Case Number : Case Number : Case 1994 - 26 Jan 2018 Posted By: Dr. Richard Carr

Bowenoid papulosis?

Sorry its another conjunctival case.

Conjunctival squamous papilloma with conjunctival intraepithelial neoplasia (CIN 3/ carcinoma in situ) ?

Herpes and HPV associated atypical papilloma? (Hyper immunoglobulin E syndrome? ) if in oral mucosa I would have done the diagnosis of Heck Syndrome because my impression is of mitosoid  bodies and some virus induced change. 

Thanks for additional comments. I'm asking for IHC to be posted.

Wow! Never seen anything like this. I also thought of HPV driven SCCIS, similar to the vulva.

Very interesting. But honestly, I don't know what to do with p16 immunopositivity in this  conjunctival lesion. I have seen p16 immunopositivity in a lot of tumors. Usually I accept p16 block-like immunoposivity as a surrogate marker for HPV driven high-grade squamous lesions only when it occurs in specific sites such as the vulva, vagina, uterine cervix or oropharynx or sometimes nasopharynx because it has been proven that most of these lesions are HPV-related. Remember, p16 is probably just an oncogene so there are more than on pathways to cause overexpression of p16 besides HPV. So in unusual sites like this case, it just proves that the lesion is high-grade but the significance of p16 positivity is unclear and doesn't mean that the lesion is HPV driven. If the clinicians want to prove it, I probably would do high-risk HPV DNA testing.

Conjunctival high grade intra-epithelial lesion 

I reported this as high grade conjunctival intra-epithelial neoplasia (or CIN3) supported by the Ki67 and block positivity for p16. I agree p16 is not specific to HPV but it is exceedingly sensitive for cutaneous bowen's (whether classical or actinic). Heinz Kutzner once said to me via e-mails that p16 is as sensitive to cutaneous bowenoid dysplasia as BerEP4 is to BCC. I gather that around 30% of conjunctival intra-epithelial neoplasias have been associated with HPV. I did note in the report that the dysplasia appears to have arisen in the setting of a conjunctival papilloma.