Erythroplasia of queyrat: coinfection with cutaneous carcinogenic human papillomavirus type 8 and genital papillomaviruses in a carcinoma in situ

Urologic dermatology: a comprehensive foray into the noninfectious etiologies of balanitis

Balanitis is classically defined as inflammation of the glans penis, often also encompassing the prepuce (balanoposthitis). Several investigations have found that a sizable proportion of urology clinic visits are due to balanitis or related complaints. Balanitis can have numerous complications, including severe pain, urethral stenosis, phimosis, sexual dysfunction, and if untreated, malignancy. Unfortunately, there is no recent or comprehensive review that describes the various etiologies, clinical workup, and treatments for balanitis. Herein this review, we attempt to provide the reader with a complete and updated guide to balanitis in an attempt to improve clinical outcomes.

Viral Venereal Diseases of the Skin

Viral venereal diseases remain difficult to treat. Human papilloma virus (HPV) and herpes simplex virus (HSV) are two common viral venereal diseases. HPV infections are characterized by anogenital warts and less commonly by premalignant or malignant lesions. HSV infections classically present as grouped vesicles on an erythematous base with associated burning or pain; however, immunosuppressed patients may have atypical presentations with nodular or ulcerative lesions. This review discusses the epidemiology, diagnosis, and management of anogenital HPV and HSV infections with an emphasis on treatment modalities for the practicing dermatologist. Diagnosis of these diseases typically relies on clinical assessment, although multiple diagnostic techniques can be utilized and are recommended when diagnosis is uncertain or evaluating an individual with increased risk of malignancy. Management of HPV and HSV infections involves appropriate counseling, screening, and multiple treatment techniques. Particularly for HPV infections, a practitioner may need to use a combination of techniques to achieve the desired outcome.

The prevalence of human leucocyte antigen and human papillomavirus DNA in penile intraepithelial neoplasia in England 2011-2012

BACKGROUND

The pathogenesis of penile intraepithelial neoplasia (PeIN) is unclear but human papillomavirus (HPV) infection and polymorphisms in human leucocyte antigen (HLA).

OBJECTIVES

To examine the prevalence of HPV DNA and HLA in PeIN.

METHODS

Adult Caucasian men with a clinical and histological diagnosis of PeIN, that is, Bowenoid papulosis (BP), Bowen's disease of penis (BDP) and erythroplasia of Queyrat (EQ) were selected and phenotyped from the clinical records. DNA was extracted from blood and paraffin-embedded sections for HLA and HPV typing, respectively. Human leucocyte antigen allele frequencies were compared with those derived from the UK-based Caucasian population.

RESULTS

Seventy-two cases of PeIN (20 BP, 34 BDP and 18 EQ) were studied. Human papillomavirus DNA was identified in 65/72 (90.2%) PeIN; Alphapapillomavirus types were detected in 62/72 (85%) followed by Betapapillomavirus types in 9/72 (12.5%) and cutaneous types in 7/72 (9.7%); HPV16 was the most prevalent genotype at 35/72 (48.6%) followed by HPV33 at 7/72 (9.7%); multiple infections were seen in 18/72 (25%) PeIN. HLA-C*15 (Bonferroni corrected p = 0.049) confers susceptibility to PeIN, whereas HLA-DQA1*01 (corrected p = 0.02) protects against PeIN. HPV16-associated PeIN cases showed no statistically significant association with HLA genotype after multiple corrections.

CONCLUSION

Human papillomavirus is involved in the pathogenesis of PeIN. Immunogenotype may play a role in the pathogenesis of PeIN.

Progress on Management of Penile Cancer in 2020

OPINION STATEMENT

Management of penile cancer represents a challenge to urologic oncologists due to the disease's rarity and sparse data in the literature. Squamous cell carcinoma represents the most common histologic subtype of penile cancer. Penile cancer has a disastrous effect on patients' psychological and physical health. Penile cancer accounts for approximately 1% of cancer deaths in the USA annually. However, in recent years, the management of penile cancer has achieved marked progress in both diagnostic and therapeutic approaches with the intent to avoid radical surgeries. The traditional total penile amputation has been replaced by penile preserving procedures in many patients. Nowadays, total penile amputation (total penectomy) is preserved only for patients with proximal lesions. The introduction of minimally invasive surgical techniques in the management of penile cancer-infiltrated lymph nodes has been reported. Given the dismal prognosis with conventional cytotoxic therapies, new systemic therapies have been investigated in patients with locally advanced or metastatic penile cancer. Multiple studies have shown promising outcomes. All these efforts have resulted in a remarkable improvement in patient quality of life. The objectives of our review are to update clinicians on the advances in the management of penile cancer and to summarize the recent guidelines and recommendations.

Human papillomavirus vaccination and prevention of intraepithelial neoplasia and penile cancer: review article

PURPOSE OF REVIEW

The objective of the current article is to promote a literature revision of the relationship between the prevention of intraepithelial neoplasms (PeIN) and invasive penile cancer, and human papillomavirus (HPV) vaccination, aiming to enumerate the pros and cons of immunization.

RECENT FINDINGS

The immunization against the HPV is sufficiently safe and many countries have incorporated the vaccine to their immunization calendar. Compared with men, the sampling size and the evidence quality of scientific researches among the female population are more robust. Some randomized and nonrandomized studies suggest that vaccination reduces the incidence of genital warts and no PeIN and penile cancer cases were developed in the vaccinal group. However, 70% of patients can evolve with the neoplasia despite having been immunized and even among HPV infected patients, only 1% will develop cancer.

