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Pathology shows benign squamous papilloma. Noticed growth from uvula. Reported squamous papilloma with HPV associated cellular change. Guide?

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ENT Specialist
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     h i had a papilloma that coughed up in feb 2013. I took it for pathology. The pathology only said benign squamous papilloma. Then on XXXXXXX 10 2013 found something growing off my uvula. I would normally not have noticed this as it almost looked like just part of my uvula. I went to an ENT who cut it off the entire growth and sent for path. This is what he report says: High grade squamous dysplasia (moderate squamous dysplasia) arising in squamous papilloma with human papillomavirus associated cellular change. The sections show a polypoid biopsy of squamous mucosa in which there is prominent irregular acanthosis, papillomatosis and focal parakeratosis. In addition there are numerous areas with koilocytotic change characteristic of human papillomavirus cellular effect. In addition there are many areas in which there is a lack of maturation with atypia and mitoses in the epithelial cells involving the middle third of the epithelium consistent with moderate squamous dysplasia. Does this mean I will eventually have oral cancer now? Is this like a time bomb that will eventually pop up again as cancer? I am having a difficult time finding out information on the Internet about oral warts containing dysplasia. Is this so rare? I went to yet another ENT specializing in head and neck cancers at Emory University in Atlanta. He told me that from all the hpv positive oral cancers he's treated, he has never treated one arising from a wart/papilloma. If this were to regrow in a different area in my mouth in the same form of a wart with dysplasia, will it likely turn cancerous and spread to other areas like a regular oral squamous cell cancer? This doctor also only recommended yearly follow ups, I feel I should have follow ups every 3 months.
Posted Mon, 29 Jul 2013 in Ear, Nose and Throat Problems
 
 
Answered by Dr. Naveen Kumar 3 hours later
Hi

Thanks for posting the query.

Your present situation is infact quite tricky, it is very unusual to pick up dysplastic changes in a papillomatous growth. Although it is established that oral potentially malignant lesions and epithelial dysplasia are statistically more likely to progress to cancer, the actual mechanisms are poorly understood and it is not inevitable that a dysplastic lesion will progress to cancer. In this situation, it is wiser to get a regular follow up done to pick up an early lesion if any.

Secondly, even though, oncogenic Human Papilloma Virus have been identified in many oral precancerous dysplastic and squamous carcinoma tissues; HPV 16 has been localized in normal oral mucosa as well. Hence, it is very difficult to conclude that the lesion over the uvula was initially a wart.

In my experience, I have never come across a papillomatous lesion turning into a malignant lesion on a later date. Unfortunately, there are no molecular markers which enable us to distinguish lesions that may progress from those that will not.

Finally, moderate dysplasias have a malignant transformation potential of 3–15% compared to mild epithelial dysplasia which shows a very low risk (<5%). Hence to be on a safer side, we need to do a oral check up at regular intervals to identify similar lesions elsewhere in the oral cavity. I too agree with you to visit your doctor once in three months.

In future, if you come across similar lesions, you can as well get a PET Scan done to identify the lesions elsewhere in the body and distant metastasis if any. Also, you can try taking Beta-carotene and the retinoids, the most commonly used antioxidant supplements for chemoprevention of oral cancer.

Hope I have answered your query; I will be available for the follow up queries.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Pathology shows benign squamous papilloma. Noticed growth from uvula. Reported squamous papilloma with HPV associated cellular change. Guide? 16 hours later
Hi,
Thank you for your reply. I do have a few follow up questions. In your second paragraph that says it is difficult to conclude that the lesion on the uvula was a wart. I'm not sure I understand what this means. Can you explain further? If not a wart/papilloma, what else could it have been?

Also, I understand you are saying you have never come across a papilloma type lesion progressing into malignancy but have you ever seen a papillomatous lesion with moderate dysplasia in it or any dysplasia? Is this so rare for this to occur ?

