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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lichen sclerosus is a chronic inflammatory skin disease that is common in white postmenopausal women and affects between 1 in 1000 and 1 in 300 individuals in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It presents on an anogenital site in 85&#37;&#8211;98&#37; of cases and on an extragenital site in only 15&#37;&#8211;20&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The exact causes are not known&#44; but autoimmune&#44; genetic&#44; hormonal&#44; and infectious factors have been implicated&#46; Clinically&#44; lichen sclerosus presents as polygonal papules that coalesce to form pearly plaques&#46; Sometimes&#44; telangiectasias&#44; fissures&#44; ulceration&#44; and internal erosion are associated with the papules&#46; It can be asymptomatic or associated with pruritus and a local burning sensation&#46; Histologic study shows orthokeratotic hyperkeratosis&#44; hydropic degeneration of the basal cells&#44; edema of the upper dermis&#44; and homogenization of collagen associated with a predominantly lymphocytic inflammatory infiltrate&#46; Treatment is with high-potency corticosteroids &#40;level A evidence&#41; and topical immunomodulators &#40;level B and C evidence&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Given the potential for long-term malignancy&#44; check-ups at least every 6 months are recommended for patients with anogenital lichen scerlosus&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Human papillomavirus &#40;HPV&#41; is a DNA virus of the <span class="elsevierStyleItalic">Papovaviridae</span> family&#46; To date&#44; more than 100 different types have been identified&#46; Of these&#44; 5 genera &#40;&#945;&#44; &#946;&#44; &#947;&#44; &#956;&#44; and &#957;&#41; only affect humans&#46; &#945;-HPVs &#40;the mucosal form&#41; are implicated in cervical cancer&#44; genital carcinomas&#44; and head and neck carcinomas while &#946;-HPVs are associated with verruciform epidermodysplasia and nonmelanoma skin cancers such as squamous cell carcinoma &#40;SCC&#41; in particular&#46; &#947;-HPV and &#957;-HPV are usually associated with benign lesions&#44; although they too have been implicated in the development of different nonmelanoma skin cancers&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The exact oncogenic mechanism of HPV has not yet been elucidated&#46; Cellular abnormalities in the <span class="elsevierStyleItalic">p53</span> gene and the retinoblastoma gene caused by viral E6 and E7 proteins&#44; encoded by mucosal HPV&#44; are thought to play a role in cellular immortality&#46; In the case of subtypes with a lower oncogenic potential &#40;&#946; and &#947; types&#41;&#44; environmental factors such as ultraviolet radiation are required to favor cell proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Association between Lichen Sclerosus and SCC</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Lichen Sclerosus and SCC in Women</span><p id="par0015" class="elsevierStylePara elsevierViewall">The association between anogenital lichen sclerosus and SCC &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41; has been extensively reported in the literature&#46; We only found 1 isolated report of SCC occurring on extragenital lichen sclerosus&#44; so we cannot rule out the possibility that it was a chance finding&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Between 3&#37; and 7&#37; of vulvar SCCs occur on vulvar lichen sclerosus&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Careful histologic study of samples from patients with vulvar SCC shows evidence of lichen sclerosus in 60&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Derrick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> published a retrospective observational study of 23 women with anogenital SCC&#44; 8 &#40;34&#37;&#41; of whom had lichen sclerosis of several years&#8217; duration&#46; An association between lichen sclerosus and vulvar SCC was found in 14 &#40;31&#37;&#41; of the 44 patients studied by Chiesa-Vottero et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> by 7 &#40;50&#37;&#41; of the 14 patients studied by Poulsen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and by 47 &#40;61&#37;&#41; of the 78 patients studied by Leibowitch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In 1995&#44; Carli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> reported an incidence of vulvar SCC on lichen sclerosus of 1&#46;4&#37; &#40;3&#47;211&#41; after 20 months of follow-up&#46; Few other prospective studies on the topic have been published in the literature&#46; Overall though&#44; the evidence suggests that lichen sclerosus is an HPV-independent carcinogenic factor&#46; This corroborates its potential for malignant transformation and the need for long-term follow-up in these patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although the exact carcinogenic mechanism of lichen sclerosus is still under debate&#44; several HPV-independent hypotheses have been put forward&#46; Ueda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> demonstrated cellular monoclonality in 6 patients with vulvar lichen sclerosus but no HPV infection or clinical manifestations indicative of associated SCC&#46; Such an observation pointed to the malignant potential of lichen sclerosus in absence of clinical manifestations that might lead to suspicion of neoplastic proliferation&#46; Rolfe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> observed mutations in the <span class="elsevierStyleItalic">p53</span> gene in 10 out of 12 patients with lichen sclerosus and in 7 of these 10&#44; the mutation was located in the same codon as the one implicated in the SCC lesions&#46; The authors therefore concluded that they were dealing with another carcinogenic mechanism&#44; independent of HPV&#44; for the development of anogenital SCC&#46; Mutations in the <span class="elsevierStyleItalic">PTEN</span> gene in some differentiated vulvar SCCs and vulvar intraepithelial neoplasias &#40;VINs&#41; have also been observed&#44; as well as microsatellite instability in 20&#37; and 12&#37; of differentiated VINs and lichen sclerosus lesions&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Finally&#44; in 2010&#44; a study was published that demonstrated hypermethylation of genes such as <span class="elsevierStyleItalic">RASSF2A</span>&#44; <span class="elsevierStyleItalic">MGMT</span>&#44; and <span class="elsevierStyleItalic">TSP-1</span> in SCC only when associated with lichen sclerosus&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> It seems that chronic inflammation associated with lichen sclerosus could lead to molecular abnormalities that in turn could facilitate neoplastic proliferation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The precursor lesion in vulvar SCC is VIN&#46; Traditionally&#44; the literature described 3 grades of VIN&#58; VIN 1&#44; VIN 2&#44; and VIN 3&#44; according to whether the epithelial dysplasia was mild&#44; moderate&#44; or severe&#44; respectively&#46; This classification was used to ensure alignment with the well-known classification of cervical intraepithelial neoplasia &#40;CIN&#41;&#46; The VIN terminology was&#44; however&#44; modified in 2004&#44; and the term VIN 1 fell into disuse&#46; Currently&#44; we only have 2 categories&#44; VIN 2 and VIN 3&#44; to refer to moderate and severe vulvar dysplasias&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Jones et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and Neill et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> established 2 clinicopathologic types of VIN&#58; usual VIN &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and differentiated or simplex VIN &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The latter accounts for between 2&#37; and 10&#37; of all diagnosed VIN&#46; <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> shows the clinical and immunohistochemical characteristics of each subtype&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;20</span></a> Differentiated or simplex VIN is the precursor of vulvar