SUMMARY

The studies about vaccination against HPV and prevention on penile cancer are conflicting and the main academic urology societies still have not incorporated vaccination of men in their guidelines. Future studies are necessary to confirm the efficiency and cost-benefit of the vaccine in men to prevent intraepithelial neoplasms and invasive penile cancer.

Human Papillomavirus Infection of the Skin

CONTEXT

- Human papillomavirus is implicated in the pathogenesis of benign and malignant neoplasms of the skin.

OBJECTIVE

- To review the role of human papillomavirus in the development of malignancies and their precursor lesions in skin.

DATA SOURCES

- The study comprised a review of the literature.

CONCLUSIONS

- The use of low-grade squamous intraepithelial lesion and high-grade squamous intraepithelial lesion terminology brings order and simplicity to these lesions, correlates with the current understanding of the biology of human papillomavirus infections, and helps to promote accurate diagnosis of and appropriate treatment for these lesions.

Premalignant male genital dermatoses

The spectrum of conditions affecting the penile skin is varied and ranges from simple, benign dermatoses to premalignant and malignant conditions. Anogenital malignancies and premalignancies are an important personal/public health problem due to their effects on individuals' physical, mental, and sexual health. Furthermore, due to their etiological association with human papillomavirus infection, anogenital malignancies, and premalignancies constitute an immense public health burden. Bowen's disease, Bowenoid papulosis, and erythroplasia of Queyrat are the most widely seen premalignancies of anogenital region and are all forms of squamous intraepithelial neoplasia. Histopathologically, these conditions share identical histologic features of squamous cell carcinoma in situ, but their clinical features differ. In this article, we explore the common precancerous states that can lead to penile carcinoma.

Prevalence of human papillomavirus DNA and p16INK4a in penile cancer and penile intraepithelial neoplasia: a systematic review and meta-analysis

BACKGROUND

Although previous meta-analyses have examined human papillomavirus (HPV) DNA prevalence in penile cancer, none, to our knowledge, have assessed pooled HPV DNA prevalence in penile intraepithelial neoplasia or p16^INK4a percent positivity in penile cancer and penile intraepithelial neoplasia. Therefore, we aimed to examine the prevalence of HPV DNA and p16^INK4a positivity in penile cancer and penile intraepithelial neoplasia worldwide.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Embase, and the Cochrane Library until July 24, 2017, for English-language articles published from Jan 1, 1986, onwards reporting the prevalence of HPV DNA and p16^INK4a positivity, either alone or in combination, in at least five cases of penile cancer or penile intraepithelial neoplasia. Only studies that used PCR or hybrid capture for the detection of HPV DNA and immunohistochemical staining or methylation for the detection of p16^INK4a were included. Data were extracted and subsequently crosschecked, and inconsistencies were discussed to reach consensus. Using random-effects models, we estimated the pooled prevalence and 95% CI of HPV DNA and p16^INK4a positivity in penile cancer and penile intraepithelial neoplasia, stratifying by histological subtype and HPV DNA or p16^INK4a detection method. Type-specific prevalence of HPV6, HPV11, HPV16, HPV18, HPV31, HPV33, and HPV45 in penile cancer was estimated.

FINDINGS

Our searches identified 1836 non-duplicate records, of which 73 relevant papers (71 studies) were found to be eligible. The pooled HPV DNA prevalence in penile cancer (52 studies; n=4199) was 50·8% (95% CI 44·8-56·7; I²=92·6%, p_{heterogeneity}<0·0001). A high pooled HPV DNA prevalence was seen in basaloid squamous cell carcinomas (84·0%, 95% CI 71·0-93·6; I²=48·0%, p_{heterogeneity}=0·0197) and in warty-basaloid carcinoma (75·7%, 70·1-81·0; I²=0%, p_{heterogeneity}=0·52). The predominant oncogenic HPV type in penile cancer was HPV16 (68·3%, 95% CI 58·9-77·1), followed by HPV6 (8·1%, 4·0-13·7) and HPV18 (6·9%, 2·9-12·4). The pooled HPV DNA prevalence in penile intraepithelial neoplasia (19 studies; n=445) was 79·8% (95% CI 69·3-88·6; I²=83·2%, p_{heterogeneity}<0·0001). The pooled p16^INK4a percent positivity in penile cancer (24 studies; n=2295) was 41·6% (95% CI 36·2-47·0; I²=80·6%, p_{heterogeneity}<0·0001), with a high pooled p16^INK4a percent positivity in HPV-related squamous cell carcinoma (85·8%, 95% CI 72·1-95·4; I²=56·4%, p_{heterogeneity}=0·0011) as compared with non-HPV-related squamous cell carcinoma (17·1%, 7·9-29·1; I²=78·3%, p_{heterogeneity}<0·0001). Moreover, among HPV-positive cases of penile cancer, the p16^INK4a percent positivity was 79·6% (95% CI 65·7-90·7; I²=89·9%, p_{heterogeneity}<0·0001), compared with 18·5% (9·6-29·6; I²=89·3%, p_{heterogeneity}<0·0001) in HPV-negative penile cancers. The pooled p16^INK4a percent positivity in penile intraepithelial neoplasia (six studies; n=167) was 49·5% (95% CI 18·6-80·7).

INTERPRETATION

A large proportion of penile cancers and penile intraepithelial neoplasias are associated with infection with HPV DNA (predominantly HPV16), emphasising the possible benefits of HPV vaccination in men and boys.

