Papillomavirus in human conjunctival papillomas

Cancers with epidemiologic signatures of viral oncogenicity among immunocompromised populations in the United States

BACKGROUND

Immunosuppressed individuals have elevated risk of virus-related cancers. Identifying cancers with elevated risk in people with HIV and solid organ transplant recipients, 2 immunosuppressed populations, may help identify novel etiologic relationships with infectious agents.

METHODS

We used 2 linkages of population-based cancer registries with HIV and transplant registries in the United States. Cancer entities were systematically classified according to site and histology codes. Standardized incidence ratios were used to compare risk in people with HIV and solid organ transplant recipients with the general population. For selected cancer entities, incidence rate ratios were calculated for indicators of immunosuppression within each population.

RESULTS

We identified 38 047 cancer cases in solid organ transplant recipients and 53 592 in people with HIV, yielding overall standardized incidence ratios of 1.66 (95% confidence interval [CI] = 1.65 to 1.68) and 1.49 (95% CI = 1.47 to 1.50), respectively. A total of 43 cancer entities met selection criteria, including conjunctival squamous cell carcinoma (people with HIV standardized incidence ratio = 7.1, 95% CI = 5.5 to 9.2; solid organ transplant recipients standardized incidence ratio = 9.4, 95% CI = 6.8 to 12.6). Sebaceous adenocarcinoma was elevated in solid organ transplant recipients (standardized incidence ratio = 16.2, 95% CI = 14.0 to 18.6) and, among solid organ transplant recipients, associated with greater risk in lung and heart transplant recipients compared with recipients of other organs (incidence rate ratio = 2.3, 95% CI = 1.7 to 3.2). Salivary gland tumors, malignant fibrous histiocytoma, and intrahepatic cholangiocarcinoma showed elevated risk in solid organ transplant recipients (standardized incidence ratio = 3.9,  4.7, and  3.2, respectively) but not in people with HIV. However, risks for these cancers were elevated following an AIDS diagnosis among people with HIV (incidence rate ratio = 2.4, 4.3, and  2.0, respectively).

CONCLUSIONS

Elevated standardized incidence ratios among solid organ transplant recipients and people with HIV, and associations with immunosuppression within these populations, suggest novel infectious causes for several cancers including conjunctival squamous cell carcinoma, sebaceous adenocarcinoma, salivary gland tumors, malignant fibrous histiocytoma, and intrahepatic cholangiocarcinoma.

Novel automated non-invasive detection of ocular surface squamous neoplasia using artificial intelligence

Ocular surface squamous neoplasia (OSSN) is a common eye surface tumour, characterized by the growth of abnormal cells on the ocular surface. OSSN includes invasive squamous cell carcinoma (SCC), in which tumour cells penetrate the basement membrane and infiltrate the stroma, as well as non-invasive conjunctival intraepithelial neoplasia, dysplasia, and SCC in-situ thereby presenting a challenge in early detection and diagnosis. Early identification and precise demarcation of the OSSN border leads to straightforward and curative treatments, such as topical medicines, whereas advanced invasive lesions may need orbital exenteration, which carries a risk of death. Artificial intelligence (AI) has emerged as a promising tool in the field of eye care and holds potential for its application in OSSN management. AI algorithms trained on large datasets can analyze ocular surface images to identify suspicious lesions associated with OSSN, aiding ophthalmologists in early detection and diagnosis. AI can also track and monitor lesion progression over time, providing objective measurements to guide treatment decisions. Furthermore, AI can assist in treatment planning by offering personalized recommendations based on patient data and predicting the treatment response. This manuscript highlights the role of AI in OSSN, specifically focusing on its contributions in early detection and diagnosis, assessment of lesion progression, treatment planning, telemedicine and remote monitoring, and research and data analysis.

