Lichen sclerosus, an unusual chronic mucocutaneous condition of the penis, has been found in association with invasive penile cancer, and squamous cell carcinoma has been reported in patients with longstanding lichen sclerosus. The aim of this study was to determine the anatomic distribution and prevalence of lichen sclerosus in patients with squamous cell carcinoma of the penis and to search for a correlation with special types of carcinomas. Clinical and pathologic data from 207 penectomy and circumcision specimens with squamous cell carcinomas and giant condylomas were evaluated, and 68 patients with lichen sclerosus were identified. Mean age was 61 years. The preferential anatomic site of lichen sclerosus was the foreskin, but other sites (glans and coronal sulcus) including urethra were also involved. Grossly, the lesions showed white–gray smooth or irregular patches and plaques adjacent to invasive cancers. Microscopically, the lesion was stromal–epithelial with atrophic and hyperplastic epithelium and edematous or densely eosinophilic hyalinized lamina propria. A variable band of lymphocytic infiltration beneath the sclerosis was noted. Lichen sclerosus were preferentially associated with non-human papillomavirus variants of squamous cell carcinoma. When lichen sclerosus was associated with malignancy, it often showed, in addition to the hyperplastic epithelium, a low-grade squamous intraepithelial lesion. These findings suggest that lichen sclerosus may represent preneoplastic condition for at least some types of penile cancers, in particular those not related to human papillomavirus.
Lichen sclerosus, described in the penis as balanitis xerotica obliterans by Stuhmer in 1928, 42 is a chronic and atrophic mucocutaneous condition affecting penile epithelium and lamina propria. 1,30,36 Different names have been applied to this disease depending on the lesional location and the specialty of the author. Balanitis xerotica obliterans is a descriptive term commonly used as a synonym for penile lichen sclerosus. Because some authors prefer to use the term balanitis xerotica obliterans for the end-stage condition and to unify gynecologic and urological terminology, the use of lichen sclerosus is recommended. 27,30,34 The term lichen sclerosus is also preferred over lichen sclerosus et atrophicus because the epithelial “atrophic” feature may not represent actual atrophy at all. 21,25,30 As a single site, it affects most commonly the foreskin, but the coronal sulcus and glans may also be involved. 8 Uncircumcised men experience more symptoms than those circumcised. Symptomatic individuals report pruritus, soreness, difficulty in retracting the foreskin, burning with urination, poor urinary stream, and painful erections. Clinical examination reveals areas of pallor, atrophy, and sclerotic patches and plaques, commonly with a nonretractile prepuce. 27,30,36 Recurrence of lichen sclerosus may occur at the site of the circumcision scar. While extragenital lichen sclerosus appears to carry no risk for malignant transformation, the relationship of anogenital lichen sclerosus and squamous cell carcinoma (SCC), especially in penile location, is more controversial. 30–32,35 Although the association of vulvar lichen sclerosus with SCC is well recognized, 10,11,40 there are fewer studies on penile location. Nasca et al found 5 cases of SCC in 86 patients with long-standing penile lichen sclerosus; 3 of these cases were SCC of usual type, 1 was a verrucous carcinoma, and 1 was a carcinoma in situ. 32 Later, the same authors reported that 3 additional patients of this group developed SCC, making a total of 8 carcinomas of 86 patients with lichen sclerosus (9.3%). 31 Bouyssou-Gauthier et al reported one carcinoma in a group of 16 patients followed for 15 years. 8 Other authors published case reports of 1 to 3 patients with carcinomas arising in penile lichen sclerosus. 5,6,9,20,22,28,34,37,41,45,46 Many of these studies are clinically oriented, and no detailed analysis of the morphologic features of the lesions is available. We found no detailed pathologic description of the epithelial component of penile lichen sclerosus or a comprehensive correlation of lichen sclerosus with histologic subtypes of SCC. Objectives of this study were as follows: 1) to determine the anatomic distribution of penile lichen sclerosus; 2) to estimate its overall incidence in tissues adjacent to penile carcinomas and giant condylomas; 3) to document the presence of cellular atypia in the epithelial component of the lesion; and 4) to establish a correlation, if it exists, between lichen sclerosus and different subtypes of SCC.