SCC associated with lichen sclerosus &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In 2011&#44; Van de Nieuwenhof et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> published a study showing that a high percentage of patients with lichen sclerosus that progressed to SCC should have been diagnosed initially with differentiated VIN&#46; Of a total of 60 cases of lichen sclerosus associated with SCC&#44; 42&#37; were reclassified in a second histologic study as differentiated VIN&#46; The majority of reclassified lesions had initially been diagnosed as lichen sclerosus associated with HPV-dependent lesions&#44; as they showed signs of cellular atypia or epidermal hyperplasia&#46; The authors observed that the time to progression to SCC was shorter when the precursor pathological process was differentiated VIN &#40;28 months on average&#41; compared to when it was lichen sclerosus &#40;84 months on average&#41;&#46; According to previous studies by the same authors&#44; up to 33&#37; of differentiated VIN progressed to SCC&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> in contrast to the percentage of 3&#37;&#8211;7&#37; cited earlier for lichen sclerosus&#46; Moreover&#44; these authors found that the histologic presence of dyskeratosis&#44; hyperkeratosis&#44; hyperplasia&#44; and atypia in the basal keratinocytes of patients diagnosed initially with lichen sclerosus was associated with a greater risk of vulvar SCC&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Lichen Sclerosus and SCC in Men</span><p id="par0045" class="elsevierStylePara elsevierViewall">The association between lichen sclerosus and penile SCC is less extensively documented in the literature &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; It has been postulated that concomitant factors such as diabetes mellitus&#44; recurrent balanitis&#44; phimosis&#44; HPV infection&#44; and poor hygiene could be etiopathogenic factors implicated in penile SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Data on penile SCC in the literature are variable and inconclusive&#44; with 5&#46;8&#37;&#8211;30&#37; of patients with lichen sclerosus having malignant disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> In a study of 130 men with genital lichen sclerosus&#44; Barbagli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> found that 8&#46;4&#37; of lesions were malignant &#40;SCC&#44; verrucous carcinoma&#41; or premalignant &#40;Queyrat erythroplasia&#41;&#46; The time interval between diagnosis of lichen sclerosus and the development of SCC was 14&#8211;30 years&#46; In their series of 54 patients with lichen sclerosus&#44; Campus et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> reported 2 cases &#40;3&#46;7&#37;&#41; of penile SCC&#46; Wallace<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> described 2 patients out of 44 &#40;4&#46;5&#37;&#41; with lichen sclerosus who developed penile SCC&#46; According to the above studies&#44; the risk of developing penile SCC in patients with lichen sclerosus ranges from 4&#37; to 8&#37;&#46; If we now analyze how many patients with penile SCC have histologic evidence of lichen sclerosus&#44; the percentage is 32&#37;&#8211;50&#37;&#46; Velazquez and Cubilla<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> observed that 68 &#40;32&#46;8&#37;&#41; out of 207 of their patients with penile SCC had histologic evidence of lichen sclerosus&#46; Perceau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> found histologic evidence of lichen sclerosus in 8 &#40;44&#37;&#41; of their 18 patients with penile SCC&#44; while Powell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> reported similar evidence in 8 of their 20 patients &#40;40&#37;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Recently&#44; by analogy with the VIN categories&#44; the grades PIN 2 and PIN 3 have been introduced to refer to penile intraepithelial neoplasm with moderate or severe dysplasia&#44; respectively&#46; Two forms of PIN have been described&#58; differentiated PIN&#44; equivalent to differentiated VIN and often associated with penile lichen sclerosus&#44; and undifferentiated or Bowenoid PIN&#44; equivalent to usual VIN and associated with HPV infection &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; Renaud-Vilmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> performed a retrospective analysis of 53 patients with penile SCC with the aim of assessing the histologic abnormalities observed in lesions adjacent to the tumor&#44; as well as the possible relation between these lesions and different types of SCC&#46; HPV-associated SCCs were warty&#44; basaloid&#44; or mixed in nature&#44; and accounted for approximately 45&#37; &#40;24 out of 53&#41; of all penile SCCs in their series&#46; They observed underlying Bowenoid PIN in all cases of these carcinomas&#46; The etiopathogenic role of HPV in Bowenoid PIN was also demonstrated by Chaux et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> who found that overexpression of the <span class="elsevierStyleItalic">p16</span> gene<span class="elsevierStyleSup">INK4a</span>&#8212;which is strongly associated with HPV infection&#8212;was positive in penile basaloid and warty SCCs &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;0001&#41; but not in SCCs associated with differentiated PIN and lichen sclerosus&#46; The histologic subtypes of SCC not associated with HPV infection are the usual and verrucous forms &#40;well-differentiated variant of SCC with no evidence of associated koilocytosis&#41; and accounted for 55&#37; of all cases &#40;29 out of 53&#41; in the study by Renaud-Vilmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Underlying lichen sclerosus was detected in 93&#37; of these carcinomas&#46; Likewise&#44; no association has been found between HPV infection and sarcomatoid SCC of the penis in studies published to date&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Renaud-Vilmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> also observed that the presence of acanthosis and orthokeratotic hyperkeratosis&#44; the so-called squamous cell hyperplasia&#44; was frequently associated with differentiated PIN and lichen sclerosus&#46; Similar findings were also reported by Van de Nieuwenhof et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> in their study of vulvar SCC&#44; where squamous cell hyperplasia was more frequent in patients with lichen sclerosus that progressed to SCC&#46; Lichen sclerosus is an HPV-independent etiopathogenic factor in some types of usual and verrucous penile SCC&#44; with differentiated PIN and squamous cell hyperplasia being the histological variants associated with and implicated in carcinogenesis&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Association Between Lichen Sclerosus and Verrucous Carcinoma</span><p id="par0060" class="elsevierStylePara elsevierViewall">Anogenital verrucous carcinoma&#44; also known as Buschke-L&#246;wenstein tumor&#44; is a low-grade indolent tumor that rarely undergoes local metastasis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There are 29 cases of anogenital verrucous carcinoma and lichen sclerosus reported in the literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Of these&#44; 12 were on the vulva and 17 on the penis&#46; Only 4 were tested for HPV infection&#44; with positive results in 2 patients&#44; 1 with type 16 HPV infection and the other with type 11 HPV infection&#46; In a retrospective study by Wang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> the objective was to assess a possible association between lichen sclerosus and verrucous carcinoma&#46; In total&#44; 13 patients with genital and perianal verrucous carcinomas were included &#40;5 with a vulvar lesion&#44; 3 with a penile lesion&#44; and 5 with a perianal lesion&#41;&#46; None of the perianal verrucous carcinomas reported were associated with lichen sclerosus&#46; The authors observed that the 5 patients with vulvar verrucous carcinoma had associated lichen sclerosus&#44; whereas only 1 of the patients with penile verrucous carcinoma and none of those with perianal verrucous carcinoma had evidence of lichen