Looked like penile cancer but wasn’tColm O’Mahony, Natalie Meara (Chester)

Man in his 50’s attended complaining of 2 large ulcerated areas on the underside of his penis. He had been unable to retract the foreskin for years. He was in a stable relationship and there had been no other contacts. On examination, it looked like severe Lichen Sclerosus and the ulcerated areas looked malignant. He was seen by the plastic surgeons and had 5 punch biopsies done the following day. Histopathology was reassuring but did query infection. However, PCR for syphilis and herpes and blood tests were all negative so he proceeded to full circumcision and made a full recovery and no malignancy Lesson from the case:- All penile ulcers should have STI screening done as even on a background of obvious Lichen Sclerosus, histology of an ulcerated area cannot easily distinguish infection from LS inflammation.

Bx of ulcerSurface ulceration

Plasma cells surrounding nerves

Abundant plasma cells with vasculitis

Swollen endothelial cells

Foreskin showing dermal band-like hyalinisation, typical of LS.

HISTOLOGYHistology report of biopsies of ulcers (5 punch biopsies): All of the biopsies show features consistent with lichen sclerosus but in addition there are varying degrees of surface ulceration and a severe chronic inflammatory cell infiltrate extending deep into the dermis. This comprises large numbers of plasma cells with lymphocytes and eosinophils and there is evidence of vasculitis. There is no dysplasia. Special stains for micro-organisms have been unhelpful but an infective aetiology should be excluded. Histology report of foreskin following circumcision: The appearances are those of established lichen sclerosus et atrophicus with additional active chronic balanitis. No dysplasia or malignancy.