Lacrimal Caruncle Nevus with Papilloma
Introduction Various kinds of tumors arise from the lacrimal caruncle, of which nevus and papilloma are the most frequent. However, only 1 case report has illustrated a compound caruncle tumor composed of a papilloma with scattered intradermal nevus cells. This is the case of a lacrimal caruncle nevus with a papilloma, the pathology of which is different from the previous report.
Case Report A 39-year-old female presented with a slowly progressing pigmented lesion on the left lacrimal caruncle. She had been aware of a raised whitish wart on the top of this pigmented lesion for several months before her initial visit. She had no history of a wart on the same site.
Slit lamp examination revealed a papillomatous lesion over a well-circumscribed, pigmented lesion on the left lacrimal caruncle. The combined tumor was completely removed under local anesthesia. The histopathological examination disclosed 2 characteristic findings, which include nests of nevus cells within the dermis and papillomatous structures which had fibrovascular cores overlying squamous cell epithelia with variable levels of acanthosis.
Treatment Nevus cells and squamous epithelial cells showed no atypia. The findings were consistent with an intradermal nevus and a papilloma arising from the conjunctival epithelium of the nevus. At the 6-month follow-up, there was no evidence of recurrence.
Discussion This is the first case of a lacrimal caruncle tumor which contained 2 lesions, a nevus and a papilloma. Nevus and papilloma are the 2 most common tumors that independently arise from the lacrimal caruncle. The frequency of these lesions ranges from 33.7 to 59.5% for nevus and from 21.5 to 31.6% for papilloma. No report has, however, demonstrated the occurrence of a papilloma on a nevus as a combined lesion.A nevus mainly has 3 pathological types depending on the location of the nevus cells: an intradermal nevus, located in the dermis, such as in this case; a junctional nevus, located in the dermoepidermal junction; and a compound nevus, involving both the dermoepidermal junction and the dermis. While junctional and compound nevi may undergo malignant changes, an intradermal nevus shows a benign course as its epithelium remains intact.Conjunctival papillomas, caused by human papillomavirus (HPV), have a tendency to be located medially especially on the lacrimal caruncle because of the tear flow direction (and hence the flow of HPV particles) from the lacrimal lake towards the medial conjunctiva. Rubbing of eyes also involves the medial canthus, which may precede viral autoinoculation.Most conjunctival papillomas (81%) harbor HPV, particularly low-risk HPV types 6 and 11, while normal conjunctival specimens are HPV negative, although hybrid capture II and polymerase chain reaction assays were not performed in this case.As the epithelium of an intradermal nevus remains intact, the papilloma can arise from the normal caruncular epithelium in the intradermal nevus as a consequence of HPV autoinoculation. The clinical history and pathological findings of this case also underscore the development of papilloma from an underlying intradermal nevus. On the other hand, it is unclear whether a papilloma can arise from an abnormal epithelium in a junctional or compound nevus.In conclusion, we presented the first case of a lacrimal caruncle nevus with papilloma. Combined lesions should also be considered as a differential diagnosis for lacrimal caruncle lesions.
Keywords Lacrimal caruncle, Intradermal nevus, Papilloma
Author : Eri Ishikawa et.al