FUNDING

None.

Penile intraepithelial neoplasia: Nomenclature, incidence and progression to malignancy in the Netherlands

OBJECTIVE

To determine the incidence of penile intraepithelial neoplasia in the Netherlands using a nationwide histopathology registry and to discuss the nomenclature of premalignant penile lesions.

METHODS

Data from patients in the Netherlands diagnosed with a premalignant penile lesion between January 1998 and December 2007 were collected from the nationwide histopathology registry (PALGA); this database covers all pathology reports of inhabitants in the Netherlands. The premalignant lesions included were erythroplasia of Queyrat; Bowen's disease; bowenoid papulosis; mild, moderate and severe dysplasia; and carcinoma in situ of the penis. The terminology used in the pathological reports was translated to penile intraepithelial neoplasia. The grading was made analogous to that of vulvar premalignant lesions.

RESULTS

The PALGA database enrolled 380 patients with premalignant penile lesions. Severe premalignant lesions, penile intraepithelial neoplasia III, were found in 254 patients (67%), penile intraepithelial neoplasia II in 84 (22%) and penile intraepithelial neoplasia I in 42 patients (11%). Most lesions were located on the prepuce (45%), followed by glans (38%) and shaft (3%). The median age of patients with penile intraepithelial neoplasia was 58 years. Progression to malignant disease occurred (2% for penile intraepithelial neoplasia I vs 7% for penile intraepithelial neoplasia III) in 26 patients.

CONCLUSIONS

Penile intraepithelial neoplasia is a rarely diagnosed condition. Because of the wide variation of terms used for premalignant intraepithelial neoplasia of the penis, we recommend restricting this nomenclature to penile intraepithelial neoplasia.

Male Genital Dermatology: A Primer for the Sexual Medicine Physician

INTRODUCTION

The dermatologic conditions affecting the male genitalia are diverse and range from normal variants and benign growths to overt malignancy. Unfortunately, there is a dearth of urologic dermatology training in most residency programs, and many dermatologic lesions with a classic appearance on other areas of the body may have atypical presentations on the genitalia. Patients may present to a variety of physicians without receiving a definitive diagnosis, which can be highly distressing to the afflicted individual.

AIM

To provide sexual medicine physicians tools to aid in the evaluation and diagnosis of urologic dermatology lesions, whether they are limited to the genitalia or part of a widespread systemic disease.

METHODS

Comprehensive review of the literature pertaining to genital dermatology in men.

MAIN OUTCOME MEASURE

We stratify each condition into 1 of 5 groups (normal variants and benign lesions, inflammatory lesions, transmissible lesions, premalignant lesions, and malignant lesions) and focus on presentation and prevalence of these conditions.

RESULTS

Sexual medicine physicians should emphasize the non-pathologic nature of normal variants of genital anatomy (ie, penile hyperpigmentation, pearly penile papules) and stress that removal of these lesions is only appropriate for cosmetic purposes. Benign genital growths (ie, sebaceous cysts, seborrheic keratoses) may not require intervention, but they should be monitored for atypical features and infection. In contrast, transmissible (ie, herpes, syphilis) and inflammatory (ie, psoriasis) lesions may necessitate prompt intervention to reduce transmission and complications of late-stage disease. Premalignant and malignant lesions may mimic many of the aforementioned conditions; it is important that patients receive routine follow-up after treatment. All suspicious non-healing or ulcerating lesions should undergo pathologic evaluation to rule out malignancy.

CONCLUSION

Urologic dermatology can be a diagnostic challenge for sexual medicine physicians. This review simplifies the diagnostic approach and emphasizes pathologic features of each condition to guide management. Gabrielson AT, Le TV, Fontenot C, et al. Male genital dermatology: A primer for the sexual medicine physician. Sex Med Rev 2019;7:71-83.

Erythroplasia of Queyrat treated with topical 5-fluorouracil

We report a 33-year-old male patient diagnosed with erythroplasia of Queyrat. The patient had an erythematous and eroded lesion affecting more than 50% of the glans associated with bleeding and local pain. Despite previous indication of penectomy, he was successfully treated with topical 5-fluorouracil.

Comparison of the Natural History of Genital HPV Infection among Men by Country: Brazil, Mexico, and the United States

Background: Male genital human papillomavirus (HPV) prevalence and incidence has been reported to vary by geographical location. Our objective was to assess the natural history of genital HPV by country among men with a median of 48 months of follow-up.Methods: Men ages 18-70 years were recruited from United States (n = 1,326), Mexico (n = 1,349), and Brazil (n = 1,410). Genital specimens were collected every 6 months and HPV genotyping identified 37 HPV genotypes. Prevalence of HPV was compared between the three countries using the Fisher exact test. Incidence rates and 95% confidence intervals were calculated. The median time to HPV clearance among men with an incident infection was estimated using the Kaplan-Meier method.Results: The prevalence and incidence of the genital HPV types known to cause disease in males (HPV 16 and 6) was significantly higher among men from Brazil than men from Mexico. Prevalence and incidence of those genital HPV types in the United States varied between being comparable with those of Mexico or Brazil. Although genital HPV16 duration was significantly longer in Brazil (P = 0.04) compared with Mexico and the United States, HPV6 duration was shortest in Brazil (P = 0.03) compared with Mexico and the United States.Conclusions: Men in Brazil and Mexico often have similar, if not higher prevalence of HPV compared with men from the United States.Impact: Currently, there is no routine screening for genital HPV among males and while HPV is common in men, and most naturally clear the infection, a proportion of men do develop HPV-related diseases. Men may benefit from gender-neutral vaccine policies. Cancer Epidemiol Biomarkers Prev; 26(7); 1043-52. ©2017 AACR.

