Satia MN*, Mali K**, Kolhe A***, Mandaokar V****
(* Professor, ** Assistant Professor, **** Second Year Resident, Department of Obstetrics and Gynecology, *** Assistant Professor, Pathology Department, Seth GS Medical College and KEM Hospital, Mumbai, India.)
Squamous papilloma of uterine cervix is a rare and benign tumor generally observed in teenagers and young women. The prognosis is typically excellent with treatment, since these are benign tumors. We report one such case in a 19 year old girl with a verrucous mass at the vulva with a foul smelling discharge. It was excised and histopathology was suggestive of papillary exuberant immature metaplasia (PIM). The human papilloma virus (HPV) 18 genotype testing was positive.
A squamous cell benign papilloma most commonly arises from the stratified squamous epithelium of either the skin, lips, cervix, vagina or anal canal. Squamous papillomas are slow-growing and benign tumors quite uncommon in the uterine cervix. The common locations are vulva and vagina. Human papilloma virus (HPV) infection is a major cause of these lesions though most HPV infections do not cause cancer. However there are a number of other conditions that cause papillomas; however, in many cases the cause is unknown. Estimated rate of recurrence is 60 to 66% and malignant transformation is seen in 30 to 40% of cases. A thorough physical examination along with Pap smear & colposcopic directed biopsy is mandatory for diagnostic evaluation because this benign tumor may be confused for a low-grade squamous intraepithelial lesion (LSIL) which is a pre malignant condition or condyloma acuminatum of the cervix or it may resemble cervical cancer. Differential diagnosis should include condyloma acuminatum, and focal epithelial hyperplasia and differentiation is done accurately by microscopic examination only. Antigens of the HPV types 6 and 11 are identified in approximately 50% of cases of squamous cell papillomas by the immunoperoxidase stains. There is no evidence that papillomas are pre malignant. Patient can be completely cured when a meticulous surgical excision is done to remove the tumor completely. Follow-up care with regular screening is important and should be encouraged. The prognosis of squamous papilloma of uterine cervix is generally excellent with appropriate treatment since it is a benign tumor.
A 19 year old girl presented to the gynecology out patient department (OPD) of a tertiary care center with complaints of purulent vaginal discharge since last 6 months with itching around the vulva since then. Initially on inquiry she did not give history of sexual exposure, however later she agreed for the same and gave a history of sexual exposure for the past 2 years. On clinical examination her vital parameters were stable & on local examination she had verrucous lesions at the vulva with purulent and foul smelling discharge around them as shown in figure 1.
Figure 1. Verrucous growth seen at the introitus.
As she denied any history of sexual intercourse a speculum and bimanual vaginal examination was not done. A clinical impression of condylomata accuminata was made & she was referred to skin OPD where she was examined and a biopsy was taken. Histopathology report was suggestive of syringocystadenoma papilliformis which is an apocrine sweat gland tumor and she was referred back to us. After preoperative evaluation, VDRL and HIV testing which were negative an examination under anesthesia (EUA) was done. On EUA the mass appeared as a polypoidal growth from the posterior lip of the cervix. It was clamped cut and ligated with polyglactin suture (figure 2). Electrocautery of the bleeding points on the posterior lip of the cervix was done.
Figure 2. Excision of the verrucous lesion of the cervix.
Post operative period was uneventful. She remained asymptomatic. Histopathology report was endocervical polyp with exuberant squamous metaplasia with papillary hyperplasia. (figure 3)
Figure 3. Histopathology picture shows high power and low power microscopy showing squamous metaplasia.
She was advised HPV testing to find out the strain. Genetic testing of the tissue which was sent for biopsy was done which came positive for high risk HPV 18. She has been explained & reassured about the prognosis and the need for regular annual follow up and Pap smear.
Human Papilloma viruses belong to the family of Papova viruses. These viruses promote cell proliferation and results in the development of benign papillomatous lesions of the genital tract, upper respiratory tract, cutaneous lesions of the skin and at other sites. There are more than 70 different types of HPV viruses and they are identified by molecular hybridization of DNA extracted from warty lesions from various sites. Each virus type has a definite site of infection. HPV infections can be spread inadvertantly by people who remain symptom free despite having the HPV infection. Mode of transmission remains sexual contact. These infected persons do not develop any lesions or warts nor does it progress to cancer. They may remain symptom free always. The causative viruses for these lesions are HPV 6 and 11 and HPV types 16,18, 31 and 33 are often associated with neoplastic transformation. HPV DNA genotyping is required to determine whether the patient is infected with HPV. Whether the body's immune system can permanently clear the HPV infection is not clear. In some cases patients may test positive for HPV infection and then the test may come negative for months to years, only to have a positive test result many years later. It is difficult to identify whether the infection is due to latent viral infection or is due to reinfection of the virus. A papilloma is a benign epithelial tumor which grows outwards as finger-like projecions. It shares some histologic and cytologic features with squamous metaplasia (SM), atypical immature squamous metaplasia (AIM), high-grade squamous intraepithelial neoplasia (HSIL) and papillary squamous cell carcinoma (PSC). PIM has been suggested to be a subset of condyloma associated with low-risk type human papilloma virus but HPV genotyping of the tissue sample was reported as HPV 18 though the etiologic role and biologic behavior of the disease are still elusive. The diagnosis can be difficult with cytological characteristic. The lesions appear histologically as an exophytic mass with epidermal hyperplasia, hyperkeratosis but without basement membrane disruption.
In a number of cases, body's immune system defeats a HPV infection before it creates warts. The warts may look like flat lesion or cauliflower like lesions. Repeated infection with certain HPV strains can cause precancerous lesions over time. If not treated, these lesions can become cancerous. Hence, it is important for women to have regular Pap tests, which can detect precancerous changes in the cervix that might lead to cancer. Hence current guidelines recommend that women between 21 to 29 years of age should have a Pap test every three years. Women between 30 to 65 years of age are advised to continue having a Pap test every three years, or every five years.
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Satia MN, Mali K, Kolhe A, Mandaokar V. A Rare Variety Of Squamous Papilloma Of The Uterine Cervix In A Teenage Girl. JPGO 2017. Volume 4 No.5. Available from: http://www.jpgo.org/2017/05/a-rare-variety-of-squamous-papilloma-of.html