sclerosus&#46; Evidence of local recurrence was not observed in patients with no associated lichen sclerosus&#44; whereas 3 &#40;50&#37;&#41; of the 6 patients with lichen sclerosus had recurrence&#46; According to the authors&#44; the chronic inflammation and oxidative cell damage caused by lichen sclerosus could explain the propensity for local recurrence&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The exact mechanisms responsible for the association of lichen sclerosus and verrucous carcinoma are not clear&#44; but factors such as HPV infection&#44; mutations in the <span class="elsevierStyleItalic">p53</span> gene&#44; chronic inflammation&#44; and oxidative stress could all play a part&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The prevalence of HPV infection in patients with lichen sclerosus is still subject to much debate&#44; and a wide range of percentages can be found in the literature&#46; In 18&#37;&#8211;67&#37; of patients&#44; the most common genotypes found are 6 and 11&#44; both of which are implicated in the pathogenesis of verrucous carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Prolonged treatment with the highly potent topical corticosteroids prescribed for lichen sclerosus could favor reactivation of latent HPV infections and increased carcinogenis&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> On the other hand&#44; it has been demonstrated that mutations in the <span class="elsevierStyleItalic">p53</span> gene in patients with vulvar lichen sclerosus<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> and greater oxidative tissue damage resulting from impaired enzymatic antioxidant defense could explain the greater oncogenic risk&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Case reports have been published of basal cell epitheliomas&#44; melanomas&#44; and Merkel cell carcinomas located on anogenital lichen sclerosus&#44; but lichen sclerosus has not been shown to be associated with a greater incidence of these malignancies or to be implicated in their development&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Association between Lichen Sclerosus and HPV</span><p id="par0085" class="elsevierStylePara elsevierViewall">The prevalence of HPV infection in patients with lichen sclerosus varies from 1&#37; to 21&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> With the aim of investigating whether the prevalence of HPV infection was greater in patients with lichen sclerosus than in the healthy population&#44; Nasca et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> studied 46 men with lichen sclerosus and compared them with a control group&#46; With polymer chain reaction techniques to identify HPV infection&#44; they found that 17&#46;4&#37; of patients with lichen sclerosus tested positive for HPV &#40;75&#37; of them with type 16 HPV&#41; compared to 8&#46;7&#37; for the control group &#40;odds ratio&#44; 2&#46;55&#41;&#46; In a previous study of 86 patients with lichen sclerosus and penile SCC&#44; the authors observed that 8 &#40;9&#46;3&#37;&#41; of the 86 patients were HPV-16 positive and the latency time between lichen sclerosus and the onset of SCC was less &#40;average 15 years&#41; in HPV-positive patients than in HPV-negative ones &#40;average 23 years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The authors suggested that infection with HPV could accelerate the malignant process&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Vignale et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> reported that clinical improvement in their 2 HPV-positive patients with lichen sclerosus was only achieved after adding imiquimod for 3 months to topical corticosteroid treatment&#46; The authors proposed 2 possible explanations for this observation&#58; either the virus might be directly linked to development of lichen sclerosus or it was a contaminant unrelated to development of the disease&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Different hypotheses have been put forward to explain the association between lichen sclerosus and HPV&#46; Patients with lichen sclerosus might have a greater risk of HPV infection as a result of genetic predisposition for defective viral clearance&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> On the other hand&#44; prolonged use of potent topical corticosteroids could reactivate latent opportunistic high- and low-risk mucosotropic HPV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Finally&#44; other authors suggest that patients with lichen sclerosus are more susceptible than healthy individuals to the development of malignancies caused by oncogenic HPV types&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In contrast to the 2 studies commented earlier&#44; Aid&#233; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> investigated the presence of HPV in 34 patients with vulvar lichen sclerosus&#44; and made a comparison with 17 patients without vulvar disease &#40;control group&#41;&#46; None of the samples from patients with lichen sclerosus had concurrent HPV infection&#44; although such infection was found in 23&#46;2&#37; of samples from the control group&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In short&#44; there are studies that suggest that concurrent infection with HPV in patients with lichen sclerosus could be an extra oncogenic factor for the development of anogenital SCC&#46; Currently&#44; the data are still subject to debate&#46; Larger studies with longer follow-up are needed to clarify whether this association is a chance occurrence or whether HPV may really have an etiopathogenic role in anogenital lichen sclerosus&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Anogenital lichen sclerosus should be considered as a condition with potential for malignant transformation to SCC&#46; We should therefore ensure that these patients receive long-term follow-up&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Although the risk of developing penile SCC is 4&#37;&#8211;8&#37; in patients with lichen sclerosus according to published series&#44; there is histologic evidence of lichen sclerosus in between 32&#37; and 50&#37; of samples from patients with penile SCC&#46; Similar findings have been reported for the association between vulvar SCC and lichen sclerosus&#46; Thus&#44; although widely accepted figures put the percentage of SCCs occurring on lichen sclerosus at 3&#37;&#8211;7&#37; of cases&#44; histologic evidence of lichen sclerosus can be found in up to 60&#37; of vulvar SCC studies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">HPV-independent oncogenic molecular changes have been shown that could explain the malignant potential of lichen sclerosus in its own right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are 2 clinicopathologic forms of vulvar SCC&#44; usual VIN&#44; which is associated with HPV infection&#44; and differentiated VIN&#44; which is the precursor for malignant transformation in cases of lichen sclerosus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">By analogy with VIN&#44; 2 variants of PIN have been described recently&#44; the undifferentiated or Bowenoid form associated with HPV infection and differentiated PIN&#44; which is the premalignant precursor of penile SCC in patients with lichen sclerosus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">We do not have sufficient evidence of an association between HPV and lichen sclerosus&#44; as the studies in the literature are contradictory&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Association between Lichen Sclerosus and SCC"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Lichen Sclerosus and SCC in Women"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Lichen Sclerosus and SCC in Men"
            ]
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          "titulo" => "Association Between Lichen Sclerosus and Verrucous Carcinoma"
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        7 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Association between Lichen Sclerosus and HPV"
        ]
        8 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conclusions"
