Lichen sclerosus, invasive squamous cell carcinoma, and human papillomavirus

An evaluation of the pharmacotherapeutic options for the treatment of adult phimosis. A systematic review of the evidence

INTRODUCTION

Topical pharmacotherapy is often practiced in the treatment of adults with phimosis or Lichen Sclerosus (LS). However, it is unclear if it is effective.

AREAS COVERED

The authors review pharmacological treatments in adults with phimosis or LS using the Preferred Reporting of Items for Systematic Reviews and Meta- analysis (PRISMA) methodology. They searched seven databases using key words phimosis, drug treatment, medical, treatment, lichen sclerosis, pharmacological treatment, medications, comparison study for all English language articles from 1962-2021. Inclusion criteria were patients >18 yr., and the use of topical medical treatment with outcome data. The article includes the authors' expert opinion and their perspectives for the future.

EXPERT OPINION

There is limited research, with significant heterogeneity, which suggests the probable safety of topical steroids with some potential to reduce the signs and symptoms of LS. However, good quality research, with patient reported outcome data, is required to establish its true role and effectiveness.

Regulatory T Cells with Additional COX-2 Expression Are Independent Negative Prognosticators for Vulvar Cancer Patients

Vulvar cancer incidence numbers have been steadily rising over the past decades. In particular, the number of young patients with vulvar cancer has recently increased. Therefore, the need to identify new prognostic factors and, in addition, therapeutic options for vulvar carcinoma is more apparent. The aim of this study was to analyze the influx of COX-2 positive tumor-infiltrating lymphocytes and monocytes and their influence on prognosis. Using subtyping by immunofluorescence, the majority of COX-2 expressing immune cells were identified as FOXP3-positive regulatory T cells. In addition, peri- and intra-tumoral macrophages in the same tumor tissue were detected simultaneously as M2-polarized macrophages. COX-2 positive immune cells were independent negative prognostic markers in long-term overall survival of patients with vulvar cancer. These results show an influence of immune cell infiltration for vulvar carcinoma patients. Immune cell infiltration and immune checkpoint expression may, therefore, become interesting targets for further research on new vulvar cancer treatment strategies.

Combined COX-2/PPARγ Expression as Independent Negative Prognosticator for Vulvar Cancer Patients

Vulvar cancer incidence numbers have been rising steadily over the past decades. Especially the number of young patients with vulvar cancer increased recently. Therefore, the need to identify new prognostic factors for vulvar carcinoma is more apparent. Cyclooxygenase-2 (COX-2) has long been an object of scientific interest in the context of carcinogenesis. This enzyme is involved in prostaglandin synthesis and the latter binds to nuclear receptors like PPARγ. Therefore, the aim of this study was to investigate COX-2- and PPARγ- expression in tissues of vulvar carcinomas and to analyze their relevance as prognostic factors. The cytoplasmatic expression of COX-2 as well as PPARγ is associated with a significantly reduced survival, whereas nuclear expression of PPARγ results in a better survival. Especially the combined expression of both COX-2 and PPARγ in the cytoplasm is an independent negative prognosticator for vulvar cancer patients.

Genital diseases in the mature woman

Vulvovaginal conditions are common in mature women. This reflects age-related changes in immunity and skin barrier function of vulvovaginal tissues. Vaginal atrophy is commonly complicated by dryness and inflammation, which makes postmenopausal atrophic vaginitis a virtually ubiquitous condition. The differential of vaginitis includes inflammatory, infectious, and malignant diseases, plus drug hypersensitivity. Atrophic vaginitis is treated with estrogen replacement therapy. Vulvovaginal malignant melanoma occurs predominantly in postmenopausal women and carries a poor prognosis. Similarly, the incidence of vulvovaginal malignancies, such as squamous cell carcinoma and extramammary Paget disease, rises exponentially after 65 years of age. Early diagnosis of these malignancies is of utmost importance. Lichen sclerosus et atrophicus and vulvovaginal candidosis are among the most common postmenopausal vulvovaginal conditions. Lichen sclerosus et atrophicus is associated with significant morbidity, and its management can be challenging. The incidence of vulvovaginal candidosis increases in patients on estrogen replacement therapy.

Squamous Cell Carcinoma Penis in a Case of Urethral Stricture Due to Lichen Sclerosus Balanitis Xerotica Obliterans: A Case Report and Review of Literature

Penile carcinoma is considered a delayed sequel of lichen sclerosus. It is important to recognize this not so uncommon complication in time as survival of patients with Squamous Cell Carcinoma (SCC) depends on early diagnosis and treatment. We describe a case of a 49-year-old male presenting with urethral stricture due to lichen sclerosus. He was treated for stricture disease and later on developed SCC penis after ten years of presentation.