Human Papillomavirus Related Neoplasia of the Ocular Adnexa

Human papillomaviruses (HPV) are a large group of DNA viruses that infect the basal cells of the stratified epithelium at different anatomic locations. In the ocular adnexal region, the mucosa of the conjunctiva and the lacrimal drainage system, as well as the eyelid skin, are potential locations for HPV-related neoplasia. The role of HPV in squamous cell neoplasia of the ocular adnexa has been debated for several decades. Due to the rarity of all these tumors, large studies are not available in the scientific literature, thereby hampering the precision of the HPV prevalence estimates and the ability to conclude. Nevertheless, increasing evidence supports that defined subsets of conjunctival papillomas, intraepithelial neoplasia, and carcinomas develop in an HPV-dependent pathway. The role of HPV in squamous cell tumors arising in the lacrimal drainage system and the eyelid is still uncertain. Further, the potential of HPV status as a diagnostic, prognostic, or predictive biomarker in these diseases is a topic for future research.

Human papillomavirus infection and ocular surface disease (Review)

Human papillomavirus (HPV) infection has been implicated as a primary cause of lesions in the anogenital region, skin, oropharynx and respiratory tract. Additionally, the role of HPV in the pathogenesis of ocular surface disease has also been extensively studied. Conjunctival papilloma development has been strongly associated with the HPV infection of certain subtypes. On the other hand, the role of HPV in conjunctival pterygium, conjunctival intraepithelial neoplasia (CIN) and ocular surface squamous neoplasia (OSSN) remains controversial. Genetic predisposition and environmental factor is important in HPV hosts as regards the pathogenesis of ocular surface disease. Several studies have indicate a synergic role of HPV with ultraviolet radiation in pterygium establishment. A higher recurrence risk rate and more aggressive disease of ophthalmic pterygium is observed in cases of HPV infection. The purpose of this review was to provide a systematic review of the literature and to assist in a better understanding of the role of HPV in ocular surface disease.

Update on conjunctival pathology

Conjunctival biopsies constitute a fairly large number of cases in a typical busy ophthalmic pathology practice. They range from a single biopsy through multiple mapping biopsies to assess the extent of a particular pathological process. Like most anatomical sites, the conjunctiva is subject to a very wide range of pathological processes. This article will cover key, commonly encountered nonneoplastic and neoplastic entities. Where relevant, sections will include recommendations on how best to submit specimens to the ophthalmic pathology laboratory and the relevance of up-to-date molecular techniques.

Tumors of the ocular surface: A review

Tumors of the Ocular Surface clinically manifest with a very wide spectrum and include several forms of epithelial, stromal, caruncular, and secondary tumors. As a group, these tumors are seen commonly in the clinical practice of a comprehensive ophthalmologist, cornea specialist, and an ocular oncologist. This review is aimed to discuss the common tumors of the ocular surface and emphasize on their clinical diagnosis and appropriate management.

Occurrence of human papillomavirus in pterygia

PURPOSE

The aim of the study was to assess the occurrence of human papillomavirus (HPV) DNA in pterygium.

METHODS

The study involved 89 patients undergoing surgical procedures at the Department of Ophthalmology, Medical University of Lublin, Poland. Group 1 included 58 patients with clinically diagnosed pterygium. Group 2 consisted of 31 individuals with normal conjunctiva. The material was collected during elective surgical procedures. The presence of HPV genome was determined using polymerase chain reaction (PCR). Once the presence of HPV DNA was confirmed, 28 HPV genotypes were determined using reverse hybridization.

RESULTS

The determinations confirmed the presence of HPV DNA in pterygium. In the material collected from 58 cases of pterygium (group 1), HPV DNA was identified in 16 patients (27.6%). In the material from 31 diagnostic specimens of normal conjunctiva (group 2), the presence of HPV was demonstrated in three cases (9.7%). A statistically significant difference was found in the presence of HPV DNA between the patients from groups 1 and 2 (p = 0.041). HPV type 16 was most common and was demonstrated in 56% of HPV-positive cases of pterygium. HPV 16 and HPV 6 co-infections were found in 19% of cases, while HPV 18 and HPV 6 co-infections were observed in 13%. In group 2, all three patients with HPV showed HPV 18.

CONCLUSION

It seems that HPV is not necessary to induce pterygium; however, it might play a synergistic role in the multi-stage process of its development.

