Sexually transmitted papillomavirus infections: epidemiology pathogenesis, clinic, morphology, important differential diagnostic aspects, current diagnostic and treatment options

[Skin manifestations of the external male genitals]

The urological examination includes the inspection of the external male genitals. Harmless normal variants, such as heterotopic sebaceous glands and pearly penile papules must be differentiated from malignant and infectious manifestations. Lichen sclerosus et atrophicus is a frequent connective tissue disease that can lead to functional impairments and an associated high level of suffering for those affected. Both conservative and invasive treatment options are available. Sexually transmitted diseases, such as syphilis, are gaining increasing importance in routine clinical and daily practice due to the increasing incidence in recent years. An early diagnosis and treatment of malignant neoplasms, such as Queyrat's erythroplasia can be carried out by routine inspection of the genital skin.

Wide Spectrum Analysis of Human Papillomavirus Genotypes in External Anogenital Warts

External anogenital warts (EGW) are primarily associated with the low-risk human papillomavirus (HPV) genotypes 6 and 11, though coinfection with other low-risk and oncogenic high-risk HPV genotypes also occurs. Although there have been many studies on HPV-associated disease, the prevalence of HPV genotypes associated with EGW is not well characterized. The objective of our retrospective study was to determine the prevalence of HPV genotypes among patients diagnosed with EGW in the south-west of Hungary. Archived formalin-fixed paraffin-embedded tissues from 94 patients were processed in our study. HPV genotypes were determined, applying HPV Direct Flow CHIP test. The overall prevalence of HPV DNA in the EGW samples was 100%, yielding 131 infections among the 94 samples. Of these cases, 72.3% were mono while 27.6% were multi-infections. Out of the 131 infections, the cumulative prevalence of HPV 6 and 11 was 71%. A total of 98.9% of the samples were carrying at least one of these genotypes, while 19.1% of the cases occurred with at least one high-risk genotype. Data from our study could provide invaluable information concerning the prevalence of HPV types among patients with EGW, enabling improved assessment of the actual and future efficacy of vaccination programs, vaccine development, and forecast changes in infection patterns.

Perianal warts as a risk marker for anal high-risk-human papillomavirus (HPV) detection and HPV-associated diseases

BACKGROUND

Genital warts are the most common sexually transmitted infection (STI) and are caused by human papillomavirus (HPV). Persistent anal infection by oncogenic genotypes of HPV is a determinant for anal cancer. Currently, anal cancer screening is not widely implemented.

OBJECTIVES

Our aim is to evaluate the role of perianal warts as a risk marker for anal high-risk (HR) HPV detection and anal dysplasia.

METHODS

In this observational, retrospective, cohort study of attendees of a STI outpatient clinic between January 2010 and June 2018, all human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) who performed anal cytology, anal HPV DNA detection and anoscopy were included. A comparison was made between patients with and without perianal warts. Primary endpoint: proportion of patients with an abnormal anal cytology. Secondary endpoints: proportion of patients with (i) anal HR-HPV detection; (ii) anal HPV 16 detection; (iii) abnormal anal biopsy; and (iv) anal high-grade squamous intraepithelial lesion (HSIL).

RESULTS

Seventy-eight individuals were included: 39 with perianal warts and 39 without perianal warts. Subjects with perianal warts more frequently had an abnormal anal cytology (71.8% vs. 38.5%; P = 0.003). This group also had a higher rate of anal HPV 16 detection (38.5% vs. 12.8%; P = 0.01). No differences were detected in the proportion of patients with anal HR-HPV detection, with an abnormal anal biopsy or with anal HSIL. Perianal warts was an independent risk factor for an abnormal anal cytology (OR: 7.2) and for anal HPV 16 detection (OR: 6.7).

CONCLUSION

Given the high risk of anal cancer in HIV-positive MSM, effective screening strategies are greatly needed. This study suggests that the presence of perianal warts is a suitable risk marker for anal HPV 16 detection and anal dysplasia.

Translation of Cryobiological Techniques to Socially Economically Deprived Populations—Part 2: Cryosurgery

Cold and cryogenic temperatures are used for treating cancer and other pathological conditions in various fields of medicine. Cryosurgery, which resides at the interface of medicine and engineering, has attracted the interest of engineers, scientists, and medical doctors. Recently, particularly since the end of the 1980s, technological developments in cryotherapy equipment and enormous advances in imaging techniques, such as computed tomography and ultrasonography, have allowed surgeons and interventional radiologists to precisely guide cryogenic probes into tumors while avoiding damage to surrounding tissues. Extensive studies have allowed us to conclude that the use of cryogenics facilitates the successful treatment of solid tumors in various organs such as lung, liver, bones, kidneys, prostate, etc. Its simplicity of use, effectiveness, low cost, and limited demand on hospital infrastructure and personnel have made cryosurgery particularly suitable for the treatment of patients of socio-economically deprived populations.