The contemporary management of urethral strictures in men resulting from lichen sclerosus

Lichen sclerosus (LS) is a chronic, inflammatory disease primarily involving the genital skin and urethra in males. Historically, the treatment of this common condition was a challenge due to its uncertain etiology, variable response to therapy, and predilection to recur. The etiology of LS is still debated and has been linked to autoimmune disease, infection, trauma, and genetics. Today, topical steroids are a mainstay of therapy for patients, even in the presence of advanced disease, and can induce regression of the disease. In advanced cases, surgery may be required and range from circumcision, meatoplasty, or, in the case of advanced stricture disease, urethroplasty or perineal urethrostomy. When urethroplasty is required, the use of genital skin as a graft or flap is to be avoided due to the predilection for recurrence. Surgical management should be approached only after failure of more conservative measures due to the high risk of recurrence of LS in the repaired site despite the use of buccal grafting. LS may be associated with the development of squamous cell carcinoma and for this reason, patients should undergo biopsy when LS is suspected and long-term surveillance is recommended.

Penile lichen sclerosus: An urologist's nightmare! - A single center experience

PURPOSE

Penile lichen sclerosus (LS) is a nagging condition and its progression result in devastating urinary and sexual problems and reduction in the quality-of-life. This study has been carried out to present our experience about this disease with simultaneous review of the available literature.

MATERIALS AND METHODS

This retrospective study has been done at a tertiary care center of eastern India. The data of 306 patients affected with LS were analyzed for clinical presentation, physical examination, investigations, and treatment offered.

RESULTS

Presenting symptoms were non-specific. The prepuce was most commonly involved location followed by glans and meatus. Urethral involvement was not isolated as the primary site. Circumcision was done in 237 patients, while 63 patients underwent meatotomy. Thirty-six of 39 cases of LS induced stricture were treated with buccal mucosal graft (BMG) either in one stage or in two stages.

CONCLUSION

LS varies from being a highly aggressive disease of the penis and anterior urethra to a burnt out condition affecting just the meatus and surrounding glans. Early diagnosis and treatment are required to prevent its complication and associated morbidity. Management depends on the anatomical location of lesion, extent of involvement, rapidity of progression and its severity. Use of BMG in LS induced urethral stricture has shown encouraging results.

SIU/ICUD Consultation on Urethral Strictures: Anterior urethra-lichen sclerosus

We reviewed the current literature on lichen sclerosus as it related to urethral stricture disease using MEDLINE and PubMed (U.S. National Library of Medicine, National Institutes of Health) up to the current time. We identified 65 reports, 40 of which were considered relevant and form the basis of this review. Lichen sclerosus is now the accepted term, and balanitis xerotica obliterans is no longer acceptable. This common chronic inflammatory skin condition, mainly affecting the genitalia, remains an enigma, with uncertain etiology, varied presentation, and multiple treatments. In the early stages of the condition, a short course of steroids may be beneficial for some patients. If persistent, patients need long-term surveillance because of the potential development of squamous cell carcinoma. If diagnosed early, lichen sclerosus can be controlled, preventing progression. But once the disease has progressed, it is very difficult to treat. Surgical treatment by circumcision can be curative if the disease is treated early when still localized. Once progression to urethral involvement has occurred, treatment is much more difficult. Meatal stenosis alone is likely to require meatotomy or meatoplasty. Treatment of the involved urethra requires urethroplasty. Single-stage and multiple-stage procedures using oral mucosa have both been reported to give acceptable results, but the use of skin, genital or nongenital, is not recommended, because being skin, it remains prone to lichen sclerosus. With extensive disease, affecting the full length of the urethra, consideration should be given to perineal urethrostomy. A significant number of patients may prefer this simpler option.

Lichen sclerosus and squamous cell carcinoma

Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy. The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma. Two pathogenic pathways, differentiated vulvar and penile intraepithelial neoplasias, which have recently been described in relation to squamous cell carcinoma, are both highly associated with genital lichen sclerosus independently of human papilloma virus (HPV) infection. Furthermore, tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus. The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion, and the prognostic importance of the overlapping of these 2 diseases is still unclear. This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas, the possible oncogenic mechanisms involved, and their possible association with HPV infection.

[Lichen sclerosus and squamous cell carcinoma]

Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy. The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma. Two pathogenic pathways, differentiated vulvar and penile intraepithelial neoplasias, which have recently been described in relation to squamous cell carcinoma, are both highly associated with genital lichen sclerosus independently of human papilloma virus (HPV) infection. Furthermore, tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus. The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion, and the prognostic importance of the overlapping of these 2 diseases is still unclear. This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas, the possible oncogenic mechanisms involved, and their possible association with HPV infection.

