Genital Lichen Sclerosus Et Atrophicus LS

Balanitis Xerotica Obliterans (BXO) is now better defined as the male genital variant of lichen sclerosus et atrophicus (LS). It was initially described as a chronic, progressive, scleroatrophic inflammatory process of unknown etiology affecting the glans penis, prepuce, and in advanced cases, the anterior urethra and meatus, either individually or in any combination. It occurs almost exclusively in uncircumcised men. Lesions classically appear as pale, atrophic plaques, which may coalesce and sclerose, causing phimosis and meatal stenosis (Fig. 5.6). It presents most commonly in men in their third and fourth decades. Its exact etiology remains unclear; theories have hypothesized a possible autoimmune element,34 or even a genetic basis based on HLA antigens,35 although the true pathogenesis is likely to be multifactorial.

LS was initially considered to be a benign condition. However, in the late 1970s, case reports first suggested a possible association between LS and penile cancer.36,37 Studies in the last decade have looked at this association in more detail. Barbagli et al. retrospectively reviewed the histology of 130 patients with LS and reported premalignant or malignant features in 11 (8.4%), with 6 (55%) of this group showing hyperplasia/low grade PIN

1 grade PtN

lichen scleroses

Histopathology

Clinical manifestations hrHPV positivity (%)

Progression to cancer hyperplasia/low grade PIN

Histopathology

Clinical manifestations

Penile Lesion
flat penile lesion

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Bowenoid papulosis

1 grade PtN

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Erythroplasia of Queyrat* Genital Bower)'s disease

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Penile Cancer

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I c he n scleroses no association HPV

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80-100%

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keratinizing I 65-70%

HPVpos

basaloid

verrucous HPVneg

Fig. 5.5 Relationship between histology, HPV presence, clinical manifestation, and putative transformation of penile precursor lesions into penile (With kind permission from Springer Science + Business Media: Bleeker et al.,33 Fig. 1)

were also areas of CIS on the glans penis

Fig. 5.6 Extensive lichen sclerosus in a 45-year-old man affecting the foreskin and the glans penis. There were also areas of CIS on the glans penis

Fig. 5.6 Extensive lichen sclerosus in a 45-year-old man affecting the foreskin and the glans penis. There

Lichen Sclerosus Years Old

evidence of some epithelial dysplasia.38 Nasca et al. reported on a series of 86 patients with LS. SCC was subsequently found in 5.8%, with a mean interval from onset of LS to invasive tumor of 17 years (range 10-24 years). In all cases epithelial dysplasia and LS were found adjacent to tumor foci, indicating possible histological progression from chronic inflammation to dysplasia and eventually to malignant transformation.39 The mechanism by which invasive malignancy may develop in LS remains elusive. In the largest series to date, SCC was found in 2.3% of 522 patients diagnosed with LS.40 As well as this metachronous relationship, other series reviewing patients referred for treatment of penile cancer found LS to be a much more common synchronous finding in this group. Rates between 28% and 50% have been reported.41-43

The concept of LS as a premalignant lesion remains contentious. For many, the discrepancy between the high rates of synchronous LS compared to the low rates of metachronous tumors points to this being an associated risk factor as opposed to a causal factor. Indeed, many urologists do not routinely follow up patients with LS particularly once they have been circumcised. With vulval carcinoma, where lichen sclerosus has been shown more definitively to progress to invasive cancer in 4-5% of cases,44 patients with vulval LS are closely reviewed with frequent repeat biopsy.45 Although European guidelines consider LS to be a premalignant condition,4 6 no consensus has been agreed on how best to follow up these patients.21 The low rate of metachronous transformation and long latency period makes routine follow-up of all patients with LS unfeasible. One solution is to limit specialist follow-up to patients with chronic active disease, teaching the remaining patients, in whom LS regresses after treatment, self examination.4 1 The development of persistent skin lesions or chronic inflammation in patients with LS should be monitored closely and biopsied to ensure no concurrent cancer exists.

Fig. 5.7 Cutaneous penile horn on the penis. Courtesy of Bhushan Kumar, Chandigarh, India (Reproduced by permission of Prof CB Bunker and Elsevier Saunders47)

Fig. 5.7 Cutaneous penile horn on the penis. Courtesy of Bhushan Kumar, Chandigarh, India (Reproduced by permission of Prof CB Bunker and Elsevier Saunders47)

Condyloma Acuminata PapuleCondyloma Acuminata Papule

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