Immunohistochemical localization of human papilloma virus in conjunctival neoplasias: a retrospective study

BACKGROUND

The extent of association of human papilloma virus (HPV) in human conjunctival neoplasias has been debated in studies originating from different parts of the world, but no substantial evidence has been generated on Indian subjects. This prompted us to carry out a retrospective study on conjunctival neoplasias diagnosed over the past 12 years.

MATERIALS AND METHODS

Histopathological and immunohistochemical analysis of 65 specimens of ocular neoplasias and 30 normal controls diagnosed between 1991 and 2002 at a tertiary eye care hospital, was undertaken. Formalin-fixed, paraffin-embedded tissues were reviewed for confirming histopathological diagnosis, presence of koilocytosis and changes related to actinic keratosis. Immunohistochemical analysis was done using HPV-specific monoclonal antibodies. Clinicopathological correlation and the association of HPV antigen with the histopathological features were performed.

RESULTS

Out of the 65 cases analyzed, 35 were papillomas and 30 were ocular surface squamous neoplasias (OSSN). The mean age was 48 years with a male preponderance. Histologically, koilocytosis was observed in 17.1% of papillomas and 36.6% of OSSN. Actinic keratosis was present in 33% of OSSN. Immunohistochemically 17.1% conjunctival papillomas stained positive for HPV antigen, all cases of OSSN were negative for HPV. There was no correlation between koilocytosis or actinic keratosis and the detection of HPV antigen.

CONCLUSIONS

The association between HPV and conjunctival neoplasias is variable in different geographical areas and also depends on the methods of detection used. This study warrants the need for applying more advanced techniques at a molecular level to determine the possible etiology of HPV in conjunctival neoplasias among Asian-Indians.

Failure to detect human papillomavirus DNA in malignant epithelial neoplasms of conjunctiva by polymerase chain reaction

To elucidate the putative role of human papillomavirus (HPV) infection in the etiology of conjunctival tumors, 44 formalin-fixed, paraffin-embedded specimens of conjunctival tumors (24 patients with papillomas and 20 patients with dysplastic and/or malignant tumors) were screened for HPV infection using 4 different polymerase chain reactions (PCRs). Of the 24 samples of papilloma, 14 (58%) displayed positive results by applying nested PCR using primer sets of HPV consensus L1 region. HPV type 6 or 11 was detected in 9 cases of papilloma by type-specific primer sets, but none of them were positive for HPV type 16 or 18. However, by using the highly sensitive PCR technique, we failed to demonstrate the HPV DNA of HPV types 6, 11, 16, and 18 in any of the 20 malignant epithelial tumors of conjunctiva. We conclude that HPV-6 or HPV-11 is present in a substantial percentage of conjunctival papillomas, which is in accordance with findings of previously reported studies. In contrast, malignant conjunctival carcinomas are not associated with HPV infection; other pathogenic mechanisms, such as UV light, probably are more important in the cause of these malignant lesions.

Human papillomavirus in corneal and conjunctival carcinoma

PURPOSE

To investigate the role of human papillomavirus (HPV) types, 6, 11, 16 and 18 in corneal and conjunctival carcinoma, we examined 88 dysplastic corneal and conjunctival specimens and 66 controls that had been formalin-fixed and paraffin-embedded.

METHODS

Sections were graded for histological abnormality by light microscopy and the presence of HPV DNA was determined by polymerase chain reaction using LI consensus primers.

RESULTS

Human papillomavirus DNA was detected in 34 (39%) dysplasias and in five (7.5%) controls. Of dysplasias that were HPV-positive, 20 (59%) contained either types 16 or 18, 13 (38%) contained only types 6/11, while combinations of HPV types were present in 11 (32%). A histological correlation was found with HPV positivity (all genotypes) and unusually large ('epithelioid') dysplastic cells.

CONCLUSION

The present study demonstrates a lower incidence of HPV in corneal and conjunctival carcinoma than previously reported, but shows an unexpectedly high incidence of HPV 6/11 in conjunctival carcinomas.

Detection of human papillomavirus infection in squamous tumours of the conjunctiva and lacrimal sac by immunohistochemistry, in situ hybridisation, and polymerase chain reaction

BACKGROUND

Squamous tumours of the ocular surface, including the lacrimal pathway, range from benign lesions to invasive carcinomas. Some of these tumours are associated with human papillomavirus (HPV) infection, with the types of HPV differing among papillomas and dysplastic or malignant lesions.