Epstein-Barr virus and human papillomavirus infection in vulvar lichen sclerosus

OBJECTIVE

We investigated the presence of the Epstein-Barr virus (EBV) and human papillomavirus (HPV) in patients with vulvar lichen sclerosus (LS).

MATERIALS AND METHODS

We investigated the presence of HPV and EBV from 34 vulvar biopsies of patients with LS who had had no previous treatment and from 17 normal vulvar brushings used as controls. We used polymerase chain reaction to amplify DNA sequences of these viruses. Human papillomavirus and EBV DNA detection was carried out using MY09/MY11 and TC67/TC69 consensus primers, respectively. The amplified polymerase chain reaction products were analyzed by 10% polyacrylamide gel.

RESULTS

The mean age of the patients was 57 years old, with the majority postmenopausal. Human papillomavirus DNA was not found in the LS samples studied, but it was found in 23.2% (4/17) of the controls. However, EBV DNA was found in 26.5% (9/34) of the LS samples analyzed, and it was not found in the controls.

CONCLUSIONS

Our results showed no relationship between HPV and LS. This result is in accordance with the literature. We have found 26.5% of EBV in our samples. This is a preliminary study, and the follow-up of these patients will elucidate whether EBV could play a role in cases of LS.

Differentiated vulvar intraepithelial neoplasia contains Tp53 mutations and is genetically linked to vulvar squamous cell carcinoma

Differentiated vulvar intraepithelial neoplasia is a unique precursor to vulvar squamous cell carcinoma that is typically HPV-negative and frequently associated with nuclear p53 staining. These features imply a mode of pathogenesis involving somatic mutations. However, the genetic relationship of differentiated vulvar intraepithelial neoplasm and vulvar squamous cell carcinoma and the role of Tp53 mutations in this process have not been resolved. We analyzed 11 differentiated vulvar intraepithelial neoplasms and 6 associated vulvar squamous cell carcinomas. Sections were stained for p53 and p63 and DNA from multiple epithelial sites, representing normal control tissues (n=10), differentiated vulvar intraepithelial neoplasias (n=18), and vulvar squamous cell carcinomas (n=6), were obtained by laser capture microdissection, and sequenced for exons 2-11 of Tp53. Six of 10 cases contained at least one Tp53 mutation-positive differentiated vulvar intraepithelial neoplasia focus; 4 strongly p53 immuno-positive and 2 negative. Staining for p53 and p63 co-localized, targeting the immature epithelium, but surface epithelium was Tp53 mutation-positive. Four of five vulvar squamous cell carcinomas were Tp53 mutation-positive; two shared identical Tp53 mutation with adjacent differentiated vulvar intraepithelial neoplasia. Disparate foci of differentiated vulvar intraepithelial neoplasia often showed different mutations consistent with multiple neoplastic clones. Differentiated vulvar intraepithelial neoplasia is, with few exceptions, associated with Tp53 mutations and will be p53 immunopositive when missense mutations (versus some nonsense and all deletion mutations) are present. Multiple Tp53 mutations in different sites supports the presence of multiple independent genetic events, but shared Tp53 mutations in both differentiated vulvar intraepithelial neoplasia and vulvar squamous cell carcinoma support a genetic relationship between the two. The confinement of p53 staining to immature cell nuclei is consistent with maturation-dependent degradation of mutant p53 protein.

Lichen sclerosus: review of the literature and current recommendations for management

PURPOSE

We reviewed the literature regarding the clinical presentation, etiology, natural history, and medical and surgical management of lichen sclerosus in men.

MATERIALS AND METHODS

We performed a comprehensive search of the literature in PubMed, MEDLINE and other electronic databases between 1950 and 2006 using the key words lichen sclerosis, balanitis xerotica obliterans and urethral stricture. Our search resulted in 1,268 sources containing the words lichen sclerosus or balanitis xerotica obliterans. We reviewed 68 articles in the peer reviewed journals and 2 chapters on this subject.

RESULTS

Lichen sclerosus is a chronic, lymphocyte mediated skin disease that was first described in 1887. It shows a predilection for the anogenital area in men and women. Much has been discovered regarding the epidemiology, natural history and histological features of this disease process during the last century, including the discovery of a strong association between lichen sclerosus and squamous cell carcinoma. The techniques of medical and surgical management of this disorder are still being elucidated. Biopsy of the initial lesion for definitive diagnosis and long-term followup of affected patients are well established, critical elements in the management of lichen sclerosus.

CONCLUSIONS

Lichen sclerosus is a chronic, debilitating condition that may progress to cause significant voiding complications. Biopsy is recommended in all patients suspected of having lichen sclerosus to rule out squamous cell carcinoma. Further research is needed to improve the prevention, understanding and treatment of this challenging condition.

