| Comments from Faculty and Members |
Ted Rosen MD Professor of Dermatology, Baylor College
of Medicine, Houston, TX, USA on Apr 8, 2007
Although some might like to "split" SCCIS based on
morphology, the fact is that even Bowenoid papulosis should
be considered potentially a source of invasive SCCA. Virtually
all of these are due to oncogenic HPV (16,18,33,34 mostly) and
his wife has been exposed. There are cases of VIN and CIN arising
in the female partners of penile SCCIS patients, and therefore
she needs to have the usual yearly (or perhaps twice yearly)
gynecological exam with thin prep PAP smears. The real risk
of conversion of SCCIS at ANY site into invasive disease actually
is quite small, estimated at 3-10% (in the non-HIV+ and non-transplant
patient). Nonetheless, this patient's disease is worsening,
albeit slowly.
The therapeutic options include: fairly heavy cryo (favored
by British standards), radiotherapy (probably overkill here),
imiquimod and 5FU (both of which are hard due to truck driving,
but could be "sold" to the patient by telling him
he faces the possibility of penectomy!), PDT (nobody knows exactly
the best regimen), surgery or Mohs surgery (big job with this
extensive lesion).
Almost all Rx options have a downside, carry about the same
cure (90%+) and some risk of recurrence (or appearance of invasive
disease) over the ensuing five years. Frankly, I'd talk him
into the imiquimod (or 5FU) and tell him he just needs to put
up with the discomfort for a while to cure the problem. The
other "best" option would be LN2, several sessions,
with close follow-up.
Diane Taylor MD, on April 8, 2007
Why is it difficult to treat him with imiquimod?
Monroe Richman MD, Koloa, HI, USA on April
8, 2007
What an unusual case!!
John Kaiser MD, Austin, TX, USA on April 8,
2007
It is likely that this man's lesions are caused by oncogenic
genotypes of HPV. Although the risk of invasive SCC is probably
low, it is not non-existent.
I wonder in what way his driving schedule caused him to not
tolerate imiquimod treatment. It would seem that this would
be the least invasive, least intrusive form of therapy for his
disease. In my opinion, imiquimod would be the treatment of
choice. Alternatives would include: 5-fluorouracil cream, which
would be even less well tolerated, or destructive modalities,
such as, electrosurgery, cryosurgery, TCA or laser ablation,
all with varying risks of scarring.
I would make certain the patient understands the fact that
he likely is infected with a cancer-causing virus that he may
pass to his wife, possibly placing her at risk for cervical
cancer, and that imiquimod may facilitate his immune system's
elimination of this virus, with the least risk of scarring.
Regardless of the intervention pursued, he needs regular follow-up.
Although the HPV vaccine may not be of benefit to his wife if
she already has contracted HPV, it should be discussed with
her. She definitely needs regular gynecologic exams and Pap
smears.
Amanda Oakley FRACP, Clinical Associate Professor of
Dermatology, University of Auckland, Hamilton, New Zealand on
April 8 2007
Photodynamic therapy may be better tolerated than imiquimod
or fluorouracil because recovery time is shorter.
Anthony Benedetto MD, Clin Assist Prof Dermatol, University
of PA, Philadelphia, PA, USA on April 8, 2007
Mohs micrographic surgery is the only treatment that will
give the best results for a complete removal of the lesion.
Otherwise in time it will become invasive and life threatening.
Wife should use protection during sexual intercourse and insist
that her husband have a complete extirpation of the lesion.
Khalifa Shaquie MD, PhD, Professor of Dermatology,
College of Medicine, University of Baghdad, Baghdad, Iraq
on April 9, 2007
According to my experience, I will call this case as ordinary
genital viral warts although the border of distinction between
bowenoid papulosis and ordinary genital warts is very thin and
similarly applied to the histopathology of both conditions.
But often dermatologists are obssesive in this regard and searching
fo complex things to highlight their images in front of themselves
and to their patients. Still this behaviour is for the benefit
of patients. If this patient belongs to me, I will treat him
with 25% podophyllin in benzoin co applied every 5 days until
full clearance. Imiquimod is also a good choice although I have
no experience with it as it is not available because of occupation
of Iraq and very bad health situations. Regarding wife should
be examined well and managed accordingly.
Ian McColl FRACP, Consultant Dermatologist, John Flynn
Medical Centre
Tugun, Gold Coast, Australia on April 9, 2007
This is multifocal viral disease. Mohs would be a waste of
time and money. You could never be sure you were clear. Imiquimod
is the only rational treatment. You would have fun and games
trying to apply Metvix PDT cream to this extensive area on the
shaft of the penis extending down to the scrotum and apparently
up into the pubic area. You could CO2 laser off what you can
see and apply Imiquimod afterwards to clean up what was left.
This should make the inflammatory reaction less and allow him
to work with less discomfort.
Khaled el-hoshy MD, USA
on April 9, 2007
Mohs surgery 1st option. RadioRx is another option. Had similar
case that recurred after urologist did primary excision. Doing
well after Mohs 22 months f/up so far.
Carlos Garcia MD, Associate Professor, Department of
Dermatology at the University of Oklahoma, Oklahoma City, OK,
USA on April 9, 2007
- Etiology: HPV-16 and others
- Therapeutic suggestions: TCA 25-50%, podophyllin, cryotherapy
alone or in combination with TCA or podophyllin
- Advice: Intercourse using condom, gynecologic evaluation
for wife, pap smear
- Risk for invasive SCC: Minimal. Aggressive therapy is not
indicated.
Doug Johnson MD, Assoc Prof Dermatol, Department of
Medicine, University of Hawaii School of Medicine, Honolulu,
HI, USA on April 9, 2007
Xylocaine with epinephrine and desiccate. Should be cleared
with one treatment.
Samer Ghosn MD Assistant Professor, Department of Dermatology,
American University of Beirut Medical Center, Riad El Solh,
Beirut, Lebanon on April 12, 2007
Clearly, the histology is that of SCCIS, full thickness epidermal
atypia type and the differential diagnosis in this case includes
both Bowen's disease and bowenoid papulosis (BP). Differentiation
between the two can be made only on clinical basis and is important
for management. The first entity is presumably not virally induced
and has a high risk of invasion. BP, on the other hand, is caused
by HPV, particularly HPV 16, but also other HPV types such as
18, 31, 32, 33, 34, 35, 39, 42, 48, 51, 52, 53, and 54.
Given the clinical picture, especially the multicentricity
and the warty look of the lesion, our case is most likely a
case of BP rather than Bowen's disease. Although BP runs a benign
self limited course in young immunocompetent individuals, a
chronic course complicated in 2.6% of cases by malignant invasive
transformation is the rule in elderly and immunosuppresed patients.
As part of management, aldara sounds to be the best management
and I cannot understand why the patient could not tolerate it.
White vinegar (5% acetic acid) application may make subclinical
lesions visible within 5-10 minutes. This is a simple test that
may be used on follow-up visits to estimate the progression
of the disease during and after therapy.
Female sexual partner(s)should be seen for a thorough cervical
examination because of the increased risk of malignancy.
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