METHODS

The relation between squamous tumours of the conjunctiva and lacrimal sac and HPV infection was investigated in 17 individuals with such tumours. Nine of the 17 tumours were benign, four were dysplastic lesions, and four were carcinomas.

RESULTS

Eight specimens showed positive immunohistochemical staining with antibodies to HPV; four of these eight were papillomas, three were dysplastic lesions, and one was a carcinoma. Koilocytosis was detected in seven of these eight tumours. Five of the eight specimens positive for immunohistochemical staining were also positive for HPV DNA by in situ hybridisation, and all eight were positive for HPV DNA by the polymerase chain reaction (PCR) method.

CONCLUSION

Approximately 50% of squamous tumours of the ocular surface and lacrimal sac were associated with HPV infection. This is the first report, to our knowledge, of the detection of HPV in the field of ophthalmology by a combination of immunohistochemistry, in situ hybridisation, and PCR.

Squamous cell carcinoma of the conjunctiva. Failure to demonstrate HPV DNA by in situ hybridization and polymerase chain reaction

Squamous cell carcinoma of the conjunctiva is a distinct rarity, often arising at the corneoscleral limbus and initially resembling pterygium or chronic keratoconjunctivitis. In this paper we report 4 patients with conjunctival squamous cell carcinoma/carcinoma in situ, which comprise all the cases found in the files of Kuopio University Hospital during 1959-1991. The clinical appearance, diagnosis and treatment of the lesions are described. All biopsies were studied for the presence of Human papillomavirus (HPV) DNA (recently demonstrated in conjunctival squamous cell papillomas, precancer lesions and carcinomas) by using in situ DNA hybridization (ISH) and polymerase chain reaction (PCR). Both techniques failed to demonstrate the DNA of any of the following HPV types: HPV 6, 11, 16 and 18 in any of the lesions. The results are discussed in the light of the recently proposed HPV etiology of these lesions.

A spectrum of bilateral squamous conjunctival tumors associated with human papillomavirus type 16

Three patients with bilateral tumors presenting as multiple keratinizing and verrucous lesions of the bulbar and tarsal conjunctiva were determined by DNA amplification and hybridization studies to harbor human papillomavirus type 16 (HPV-16). Results of biopsy in two patients showed infiltrating squamous cell carcinoma in one eye and dysplasia or carcinoma in situ in the fellow eye. In the third patient, focal, inflamed, hypertrophic, papillary lesions with pseudoglandular invaginations of the surface epithelium were found in the tarsal conjunctivae of both eyes. These are the first documented cases of bilateral conjunctival tumors associated with human papillomavirus.

Recurrent conjunctival papilloma causing nasolacrimal duct obstruction

We treated two patients who had recurrent conjunctival papillomas that invaded the nasolacrimal sac and caused complete canalicular and nasolacrimal duct obstruction. The ophthalmologist should be aware of the possibility of a conjunctival papilloma invading the lacrimal sac when treating patients with conjunctival papillomas. Excision should be complete, and adjunctive therapy such as cryotherapy should be considered to reduce the chance of tumor recurrence.

Detection of human papillomavirus type 11 DNA in a conjunctival squamous cell papilloma by in situ hybridization with biotinylated probes

A 44-year-old man presented with an exophytic papillomatous growth in the tarsal conjunctiva of his right eye. The tumour was excised and subjected to histological examination. On light microscopy, a squamous cell papilloma without signs of dysplasia was disclosed, because the entire tissue block was cut into sections, the performance of a conventional in situ hybridization for detection of human papillomavirus (HPV) DNA was not possible. An alternative approach was used to demonstrate the presence of HPV 11 DNA in the papilloma. The cover slip was removed. The individual van Gieson-stained sections on the (routine, uncoated) slides were cut apart by glass knife, and mounted (still attached on the original slide) separately on new microscopy slides. These slides were subjected to in situ DNA hybridization with biotin-labelled DNA probes of HPV 6, 11, 16, and 18, under conditions of high stringency (Tm-17 degrees C). Special caution was taken to prevent the detachment of sections. The papilloma displayed positive hybridization with the HPV-II probe, the intense signals being localized on the nuclei of koilocytotic cells. Infection with HPV-6 (or the closely related HPV-11) appears to be responsible for the majority of the conjunctival papillomas of children and young adults reported so far. The presence of genital tract HPV types 6/11 in these lesions suggests that some of the infections might have been acquired during the passage through an infected birth canal. The presence of HPV 6/11 in adult conjunctival papillomas might reflect a) an activation of a latent infection acquired as above, or b) a new infection transmitted from other mucosal sites, the genital tract included. The role of HPV in conjunctival dysplasias and malignant transformation is not clear as yet.