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        9 => array:2 [
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          "titulo" => "Conflict of Interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2011-03-07"
    "fechaAceptado" => "2011-05-26"
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          "clase" => "keyword"
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          "palabras" => array:6 [
            0 => "Lichen sclerosus"
            1 => "Squamous cell carcinoma"
            2 => "Verrucous carcinoma"
            3 => "Human papilloma virus"
            4 => "Vulvar intraepithelial neoplasia"
            5 => "Penile intraepithelial neoplasia"
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          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec82757"
          "palabras" => array:6 [
            0 => "Liquen escleroso"
            1 => "Carcinoma epidermoide"
            2 => "Carcinoma verrucoso"
            3 => "Virus del papiloma humano"
            4 => "Neoplasia Intraepitelial Vulvar diferenciado"
            5 => "Neoplasia Intraepitelial de Pene diferenciado"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy&#46; The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma&#46; Two pathogenic pathways&#44; differentiated vulvar and penile intraepithelial neoplasias&#44; which have recently been described in relation to squamous cell carcinoma&#44; are both highly associated with genital lichen sclerosus independently of human papilloma virus &#40;HPV&#41; infection&#46; Furthermore&#44; tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus&#46; The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion&#44; and the prognostic importance of the overlapping of these 2 diseases is still unclear&#46; This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas&#44; the possible oncogenic mechanisms involved&#44; and their possible association with HPV infection&#46;</p>"
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        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El liquen escleroso &#40;LE&#41; es una enfermedad inflamatoria cr&#243;nica con un potencial maligno conocido&#46; En la literatura se recogen datos de su asociaci&#243;n tanto con el carcinoma epidermoide &#40;CE&#41; como con el carcinoma verrucoso de localizaci&#243;n anogenital&#46; Recientemente se han descrito dos modalidades de neoplasias intraepiteliales de vulva y pene&#44; el <span class="elsevierStyleItalic">Vulva Intraepithelial Neoplasia</span> &#40;Neoplasia Intraepitelial Vulvar &#91;VIN&#93;&#41; y el <span class="elsevierStyleItalic">Penile Intraepithelial Neoplasia</span> &#40;Neoplasia Intraepitelial de Pene &#91;PIN&#93;&#41; diferenciados&#44; relacionadas con el CE genital&#46; Ambas son entidades altamente ligadas al LE genital e independientes de la infecci&#243;n por el virus del papiloma humano &#40;VPH&#41;&#46; Adem&#225;s&#44; se han demostrado alteraciones moleculares oncog&#233;nicas independientes de la infecci&#243;n por VPH que podr&#237;an explicar el potencial maligno del LE por s&#237; mismo&#46; La posible relaci&#243;n entre el VPH y el LE genital sigue siendo un tema controvertido en el momento actual&#44; y se desconoce la implicaci&#243;n pron&#243;stica cuando coexisten ambas entidades&#46; En el presente art&#237;culo revisaremos la relaci&#243;n del LE con el carcinoma epidermoide y el carcinoma verrucoso&#44; los mecanismos oncog&#233;nicos implicados&#44; as&#237; como su posible asociaci&#243;n con el VPH&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Guti&#233;rrez-Pascual M&#44; et al&#46; Liquen escleroso y carcinoma escamoso&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;21&#8211;8&#46;</p>"
      ]
    ]
    "multimedia" => array:9 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 853
            "Ancho" => 802
            "Tamanyo" => 132371
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Squamous cell carcinoma on a vulvar plaque of lichen sclerosus&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1003
            "Ancho" => 802
            "Tamanyo" => 163124
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Squamous cell carcinoma on a perianal plaque of lichen sclerosus&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 761
            "Ancho" => 952
            "Tamanyo" => 272188
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin&#8211;eosin&#44; original magnification&#44; &#215;100&#46; Usual VIN&#46; Keratinocytes with clear perinuclear halo and irregular nuclei throughout the epidermis corresponding to koilocytes&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 761
            "Ancho" => 952
            "Tamanyo" => 282081
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin&#8211;eosin&#44; original magnification&#44; &#215;200&#46; Differentiated or simplex VIN&#46; Dysmaturation in the lower third of the epidermis&#46; Isolated mitoses&#46; Associated parakeratosis&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 3366
            "Ancho" => 2257
            "Tamanyo" => 364770
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Epidemiological&#44; clinical&#44; prognostic&#44; and immunohistochemical characteristics of usual VIN and differentiated VIN&#46; HPV indicates human papillomavirus&#59; VIN&#44; vulvar intraepithelial neoplasm&#59; <span class="elsevierStyleItalic">p53</span>&#44; <span class="elsevierStyleItalic">p53</span> tumor suppressor gene&#59; <span class="elsevierStyleItalic">p16</span>&#44; p16 protooncogen<span class="elsevierStyleSup">INK4A</span>&#59; MIB1&#44; monoclonal antibody against Ki67 nuclear antigen&#59; LS&#44; lichen sclerosus&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1392
            "Ancho" => 1971
            "Tamanyo" => 113794
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pathogenic pathways implicated in vulvar squamous cell carcinoma according to Neill et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> LS indicates lichen sclerosus&#59; HPV&#44; human papillomavirus&#59; VIN&#44; vulvar intraepithelial neoplasm&#59; SCC&#44; squamous cell carcinoma&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 640
            "Ancho" => 802
            "Tamanyo" => 138283
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Penile squamous cell carcinoma on lichen sclerosus on the glans and balanoprepucial groove&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 1435
            "Ancho" => 1662
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pathogenic pathways implicated in penile squamous cell carcinoma&#46; HPV indicates human papillomavirus&#59; LS&#44; lichen sclerosus&#59; PIN&#44; penile intraepithelial neoplasm&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; HPV&#44; human papillomavirus&#59; NR&#44; not reported&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Author and Year of Publication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; of Cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">HPV Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brisigotti et al&#46; &#40;1989&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Derrick et al&#46; &#40;2000&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nascimiento et al&#46; &#40;2004&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weber et al&#46; &#40;1987&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Luz et al&#46; &#40;1999&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Micali et al&#46; &#40;2001&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HPV 16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vel&#225;zquez and Cubilla &#40;2003&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Barbagli et al&#46; &#40;2006&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wang et al&#46; &#40;2009&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 case of HPV 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
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Controversies in Dermatology
Lichen Sclerosus and Squamous Cell Carcinoma
Liquen escleroso y carcinoma escamoso
M. Gutiérrez-Pascual
Autor para correspondencia
mgutierrezpas@hotmail.com

Corresponding author.