Erythroplasia of Queyrat Treated with 5% Imiquimod Cream — Case Report Emphasizing the Role of Human Papilloma Virus Testing in a Clinical Setting

Background:Anogenital premalignancies and malignancies often affect females and males, and human papillomavirus infection plays a crucial role in their etiopathogenesis. These lesions are very important and represent an immense public health burden.

Case presentation:A 78-year-old Caucasian male presented to the Dermatology Unit for persistent, slowly progressing, well-demarcated, erythematous plaques on the glans penis, observed by the patient 18 months prior to the consultation. Variable topical treatments were applied, with no improvement and with the denial of a punch biopsy. A clinical diagnosis of erythroplasia of Queyrat was established and the test for HPV revealed an association with subtype 16 (which excluded other benign inflammatory conditions). Positive results were obtained after 4 weeks of topical application of 5% imiquimod cream, once daily, 5 times a week.

Conclusion:Erythroplasia of Queyrat should be diagnosed in a non-compliant patient based on the clinical picture and HPV testing even in the absence of a biopsy, and a non-surgical treatment should be initiated immediately.

Country-specific HPV-related genital disease among men residing in Brazil, Mexico and The United States: The HIM study

The purpose of this study was to assess whether the incidence of histopathologically confirmed condyloma and penile intraepithelial neoplasia (PeIN) and rates of genital HPV infection progression to these lesions differs by country (Brazil, Mexico and the U.S.). At each visit, lesions were biopsied and were categorized by pathologic diagnoses. The Linear Array genotyping method was used to identify HPV genotypes from genital swabs, while the INNO-LiPA HPV Genotyping Extra method was used for tissue specimens. Age-specific analyses were conducted for lesion incidence by country, with Kaplan-Meier estimation of cumulative incidence. The proportion of HPV infections that progressed to condyloma and PeIN, the median time to lesion development and the incidence rates were estimated by country. When comparing demographic and sexual characteristics across the three countries, sexual orientation (p = 0.008) and lifetime number of female sexual partners (p < 0.0001) were differentially associated with lesion incidence in the three countries. Condyloma incidence in Brazil and the U.S. decreased with age, while incidence remained constant across the lifespan in Mexico. There were no differences by country and age for PeIN incidence. HPV types 6 and 11 were the most common types to progress to condyloma and HPV types 16, 6 and 11 were the most common types to progress to PeIN in all three countries. The continuous risk of condyloma and PeIN across all age groups and countries in this study emphasizes the need to ensure that strong HPV immunity, such as that obtained through vaccination, is maintained across the lifespan of men.

Seroprevalence of cutaneous human papillomaviruses (HPVs) among men in the multinational HPV Infection in Men study

Data on cutaneous human papillomavirus (HPV) seroprevalence are primarily derived from skin cancer case-control studies. Few studies have reported the seroprevalence of cutaneous HPV among healthy men. This study investigated the seroprevalence of cutaneous HPV types and associated risk factors among men residing in Brazil, Mexico and the USA. Six hundred men were randomly selected from the HPV Infection in Men study. Archived serum specimens were tested for antibodies against 14 cutaneous HPV genotypes, β-HPV types (5/8/12/14/17/22/23/24/38/48), α-HPV 27, γ-HPV 4, µ-HPV1 and ν-HPV 41 using a glutathione S-transferase L1-based multiplex serology assay. Risk factor data were collected by a questionnaire. Binomial proportions were used to estimate seroprevalence, and logistic regression to examine factors associated with seropositivity. Overall, 65.4 % of men were seropositive to ≥1 of the 14 cutaneous HPV types, and 39.0 % were positive for ≥1 β-HPV types. Seroprevalence was 8.9, 30.9, 28.6 and 9.4 % for α-HPV 27, γ-HPV 4, µ-HPV 1 and ν-HPV 41, respectively. In multivariate analyses, seropositivity for any cutaneous HPV type was associated with higher education [adjusted odds ratio (AOR) 1.75; 95 % confidence interval (CI) 1.08-2.83], and seropositivity of any β-HPV type was significantly associated with increasing age (AOR 1.72; 95 % CI 1.12-2.63, for men aged 31-44 years vs men aged 18-30 years). Other factors associated with various type-specific cutaneous HPV seropositivity included country, circumcision and lifetime number of male sexual partners. These data indicate that exposure to cutaneous HPV is common. Future studies are needed to assess the role of cutaneous HPV in diseases.

Seroprevalence of Cutaneous Human Papillomaviruses and the Risk of External Genital Lesions in Men: A Nested Case-Control Study

Background

A variety of cutaneous human papillomaviruses (HPV) are detectable in genital epithelial lesions in men and non-melanoma skin cancer patients. It remains unclear whether these viruses are associated causally with skin lesions. To date, no study has prospectively examined the association between cutaneous HPV seropositivity and development of external genital lesions (EGLs) in men.

Objectives

To examine the association between seropositivity to cutaneous HPV types and the risk of subsequent development of EGLs.