DNA of human papillomavirus type 16 in dysplastic and malignant lesions of the conjunctiva and cornea

Human papillomaviruses are receiving attention for their role in the pathogenesis of cancer, especially cancer of the anogenital tract. Although strains of human papillomavirus are associated with benign lesions of the conjunctiva, their association with conjunctival dysplastic lesions and carcinomas has remained unclear. We examined a group of neoplastic lesions of the conjunctiva for the presence of DNA sequences for human papillomavirus types 16 and 18, using in vitro gene amplification with the polymerase chain reaction. Tissue specimens of five conjunctival dysplastic lesions and one invasive carcinoma and swab specimens of the mucosa of both corneas of a patient with unilateral corneal dysplasia contained DNA sequences related to human papillomavirus type 16. All dysplastic specimens examined were positive for DNA sequences. Viral DNA was not detected in six control specimens from patients with conjunctival melanoma, papilloma, nevus, or pterygium. We conclude that DNA from human papillomavirus type 16 is present in a substantial percentage of conjunctival premalignant and malignant lesions. It may play a part in the development of conjunctival dysplasia and carcinoma, as it does in cancers of certain other body sites.

Detection of human papillomavirus type 6/11 DNA in conjunctival papillomas by in situ hybridization with radioactive probes

Twenty-three conjunctival papillomas and 28 conjunctival dysplasias were examined for human papillomavirus (HPV)-DNA sequences by in situ hybridization with nick-translated 35S-labeled HPV probes. Adjacent paraffin sections were hybridized with HPV type 2, 6, 16, and 18 probes at Tm - 17 degrees C. Fifteen tissues, all papillomas, displayed positive hybridization with the HPV-6 probe. Infection with HPV-6 (or the closely related HPV-11) appeared to be responsible for most of the conjunctival papillomas of children and young adults. The presence of genital tract HPV-6 in these lesions suggests that some of the infections were acquired during passage through an infected birth canal. The lack of hybridization in adult conjunctival dysplasias indicates either that HPVs are not associated with this condition or that the probes and the technique utilized were not adequate for demonstration of this association.

Demonstration of human papillomavirus DNA in oral condyloma acuminatum

Condyloma acuminatum arising on oral mucous membranes exhibits distinct histopathological features that allow for differentiation from the more common squamous papilloma. These lesions are parakeratinized with cryptic invagination of cornified cells extending into an acanthotic spinous cell layer. Superficial spinous layer koilocytosis is a prominent feature and the condylomatous papillomas exhibit a tendency for sessile architecture. Among 62 instances, the average age was 39.7 years with a predilection for the 3rd and 4th decades. The male to female ration was 5.7:1 and the tongue, gingiva and lips were the favored sites. Whereas 25% of the evaluated cases demonstrated upper spinous layer papillomavirus common antigen immunoreactivity, DNA in situ hybridization under conditions of high stringency disclosed the presence of human papillomavirus Types 6, 11 or related genomes in 85% of the lesions. A single case was found to harbor human papillomavirus Type 2.