, F.J. Vicente-Martín, J.L. López-Estebaranz
Servicio de Dermatología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pathogenic pathways implicated in penile squamous cell carcinoma&#46; HPV indicates human papillomavirus&#59; LS&#44; lichen sclerosus&#59; PIN&#44; penile intraepithelial neoplasm&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lichen sclerosus is a chronic inflammatory skin disease that is common in white postmenopausal women and affects between 1 in 1000 and 1 in 300 individuals in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It presents on an anogenital site in 85&#37;&#8211;98&#37; of cases and on an extragenital site in only 15&#37;&#8211;20&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The exact causes are not known&#44; but autoimmune&#44; genetic&#44; hormonal&#44; and infectious factors have been implicated&#46; Clinically&#44; lichen sclerosus presents as polygonal papules that coalesce to form pearly plaques&#46; Sometimes&#44; telangiectasias&#44; fissures&#44; ulceration&#44; and internal erosion are associated with the papules&#46; It can be asymptomatic or associated with pruritus and a local burning sensation&#46; Histologic study shows orthokeratotic hyperkeratosis&#44; hydropic degeneration of the basal cells&#44; edema of the upper dermis&#44; and homogenization of collagen associated with a predominantly lymphocytic inflammatory infiltrate&#46; Treatment is with high-potency corticosteroids &#40;level A evidence&#41; and topical immunomodulators &#40;level B and C evidence&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Given the potential for long-term malignancy&#44; check-ups at least every 6 months are recommended for patients with anogenital lichen scerlosus&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Human papillomavirus &#40;HPV&#41; is a DNA virus of the <span class="elsevierStyleItalic">Papovaviridae</span> family&#46; To date&#44; more than 100 different types have been identified&#46; Of these&#44; 5 genera &#40;&#945;&#44; &#946;&#44; &#947;&#44; &#956;&#44; and &#957;&#41; only affect humans&#46; &#945;-HPVs &#40;the mucosal form&#41; are implicated in cervical cancer&#44; genital carcinomas&#44; and head and neck carcinomas while &#946;-HPVs are associated with verruciform epidermodysplasia and nonmelanoma skin cancers such as squamous cell carcinoma &#40;SCC&#41; in particular&#46; &#947;-HPV and &#957;-HPV are usually associated with benign lesions&#44; although they too have been implicated in the development of different nonmelanoma skin cancers&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The exact oncogenic mechanism of HPV has not yet been elucidated&#46; Cellular abnormalities in the <span class="elsevierStyleItalic">p53</span> gene and the retinoblastoma gene caused by viral E6 and E7 proteins&#44; encoded by mucosal HPV&#44; are thought to play a role in cellular immortality&#46; In the case of subtypes with a lower oncogenic potential &#40;&#946; and &#947; types&#41;&#44; environmental factors such as ultraviolet radiation are required to favor cell proliferation&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Association between Lichen Sclerosus and SCC</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Lichen Sclerosus and SCC in Women</span><p id="par0015" class="elsevierStylePara elsevierViewall">The association between anogenital lichen sclerosus and SCC &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41; has been extensively reported in the literature&#46; We only found 1 isolated report of SCC occurring on extragenital lichen sclerosus&#44; so we cannot rule out the possibility that it was a chance finding&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Between 3&#37; and 7&#37; of vulvar SCCs occur on vulvar lichen sclerosus&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Careful histologic study of samples from patients with vulvar SCC shows evidence of lichen sclerosus in 60&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Derrick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> published a retrospective observational study of 23 women with anogenital SCC&#44; 8 &#40;34&#37;&#41; of whom had lichen sclerosis of several years&#8217; duration&#46; An association between lichen sclerosus and vulvar SCC was found in 14 &#40;31&#37;&#41; of the 44 patients studied by Chiesa-Vottero et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> by 7 &#40;50&#37;&#41; of the 14 patients studied by Poulsen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and by 47 &#40;61&#37;&#41; of the 78 patients studied by Leibowitch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In 1995&#44; Carli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> reported an incidence of vulvar SCC on lichen sclerosus of 1&#46;4&#37; &#40;3&#47;211&#41; after 20 months of follow-up&#46; Few other prospective studies on the topic have been published in the literature&#46; Overall though&#44; the evidence suggests that lichen sclerosus is an HPV-independent carcinogenic factor&#46; This corroborates its potential for malignant transformation and the need for long-term follow-up in these patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although the exact carcinogenic mechanism of lichen sclerosus is still under debate&#44; several HPV-independent hypotheses have been put forward&#46; Ueda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> demonstrated cellular monoclonality in 6 patients with vulvar lichen sclerosus but no HPV infection or clinical manifestations indicative of associated SCC&#46; Such an observation pointed to the malignant potential of lichen sclerosus in absence of clinical manifestations that might lead to suspicion of neoplastic proliferation&#46; Rolfe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> observed mutations in the <span class="elsevierStyleItalic">p53</span> gene in 10 out of 12 patients with lichen sclerosus and in 7 of these 10&#44; the mutation was located in the same codon as the one implicated in the SCC lesions&#46; The authors therefore concluded that they were dealing with another carcinogenic mechanism&#44; independent of HPV&#44; for the development of anogenital SCC&#46; Mutations in the <span class="elsevierStyleItalic">PTEN</span> gene in some differentiated vulvar SCCs and vulvar intraepithelial neoplasias &#40;VINs&#41; have also been observed&#44; as well as microsatellite instability in 20&#37; and 12&#37; of differentiated VINs and lichen sclerosus lesions&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Finally&#44; in 2010&#44; a study was published that demonstrated hypermethylation of genes such as <span class="elsevierStyleItalic">RASSF2A</span>&#44; <span class="elsevierStyleItalic">MGMT</span>&#44; and <span class="elsevierStyleItalic">TSP-1</span> in SCC only when associated with lichen sclerosus&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> It seems that chronic inflammation associated with lichen sclerosus could lead to molecular abnormalities that in turn could facilitate neoplastic proliferation&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The precursor lesion in vulvar SCC is VIN&#46; Traditionally&#44; the literature described 3 grades of VIN&#58; VIN 1&#44; VIN 2&#44; and VIN 3&#44; according to whether the epithelial dysplasia was mild&#44; moderate&#44; or severe&#44; respectively&#46; This classification was used to ensure alignment with the well-known classification of cervical intraepithelial neoplasia &#40;CIN&#41;&#46; The VIN terminology was&#44; however&#44; modified in 2004&#44; and the term VIN 1 fell into disuse&#46; Currently&#44; we only have 2 categories&#44; VIN 2 and VIN 3&#44; to refer to moderate and severe vulvar dysplasias&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Jones et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and Neill et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> established 2 clinicopathologic types of VIN&#58; usual VIN &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and differentiated or simplex VIN &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The latter accounts for between 2&#37; and 10&#37; of all diagnosed VIN&#46; <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a> shows the clinical and immunohistochemical characteristics of each subtype&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;20</span></a> Differentiated or simplex VIN is the precursor of vulvar SCC associated with lichen sclerosus &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In 2011&#44; Van de Nieuwenhof et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> published a study showing that a high percentage of patients with lichen sclerosus that progressed to SCC should have been diagnosed initially with differentiated VIN&#46; Of a total of 60 cases of lichen sclerosus associated with SCC&#44; 42&#37; were reclassified in a second histologic study as differentiated VIN&#46; The majority of reclassified lesions had initially been diagnosed as lichen sclerosus associated with