Effect of human papillomavirus vaccines on vulvar, vaginal, and anal intraepithelial lesions and vulvar cancer

OBJECTIVE

Human papillomavirus (HPV) is a necessary cause for cervical cancer, and it has been associated with vulvar and vaginal cancer and vulvar (VIN) and vaginal (VaIN) and anal (AIN) intraepithelial neoplasia. We assessed the prevalence of HPV (and the types) to estimate the possible effect of a HPV vaccine on lower genital tract disease prevention.

METHODS

Two hundred fifty-eight samples of VIN, VaIN, AIN, and vulvar cancer from 241 women were included in the study. The diagnosis of surgical samples was made using published histomorphologic criteria. The DNA was extracted for HPV detection and typed using polymerase chain reaction and sequencing.

RESULTS

The analyses were performed on 210 intraepithelial neoplasia samples (VIN2/3, VaIN2/3, AIN2/3) and 48 vulvar carcinoma samples. Human papillomavirus DNA was detected in 92%, 91%, 89%, and 60% of the VIN, VaIN, AIN, and vulvar carcinoma samples, respectively. High-risk HPV types 16 or 18 were detected in 76%, 64%, 81%, and 42% of the VIN2/3, VaIN2/3, AIN, and vulvar carcinoma samples. Women with HPV-positive samples were younger than those with HPV-negative samples (46 years compared with 55 years and 51 years compared with 61 years, for the VIN2/3 and vulvar carcinoma samples, respectively). Human papillomavirus-positive vulvar carcinoma was more frequent in women aged younger than 56 years (77%), than in those aged 56 years or older (41%).

CONCLUSION

Based on the data obtained in this study, widely-implemented prophylactic HPV vaccination could make an important contribution to the reduction of the risk for cervical cancer and could also prevent about half the vulvar carcinomas in younger women and about two thirds of the intraepithelial lesions in the lower genital tract.

LEVEL OF EVIDENCE

II-3.

Human papillomavirus and vulval intra-epithelial neoplasia

The association between human papillomavirus vulval skin infection and vulval intra-epithelial neoplasia is strong. Vulval skin carcinogenesis is, however, multifactorial. Both human papillomavirus oncogenic subtype infection and p53 mutations are likely to contribute to the risk of malignant transformation of normal epithelium. The long-term cumulative risk of developing vulval squamous carcinoma following the diagnosis of high-grade vulval intra-epithelial neoplasia is thought to be approximately 6% per decade, but observational data supporting this are mostly non-population based and retrospective. Surgical treatment may reduce this risk, but the rates of recurrence and treatment-related morbidity are high. Surveillance should therefore be discussed as an alternative. New treatments being researched include photodynamic therapy, human papillomavirus vaccines, immunotherapy, immune modulators and gene therapy. The advantages of these new modalities over surgery is the potential to preserve body image and sexual functioning while targeting more generalized epithelial molecular dysfunction.

Ploidy in human papillomavirus positive and negative vulvar squamous cell carcinomas and adjacent skin lesions

To better characterize the two clinicopathologic types of squamous cell carcinoma, human papillomavirus (HPV) positive and negative, and their adjacent skin changes, we performed cytomorphometric analysis on 12 HPV-positive squamous cell carcinomas and adjacent vulvar intraepithelial neoplasia and 22 HPV-negative squamous cell carcinomas and adjacent squamous cell hyperplasia and lichen sclerosis. Our results were that 83% (10 of 12) HPV-positive carcinomas and 78% (7 of 9) adjacent vulvar intraepithelial neoplasia were aneuploid, compared with 59% (13 of 22) HPV-negative carcinomas, 6% (1 of 16) squamous cell hyperplasias and 0% (0 of 20) lichen scleroses. Seventy-five percent (9 of 12) HPV carcinomas and 78% (7 of 9) vulvar intraepithelial neoplasias showed two aneuploid peaks, but no HPV-negative carcinoma or non-neoplastic epithelial lesion showed multiple aneuploid peaks. Fifty percent of squamous cell hyperplasias (8 of 16) and lichen scleroses (10 of 20) adjacent to HPV-negative carcinomas were hypodiploid. The mean DNA indices were: 1.70 for the dominant tumor cell population of HPV-positive carcinoma, 1.64 for the dominant population of vulvar intraepithelial intraepithelial neoplasia, 1.41 for HPV-negative carcinoma, 0.85 for squamous cell hyperplasia and 0.83 for lichen sclerosis. In conclusion, the higher rate of aneuploidy, higher mean DNA index, and presence of multiploid peaks in HPV-positive carcinomas and adjacent vulvar intraepithelial neoplasias compared with the lower rate of aneuploidy, lower mean DNA index, absence of multiploid peaks of HPV-negative carcinomas and tendency to hypodiploidy in squamous cell hyperplasia and lichen sclerosis support the hypothesis that there are two clinicopathologic types of vulvar carcinoma, with different pathogenetic mechanisms. The similarities in ploidy findings between vulvar HPV-positive carcinomas and vulvar intraepithelial neoplasia and those previously published for cervical carcinoma and cervical intraepithelial neoplasia support the view that these two cancers are analogous and have similar pathogenetic mechanisms. The frequent finding of hypodiploidy in squamous cell hyperplasia and lichen sclerosis next to HPV-negative carcinomas requires further investigation of the molecular pathogenesis of this cancer type.

