| Background and ObjectiveBowen’s disease reported firstly by Bowen in 1912,also known as squamous cell carcinoma in situ,is a kind of intraepidermal squamous cell carcinoma.BD often happens in the middle-aged and elderly and various parts of the skin or mucous membrane.At present,the etiology of BD is not clear,which may be related to radiation,arsenic compounds,HPV infection and other factors.The appearance of most lesions is dark red or reddish macular papules,irregular shape,with a little scab or scales on the surface,which is easy to be confused with squamous cell carcinoma,basal cell carcinoma,seborrheic keratosis and so on.Histopathological examination is the gold standard for its diagnosis.Clinically,patients with BD are often treated alone or in combination with surgical resection,photodynamic,cryosurgery,imiquimod and so on.It has been reported that 3%to 5%of BD can evolve into squamous cell carcinoma,and the risk of perineal BD developing into invasive one is higher,up to 10%.Earlier diagnosis and standardized therapy are essential for the prognosis of patients.Nowadays,the relevant literature on this kind of disease is limited at home and abroad,and clinicians do not have enough understanding of the clinical features of the disease.The aim of this research is to summarize the clinical characteristics of BD,so as to provide reference materials for the diagnosis and treatment of BD.MethodsThe clinical data of 112 patients with BD diagnosed by dermatology,plastic surgery and pathological examination in the first affiliated Hospital of Zhengzhou University from Jan 2013 to Aug 2020 were analyzed retrospectively in the first part of this study,including sex,age,course of disease,location of lesion,size of focus,number of lesions,characteristics of skin lesions,concomitant symptoms,exposure history of arsenic compounds,pathological features,treatment regimen,changes of skin lesions and recurrence after treatment.A total of 95 patients were followed up successfully and effectively,with a follow-up rate of 84.8%,including 47 males and 48 females,with the shortest follow-up period of 2 months.The second part of the study conducted a systematic review and meta-analysis of the literature published before January 31,2021,comparing the efficacy of photodynamic therapy with non-surgical treatment options such as cryotherapy,imiquimod,and 5-fluorouracil in the treatment of BD.Results1.Gender distribution Ninety-five patients with BD include 47 males and 48 females,with a sex ratio of 1.02.2.Age distribution The age for origin diagnosis was 22～97 years old at first visit,with the(62.8 ± 14.4)years old for average age.The age for origin diagnosis was mostly over 50 years old,with a total of 79 cases(83.2%),the most in the age group of 60 to 69 years old,a total of 33 cases(34.2%).3.The course of disease The pathogenesis of disease was from 1 month to 40 years,with an average course of disease was(4.6±1.7)years.4.Size,quantity and location of lesions The lesion area of 95 patients in this group was about 0.5×0.2cm2～7.0×6.0cm2,in which the maximum diameter of lesions≤3cm and>3cm were 56 and 39 cases respectively.The total number of lesions was 116(95 cases),81 cases(85.3%)were single,and 14 cases(14.7%)were sporadic.Among them,8 patients had 2 different skin lesions at the same time,6 patients had 3 or more skin lesions at the first visit.There were 22 lesions in the head and neck(20 cases),47 lesions in the trunk(42 cases),including 8 in the chest wall,12 in the abdominal wall,24 in the back(19 cases),3 in the buttocks,6 in the perineum(5 cases),4 in the upper limbs except the hands,1 in the upper arm,3 in the forearms,and 17 in the hands(13 cases).There were 15 lower limbs(13 cases)except the foot,including 11 thighs(9 cases),4 calves and 5 feet(including sole,heel and toe).5.Concomitant symptoms Sixty-four cases(67.3%)with concomitant symptoms had no symptoms,24 cases(25.0%)complained of mild itching,and 7 cases(7.7%)complained of mild itching with mild tenderness.6.Arsenic exposure history Four of 95 patients with BD had a long history of arsenic exposure,3 of 4 were diagnosed as arsenic keratosis,and one of 3 patients with arsenic keratosis received long-term intravenous drip of arsenic trioxide due to the treatment of acute promyelocytic leukemia.7.Pathological features All the pathological specimens of 95 patients with BD showed hyperkeratosis or incomplete epidermis and mild hyperplasia of the spinous layer,well-defined epidermis,dermis and intact basal cell layer.the cells in the epidermis were disordered,the size and shape of the cells were not consistent,the nucleus was large and dark stained,and the nucleolus was obvious.a few blood vessels in the dermis were dilated with infiltration of lymphoid cells around the vessels.8.HPV infection Among the 14 patients who underwent HPV testing,the skin lesions were located on the hands in 6 cases,the perineum in 5 cases,the feet in 2 cases,and the trunk in 1 case,A total of 5 patients with HPV infection were detected,of which 3 had skin lesions in the perineum,and the other 2 were in the hands and groin respectively.9.Misdiagnosis rate Eleven cases were suspected to be squamous cell carcinoma,with 7 for solar keratosis,7 for psoriasis,5 for eczema,5 for basal cell carcinoma,4 for Bowenoid papulosis,3 for seborrheic keratosis and 2 cases of Extramammary Paget’s disease before clear diagnosis.The remaining cases was consistent with the pathological diagnosis,with a misdiagnosis for 46.3%.10.Treatment and prognosis Ninety-five BD patients were treated with a total of 5 treatment options:76 cases underwent surgical resectio,and 2 recurrences were followed up;11 cases were treated with photodynamic therapy,and the skin lesions had resolved significantly,and 1 recurrence was followed up;5 cases undergoing cryotherapy combined with photodynamic therapy,and skin lesions are significantly relieved,with none recurrence during follow-up;3 cases were treated with topical imiquimod and skin lesions are significantly relieved,with none recurrence during follow-up.11.Meta-analysis The cure rate of the photodynamic group was higher than that of the freezing group(OR=4.74,P=0.0001),the 5-fluorouracil group(OR=7.55,P<0.00001),and the imiquimod group(OR=9.75,P=0.01).There were differences Statistically significant;the recurrence rate of the photodynamic group was lower than that of the 5-fluorouracil group,and the difference was statistically significant(OR=0.38,P=0.03);the recurrence rate of the photodynamic group was not significantly different from that of the freezing group(OR=0.56,P=0.12).Conclusions1.BD may be related to arsenic compounds and HPV infection.Patients with a history of arsenic exposure should be tested for arsenic content,and patients with skin lesions in the perineum should be tested for HPV.2.Surgical resection is the primary option for BD therapy.For patients with multiple skin lesions,large area,special location,aesthetic appearance requirements and surgical contraindications,photodynamic therapy,cryotherapy and imiquimod can be considered alone or in combination.3.The efficacy of photodynamic therapy for BD is better than freezing,imiquimod and 5-fluorouracil. |
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