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In this section we have spot diagnoses posted on a daily basis since June 2010, now over 1700! You can review the archived cases and read the suggested diagnoses by users and the final comment by Dr Uma Sundram, the Editor-in-Chief and main spot diagnosis host. Case are uploaded each week day by 10 a.m. UK time with the correct diagnosis will generally be posted at 8 p.m. UK time. Why not view the most recent spot diagnosis and proffer a diagnosis?

Case Number : Case 2249 - 25 January 2019 Posted By: Dr. Richard Carr

Please read the clinical history and view the images by clicking on them before you proffer your diagnosis.
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M30. Keratotic endophytic papule, 6/12, ?Picker's nodule, ?Lichen simplex

Edited by Admin_Dermpath


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vincenzo

Posted (edited)

It looks like an intraoral Heck's disease. I don't have much experience in this cases. Single focus?

Edited by vincenzo

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No biopsy site given, but guessing from the superficial submucosal skeletal muscle, it can be from tongue, lips or other oral mucosal sites. The epithelial mucosa is clearly hyperplastic with areas of possible HPV changes ( kiolocytosis), the last two images show some karyorrhectic so called “mitosoid” bodies. So agree with Vincenzo that this is possible Heck disease. Is this young man from Africa, Middle East, or Latin America ? HIV status or immune suppressed?

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Dr. Richard Carr

Posted

Apologies biopsy site was lower lip seems to be outer vermillion but near skin. Lesion is apparently solitary, present for 3 years. Appeared after he had dry cracked skin and also he cut his lip on cigarrette paper. He sometimes catches it in his teeth and the lesion bleeds. PMH Psoriasis, warts, obesity.

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Dr. Richard Carr

Posted

I've posted some IHC if that helps or changes things.

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Basal and soprabasal ki67 activity, in keeping with hyperplastic lesion.  Few and not continuous P16+ cells in basal layer, in keeping with Heck's disease(HPV13/32). My spot doesn't change. 

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2 hours ago, Dr. Richard Carr said:

I've posted some IHC if that helps or changes things.

Thanks Dr Carr for the clinical history and additional IHC. It seems like there is clearly some dysplasia going on here given the high Ki67 status. And due to negative P16 and positive for P53, it is less likely be related HPV, and more likely P53 pathway, so it may be those differentiated type intraepithelial neiplasia ( we can coin a term differentiated Lip Intraepithelial Neoplaisia-dLIN, like those in vulva dVIN).  That is my take for now.

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Dr. Richard Carr

Posted

I found this one very tricky. I thought this was probably a dysplastic HPV associated lesion. I have not seen Ki67 up in the upper reaches of reactive epithelium previously although I confess I did sit on the fence a little as my "ENT" colleague was not so convinced by dysplasia. I liked the suggestion of Heck's and will try to arrange HPV sub-typing and have asked for more information from the clinical colleague - thanks for that suggestion. Regarding p53 it's wild type expression here. Regarding the p16 I actually wonder if this is a null pattern indicative of a mutation that has suppressed the expression by the antibody. Our p16's are usually ultra positive and this one is curiously negative. Usually there is some reactive wild type staining. I wondered if anyone had come across this concept?  I've had similar experience in genital bowenoid lesions so would be most interested if there is any mileage in the hypophesis (analagous to null p53).

Thanks for the helpful comments again.

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So it could really be a differentiated OIN, as Henry posted...

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