Not all pyogenic granulomas are equally safe. Some of them may comprise an elements of ocular surface squamous neoplasia, OSSN (conjunctival intraepithelial neoplasia, CIN). The paper Herwig-Carl MC, Grossniklaus HE, Müller PL, et al. Br J Ophthalmol Epub. doi:10.1136/ bjophthalmol-2018-312960 highlighted 9 such cases.
OSSN is extremely common in the areas with widespread HIV-prevalence. Human papilloma virus is responsible for this, as a typical opportunistic infection. Knowledge of the potential of OSSN to mimic pterygia and pyogenic granulomas is crucial, especially for the mid level ophthalmic personnel, as they are the primary surgeons for these conditions in many areas.
Aims: To systematically describe the clinical and histopathological features of a case series of conjunctival carcinomatous lesions underlying as-and also masquerading-pyogenic granuloma.
Methods: Nine cases of conjunctival carcinomatous lesions underlying a pyogenic granuloma (which were clinically predominant) were retrospectively identified. Patients’ records were analysed for demographic data, clinical appearance and the postoperative course. Formalin-fixed paraffin-embedded specimens were routinely processed and stained with H&E and periodic acid-Schiff. Immunohistochemical stains for cytokeratin were performed in selected cases.
Results: All nine tumours were located in the conjunctiva (bulbar, tarsal, limbal conjunctiva) of patients between 44 and 80 years. The lesions exhibited clinical features of pyogenic granuloma which dominated the clinical appearance. Additional features comprised a papillomatous appearance of the adjacent conjunctiva, a more whitish aspect of the lesion and a history of squamous cell carcinoma (SCC) respectively surgery for other entities. Histopathological analysis revealed a carcinomatous lesion (conjunctival intraepithelial neoplasia or SCC) at the base of a classic pyogenic granuloma in all nine cases. Surgical removal (R0 resection) was performed. Three cases received adjuvant mitomycin C or interferon α2b treatment. Two lesions locally recurred within 2 years after initial presentation.
Conclusion: Carcinomatous lesions may be accompanied by a pyogenic granuloma which may dominate the clinical pictures. As the tumour is usually located at the base of the lesion, a complete surgical excision followed by histopathological analysis is mandatory for each lesion appearing as conjunctival pyogenic granuloma.
Keywords: conjunctival intraepithelial neoplasia; histology; pyogenic granuloma; squamous cell carcinoma; tumour.