Methods

A nested case-control study including 163 incident EGL cases and 352 EGL-free controls in the HPV Infection in Men (HIM) Study cohort was conducted. Cases were ascertained at each of up to 10 biannual clinical visits and verified through biopsy and pathological diagnoses. EGLs were categorized as condyloma, suggestive of condyloma, penile intraepithelial neoplasia (PeIN), and other EGLs. Archived serum specimens collected at baseline were tested for antibodies against 14 cutaneous HPV types (β types (5, 8, 12, 14, 17, 22, 23, 24, 38, and 47), α type 27, γ type 4, μ type 1, and ν type 41) using a GST L1-based multiplex serology assay. Socio-demographic and sexual behavior data were collected through a questionnaire. Using logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated.

Results

Overall, seropositivity to ≥1 cutaneous HPV type (any-HPV) and ≥1 β types (any-β) was 58.3% and 37.5% among other EGL cases, 71.6% and 46.8% among condyloma, 66.8% and 50.0% among PeIN, and 71.9% and 38.4% among controls, respectively. Type-specific seropositivity was most common for ɤ-HPV 4, μ-HPV 1, and β-HPV 8. No statistically significant association was observed between any-HPV, any-β, and type-specific HPV seropositivity and subsequent development of EGLs across all pathological diagnoses.

Conclusions

Overall, seropositivity to cutaneous HPV was common among men; however, it appears that cutaneous HPV is not associated with the development of genital lesions in men.

Cutaneous beta human papillomaviruses and the development of male external genital lesions: A case-control study nested within the HIM Study

BACKGROUND

Cutaneous human papillomaviruses (HPVs) increase the risk of non-melanoma skin cancer in sun-exposed skin. We examined the role of beta-HPV in the development of male external genital lesions (EGLs), a sun-unexposed site.

METHODS

In this nested case-control study (67 men with pathologically-confirmed EGLs and 134 controls), exfoliated cells collected from the surface of lesions and normal genital skin 0, 6, and 12 months preceding EGL development were tested for beta-HPV DNA using a type-specific multiplex genotyping assay. Beta-HPV prevalence was estimated and conditional logistic regression was used to evaluate the association with condyloma, the most common EGL.

RESULTS

While beta-HPV prevalence among controls remained stable, the prevalence among cases was lowest on the surface of lesion. Detecting beta-HPV on the normal genital skin was not associated with the presence or development of condyloma.

CONCLUSIONS

Cutaneous beta-HPV does not appear to be contributing to pathogenesis in male genital skin.

Searching beyond the usual papillomavirus suspects in squamous carcinomas of the vulva, penis and head and neck

Human Papillomaviruses (HPVs) are involved in the etiology of anogenital and head and neck cancers. The HPV DNA prevalence greatly differs by anatomical site. Indeed, the high rates of viral DNA prevalence in anal and cervical carcinomas contrast with the lower fraction of cancer cases attributable to HPVs in other anatomical sites, chiefly the vulva, the penis and head and neck. Here we analyzed 2635 Formalin Fixed Paraffin Embedded surgical samples that had previously tested negative for the presence of HPVs DNA using the SPF10/DEIA procedure, in order to identify the presence of other PVs not explicitly targeted by standard molecular epidemiologic approaches. All samples were reanalyzed using five broad-PV PCR primer sets (CP1/2, FAP6064/FAP64, SKF/SKR, MY9/MY11, MFI/MFII) targeting the main PV main clades. In head and neck carcinoma samples (n=1141), we recovered DNA from two BetaHPVs, namely HPV20 and HPV21, and from three cutaneous AlphaPVs, namely HPV2, HPV57 and HPV61. In vulvar squamous cell carcinoma samples (n=902), we found one of the samples containing DNA of one cutaneous HPV, namely HPV2, and 29 samples contained DNA from essentially mucosal HPVs. In penile squamous cell carcinoma samples (n=592), we retrieved the DNA of HPV16 in 16 samples. Our results show first that the SPF10/DEIA is very sensitive, as we recovered only 2.1% (55/2635) false negative results; second, that although the DNA of cutaneous HPVs can be detected in cancer samples, their relative contribution remains anyway minor (0.23%; 6/2635) and may be neglected for screening and vaccination purposes; and third, their contribution to malignancy is not necessarily warranted and needs to be elucidated.

Human papillomavirus infection and p16 expression in the immunocompetent patients with extragenital/extraungual Bowen's disease

BACKGROUND

The role of human papillomaviruses (HPV) in the development of squamous cell carcinoma (SCC) has been established for anogenital lesions but still remains controversial for carcinomas in other sites. The aim of this study was to determine the α-HPV and β-HPV prevalence and their association with p16 expression, sun exposure, and clinicopathological findings in patients with Bowen's disease (BD).

METHODS

One hundred sixty nine skin biopsy specimens from 157 immunocompetent patients with extragenital/extraungual BD were examined for HPV status and p16 expression. The presence of koilocyte-like changes, solar elastosis and papillomatosis was recorded for each specimen.

RESULTS

BD was diagnosed more often in potentially sun-exposed sites with prevalence 73.6 % and a remarkable predilection for the head and neck region. High risk α-HPV or β-HPV were detected in 34.7 % of lesions and β-HPV infections dominated over α-HPV. Higher prevalence of koilocyte-like changes and papillomatosis was found in HPV-positive specimens but it was not statistically significant. The expression of p16 was detected in 79.8 % of lesions and displayed no correlation with the HPV status. HPV-positivity tended to be detected more often in sun-protected sites. Dual infections by α-HPV/β-HPV genera and mixed α-HPV infections were not detected, while 37.5 % of β-HPV positive specimens were infected by two or more β-HPV genotypes. HPV 9 was significantly associated with mixed β-HPV infections.