Burden of genital warts in Peru: an observational study

Genital warts (GW) are mucosal or skin lesions caused by sexual transmission of human papillomavirus (HPV). This study estimates the frequency of GW cases in physicians' clinics and physicians' usual practices of GW referral and diagnosis in Peru. Participants in this study were a convenience sample of 100 physicians in five specialties: primary care (17), gynecology (37), urology (10), dermatology (31), and infectious diseases (5). Physicians completed a survey and daily log of all patients aged 18-60 years seen over ten days in their offices located in Peru. The survey recorded GW referral patterns and the daily log recorded patient demographic information and GW diagnosis. Among 12,058 patients, the annual GW prevalence (95% confidence interval [CI]) was 2.28% (2.02-2.56) and cumulative incidence (95% CI) was 1.60% (1.38-1.84). Physicians reported that most GW patients were direct consult (73.5% of male and 67.9% of females) and physicians treated most GW patients themselves (73.4% of males and 76.7% of females). As reported, the most common reasons for referring were 'serious cases requiring more specialized treatment' (73.2% of male and 72.2% of female) and 'lack of resources to treat' (26.8% of male and 27.8% of female). We conclude that GW cases are commonly seen by physicians in Peru.

[Urethral condylomata acuminata]

Condyloma acuminata are the most frequent cause of infections in the anal genital area. They are caused by the human papilloma virus (HPV). Risk factors are early onset of sexual activity, multiple sexual partners, a history of sexually transmitted disease, and immunosuppression. The urethra is afflicted in only 20% of cases; of these, 80% of the warts are at the meatus and 20% in the proximal urethra. This article reports on two cases with condyloma acuminata affection of the total urethra. The current diagnostic, different treatment modalities, and prophylaxis are reviewed.

Carcinoma Cuniculatum in Course of Etanercept: Blocking Autoimmunity but Propagation of Carcinogenesis?

Carcinoma cuniculatum (CC) or verrucous squamous cell carcinoma is a rare variant of squamous cell carcinoma with low incidence of metastasis. It mainly affects men during the fifth-sixth decade of life, arising mostly on the weight-bearing surface of the foot, but it can also be found in other body areas. The favorable effects on the psoriatic, rheumatoid, juvenile polyarthritis as well as the ankylosing spondylitis after the application of Tumour Necrosis Factor (TNF)-alpha inhibitors, like etanercept, presume the availability of similarity between the etiopathogenetic mechanisms which are responsible for the generation of the inflammatory cascade. According to the latest studies, the sensitivity of the patients to TNF-alpha inhibitors could be genetically determined and may also be due to certain genetic polymorphisms of the NLP3 and CARD8 zones of the inflammasome. The blocking of the inflammatory reaction within the borderlines of the psoriatic arthritis could also be accepted as something of a “double edged sword”. There is a growing volume of literary data which informs us of the clinical manifestation, not only of skin, but also of other types of tumors after the application of TNF-alpha inhibitors. This inevitably generates the hypothesis that within a certain group of patients the TNF-alpha inhibitors have some additional, and currently obscure, effects on presumably key regulatory proteins of the so-called extrinsic apoptotic pathway. Other proteins of the human inflammasome could be also implicated in the regulation of the programmed cell death and the carcinogenesis - there are speculations, that the adapter protein, ASC/TMS1, could be one of these. The present study describes the case of a patient who developed a rare form of skin tumor - epithelioma cuniculatum - whilst undergoing etanercept therapy for psoriatic arthritis. Under discussion are the possible critical connections in the complex regulatory “networks” of the inflammatory processes, the programmed cell death (apoptosis) and the carcinogenesis which, in the near or distant future, could become the objects of a targeted therapy.

Conservative treatment of penile carcinoma - a retrospective study of 10 years

Conservative treatment of penile squamous cell carcinoma has been advocated as a method of choice for tumours at early stages. Thirty patients with a mean age of 63.2 years were treated with CO2 laser ablation, radical local excision with preputial flap, direct closure or healing by secondary intention, circumcision alone or associated with CO2 laser and topical imiquimod. Sixteen patients had local recurrence. Partial penectomy was necessary in 3 patients. Conservative treatments of penile squamous cell carcinoma in early stages (< T1a) do not seem to compromise the survival rate, so it may be advisable for this subset of patients.