Does lichen sclerosus play a central role in the pathogenesis of human papillomavirus negative vulvar squamous cell carcinoma? The itch-scratch-lichen sclerosus hypothesis

In the past decade, two types of vulvar squamous cell carcinoma (SCC) have been delineated, Human papillomavirus (HPV) positive and negative. Clinicopathologic, virologic, cytomorphometric, and genetic differences support the view that these two types of carcinoma are fundamentally different and that HPV-negative carcinoma is not simply carcinoma where viral DNA has not been able to be identified. The traditional view of HPV-negative carcinoma is that it is caused by chronic tissue damage from itching and scratching. However, itching and scratching alone do not explain the close association of carcinoma with lichen sclerosus, nor the absence of such an association with other itchy conditions such as eczema or psoriasis. These observations point to a role for lichen sclerosus in the pathogenesis of vulvar carcinoma. Most observations about the etiology of lichen sclerosus can be grouped into its immunogenetic or genital predisposition, or the Köbner phenomenon. In the itch-scratch-lichen sclerosus hypothesis, lichen sclerosus is postulated to occur as a Köbner phenomenon in women with the susceptible immunophenotype who scratch because of genital irritants such as urine, vaginal secretions and smegma, and psychological factors. Lichen sclerosus, itself a very itchy condition, contributes to a vicious cycle of itching and scratching which leads to superimposed lichen simplex chronicus, squamous cell hyperplasia, and ultimately carcinoma. The itch-scratch-lichen sclerosus hypothesis reconciles the traditional itch-scratch hypothesis with the strong clinicopathologic association of lichen sclerosus with carcinoma.

Vulvar lichen sclerosus and squamous cell carcinoma: a cohort, case control, and investigational study with historical perspective; implications for chronic inflammation and sclerosis in the development of neoplasia

The histological changes of lichen sclerosus (LS) are frequently found in association with vulvar squamous cell carcinoma (SCC). The importance of chronic inflammation and scarring in oncogenesis is well recognized. Thirty-two patients with symptomatic vulvar LS and 60 with vulvar SCC were studied. Paraffin sections of vulvar LS, and three controls groups (acute scars, normal vulva, and vulvar lichen simplex chronicus [LSC]) were investigated with a panel of seven tissue markers and for DNA content in areas without vulvar intraepithelial neoplasia (VIN). All published cases to date of vulvar LS associated with SCC were reviewed. Of the cohort of symptomatic vulvar LS patients (mean/median age, 60 years), 9% developed VIN lesions and 21% invasive SCC; symptomatic LS preceded the carcinoma by a mean of 4 years (range, 1 to 23 years). Second and third primary tumors developed in three of these patients. Of the series of 60 patients presenting with vulvar SCCa, the clinical setting and histological features of SCCs associated with LS were significantly distinctive compared with SCCas without LS: SCCs associated with LS occurred in an older age-group (74 v 65 years; P = .01), were located on the clitoris (41% v 5%; P = .003), were of conventional SCCa type (85% v 57%; P = .02), were associated with a prominent fibromyxoid stromal response (46% v 10%; P = .004), were not associated with VIN 3 (SCC in situ) (5% v 67%; P = .02) and diffusely expressed tumor suppressor gene product p53 (43% v 19%; P = .01) and cytokine TGF-beta (33% v 9%; P = .05). The epidermis of vulvar LS was similar to that of acute scars and differed significantly compared with normal vulva with respect to keratinocytic expression of markers to keratin AE 1, involucrin and filaggrin, epidermal thickness (0.13 mm [LS] v 0.05 mm [normal]; P < .03), and proliferative index by PCNA and Mib-1 labeling (53/60 [LS] v 15/19 [normal] per 200 basal cells [bc]; P < .003). Vulvar LS showed significantly higher expression of p53 than all three control groups (80 [LS] v 3 [normal]/44 [acute scar]/28 [LSC] per 200 bc; P < .008), and aneuploidy (33% v diploid controls) in the absence of VIN. Comparing LS with and without associated SCCa found significant increases in age of patients (74 v 66 years; P = .001), and DNA aneuploidy (52% v 11%; P = .0001) and no differences in epidermal thickness, sclerotic thickness, proliferative index, or p53 expression. However, those cases of LS with an aneuploid DNA content showed significantly elevated p53 expression (88 v 60/200 bc; P = .01) and epidermal thickness (0.16 v 0.11 mm; P = .005) compared with LS with a diploid DNA content. Review of published cases supports an association between LS and vulvar SCC. The phenomenon of chronic inflammation and scarring giving rise to carcinoma has been well documented. Vulvar lichen sclerosus (LS) is an inflammatory dermatosis characterized by clinicopathologic persistence and hypocellular fibrosis (sclerosis). A subset of vulvar SCCs is significantly associated with the presence of LS and diffusely express the p53 gene product. Keratinocytes affected by LS show a proliferative phenotype and can exhibit markers of neoplastic progression such as increased p53 expression and DNA aneuploidy. As a chronic scarring inflammatory dermatosis, vulvar LS could act as both "initiator and promoter" of carcinogenesis, explaining the frequent coexistence of these diseases. Because keratinocytes of LS significantly express tumor suppressor gene p53 protein, the p53 gene may be involved early in this proposed pathway of carcinogenesis.