HPV-dependent lesions&#44; as they showed signs of cellular atypia or epidermal hyperplasia&#46; The authors observed that the time to progression to SCC was shorter when the precursor pathological process was differentiated VIN &#40;28 months on average&#41; compared to when it was lichen sclerosus &#40;84 months on average&#41;&#46; According to previous studies by the same authors&#44; up to 33&#37; of differentiated VIN progressed to SCC&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> in contrast to the percentage of 3&#37;&#8211;7&#37; cited earlier for lichen sclerosus&#46; Moreover&#44; these authors found that the histologic presence of dyskeratosis&#44; hyperkeratosis&#44; hyperplasia&#44; and atypia in the basal keratinocytes of patients diagnosed initially with lichen sclerosus was associated with a greater risk of vulvar SCC&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Lichen Sclerosus and SCC in Men</span><p id="par0045" class="elsevierStylePara elsevierViewall">The association between lichen sclerosus and penile SCC is less extensively documented in the literature &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; It has been postulated that concomitant factors such as diabetes mellitus&#44; recurrent balanitis&#44; phimosis&#44; HPV infection&#44; and poor hygiene could be etiopathogenic factors implicated in penile SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Data on penile SCC in the literature are variable and inconclusive&#44; with 5&#46;8&#37;&#8211;30&#37; of patients with lichen sclerosus having malignant disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> In a study of 130 men with genital lichen sclerosus&#44; Barbagli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> found that 8&#46;4&#37; of lesions were malignant &#40;SCC&#44; verrucous carcinoma&#41; or premalignant &#40;Queyrat erythroplasia&#41;&#46; The time interval between diagnosis of lichen sclerosus and the development of SCC was 14&#8211;30 years&#46; In their series of 54 patients with lichen sclerosus&#44; Campus et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> reported 2 cases &#40;3&#46;7&#37;&#41; of penile SCC&#46; Wallace<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> described 2 patients out of 44 &#40;4&#46;5&#37;&#41; with lichen sclerosus who developed penile SCC&#46; According to the above studies&#44; the risk of developing penile SCC in patients with lichen sclerosus ranges from 4&#37; to 8&#37;&#46; If we now analyze how many patients with penile SCC have histologic evidence of lichen sclerosus&#44; the percentage is 32&#37;&#8211;50&#37;&#46; Velazquez and Cubilla<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> observed that 68 &#40;32&#46;8&#37;&#41; out of 207 of their patients with penile SCC had histologic evidence of lichen sclerosus&#46; Perceau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> found histologic evidence of lichen sclerosus in 8 &#40;44&#37;&#41; of their 18 patients with penile SCC&#44; while Powell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> reported similar evidence in 8 of their 20 patients &#40;40&#37;&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Recently&#44; by analogy with the VIN categories&#44; the grades PIN 2 and PIN 3 have been introduced to refer to penile intraepithelial neoplasm with moderate or severe dysplasia&#44; respectively&#46; Two forms of PIN have been described&#58; differentiated PIN&#44; equivalent to differentiated VIN and often associated with penile lichen sclerosus&#44; and undifferentiated or Bowenoid PIN&#44; equivalent to usual VIN and associated with HPV infection &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; Renaud-Vilmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> performed a retrospective analysis of 53 patients with penile SCC with the aim of assessing the histologic abnormalities observed in lesions adjacent to the tumor&#44; as well as the possible relation between these lesions and different types of SCC&#46; HPV-associated SCCs were warty&#44; basaloid&#44; or mixed in nature&#44; and accounted for approximately 45&#37; &#40;24 out of 53&#41; of all penile SCCs in their series&#46; They observed underlying Bowenoid PIN in all cases of these carcinomas&#46; The etiopathogenic role of HPV in Bowenoid PIN was also demonstrated by Chaux et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> who found that overexpression of the <span class="elsevierStyleItalic">p16</span> gene<span class="elsevierStyleSup">INK4a</span>&#8212;which is strongly associated with HPV infection&#8212;was positive in penile basaloid and warty SCCs &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;0001&#41; but not in SCCs associated with differentiated PIN and lichen sclerosus&#46; The histologic subtypes of SCC not associated with HPV infection are the usual and verrucous forms &#40;well-differentiated variant of SCC with no evidence of associated koilocytosis&#41; and accounted for 55&#37; of all cases &#40;29 out of 53&#41; in the study by Renaud-Vilmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Underlying lichen sclerosus was detected in 93&#37; of these carcinomas&#46; Likewise&#44; no association has been found between HPV infection and sarcomatoid SCC of the penis in studies published to date&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Renaud-Vilmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> also observed that the presence of acanthosis and orthokeratotic hyperkeratosis&#44; the so-called squamous cell hyperplasia&#44; was frequently associated with differentiated PIN and lichen sclerosus&#46; Similar findings were also reported by Van de Nieuwenhof et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> in their study of vulvar SCC&#44; where squamous cell hyperplasia was more frequent in patients with lichen sclerosus that progressed to SCC&#46; Lichen sclerosus is an HPV-independent etiopathogenic factor in some types of usual and verrucous penile SCC&#44; with differentiated PIN and squamous cell hyperplasia being the histological variants associated with and implicated in carcinogenesis&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Association Between Lichen Sclerosus and Verrucous Carcinoma</span><p id="par0060" class="elsevierStylePara elsevierViewall">Anogenital verrucous carcinoma&#44; also known as Buschke-L&#246;wenstein tumor&#44; is a low-grade indolent tumor that rarely undergoes local metastasis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">There are 29 cases of anogenital verrucous carcinoma and lichen sclerosus reported in the literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Of these&#44; 12 were on the vulva and 17 on the penis&#46; Only 4 were tested for HPV infection&#44; with positive results in 2 patients&#44; 1 with type 16 HPV infection and the other with type 11 HPV infection&#46; In a retrospective study by Wang et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> the objective was to assess a possible association between lichen sclerosus and verrucous carcinoma&#46; In total&#44; 13 patients with genital and perianal verrucous carcinomas were included &#40;5 with a vulvar lesion&#44; 3 with a penile lesion&#44; and 5 with a perianal lesion&#41;&#46; None of the perianal verrucous carcinomas reported were associated with lichen sclerosus&#46; The authors observed that the 5 patients with vulvar verrucous carcinoma had associated lichen sclerosus&#44; whereas only 1 of the patients with penile verrucous carcinoma and none of those with perianal verrucous carcinoma had evidence of lichen sclerosus&#46; Evidence of local recurrence was not observed in patients with no associated lichen sclerosus&#44; whereas 3 &#40;50&#37;&#41; of the 6 patients with lichen sclerosus had recurrence&#46; According to the authors&#44; the chronic inflammation and oxidative cell damage caused by lichen sclerosus could explain the propensity for local recurrence&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The exact mechanisms responsible for the association of lichen sclerosus and verrucous carcinoma are not clear&#44; but factors such as HPV infection&#44; mutations in the <span class="elsevierStyleItalic">p53</span> gene&#44; chronic inflammation&#44; and oxidative stress could all play a part&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The prevalence of HPV infection in patients with lichen sclerosus is still subject to much debate&#44; and a wide range of percentages can be found in the literature&#46; In 18&#37;&#8211;67&#37; of patients&#44; the most common genotypes found are 6 and 11&#44; both of which are implicated in the pathogenesis of verrucous carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Prolonged treatment with the highly potent topical corticosteroids prescribed for lichen sclerosus could favor reactivation of latent HPV infections and increased carcinogenis&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> On the other hand&#44; it has been demonstrated that mutations in the <span class="elsevierStyleItalic">p53</span> gene