Buschke -Loewenstein tumor: identification of HPV type 6 and 11

The authors report a case of exuberant giant condyloma acuminatum of Buschke-Loewenstein in a male patient, slow-growing, progressive and with locally destructive behavior in the inguinal, body of the penis, scrotum, perineal and perianal regions. After surgery he showed no signs of recurrence in 20 months of follow-up. The identification of HPV types 6 and 11 was performed using in situ hybridization.

[Urethral condyloma in a patient with neurogenic bladder dysfunction: a therapeutic challenge]

Urethral condyloma is a therapeutic challenge. This article reports the case of a patient with spinal cord injury with the incidental finding of a massive spread of urethral condyloma. After removal of the condyloma with biopsy forceps neither recurrence of the condyloma nor a urethral stricture occurred. In patients where intermittent catheterization is performed, condyloma may be dispersed into the bladder, therefore, prompt endoscopic removal is crucial. As condyloma frequently recurs even after complete removal regular controls are mandatory.

Inverted papilloma (Schneiderian papilloma) with involvement of the oral cavity: report of an unusual case

Inverted Schneiderian papilloma (ISP) is a neoplasm of epithelial lining origin which arises in the respiratory mucosa that lines the nasal cavity and paranasal sinuses. The inverted Schneiderian papilloma frequently appears as a unilateral lesion in the nasal septum and extends secondarily to the nasal and paranasal sinuses. This paper reports an unusual case of this pathology with involvement of the oral cavity in a 61-year-old white man. Clinical evaluation revealed a vegetating mass in the alveolar ridge of the right maxilla that had been present for approximately 4 months. After radiographic evaluation, involvement of the maxillary sinus was detected. Microscopic evaluation, in situ hybridization and immunohistochemical analysis of the specimen led to a diagnosis of ISP moderate dysplasia associated with HPV infection.

Treatment of perianal condyloma acuminate with topical ALA-PDT combined with curettage: outcome and safety

OBJECTIVE

The purpose of this study was to evaluate the treatment outcome and safety of topical photodynamic therapy (PDT) with aminolevulinic acid (5-ALA) combined with surgical curettage for perianal condyloma acuminata.

BACKGROUND DATA

Condyloma acuminata is the most common sexually transmitted disease, with a high relapse rate, especially in the perianal area. The outcomes of many treatment methods for perianal genital warts are not satisfactory.

METHODS

In this study, 40 cases of perianal condyloma acuminata were treated with topical aminolevulinic acid photodynamic therapy (ALA-PDT) combined with curettage. First, the warts were removed with the patient under local anesthesia. The depth of the ablation and curettage reached the dermal layer. Then, the first session of PDT was performed after 2 days. Ten percent 5-ALA cream was applied to lesional skin with occlusive dressing for a 3-h incubation period and the lesions of warts were irradiated for 10 min by using a 635-nm laser beam of 177 mW/cm(2) intensity. The ALA-PDT was repeated after 1 and 3 weeks. Follow-up evaluation was performed at our outpatient clinic at 1 and 3 months after completion of therapy. Before treatment and at each follow-up visit, the lesions were photographed; the treatment outcome was evaluated as recurrence rate, and patient satisfaction was surveyed.

RESULTS

After three PDT sessions following surgical curettage, all 40 patients were cured and there was no recurrence at 1 month off treatment. At 3 months off treatment, six cases relapsed, corresponding to a recurrent rate of 15%. The satisfaction rate of patients was 100% at 1 month and 95% at 3 months after treatment.

CONCLUSIONS

Combination of surgical curettage and topical PDT has been proven to be a safe and effective procedure, and may offer a wide clinical application for the treatment of perianal condyloma acuminata.

Treatment of human papillomavirus in childhood with imiquimod 5% cream

In children, lesions caused by the human papillomavirus (HPV) constitute a significant epidemiological issue and a therapeutic dilemma, particularly in the case of anogenital warts. The treatment of anogenital warts in children is a challenge, since standard treatments are generally painful and require the patient to be anesthetized. Imiquimod, a topical immune response modifier, constitutes an alternative therapeutic agent for the treatment of HPV. The present report describes four cases in which treatment with topically applied imiquimod 5% cream was implemented with successful results.