#dermpathjc October 2018:
Thursday, October 25, 9pm EST
Article discussed: Verruciform and Condyloma-like Squamous Proliferations in the Anogenital Region.
Author: May P. Chan from the Archives of Pathology and Laboratory Medicine
Free access at: http://www.archivesofpathology.org/doi/10.5858/arpa.2018-0039-RA
Summary prepared by Dr. Katy Veprauskas (@LinskeyKaty)
Journal Club Summary:
Background: Histologic distinction between condyloma acuminatum and various benign and malignant condyloma-like lesions in the anogenital area poses a common diagnostic challenge to pathologists across subspecialties.
Aim of study: To review the overlapping and distinguishing features of condyloma acuminatum and its mimics, and to clarify confusing terminology and diagnostic criteria for problematic entities.
Results: Correct diagnosis of condyloma acuminatum and condyloma-like lesions has important clinical implication and entails familiarization with their clinical presentations and histopathologic features. Contrary to historical belief, giant condyloma acuminatum and verrucous carcinoma should be considered distinct entities based on different pathogenetic pathways. Ancillary tools available for identifying and genotyping human papillomavirus can aid in diagnosis when histopathologic findings are inconclusive. Recognition of relatively rare entities such as bowenoid papulosis, epidermolytic acanthoma, and verruciform xanthoma would avoid overdiagnosis and unnecessary, overaggressive treatment.
Limitations: This was a literature review and did not present original data.
Twitter Journal Club Discussion Summary:
● Issue of vulvar SK (HPV and non-HPV related) was discussed; approaches include:
○ Consideration of age: younger patients generally more likely to be HPV+ and less likely to have SK in general
■ ASDP AUC used 25 yrs old as cutoff; SK very rare under that age
■ study of vulvar SK in women >50 yrs showed low incidence of HPV+, with 3/28 patients HPV+ (14%; vs other studies which showed closer to 70% in younger pts) (Reutter J, J Low Genit Tract Dis. 2014, https://www.ncbi.nlm.nih.gov/pubmed/24556611 )
○ Koilocytes helpful in diagnosing condy vs SK
○ Many participants favor a descriptive diagnosis and offer HPV testing in comment upon clinician request
○ Ki67 helpful for some; staining in upper layers of the epithelium more supportive of condy (Pirog et al AJSP 2000, Bai et al Hum Pathol 2003)
● HPV testing on low grade lesions:
○ Modalities: ISH appears most popular (though some use PCR), sendout labs used included ARUP and Mayo
○ Most do not order HPV testing routinely; will order upon clinician request
○ Important to note that there can be false positives and false negatives; some condy can be caused by high risk or HPV types other than 6/11, so condy that comes back as HPV low risk negative by ISH may be a false negative
○ HPV testing was reviewed in ASDP appropriate use committee (AUC):
https://onlinelibrary.wiley.com/doi/full/10.1111/cup.13142 ; found HPV testing “rarely appropriate” in many scenarios, exception being pediatric cases with path suggestive of condy (HPV testing “usually appropriate” in these cases)
● LAST terminology was discussed: many participants incorporate LSIL and HSIL into diagnosis of HPV related lesions of the anogenital region
○ Some only use “condyloma” for papillomatous low grade squamous lesions in the vulva and reserve LSIL for lesions that appear flat, others use both terms (“condyloma (LSIL)”)
○ It was noted that the ISSVD (International Society for the Study of Vulvovaginal Disorders) published terminology in 2015 highlighting specific issues related to vulvar SIL in the LAST criteria; they noted that LSIL should be used in regards to “flat condyloma or HPV effect” and also emphasized that LAST does not refer to differentiated VIN, which is considered a separate, non-HPV related form of high grade VIN (https://www.ncbi.nlm.nih.gov/pubmed/26704327 )
● Diagnosis of bowenoid papulosis relies on clinical correlation; suggested approach by some participants would be to diagnose case as HSIL/VIN3 and add comment that it could be c/w bowenoid papulosis in the appropriate clinical setting
● Giant condy vs verrucous CA:
○ traditionally (and still in some texts) taught that both are HPV-related, but while giant condy is usually associated with HPV 6/11, verrucous CA not HPV-related in studies with cases defined by strict histopathologic criteria
○ Giant condy usually associated with other STDs, VC assoc w/ inflammatory conditions such as lichen sclerosus
Thanks to all who participated! See you in November!