Different types of conjunctival papilloma presenting in the same eye

Morphologically aggressive appearance of a human papilloma virus (HPV)-related conjunctival papilloma that was clinically suspicious for malignancy - A case report

INTRODUCTION AND IMPORTANCE

Conjunctival squamous papilloma is a benign tumor that might be linked to Human papillomavirus (HPV) infection. The most common appearance is a pedunculated fleshy mass. We are reporting a unique of HPV-related conjunctival papilloma that was excised with the suspicious of malignancy.

CASE PRESENTATION

A 35-year-old Saudi male who has been investigated for a suspicious pancreatic lesion and presented with a concurrent right eye conjunctival yellowish cystic mass. The mass was excised for diagnostic purpose to rule out malignancy in view of the history, the clinical appearance of the lesion, and the adjacent conjunctival severe congestion. The histopathological examination concluded a viral-related conjunctival papilloma. There was no evidence of recurrence of the lesion 2 years postoperatively.

CLINICAL DISCUSSION

The common clinical appearance of a benign conjunctival papilloma is usually described as fleshy pedunculated mass with irregular grayish red surface. Such a lesion might be related to several etiologies, one of which is HPV. The mass in our case was highly vascularized and cystic with yellowish areas, which raised the suspicion of a malignant lesion. The histopathological findings, however, confirmed the benign nature of the lesion and supported the viral etiology by HPV.

CONCLUSION

HPV-related conjunctival papilloma may have various morphological appearances. Histopathological examination is the key for final diagnosis of such types of lesions.

Conjunctival Exophytic Schneiderian-type Papillomas: A Rare Occurrence

Conjunctival papillomas are common tumors that exhibit an exophytic growth pattern, comprised of multiple filiform fronds of squamous epithelium that contain fibrovascular cores. The inverted (endophytic) variety of papilloma, often termed "Schneiderian," rarely occurs on the conjunctiva, with only 15 cases reported to date. Endophytic and exophytic papillomas are well described arising in the sinonasal Schneiderian epithelium where a low rate of malignant transformation may occur in the endophytic type; malignant transformation in exophytic sinonasal papillomas is exceedingly rare. The authors describe 2 cases of exophytic conjunctival papillomas with the morphology of a sinonasal or Schneiderian-type papilloma. Both were pink, sessile acquired growths in women in the sixth decade of life involving the inferior conjunctival fornix or nasal limbus. Nonkeratinizing squamous epithelium along with numerous goblet cells, intraepithelial mucinous cysts, and microabscesses were present. Immunohistochemistry showed reactivity for cytokeratin 7 and wild-type staining for p16 and p53, paralleling the findings in common conjunctival papillomas; both were also driven by low-risk human papillomavirus.

Update on Diagnosis and Management of Conjunctival Papilloma

Conjunctival papilloma is an acquired benign squamous cell tumor that can present at any age, but most frequently in the third and fourth decades of life. Papillomas have been associated with human papilloma virus (HPV) infection, usually types 6 and 11. Although histopathological diagnosis remains the gold standard, the advent of newer non-invasive imaging modalities such as optical coherence tomography (OCT) is transforming the way we diagnose and treat ocular surface tumors, including conjunctival papilloma. Management of these lesions can prove a challenge to the treating physician since not all lesions respond to medical and/or surgical therapy and in fact may worsen after surgical manipulation. In this review, the epidemiology, pathophysiology, clinical characteristics, and diagnosis of conjunctival papilloma including the use of OCT are discussed. Indications, efficacy, and side effects of currently available management options are also reviewed to guide the selection of the best treatment approach.

Inverted papilloma of the conjunctiva

Objective

The purpose of the present study is to describe the clinical and histopathological features of conjunctival inverted papilloma, to analyse for the presence of human papillomavirus (HPV), and to determine if HPV infection is associated with this type of tumour and its inverted growth pattern.

Methods and Analysis

Cases of conjunctival inverted papillomas were retrieved from the archives of the Department of Pathology, Rigshospitalet, Denmark. Patient records and pathology reports were reviewed. Formalin-fixed and paraffin-embedded tissue was analysed for the presence of HPV by immunohistochemistry, in situ hybridisation (ISH), PCR and HPV typed by sequencing.

Results

A total of four cases were retrieved. The age at diagnosis ranged from 41 to 77 years, with an equal sex distribution. All lesions were localised to the bulbar conjunctiva and two of the cases were pigmented. Histopathological examination did not reveal areas of dysplasia. All lesions were p16-positive and p53-positive by immunohistochemistry. High-risk HPV 58 was demonstrated in one lesion by ISH and PCR.

Conclusion

Here we present four cases of conjunctival inverted papilloma, which is an exceedingly rare tumour with only 11 previously reported cases in the literature. Both clinically and histopathologically, the tumours show distinct features compared with exophytic conjunctival papillomas. Furthermore, this is the first description of high-risk HPV 58 in a conjunctival tumour. The biological behaviour of the tumour is uncertain due to its rareness. However, a complete removal of the lesion and a careful observation are recommended. The finding of HPV 58 underlines the necessity of this precaution.

Inverted mucoepidermoid papilloma of conjunctiva in a child

Inverted papillomas are benign epithelial tumors usually arising from the mucous membrane of the sinonasal cavity and the urinary tract. Similar tumors of the conjunctiva are much rarer. We describe a case of juxtalimbal inverted papilloma in an 11-year-old boy who presented with a pigmented lesion that simulated a conjunctival nevus. Excisional biopsy established the diagnosis of inverted papilloma. The patient was carefully followed for 2 years, because the tumor's behavior in the conjunctiva is unknown. There was no recurrence of the lesion.

Conjunctival inverted squamous papilloma: a case report with immunohistochemical analysis and review of the literature

A 63-year-old man presented with an asymptomatic papillary, sessile lesion of the juxtalimbal bulbar conjunctiva that was surgically excised with cryotherapy. Histopathologically, the lesion created some diagnostic confusion as it displayed an endophytic, or inverted, growth pattern-with squamous cells pushing into the substantia propria around fibrovascular cores, but without significant cytologic atypia, consistent with a conjunctival inverted papilloma (IP). Unlike previously reported cases of conjunctival IP, there were no goblet cells or cysts within the tumor. Immunostaining was diffusely positive for cytokeratin (CK) 7, and CK14 stained the basilar and suprabasilar cells, as in normal conjunctiva. CK17 weakly and non-uniformly stained the tumor, ruling out a dysplasia, which is usually strongly positive. The lesion's cytokeratin profile therefore paralleled that of normal conjunctiva. The proliferation index with Ki67 nuclear staining was extremely low (<1%), as was p53 nuclear staining (10-20%), both in contrast to squamous cell dysplasias or carcinomas that have a much higher percentage of positive cells. The lesion was negative for human papillomavirus subtypes associated with squamous neoplasias including carcinomas. We review the previous literature devoted to this comparatively rare condition and contrast its benign clinical course with that of inverted papillomas of the sinonasal, lacrimal drainage, and genitourinary systems and provide a set of criteria for establishing the diagnosis.