CONCLUSIONS

HPV may play an etiological role at least in some SCC in situ arising in extragenital sites. Sunprotected sites may be more dependent on HPV-mediated co-carcinogenesis than sun exposed areas. The presence of the p16-expression, papillomatosis or koilocyte-like change is not a reliable marker of HPV infection in SCC in situ.

Genital Human Papillomavirus Infection Progression to External Genital Lesions: The HIM Study

BACKGROUND

Human papillomavirus (HPV) causes two types of external genital lesions (EGLs) in men: genital warts (condyloma) and penile intraepithelial neoplasia (PeIN).

OBJECTIVE

The purpose of this study was to describe genital HPV progression to a histopathologically confirmed HPV-related EGL.

DESIGN, SETTING, AND PARTICIPANTS

A prospective analysis nested within the HPV Infection in Men (HIM) study was conducted among 3033 men. At each visit, visually distinct EGLs were biopsied; the biopsy specimens were subjected to pathologic evaluation and categorized by pathologic diagnoses. Genital swabs and biopsies were used to identify HPV types using the Linear Array genotyping method for swabs and INNO-LiPA for biopsy specimens.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

EGL incidence was determined among 1788 HPV-positive men, and cumulative incidence rates at 6, 12, and 24 mo were estimated. The proportion of HPV infections that progressed to EGL was also calculated, along with median time to EGL development.

RESULTS AND LIMITATIONS

Among 1788 HPV-positive men, 92 developed an incident EGL during follow-up (9 PeIN and 86 condyloma). During the first 12 mo of follow-up, 16% of men with a genital HPV 6 infection developed an HPV 6-positive condyloma, and 22% of genital HPV 11 infections progressed to an HPV 11-positive condyloma. During the first 12 mo of follow-up, 0.5% of men with a genital HPV 16 infection developed an HPV 16-positive PeIN. Although we expected PeIN to be a rare event, the sample size for PeIN (n=10) limited the types of analyses that could be performed.

CONCLUSIONS

Most EGLs develop following infection with HPV 6, 11, or 16, all of which could be prevented with the 4-valent HPV vaccine.

PATIENT SUMMARY

In this study, we looked at genital human papillomavirus (HPV) infections that can cause lesions in men. The HPV that we detected within the lesions could be prevented by a vaccine.

Prevalence of beta and gamma human papillomaviruses in the anal canal of men who have sex with men is influenced by HIV status

BACKGROUND

Mucosal high-risk human papillomavirus (HPV) types benefit differently from the immunocompromised status of the host. So far it is not known whether a similar scenario holds for the large group of the β and γ cutaneous HPV types that appear to be present at several anatomical sites.

METHODS

The presence of β (n=43) and γ (n=30) HPVs in the anal samples of 66 HIV-positive and 153 HIV-negative anonymized men who have sex with men (MSM) was determined by multiplex PCR, using type-specific primers and bead-based hybridization (Luminex technology).

RESULTS

The prevalence of β and γ HPV infection was 65.6% and 68.2%, respectively, among HIV-positive MSM and 59.1% and 57.7%, respectively, among HIV-negative MSM. β-2 and γ-10 were found to be the most prevalent species in both groups. The prevalence of infection with HPV types of the species β-1 (P=0.02), β-3 (P=0.002), γ-6 (P=0.002), and γ-7 (P=0.02) was higher in HIV-positive than HIV-negative men. In contrast, the β-2 species was equally distributed in the two groups, while the γ-10 species was slightly affected by HIV status.

CONCLUSIONS

These findings provide evidence that impairment of the host's immune surveillance impacts β and γ HPV infections differently.

Bowen's Disease Involving the Urethra

Bowen's disease developing on mucous or mucocutaneous regions is clinically called erythroplasia of Queyrat. We report herein a 56-year-old male with Bowen's disease extending from the penis shaft to the glans penis, and urethral meatus. Physical examination revealed bright red velvety plaques on the prepuce and glans penis and an irregularly pigmented scaly lesion on the dorsum of his penis shaft. Histopathological findings of both lesions were compatible with those of Bowen's disease, supporting the concept that erythroplasia of Queyrat and Bowen's disease should be regarded as one clinicopathologic entity. A partial penectomy was finally performed, because tumor cells were pathologically observed in the mucous epithelium of the urethra. Although several therapeutic modalities exist for Bowen's disease on the external genitalia, treatment options are limited when Bowen's disease extends to the urethral meatus. We discussed the recent therapeutic modalities in genital Bowen's disease.

2013 European guideline for the management of balanoposthitis

Balanoposthitis can be caused by a disparate range of conditions affecting the penile skin. This guideline concentrates on a selected group of conditions and offers recommendations on the diagnostic tests and treatment regimens needed for the effective management of balanoposthitis.

Implications for human papillomavirus in penile cancer

Human papillomavirus infection (HPV) has been implicated in penile cancer, and although the annual incidence is estimated to be 1,570 in the United States, there are areas of the world in which the incidence is as much as 20-fold higher. Ample data in the literature support testing and vaccination against HPV-related cervical cancer, but for men and penile cancer, these data are lacking. However, some preliminary data would suggest that HPV not only plays an important role in a significant subset of patients with penile cancer but also may be a target for penile cancer prevention as well via initiation of a vaccination program in high-risk male populations.