Also, for some more info., the first benign lesion mentioned in my first post that I coughed up in February 2013 came from somewhere in my oral cavity or in the throat. I did not mention that I had a sensation off and on for months of something being stuck in my throat. I also had a lot of phlegm production and I would cough to try and get it out and I could literally feel this sensation of something in my throat area that I just could not get out. I have no doubt this lesion did not come from my lungs (first benign growth). Your last paragraph really scared me, I could have these lesions growing in other places of my body such as my lungs? It almost sounds like this is treated/monitored the same as if it were cancer.....

If I had more lesions and they showed moderate dysplasia, does the 3-15% transformation to a malignancy still apply for oral lesions such as this?

And lastly, as far as beta carotene and retinoids, are those prescription or can I purchase them over the counter? Do you mean a beta carotene supplement and also, aren't retinoids used for acne??
Thanks again,
XXXXX
 
 
Answered by Dr. Naveen Kumar 17 hours later
Hi

Thanks for writing back

I am sorry, if my answer has hurt you, but that's the fact.

Let me explain to you in detail. There are various lesions of the oral cavity such as focal epithelial hyperplasia, oral squamous cell papilloma, oral verruca vulgaris and oral condyloma acuminatum, which are collectively referred to as oral warts. All the above considerations involve human papilloma virus (HPV).

Of all the above lesions, the commonest is oral squamous cell papilloma, which is pedunculated and benign in nature. There are only a few cases recorded in the world wherein a benign papilloma has
turned to be malignant. Oral condyloma is a cauliflower like growth, which shows dysplastic changes in the epithelium. Unlike papilloma, condyloma acuminatum is rarely seen in a immuno-efficient individual. This was the reason, I had doubted the lesion to be a wart.

Dysplastic tissue is the presence of abnormal cells on the skin and mucosal surface. Dysplasia is not cancer, but it is a tissue change seen prior to malignancy. Frankly, I have not come across any
papillomatous growth showing moderate dysplastic changes.

According to your description, I do feel, you had an isolated papillomatous growth somewhere in the oro-pharyngeal region which got dislodged after a violent cough or throat clearance. If it were to be
in lungs you would have developed breathing difficulty associated with the above symptoms. So, the lesion seen over the uvula could be a totally different lesion.

The statistics show that 3-15% of the lesions with moderate dysplasia in the oral cavity may turn out to be malignant. It is better to be optimistic and get a regular check up done.

Lungs are not the site of distant spread of the malignant oral lesions, if any.

Betacarotene and retinoids are both related to vitamin A. They help in maintaining the vitality of the epithelium. You can take either of them after consulting your doctor. Naturally, Beta carotene is present in abundance in carrots and sweet potato. Yes, topical retinoids are prescribed in acne and psoriasis patients. In your case, oral retinoids can be tried.

Hope this clarifies your doubts; I wish you good health.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Pathology shows benign squamous papilloma. Noticed growth from uvula. Reported squamous papilloma with HPV associated cellular change. Guide? 2 days later
Thank you for your detailed reply.

You mentioned PET scan if I find other oral lesions to see if other lesions exist in the body. If lungs are not the site of distant spread of oral lesions, where else in the body could these dysplasia lesions be? I have been to the ENT several times since the uvula growth was removed (removed XXXXXXX 10 2013) and so far nothing looks abnormal.

Your detailed explanation of the different types of oral lesions make me also wonder if this was not really a dysplastic squamous papilloma. Perhaps an oral condyloma. Would a lab easily mistaken a condyloma for a squamous papilloma? Can condylomas be treated successfully or do dysplastic ones tend to progress quickly to cancer and then spread? Since HPV changes were seen, does this likely mean in have type 16 HPV?

I think I mentioned I did have a bone marrow transplant in 1994 due to CML (leukemia). I never had to take immunosuppressive drugs and had chemo with no radiation. But now I get the yearly cold and that's about all (so far).

Anyways, thanks and if you could answer my last few remaining questions above, I definitely appreciate your very informative, detailed responses.

Thank you
XXXXX
 
 
Answered by Dr. Naveen Kumar 31 hours later
Hi

Welcome back

The commonest site of spread of the oral malignancy is the neck and the lungs are the least common site of spread.

