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Rapid onset of acute carcinoma of the glans penis arising three years after a lichen sclerosus

European Journal of Dermatology. Volume 15, Number 6, 497-9, November-December 2005, Clinical report

Summary

Author(s) : Christian Aquilina, Roland Viraben , Service de dermato-vénéréologie, Hôpital La Grave, place Lange 31052 Toulouse cedex.

Summary : Lichen sclerosus and atrophicus (LSA) is an inflammatory disease of incompletely characterised pathogenesis. If the development of squamous cell carcinoma (SCC) during the evolution of LSA is well described in women, this complication is a matter of discussion in men. We report an unusual case of acute and aggressive SCC which complicated the evolution of an LSA of the glans penis within three years. This type of observation is rarely reported in the medical literature.

Keywords : lichen sclerosus, squamous cell carcinoma

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ARTICLE

Auteur(s) : Christian Aquilina, Roland Viraben

Service de dermato-vénéréologie, Hôpital La Grave, place Lange 31052 Toulouse cedex

accepté le 20 Février 2005

There is a well documented association between LSA and carcinoma in women with a risk assessed between 5 and 7% [1, 2], but in men, this fact is until recently a matter of discussion [3]. We report an observation of acute and invasive penile squamous-cell carcinoma arising within a short time during evolution of LSA.

Observation

A 56-year-old uncircumcised man initially presented with an asymptomatic erythematous scaly patch with whitish and atrophic areas on the dorsal aspect of the glans penis, present for two years. Histologic changes were compatible with lichen sclerosus and atrophicus (LSA): hyalinization of collagen in the papillary dermis, hyperkeratosis with acanthosis without cellular atypia ( (figure 1) ). The patient had no history of HPV infection. The eruption failed to respond to topical steroids (betamethasone) and androstanolone applied together for three months. Nearly 1 year later, he developed in three weeks an acute tumor at the site of the LSA ( (figure 2) ). Pathological examination of the excised tumor confirmed the diagnosis of a well-differentiated invasive squamous cell carcinoma (SCC) ( (figure 3) ). PCR analysis on sections of biopsy tissue (Technique: Amorces consensus MY 9/11) and DNA in situ hybridization on a formalin-fixed paraffin-embedded sample, with three HPV probes for type-6,11; -16,18; -31,33 were negative. Treatment consisted of partial penectomy, and bilateral inguinal curettage was negative.

Discussion

Squamous cell carcinoma constitutes at least 95% af all penile malignancies [4]. Two different growth patterns are described : flat, the most common presentation that ulcerates early, and nodular lesions or verrucous papules that eventually become necrotic, ulcerative, as in our patient. The glans was the most commonly affected area [5]. Histopathologic classification into four different groups are described with increasing aspect of atypia of squamous cells and decreasing keratinization, from low-grade (I-II) well-differenciated lesions to more poorly differentiated SCC (III-IV).

At present, similarly to the vulvar site, several papers have reported malignant changes in men with genital LSA, as anecdotal cases [6-14] and analyses of series [15-17]. Powell [18] reports 11 of 20 patients with penile SCC who had clinical and histological evidence of LSA; the interval from the diagnosis of previous LSA was up to 12 years; three had node involvement and four had documented metastases. Nasca [5] reports malignant changes as SCC in 5.8% of a cohort of 86 white uncircumcised males with penile LSA with a lag time of 10-23 years from diagnosis of LSA to diagnosis of SCC. In our observation, the delay between the two diseases was very short (3 years) and the carcinoma was rapidly acute and invasive. In the literature, only one case describes a rapid development (within 2 months) of SCC on LSA in 3 years [9]. The origin of genital LSA remains unclear [19]. Among risk factors for invasive SCC of the penis, oncogenic HPV infection is discussed [20]. Table 1( Table 1 ) reports the main studies concerning the possible relationship between LSA and HPV [21-25]. Observations indicate that long-lasting topical corticosteroid therapy may occasionally be associated with opportunistic reactivation of a latent HPV type infection [26]. However, it is probable that, like in the general population, HPV carriage is very common during the prolonged time course of LS before SCC develops. Perceau [25] demonstrated that LS-associated penile SCC did not tend to be frequently associated with oncogenic HPV infection, compared with non-LS-associated penile SCC.

Today there is no proof of the preventive role of corticotherapy on the development of SCC. Circumcision appears the better treatment for localization on the distal foreskin; although, corticotherapy does not appear to be effective in other localizations such as glans and balano-preputial fold [27]. In our case, at least three months of topic corticotherapy were ineffective.

In conclusion, similarly to vulvar localization, a likely malignant evolution of penile LSA should be admitted. Our observation is unusual because the evolution from SLA to an acute penis cancer was made in a short time. Careful and systematic histopathological evaluation of any ulcerated or indurated lesions developing within SLA is therefore strongly recommended.
Table 1 Main studies concerning the possible relationship between LSA and HPV

Author and reference	Number of cases (SLA)	Number of cases with Positivity for HPV
Kiene 1991 [21]	18	4 (type 16/PCR)
Lau 1995 [22]	24	0
Drut 1998 [23]	23	70% (PCR and in situ hybridisation)
Simonart 1998 [24]	1	0 (PCR)
Nasca 1999 [5]	16	4 (type 16/PCR)
Perceau 2003 [25]	8	0 (type 16/PCR)

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