Ki67 expression in lichen sclerosus of vulva in patients with and without associated squamous cell carcinoma

AIMS

To investigate the malignant potential of lichen sclerosus, a study using the cell proliferation marker Ki67 comparing lichen sclerosus with and without associated squamous cell carcinoma was performed.

METHODS AND RESULTS

Formalin-fixed, paraffin-embedded slides of 13 cases of lichen sclerosus with associated carcinoma, and 31 cases without associated carcinoma, including 16 random cases, seven with epidermal thickening and eight with epidermal thinning, were examined by the immunoperoxidase technique for Ki67, a cell proliferation marker. Ki67 reactivity was mostly seen in the basal and parabasal cells in both groups of lichen sclerosus and this pattern was similar to normal skin, squamous cell hyperplasia and analogous to that of one form of squamous cell carcinoma. There was a mean of 50 Ki67 positive cells per 100 basal cells in lichen sclerosus with associated squamous cell carcinoma; however, in squamous cell hyperplasia adjacent to carcinoma this rose to 90 Ki67 positive cells per 100 basal cells. In lichen sclerosus without associated carcinoma, the random cases had a count of 53 per 100 basal cells, those with epidermal thickening 53 and those with thinning 42. Non-genital normal skin had a count of 71 per 100 basal cells.

CONCLUSION

The lack of qualitative differences of Ki67 expression in normal skin, in lichen sclerosus with and without carcinoma, in squamous cell hyperplasia and in one form of squamous cell carcinoma indicates that these conditions share a common localized pattern of cell proliferation and does not support or deny the malignant potential of lichen sclerosus. The higher Ki67 count in squamous cell hyperplasia adjacent to carcinoma could indicate premalignancy or a reaction to the carcinoma. In patients without carcinoma, the higher Ki67 count in thickened lichen sclerosus compared to thinned suggests that some or all of the cases of thickened lichen sclerosus were lichen sclerosus with squamous cell hyperplasia or that lichen simplex chronicus superimposed on lichen sclerosus has a higher Ki67 expression or that the distinction between squamous cell hyperplasia and lichen simplex chronicus is only one of terminology.

Vulval lichen planus

Lichen planus of the vulva can occur as part of more widespread disease or in isolation. Its cause is unknown, but it can become chronic and has a potential for malignant change. It may present a difficult management problem and several treatments have been used with variable success. This review focuses on the problem of vulval lichen planus, and highlights some of the treatments and management strategies that have been used to date.