in patients with vulvar lichen sclerosus<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> and greater oxidative tissue damage resulting from impaired enzymatic antioxidant defense could explain the greater oncogenic risk&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Case reports have been published of basal cell epitheliomas&#44; melanomas&#44; and Merkel cell carcinomas located on anogenital lichen sclerosus&#44; but lichen sclerosus has not been shown to be associated with a greater incidence of these malignancies or to be implicated in their development&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Association between Lichen Sclerosus and HPV</span><p id="par0085" class="elsevierStylePara elsevierViewall">The prevalence of HPV infection in patients with lichen sclerosus varies from 1&#37; to 21&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> With the aim of investigating whether the prevalence of HPV infection was greater in patients with lichen sclerosus than in the healthy population&#44; Nasca et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> studied 46 men with lichen sclerosus and compared them with a control group&#46; With polymer chain reaction techniques to identify HPV infection&#44; they found that 17&#46;4&#37; of patients with lichen sclerosus tested positive for HPV &#40;75&#37; of them with type 16 HPV&#41; compared to 8&#46;7&#37; for the control group &#40;odds ratio&#44; 2&#46;55&#41;&#46; In a previous study of 86 patients with lichen sclerosus and penile SCC&#44; the authors observed that 8 &#40;9&#46;3&#37;&#41; of the 86 patients were HPV-16 positive and the latency time between lichen sclerosus and the onset of SCC was less &#40;average 15 years&#41; in HPV-positive patients than in HPV-negative ones &#40;average 23 years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The authors suggested that infection with HPV could accelerate the malignant process&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Vignale et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> reported that clinical improvement in their 2 HPV-positive patients with lichen sclerosus was only achieved after adding imiquimod for 3 months to topical corticosteroid treatment&#46; The authors proposed 2 possible explanations for this observation&#58; either the virus might be directly linked to development of lichen sclerosus or it was a contaminant unrelated to development of the disease&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Different hypotheses have been put forward to explain the association between lichen sclerosus and HPV&#46; Patients with lichen sclerosus might have a greater risk of HPV infection as a result of genetic predisposition for defective viral clearance&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> On the other hand&#44; prolonged use of potent topical corticosteroids could reactivate latent opportunistic high- and low-risk mucosotropic HPV infection&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Finally&#44; other authors suggest that patients with lichen sclerosus are more susceptible than healthy individuals to the development of malignancies caused by oncogenic HPV types&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In contrast to the 2 studies commented earlier&#44; Aid&#233; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> investigated the presence of HPV in 34 patients with vulvar lichen sclerosus&#44; and made a comparison with 17 patients without vulvar disease &#40;control group&#41;&#46; None of the samples from patients with lichen sclerosus had concurrent HPV infection&#44; although such infection was found in 23&#46;2&#37; of samples from the control group&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In short&#44; there are studies that suggest that concurrent infection with HPV in patients with lichen sclerosus could be an extra oncogenic factor for the development of anogenital SCC&#46; Currently&#44; the data are still subject to debate&#46; Larger studies with longer follow-up are needed to clarify whether this association is a chance occurrence or whether HPV may really have an etiopathogenic role in anogenital lichen sclerosus&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Anogenital lichen sclerosus should be considered as a condition with potential for malignant transformation to SCC&#46; We should therefore ensure that these patients receive long-term follow-up&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Although the risk of developing penile SCC is 4&#37;&#8211;8&#37; in patients with lichen sclerosus according to published series&#44; there is histologic evidence of lichen sclerosus in between 32&#37; and 50&#37; of samples from patients with penile SCC&#46; Similar findings have been reported for the association between vulvar SCC and lichen sclerosus&#46; Thus&#44; although widely accepted figures put the percentage of SCCs occurring on lichen sclerosus at 3&#37;&#8211;7&#37; of cases&#44; histologic evidence of lichen sclerosus can be found in up to 60&#37; of vulvar SCC studies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">HPV-independent oncogenic molecular changes have been shown that could explain the malignant potential of lichen sclerosus in its own right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">There are 2 clinicopathologic forms of vulvar SCC&#44; usual VIN&#44; which is associated with HPV infection&#44; and differentiated VIN&#44; which is the precursor for malignant transformation in cases of lichen sclerosus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">By analogy with VIN&#44; 2 variants of PIN have been described recently&#44; the undifferentiated or Bowenoid form associated with HPV infection and differentiated PIN&#44; which is the premalignant precursor of penile SCC in patients with lichen sclerosus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">We do not have sufficient evidence of an association between HPV and lichen sclerosus&#44; as the studies in the literature are contradictory&#46;</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres95598"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec82758"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres95599"
          "titulo" => "Resumen"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec82757"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Association between Lichen Sclerosus and SCC"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Lichen Sclerosus and SCC in Women"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Lichen Sclerosus and SCC in Men"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Association Between Lichen Sclerosus and Verrucous Carcinoma"
        ]
        7 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Association between Lichen Sclerosus and HPV"
        ]
        8 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conclusions"
        ]
        9 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conflict of Interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-03-07"
    "fechaAceptado" => "2011-05-26"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec82758"
          "palabras" => array:6 [
            0 => "Lichen sclerosus"
            1 => "Squamous cell carcinoma"
            2 => "Verrucous carcinoma"
            3 => "Human papilloma virus"
            4 => "Vulvar intraepithelial neoplasia"
            5 => "Penile intraepithelial neoplasia"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec82757"
          "palabras" => array:6 [
            0 => "Liquen escleroso"
            1 => "Carcinoma epidermoide"
            2 => "Carcinoma verrucoso"
            3 => "Virus del papiloma humano"
            4 => "Neoplasia Intraepitelial Vulvar diferenciado"
