LAUSR

Human papillomavirus (HPV)-associated lesions today seem to be a much more complex issue than just ‘stubborn and recalcitrant warts’ as one of the sexually transmitted diseases (STD) ‘from the list’. However, anogenital warts representing the most common HPV-related “benign” lesions of the genitourinary tract should by no means be neglected (nothing related to the HPV is completely “benign”). The spectrum of the HPV-associated genital diseases today ranges from ‘benign’ anogenital warts to malignant cervical, vulvar, anal, penile and even extragenital cancers such as oral and tonsillar. Up to now, the most relevant (and most routinely used) diagnostic criterion for the anogenital HPV warts is clinical, thus, the proper visibility of the lesions remains a very important issue. Classically, HPV lesions can be presented in three different manifestations: clinical, subclinical and latent infection. Clinical anogenital lesions are defined as those visible to the naked eye, without any enhancing techniques. Furthermore, it has been well recognized that HPV infections are frequently associated with genital (and non-genital) precancerous lesions, including not only cervical intraepithelial neoplasia (CIN), but also vaginal (VIN), vulvar (VaIN), penile (PeIN), anal (AIN) or any other intraepithelial neoplasia involved. Latent infections, defined by the presence of HPV DNA in areas with no clinical or histological evidence of HPV infection, are probably the most common form of anogenital HPV infections and present ‘reservoir’ of HPV (high -risk HPV DNA types included). However, one half to two thirds of HPV-associated lesions are clinically invisible (‘subclinical lesions’) and could be detected only after the acetic acid test and/ or any other enhancing techniques (not many available, as a matter of fact). This practically means colposcopy (peniscopy, anoscopy, vulvoscopy, etc.), a specialized technique involving the topical application of 3–5% acetic acid prior to the beginning of the procedure in order to enhance the visibility. Subclinical lesions are ‘actively infectious’ because of the active replication of the HPV virions. Thus, the significance of the ‘subclinical lesions’ is great and that brings us to the point of the need of the good and proper visualization technique. Stereophotogrammetry is a technique that obtains two or more images from different angles, which can subsequently be reconstructed into a 3D image. It is validated for use in scars, basal cell carcinoma, wounds and wrinkle. Rijsbergen et al. in this issue have demonstrated that stereophotogrammetric 3D imaging is an accurate and precise method for the characterization of HPV-related lesions and is applicable for the assessment of these lesions in a clinical setting. It is good additional help in diagnosing cutaneous warts, anogenital warts and anogenital intraepithelial neoplasia. However, one clear limitation of the stereophotogrammetry for routine use in the diagnosis of HPV lesions is the fact that it is time-consuming, especially for anogenital warts which are usually multifocal and numerous. Since it is a portable, hand-held system, we believe that it is useful in the diagnosis of subclinical infections (intraepithelial neoplasms), instead of using colposcope/peniscope/anoscope. There is no definitive first-line aetiological treatment for anogenital and/or cutaneous warts, and no single treatment per se has demonstrated to be ideal for all patients or all warts so far. Most currently available treatments do not eradicate HPV; they physically remove lesions with a certain degree of recurrences. By measuring the physical dimensions of wounds or scars, clinicians would receive feedback about the success of a selected treatment approach. Following immunotherapy, HPV lesions can at first increase in size before regression (pseudoprogression). Accordingly, 3D photography can help to assess the response, but, on the other hand, it is time-consuming and it might require extra outpatients’ visits, not to speak of the ‘technical and financial’ aspect. However, this technique might give additional and more precise information! Overall, we believe that stereophotogrammetry is an excellent additional technique for more precise visualization and treatment follow-up of the HPV-associated genital lesions and it is certainly a step forward. Nonetheless, stereophotogrammetry, like any other method, has its limitations and should be definitely applied under the strict guidance of the very well-trained clinician experienced in the HPV-genital lesions management.