P16(INK4A) immunostaining is a strong indicator for high-risk-HPV-associated oropharyngeal carcinomas and dysplasias, but is unreliable to predict low-risk-HPV-infection in head and neck papillomas and laryngeal dysplasias

Human papillomavirus (HPV) is a risk factor for the development of benign and malignant mucosal head and neck lesions. P16(INK4A) is often used as a surrogate marker for HPV-infection, although there is still controversy with respect its reliability. Our aim was to determine if p16(INK4A) overexpression can accurately predict both high-risk and low-risk-HPV-presence in (pre)malignant and benign head and neck lesions. P16(INK4A) immunohistochemistry was performed on paraffin-embedded tissue sections of 162 oropharyngeal squamous cell carcinomas (OPSCC), 14 tonsillar and 23 laryngeal dysplasias, and 20 tonsillar and 27 laryngeal papillomas. PCR, enzyme-immunoassay and FISH analysis were used to assess HPV-presence and type. Of the 162 OPSCC and 14 tonsillar dysplasias, 51 (31%) and 10 (71%) were HPV16-positive, respectively. All tonsillar papillomas were HPV-negative and four laryngeal dysplasias and 26 laryngeal papillomas were positive for HPV6 or -11. P16(INK4A) immunohistochemistry revealed a strong nuclear and cytoplasmic staining in 50 out of 51 HPV16-positive and 5 out of 111 HPV-negative OPSCC (p < 0.0001) and in all HPV16-positive tonsillar dysplasias, whereas highly variable staining patterns were detected in the papillomas and laryngeal dysplasias, irrespective of the HPV-status. In addition, the latter lesions generally showed a higher nuclear than cytoplasmic p16(INK4A) immunostaining intensity. In conclusion, our data show that strong nuclear and cytoplasmic p16(INK4A) overexpression is a reliable surrogate indicator for HPV16 in OPSCC and (adjacent) dysplasias. For HPV6 or -11-positive and HPV-negative benign and premalignant lesions of the tonsil and larynx, however, p16(INK4A) immunostaining is highly variable and cannot be recommended to predict HPV-presence.

Cutaneous human papillomavirus types detected on the surface of male external genital lesions: a case series within the HPV Infection in Men Study

BACKGROUND

Cutaneous human papillomaviruses (HPVs) may be associated with cutaneous epithelial lesions and non-melanoma skin cancers. No study has systematically evaluated the presence of genus beta [β]-HPV in male genital skin or external genital lesions (EGLs)

OBJECTIVES

To examine cutaneous β-HPV types detected on the surface of EGLs in men and describe their presence prior to EGL development.

STUDY DESIGN

A retrospective case series was conducted among 69 men with pathologically confirmed EGLs (n=72) who participated in the HPV Infection in Men Study. Archived exfoliated cells collected from the surface of each EGL and normal genital skin specimens 6-12 months preceding EGL development were tested for β-HPV DNA using a type-specific multiplex genotyping assay.

RESULTS

β-HPV DNA was detected on 61.1% of all EGLs, with types 38 (16.7%), 5 (15.3%), and 12 (12.5%) most commonly identified. HPV prevalence differed across pathological diagnoses, with the largest number of β-HPV types detected on condylomas. Most β-HPV types were detected on normal genital skin prior to EGL development, though the prevalence was lower on EGLs compared to preceding normal genital skin.

CONCLUSIONS

EGLs and the normal genital skin of men harbor a large number of β-HPV types; however, it appears that β-HPVs are unrelated to EGL development in men. Despite evidence to support a causal role in skin carcinogenesis at UVR-exposed sites, cutaneous HPV appears unlikely to cause disease at the UVR-unexposed genitals.

Functional similarity between E6 proteins of cutaneous human papillomaviruses and the adenovirus E1A tumor-restraining module

The adenovirus E1A C-terminal region restrains oncogenic transformation through interaction with three distinct cellular protein complexes that include the DYRK1A/1B/HAN11 complex. The E6 proteins of beta-human papillomaviruses (beta-HPVs) also interact with the DYRK1/HAN11 complex. A variant of HPV5 E6 frequently found in epidermodysplasia verruciformis skin lesions interacted less efficiently with DYRK1A/HAN11. The E6 variant and E7 of HPV5 efficiently coimmortalized primary epithelial cells, suggesting that naturally arising variants may contribute potential oncogenic activities of beta-HPV E6 proteins.

Epigenetic mechanisms in penile carcinoma

Penile carcinoma (PeCa) represents an important public health problem in poor and developing countries. Despite its unpredictable behavior and aggressive treatment, there have only been a few reports regarding its molecular data, especially epigenetic mechanisms. The functional diversity in different cell types is acquired by chromatin modifications, which are established by epigenetic regulatory mechanisms involving DNA methylation, histone acetylation, and miRNAs. Recent evidence indicates that the dysregulation in these processes can result in the development of several diseases, including cancer. Epigenetic alterations, such as the methylation of CpGs islands, may reveal candidates for the development of specific markers for cancer detection, diagnosis and prognosis. There are a few reports on the epigenetic alterations in PeCa, and most of these studies have only focused on alterations in specific genes in a limited number of cases. This review aims to provide an overview of the current knowledge of the epigenetic alterations in PeCa and the promising results in this field. The identification of epigenetically altered genes in PeCa is an important step in understanding the mechanisms involved in this unexplored disease.