Papillomavirus infections--a major cause of human cancers

The papillomavirus family represents a remarkably heterogeneous group of viruses. At present, 77 distinct genotypes have been identified in humans and partial sequences have been obtained from more than 30 putative novel genotypes. Geographic differences in base composition of individual genotypes are generally small and suggest a low mutation rate and thus an ancient origin of today's prototypes. The relatively small size of the genome permitted an analysis of individual gene functions and of interactions of viral proteins with host cell components. Proliferating cells contain the viral genome in a latent form, large scale viral DNA replication, as well as translation and functional activity of late viral proteins, and viral particle assembly are restricted to differentiating layers of skin and mucosa. In humans papillomavirus infections cause a variety of benign proliferations: warts, epithelial cysts, intraepithelial neoplasias, anogenital, oro-laryngeal and -pharyngeal papillomas, keratoacanthomas and other types of hyperkeratoses. Their involvement in the etiology of some major human cancers is of particular interest: specific types (HPV 16, 18 and several others) have been identified as causative agents of at least 90% of cancers of the cervix and are also linked to more than 50% of other anogenital cancers. These HPV types are considered as 'high risk' infections. Their E6/E7 oncoproteins stimulate cell proliferation by activating cyclins E and A, and interfere with the functions of the cellular proteins RB and p53. The latter interaction appears to be responsible for their mutagenic and aneuploidizing activity as an underlying principle for the progression of these HPV-containing lesions and the role of high risk HPV types as solitary carcinogens. In non-transformed human keratinocytes transcription and function of viral oncoproteins is controlled by intercellular and intracellular signalling cascades, their interruption emerges as a precondition for immortalization and malignant growth. Recently, novel and known HPV types have also been identified in a high percentage of non-melanoma skin cancers (basal and squamous cell carcinomas). Similar to observations in patients with a rare hereditary condition, epidermodysplasia verruciformis, characterized by an extensive verrucosis and development of skin cancer, basal and squamous cell carcinomas develop preferentially in light-exposed sites. This could suggest an interaction between a physical carcinogen (UV-part of the sunlight) and a 'low risk' (non-mutagenic) papillomavirus infection. Reports on the presence of HPV infections in cancers of the oral cavity, the larynx, and the esophagus further emphasize the importance of this virus group as proven and suspected human carcinogens.

Vulvar squamous cell carcinoma

Squamous cell carcinoma of the vulva is a rare disease, mainly seen in elderly women. Risk factors are advanced age, an immunocompromised status, longstanding vulvar dystrophy, VIN, a history of vulvar human papillomavirus infection, and a history of cervical cancer. Vulvar cancer should be considered as a skin tumor and detection is possible in an early stage. However, because of patients' and doctors' delay, one in three vulvar cancers is not treated before an advanced stage. The tumor metastasizes mainly lymphatogenic. Spread starts in the inguinal lymph nodes. In the middle of this century, standard treatment, consisting of an en bloc dissection of the vulva and inguinal lymph nodes has been developed and applied. As a result, considerably improved survival rates were achieved: up to 90% 5-year survival rates for patients without lymph node metastases. However, complication rates were high. In recent years, a more individualized approach has replaced standard treatment. Surgical treatment now depends on the localization, size and extent of the tumor, and is followed or preceded by radiotherapy in selected cases. The role of chemotherapy in advanced disease is currently being studied in several referral centers. The most important success in the treatment of vulvar cancer in recent years is the maintenance of high survival rates despite considerably less extensive surgical treatment, resulting in lower complications rates. An important challenge for the near future will be the improvement of the management of advanced disease. However, an even more difficult issue may be the prevention of such large lesions. The reduction of treatment delays requires a considerable effort in education of both health care workers and the general public.

Vulvar cancer: the Cinderella of gynaecological oncology

Cancer of the vulva is a rare malignancy that increases progressively with age. The age-standardized incidence averages between 1 and 2 per 100,000 women in Western countries. The majority (80-90%) are squamous cell carcinomas, melanoma and adenocarcinoma each accounting for about 5% of cases. Internationally, the incidence of vulvar cancer varies more than 30-fold, the highest rates being seen in populations of Portuguese South America. In many populations the incidence appears to be stable but there is some evidence that the incidence of in situ carcinoma is increasing in the United States of America. Epidemiological studies have identified sexual factors, particularly human papilloma virus (HPV) infection, as increasing risk. Smoking also increases risk by interacting synergistically with HPV infection and genital warts. The aetiologies of vulvar intraepithelial neoplasia (VIN)3/in situ disease and invasive cancer appear to differ. VIN does not automatically progress to invasive cancer and is strongly associated with HPV infection. Many older women with invasive vulvar cancer do not have evidence of HPV and do not smoke. More research is needed on the cause of vulvar carcinoma in this group. Treatment has become more conservative over the years and this has reduced morbidity and probably mortality. Although FIGO data do not show much by way of improvement in survival, data from population-based cancer registries have shown definite increases in survival (5-year survival proportions in excess of 80%, when age and Stage have been taken into account). Improvement is particularly related to the preponderance of early stage disease.

Epidemiology and etiology of squamous cell carcinoma of the vulva

A literature review dealing with epidemiological and etiologic aspects of squamous cell carcinoma of the vulva is presented. It is a rare disease; the incidence is 1-2 per 100,000 women per year. Among women more than 75 years of age, the incidence is at least ten times higher. The cause of vulvar carcinoma is not known. In contrast to what has been stated for many years, in recent case-control studies no evidence was found that diabetes mellitus, obesity, vascular diseases, nulliparity, an early menopause and syphilis are risk factors for developing a vulvar carcinoma. The factors that play a role in the etiology of vulvar carcinoma are: vulvar dystrophy, a history of genital HPV-infection, a history of cervical neoplasia, advanced age, smoking and a compromised immunity. Usually, for the development of a vulvar carcinoma, more than one of the above mentioned factors have to be present.