            5 => "Neoplasia Intraepitelial de Pene diferenciado"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lichen sclerosus is a chronic inflammatory disease that can progress to malignancy&#46; The literature indicates an association with anogenital squamous cell carcinoma and verrucous carcinoma&#46; Two pathogenic pathways&#44; differentiated vulvar and penile intraepithelial neoplasias&#44; which have recently been described in relation to squamous cell carcinoma&#44; are both highly associated with genital lichen sclerosus independently of human papilloma virus &#40;HPV&#41; infection&#46; Furthermore&#44; tumor-promoting molecular changes unrelated to HPV infection have been demonstrated and may explain the malignant potential of lichen sclerosus&#46; The possible relationship between HPV and genital lichen sclerosus currently remains open to discussion&#44; and the prognostic importance of the overlapping of these 2 diseases is still unclear&#46; This review considers the relationship between lichen sclerosus and squamous cell and verrucous carcinomas&#44; the possible oncogenic mechanisms involved&#44; and their possible association with HPV infection&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El liquen escleroso &#40;LE&#41; es una enfermedad inflamatoria cr&#243;nica con un potencial maligno conocido&#46; En la literatura se recogen datos de su asociaci&#243;n tanto con el carcinoma epidermoide &#40;CE&#41; como con el carcinoma verrucoso de localizaci&#243;n anogenital&#46; Recientemente se han descrito dos modalidades de neoplasias intraepiteliales de vulva y pene&#44; el <span class="elsevierStyleItalic">Vulva Intraepithelial Neoplasia</span> &#40;Neoplasia Intraepitelial Vulvar &#91;VIN&#93;&#41; y el <span class="elsevierStyleItalic">Penile Intraepithelial Neoplasia</span> &#40;Neoplasia Intraepitelial de Pene &#91;PIN&#93;&#41; diferenciados&#44; relacionadas con el CE genital&#46; Ambas son entidades altamente ligadas al LE genital e independientes de la infecci&#243;n por el virus del papiloma humano &#40;VPH&#41;&#46; Adem&#225;s&#44; se han demostrado alteraciones moleculares oncog&#233;nicas independientes de la infecci&#243;n por VPH que podr&#237;an explicar el potencial maligno del LE por s&#237; mismo&#46; La posible relaci&#243;n entre el VPH y el LE genital sigue siendo un tema controvertido en el momento actual&#44; y se desconoce la implicaci&#243;n pron&#243;stica cuando coexisten ambas entidades&#46; En el presente art&#237;culo revisaremos la relaci&#243;n del LE con el carcinoma epidermoide y el carcinoma verrucoso&#44; los mecanismos oncog&#233;nicos implicados&#44; as&#237; como su posible asociaci&#243;n con el VPH&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Guti&#233;rrez-Pascual M&#44; et al&#46; Liquen escleroso y carcinoma escamoso&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;21&#8211;8&#46;</p>"
      ]
    ]
    "multimedia" => array:9 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Squamous cell carcinoma on a vulvar plaque of lichen sclerosus&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1003
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Squamous cell carcinoma on a perianal plaque of lichen sclerosus&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 761
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            "Tamanyo" => 272188
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin&#8211;eosin&#44; original magnification&#44; &#215;100&#46; Usual VIN&#46; Keratinocytes with clear perinuclear halo and irregular nuclei throughout the epidermis corresponding to koilocytes&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
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            "Tamanyo" => 282081
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin&#8211;eosin&#44; original magnification&#44; &#215;200&#46; Differentiated or simplex VIN&#46; Dysmaturation in the lower third of the epidermis&#46; Isolated mitoses&#46; Associated parakeratosis&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 3366
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            "Tamanyo" => 364770
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Epidemiological&#44; clinical&#44; prognostic&#44; and immunohistochemical characteristics of usual VIN and differentiated VIN&#46; HPV indicates human papillomavirus&#59; VIN&#44; vulvar intraepithelial neoplasm&#59; <span class="elsevierStyleItalic">p53</span>&#44; <span class="elsevierStyleItalic">p53</span> tumor suppressor gene&#59; <span class="elsevierStyleItalic">p16</span>&#44; p16 protooncogen<span class="elsevierStyleSup">INK4A</span>&#59; MIB1&#44; monoclonal antibody against Ki67 nuclear antigen&#59; LS&#44; lichen sclerosus&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 1392
            "Ancho" => 1971
            "Tamanyo" => 113794
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pathogenic pathways implicated in vulvar squamous cell carcinoma according to Neill et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> LS indicates lichen sclerosus&#59; HPV&#44; human papillomavirus&#59; VIN&#44; vulvar intraepithelial neoplasm&#59; SCC&#44; squamous cell carcinoma&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 640
            "Ancho" => 802
            "Tamanyo" => 138283
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Penile squamous cell carcinoma on lichen sclerosus on the glans and balanoprepucial groove&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 1435
            "Ancho" => 1662
            "Tamanyo" => 147187
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Pathogenic pathways implicated in penile squamous cell carcinoma&#46; HPV indicates human papillomavirus&#59; LS&#44; lichen sclerosus&#59; PIN&#44; penile intraepithelial neoplasm&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; HPV&#44; human papillomavirus&#59; NR&#44; not reported&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Author and Year of Publication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; of Cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">HPV Type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brisigotti et al&#46; &#40;1989&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Derrick et al&#46; &#40;2000&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nascimiento et al&#46; &#40;2004&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weber et al&#46; &#40;1987&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Luz et al&#46; &#40;1999&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Micali et al&#46; &#40;2001&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HPV 16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vel&#225;zquez and Cubilla &#40;2003&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Barbagli et al&#46; &#40;2006&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wang et al&#46; &#40;2009&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vulva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC&#43;LS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 case of HPV 11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Penis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Published Cases of Verrucous Carcinoma &#40;VC&#41; Associated With Genital Lichen Sclerosus &#40;LS&#41;&#46;</p>"
        ]
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:41 [
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                            1 => "B&#46;M&#46; Davis"
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                  "host" => array:1 [
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                      "autores" => array:1 [
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                          "etal" => false
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "V&#46; Mons&#225;lvez"
                            1 => "R&#46; Rivera"
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                            0 => "S&#46;M&#46; Neill"
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                            2 => "F&#46;M&#46; Tatnall"
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                  "contribucion" => array:1 [
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                    0 => array:1 [
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                          "etal" => false
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                            0 => "A&#46; Sergeant"
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                            2 => "L&#46;J&#46; Mackintosh"
                            3 => "P&#46; McHenry"
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                      "Revista" => array:5 [
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                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46; Henquet"
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                          "autores" => array:5 [
                            0 => "E&#46;K&#46; Derrick"
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                            2 => "A&#46; Kobza-Black"
                            3 => "P&#46;H&#46; McKee"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "H&#46; Poulsen"
                            1 => "J&#46; Junge"
                            2 => "M&#46; Vyberg"
                            3 => "T&#46; Horn"
                            4 => "F&#46; Lundvall"
                          ]
                        ]
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                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "APMIS"
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                        "paginaInicial" => "835"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The epithelial changes associated with squamous cell carcinoma of the vulva&#58; a review of the clinical&#44; histological and viral findings in 78 women"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
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                            1 => "S&#46; Neill"
                            2 => "M&#46; Pelisse"
                            3 => "M&#46; Moyal-Baracco"
                          ]
                        ]
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