Inverted mucoepidermoid papillomas of the epibulbar conjunctiva

Juxtalimbal epibulbar inverted papillomas that were locally excised without recurrence developed in two women, aged 42 and 51 at the time of initial presentation. There is only one previous report of this unusual conjunctival neoplasm, which documented involvement of the plical, caruncular, or tarsal conjunctiva. The tumor grew by acanthosis of the surface nonkeratinizing squamous epithelium, with invagination into the underlying connective tissue in the absence of inflammation or a tendency toward keratinization. The initial invaginations may be cystic in character, but solid lobules secondarily originated from their walls to push into the connective tissue. Mucus-producing goblet cells were scattered throughout the lesions; highly distinctive eosinophilic globoid bodies, probably reflecting inspissated mucoid material, were found in the walls of the cysts and entrapped within their secretions. Conjunctival inverted papilloma does not exhibit locally aggressive behavior, does not involve extensive segments of the conjunctival epithelium, and does not display diffuse spread or multicentricity. The authors therefore believe that it should be clearly separated from inverted squamous (Schneiderian) papillomas of the nasal cavity and sinuses.

Treatment of recurrent squamous papillomata of the conjunctiva by carbon dioxide laser vaporization

Complete resection of recurrent conjunctival squamous papillomata frequently may be exceedingly difficult, since such lesions are typically friable and multilobulated. Recurrent lesions often fill the fornicies and spill onto the lid margins. Moreover, since the human papillomavirus (HPV) has been linked to some of these lesions, there remains the further possibility of spread with "cold knife" resection. We discuss the benefits of carbon dioxide laser vaporization therapy for recurrent squamous papillomata of the conjunctiva that have not responded to resection and cryotherapy or topical immunotherapy. The carbon dioxide laser facilitates resection by providing a bloodless field, and reduces the possibility of viral seeding of the conjunctiva by sterilizing the operative site and sealing the lymphatics.

Detection of papillomavirus common antigens in lesions of skin and mucosa

HPV infections are associated with many proliferative lesions of cutaneous and mucosal squamous epithelium. PV genus-specific (common) antigens can be detected by immunocytochemical techniques in approximately 50% of lesions (warts and papillomas) without dysplastic changes. Dysplastic lesions of squamous epithelium are less likely to be permissive for viral expression; squamous neoplasias are rarely, if ever, productively infected. Almost any tissue that has been processed for pathology or exfoliative cytologic preparations can be reliably stained for the presence of papillomavirus common antigens. A positive staining reaction is interpreted as meaning that the lesion is associated with HPV infection and that it has a potential for being contagious.

Human papillomavirus DNA in conjunctival papilloma

A histologically proven conjunctival papilloma was examined for the presence of papillomavirus DNA by nucleic acid hybridization under relaxed conditions. It harbored papilloma-virus-specific DNA, which showed no detectable relationship with that of known virus types when tested under stringent conditions. This demonstrates that conjunctival papillomas are associated with more than one papillomavirus type. Viral diagnosis may turn out to be of prognostic value.

Lacrimal canalicular papillomatosis

Three new cases of lacrimal canalicular papillomatosis are reported and the total of 12 cases in the literature reviewed. They present with epiphora or a local mass. Multiple recurrences over many years is characteristic. A minority have papillomata of the conjunctiva or lacrimal sac. Histopathological examination shows a benign papilloma with a fibrovascular stalk. Treatment was either multiple excision or cryotherapy, but neither affected the rate of occurrence. A viral aetiology is postulated in some cases.

Dinitrochlorobenzene and debulking therapy of conjunctival papilloma

A conjunctival papilloma in a four-year-old boy had recurred despite one surgical removal, and three cryosurgical treatments. After sensitization of the child's lymphocytes to dinitrochlorobenzene (DNCB), the lesion responded rapidly and completely to debulking followed by painting the base of the tumor with DNCB. We feel that the effectiveness and simplicity of debulking and DNCB treatment of conjunctival papillomas, which have resisted previous standard forms of therapy, gives an easy, relatively inexpensive, and rapid method of treating these lesions.

Detection of human papillomavirus DNA sequences in conjunctival papilloma

Two histologically proven conjunctival papillomas (one from a 33-month-old boy and the other from a 28-year-old woman) were examined for the presence of papillomavirus by DNA molecular hybridization. The first case, a recurrent tumor known to be positive for papillomavirus structural antigen, demonstrated human papillomavirus DNA sequences that cross-hybridized to a human papillomavirus type 11 DNA probe. The second case, an initial tumor, which was negative for papillomavirus structural antigen, demonstrated no viral DNA sequences by hybridization.