report
  • Penis, dorsal glans, punch biopsy:
    • Penile intraepithelial neoplasia (PeIN), grade 2 (see comment)
    • Comment: Stratified squamous epithelium demonstrates acanthosis with scattered mitoses and atypical koilocytic cells. This moderate dysplasia does not extend below the basement membrane, consistent with PeIN, grade 2. Patient's age and appearance of lesion are noted. Clinical variants of PeIN include bowenoid papulosis, Bowen disease and erythroplasia of Queyrat. Given the presentation of multifocal skin toned, flat topped papules resembling early condyloma acuminata on the glans of a 32 year old man, this may be consistent with bowenoid papulosis. Bowenoid papulosis may spontaneously regress but also may very rarely progress to invasive squamous cell carcinoma.
Differential diagnosis
Board review style question #1


A 25 year old man presents with multiple, violaceous papules (up to 0.5 cm) on the lateral penile shaft. Images of representative microscopic findings are shown above. Immunohistochemical stain for p16 was positive, with a block-like staining pattern. What is the diagnosis?

  1. Bowen disease
  2. Bowenoid papulosis
  3. Invasive squamous cell carcinoma
  4. Verrucous carcinoma
Board review style answer #1
B. Bowenoid papulosis. Given the patient's young age and multifocality of lesions, this penile intraepithelial lesion (PeIN) is most consistent with bowenoid papulosis. Bowen disease is usually in older patients.

Comment Here

Reference: Bowenoid papulosis
Board review style question #2
What is the current standard of care for bowenoid papulosis lesions?

  1. Chemotherapy and radiation, as lesions nearly always metastasize
  2. Conservative management with local resection, ablation or medications
  3. Observation, as lesions typically spontaneously regress
  4. Penectomy, as lesions reflect underlying invasive squamous cell carcinoma
Board review style answer #2
B. Conservative management with local resection, ablation or medications. Although bowenoid papulosis may spontaneously regress, it is suspected to be a premalignant lesion that rarely progresses to Bowen disease or even invasive squamous cell carcinoma. Therefore, conservative local resection or ablation is the favored treatment to reduce risk of progression to malignancy.

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Reference: Bowenoid papulosis
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