The impact of cidofovir treatment on viral loads in adult recurrent respiratory papillomatosis

Cidofovir is an antiviral agent used in the therapy of recurrent respiratory papillomatosis (RRP). In this study, we hypothesized that cidofovir is effective in decreasing the viral load of human papillomavirus (HPV). We established a type specific real-time PCR and measured HPV DNA loads. The course of viral load of HPV types 6 and 11 after repeated applications of cidofovir intralesionally was compared to the clinical outcome using a modified Derkay score. In 6 of the 8 (75 %) patients, we detected HPV 6. In 2 (25 %) patients, we detected HPV 11. In all of the patients, the viral load and the modified Derkay score decreased significantly during the treatment. We conclude that viral load of HPV can be monitored using the technique described here. Cidofovir in combination with surgical debulking reduces the viral load in patients with RRP. Relapses of the symptoms cannot be avoided but might be delayed.

Erythroplasia of queyrat

A 58-year-old Caucasian male presented to the urology clinic reporting an approximate one-year history of a persistent irritating, slowly progressive, glans penis redness. Biopsy revealed penile squamous cell carcinoma in situ. He underwent a partial glansectomy with circumcision and skin grafting. At three months follow-up there is no evidence of local disease recurrence. In western countries, primary malignant penile cancer is uncommon, with an incidence of less than 1 per 100,000 males. Squamous cell cancer accounts for more than 95% of cases of penile cancer. Squamous cell carcinoma in situ on the penile mucosa or transitional surfaces is also known as Erythroplasia of Queyrat. In the region, one third of penile squamous cell carcinoma in situ cases progress to invasive squamous cell carcinoma.

Diagnosis and management of premalignant penile lesions

Diagnosing premalignant penile lesions from benign penile dermatoses presents a unique challenge. The rarity of these conditions and the low incidence of penile cancer mean that the majority of our knowledge is based on small, non-randomized, retrospective studies. The introduction of specialist penile cancer centres in the UK has resulted in the centralization of expertise and resources, and has furthered our understanding of the biological behaviour and management of this rare malignancy. We review the current trends in the approach to diagnosing and treating various premalignant penile conditions.

Genital HPV infection and related lesions in men

Human papillomavirus (HPV) is highly prevalent in men and there is an interest in further understanding the relationship between HPV infection and disease in men, including the development of genital warts, penile intraepithelial neoplasia and invasive penile carcinomas. Genital warts are caused by HPV 6/11 and are the most common clinical manifestation of HPV in men. Though they are benign and not associated with mortality, they are a source of psychosocial distress and physical discomfort. HPV infection can also develop into invasive penile carcinoma which is associated with morbidity and mortality. Approximately 40% of invasive penile carcinomas are attributable to HPV with HPV 16, 18, and 6/11 being the genotypes most commonly detected in penile tumors. Penile carcinomas of the basaloid and warty histologic subtypes are most likely to test positive for HPV. In addition to HPV infection, the risk factors most strongly associated with penile cancer are lack of neonatal circumcision, phimosis (the inability of uncircumcised men to fully retract the foreskin), and anogenital warts. Male vaccination with the quadrivalent HPV vaccine that protects against HPV 6/11/16/18 has been shown to significantly reduce HPV-associated anogenital infection and disease in men. If the quadrivalent vaccine is successfully disseminated to large segments of the young male population, there is the potential for substantial reduction in genital HPV infection and related lesions in men.

Infecção pelo papilomavírus humano: etiopatogenia, biologia molecular e manifestações clínicas

O papilomavírus humano (HPV) é um vírus DNA que apresenta tropismo por células epiteliais, causando infecções na pele e nas mucosas. A replicação do HPV ocorre no núcleo das células escamosas e o seu ciclo de vida é diretamente relacionado ao programa de diferenciação da célula hospedeira. Até o momento, foram completamente caracterizados cerca de 100 tipos diferentes de HPVs e há um grande número adicional de tipos ainda não sequenciados. Além de ser o responsável por lesões benignas de pele e mucosas, o HPV também está envolvido no desenvolvimento de diversos tumores cutaneomucosos: doença de Bowen, cânceres de pele não melanoma e carcinomas genitais. Esta revisão aborda as características do HPV, quadros cutâneos e mucosos benignos e malignos causados por ele e os principais métodos empregados em sua detecção e tipagem.

Recent advances in the prevention and treatment of skin cancer using photodynamic therapy

Photodynamic therapy (PDT) is a noninvasive procedure that involves a photosensitizing drug and its subsequent activation by light to produce reactive oxygen species that specifically destroy target cells. Recently, PDT has been widely used in treating non-melanoma skin malignancies, the most common cancer in the USA, with superior cosmetic outcomes compared with conventional therapies. The topical 'photosensitizers' commonly used are 5-aminolevulinic acid (ALA) and its esterified derivative methyl 5-aminolevulinate, which are precursors of the endogenous photosensitizer protoporphyrin IX. After treatment with ALA or methyl 5-aminolevulinate, protoporphyrin IX preferentially accumulates in the lesion area of various skin diseases, which allows not only PDT treatment but also fluorescence diagnosis with ALA-induced porphyrins. Susceptible lesions include various forms of non-melanoma skin cancer such as actinic keratosis, basal cell carcinoma and squamous cell carcinoma. The most recent and promising developments in PDT include the discovery of new photosensitizers, the exploitation of new drug delivery systems and the combination of other modalities, which will all contribute to increasing PDT therapeutic efficacy and improving outcome. This article summarizes the main principles of PDT and its current clinical use in the management of non-melanoma skin cancers, as well as recent developments and possible future research directions.