Human papillomavirus infection in vulvar lesions of lichen sclerosus et atrophicus

Human papillomaviruses (HPV) types 6, 11, 16 and 18 infections were investigated in 18 vulvar lesions of lichen sclerosus et atrophicus (LSA) using in situ DNA hybridization and polymerase chain reaction (PCR) on formalin-fixed paraffin-embedded specimens. Four out of 18 specimens were found to be infected with HPV type 16 using the PCR technique. Interestingly, three of these four patients were in a premenopausal state. This difference proved to be the only distinguishing feature in a comparison of HPV type 16-infected patients with non-infected patients. In situ hybridization revealed no positive result in any case and PCR demonstrated no HPV-DNA type 6, 11 or 18. Patients with HPV type 16-infected lesions may be regarded as at risk of developing vulvar cancer. Therefore, long-term follow-up of this subgroup is particularly important.

Vulvar squamous cell carcinoma and papillomaviruses: two separate entities?

Vulvar squamous precancers (vulvar intraepithelial neoplasia) are associated with sexual factors, cigarette smoking, and human papillomaviruses. However, epidemiologic studies of invasive carcinoma of the vulva have produced conflicting evidence for these associations, in part because of a strong association with vulvar inflammatory disease (dystrophies) in older women. We analyzed a series of 42 vulvar invasive carcinomas for papillomavirus nucleic acids by deoxyribonucleic acid-deoxyribonucleic acid in situ hybridization and correlated their presence with age, smoking history, and morphologic type. The carcinomas were divided into well-differentiated, moderately and poorly differentiated, and intraepithelial-like growth patterns, the latter composed of nests of invasive neoplastic epithelium with preserved cell polarity, similar to intraepithelial disease. Of the lesions studied, 28% were human papillomavirus deoxyribonucleic acid-positive. Intraepithelial-like neoplasms segregated in women with a younger mean age (64 versus 73 years) than that of women with conventional squamous cell carcinoma and they more frequently had a history of cigarette smoking (88% versus 28%). Moreover, intraepithelial-like lesions contained human papillomavirus nucleic acids more frequently (67% versus 13%) when analyzed by in situ hybridization. These observations confirm the diverse nature of vulvar squamous cell carcinoma and may explain in part why conflicting results are obtained from studies investigating the role of sexual and viral factors in the genesis of vulvar cancer. They suggest that many invasive vulvar cancers may not be linked to papillomaviruses.

Human papillomavirus type 16 in vulvar carcinoma, vulvar intraepithelial neoplasia, and associated cervical neoplasia

Vulvar intraepithelial neoplasia (VIN) is becoming more widespread and the patients are becoming still younger. Although progression to invasive vulvar carcinoma is uncommon, local recurrences are frequent and about one-quarter of the patients have multicentric genital disease. The aim of the present study was to search for a possible significant association of human papillomavirus (HPV) infection with vulvar carcinoma, recurrences, and multicentric disease. We used the polymerase chain reaction to examine vulvar and cervical biopsies from 43 patients with vulvar neoplasia for HPV type 16, which is the subtype most often detected in genital malignant or premalignant lesions. HPV 16 DNA sequences were found in 14 of 24 (58%) vulvar squamous carcinomas and in 15 of 19 (79%) VIN lesions. Nine patients (21%) had associated cervical neoplasia and six of these harbored HPV 16 in both lesions. Patients with recurrent intraepithelial neoplasia had a significantly higher incidence of HPV 16-positive lesions. No association was found with regard to the occurrence of multicentric disease or risk of malignant progression.

Pathobiology of papillomavirus-related cervical diseases: prospects for immunodiagnosis

In recent years, the relationship between human papillomaviruses (HPV) and genital neoplasia has been explored intensively, and a molecular basis for the role of HPV in the genesis of these diseases has been convincingly demonstrated. These findings have provided justification for efforts to apply this molecular information to the early detection and possible prevention of HPV-related neoplasia. The technology of detecting viral nucleic acids in genital fluids brought with it initial hopes that it would serve to identify women at risk for having or developing precancers or cancers of the cervix. Subsequent studies, however, have demonstrated limitations of the technology for predicting future disease. Recently, molecular immunology has complemented these prior efforts, with the intent to identify serological indices of exposure to HPV and perhaps delineate individuals at risk. The molecular basis for this approach, its limitations, and future prospects for immunodiagnosis are the subject of this review.