The lesions of the condyloma and other dysplastic lesions look very similar and it requires some amount of expertise to differentiate. Condylomas can be treated successfully with the modern methods of surgery.

If the lesion is a pre-malignant one, then it depends upon on both the grading and the body resistance to allow the lesion to become malignant. Remember, not all premalignant lesions turn out to become malignant. With the serological markers we can identify the type of HPV and clinically it is difficulty to comment.

I am sorry! You never mentioned about the CML or chemotherapy before. This could be one of the reason for the lesion to appear (condyloma is an oppurtunistic lesion seen in immunocompromised).

Hope this clarifies your doubts.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Pathology shows benign squamous papilloma. Noticed growth from uvula. Reported squamous papilloma with HPV associated cellular change. Guide? 2 days later
Hi,
Does this mean that more than likely, I will eventually get another growth like this again? Do hpv warts with dysplasia behave differently or do they behave the same with the 3-5 percent turning cancerous? Once cancer is confirmed, can the wart be removed or is it treated like other oral cancers such as radiation and chemo?
Thanks
XXXXX
 
 
Answered by Dr. Naveen Kumar 2 days later
Hi

Thanks for writing back

It is indeed a difficult question to answer because, if it is an oral wart, by mere excision of the lesion you can get rid of the problem. But, if it is a pre-malignant lesion, then, you have to constantly search for any subsequent lesions in the head and neck region.

The chances of dysplastic warts turning out to be cancaerous are very negligible compared to that of the premalignant lesions.

If it is an oral wart, then, complete excision of the same will suffice. It does not require any radiation or chemotherapy.

Hope this clarifies your doubts. I wish you good health.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Pathology shows benign squamous papilloma. Noticed growth from uvula. Reported squamous papilloma with HPV associated cellular change. Guide? 7 hours later
Hi,
If I may ask, I was confused about one thing you wrote:

"the chances of dysplastic warts turning out to be cancerous are very negligible compared to that of the premalignant lesions".

My wart on my uvula had moderate dysplasia. Is that different than premalignant? If premalignant is different than dysplasia, are you then saying the chances of my wart turning out to be cancerous is very negligible ?

Thanks
XXXXX
 
 
Answered by Dr. Naveen Kumar 31 hours later
Hi

Welcome back

I am sorry if I had confused you. I did mean if the lesion what we were discussing about, is an oral wart (Condylomata is known to show dysplastic changes in the histopathological findings); then the chances of it turning into malignancy is very negligible.

But if the lesion is premalignant (evidenced by different grading of dysplastic changes), then the chances of it to become malignant depends on the pathological grading. The lesser the grading, lower are the chances of malignancy.

In your case, after going through the history thoroughly and comparing the histopathological findings, I feel, it should be treated as a oral wart rather than a premalignant lesion, followed by a close follow-up.

Hope this clarifies your doubts.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
Follow-up: Pathology shows benign squamous papilloma. Noticed growth from uvula. Reported squamous papilloma with HPV associated cellular change. Guide? 19 hours later
Hi,
If I may ask one final question please. Thanks for your reply.   Is it common that a oral papilloma would be diagnosed with moderate dysplasia (the one cut off from my uvula) and another lab (Emory Univ Hospital) gets the same slides from the first lab and their report says no dysplasia found, benign.
I just found this out today and am very confused. First lab says moderate dysplasia and the Emory University Hospital Lab says no dysplasia found, benign.
Is this typical that dysplasia is diagnosed and another lab says no dysplasia ?
Thanks again,
XXXXX
 
 
Answered by Dr. Naveen Kumar 4 hours later
Hi

Thanks for writing back

As I had discussed with you before some oral warts show dysplasia and it requires expertize to differentiate a dysplastic wart from a premalignant lesion. I do agree with you that these two reports are contradicting each other and it is very difficult to decide further management.

I would suggest you to get a third opinion from a different pathologist (preferably an experienced one) to arrive at a consensus and to decide upon how to proceed further.

Regards
Dr. Naveen Kumar N.
ENT and Head & Neck Surgeon
Above answer was peer-reviewed by
 
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