Dr Handsfield - oral squamous papilloma with dysplasia

[vkjames]

      Hi, I coughed up a papilloma/wart in feb 2013. I took it for pathology. The pathology only said benign squamous papilloma. I know this growth was somewhere in my throat, not in my lungs as I had been having this stuck in throat feeling for several months along with phlegm.  During this time i never looked in my mouth to see if i could see anything.  Then on June 10 2013 , I found something growing off my uvula. I would normally not have noticed this as it almost looked like just part of my uvula. I went to an ENT who cut it off the entire growth and sent for path. It was about the size of a smaller pencil eraser.  The report said high grade dysplasia (moderate dysplasia) with hpv cellular changes.  I am having a difficult time finding out information on the Internet about oral warts containing dysplasia. Is this so rare? I went to yet another ENT specializing in head and neck cancers at Emory University in Atlanta. He told me that from all the hpv positive oral cancers he's treated, he has never treated one arising from a wart/papilloma. If this were to regrow in a different area in my mouth in the same form of a wart with dysplasia, will it likely turn cancerous and spread to other areas like oral squamous cell cancer? This doctor also only recommended yearly follow ups, I feel I should have follow ups every 3 months.  I've become obsessed with my mouth, checking it daily.  Do you know anything about these types of oral warts that have dysplasia? Am I destined to keep getting these warts or will my immune system ever clear these warts like it often does for genital hpv? Do these warts recur and spread orally and if one were to regrow again this time cancerous, is this typically treated with chemo and radiation like other cancerous lesions of the mouth?
Thanks,
Lana

[Edward W Hook, MD]

No, it would be rare for a pathologist to miss dysplasia.  EWH

[vkjames]

Hi,
If I may please ask one final question?  The Emory Univ head and neck doctor received the slides from the first lab (this is the lab that diagnosed moderate dysplasia arising from squamous papilloma on uvula). This was done per my request.  The pathology department at Emory examined the slides and said no dysplasia found, benign.  I'm just curious if you know whether or not papillomas are commonly misdiagnosed as having dysplasia when there is no dysplasia.  I just find this whole thing odd (I found this out today).
Thank you,
Lana

[Edward W Hook, MD]

Thanks for the additional information.  I am not an oral pathologist or ENT specialist and thus cannot provide statistics on the frequency of dysplasia in papillomas.  As to how it was missed, that is a good and appropriate question.  I would ask your ENTwhy is was missed, using the same terms you just used.  

The problem with ENT cancers is that they are locally invasive.,  That is the reason for repeated exams to find, and treat them before they occur.  EWH

[vkjames]

Thank you for your reply.  Yes, I have had several indirect laryngoscopies and nothing has been found.  Regarding hpv related problems growing slowly, that's what's concerning is that I went to the ENT (not the Emory doctor) 2 or 3 times after and the final time was march 2013.  Then on 6/10/13, I found the uvula growth. Either the ENT missed the uvula papilloma or it appeared and grew after March.  The ENT was more focused on the indirect scope so I guess it's possible if the growth was there on the uvula, he could have missed it.
If I may ask the last couple questions please.  Have you ever heard of or seen dysplasia arising in a squamous papilloma ?  If a papilloma becomes cancerous, does it just keep invading other healthy tissue or does the cancer stay within the papilloma so to speak?
Thanks again,
Lana

[Edward W Hook, MD]

Welcome to our Forum.  Dr. Handsfield and I share the forum and take questions based on our availability.  You got me.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.

Your situation is an unusual one.,  Papillomas are typically firmly attached to mucosal epithelial surfaces and are quite difficult to dislodge.  Further, as your ENT has told you, when person have HPV leading to precancerous lesions (dysplasia) rather than causing visible papilloma, the infection typically leads to flatter, more infiltrative changes.  I presume that when you were seen (either by your own ENT or the specialist at Emory) you had indirect laryngoscopy in which the doctor used a scope to look down into your throat and airways, correct?  If so, had he/she seen something they would have taken steps to treat it.  On the other hand, if there were no obvious lesions (or, for that matter, even if there were and they were treated) the proper next steps would be to periodically re-evaluate the area, looking for recurrences.  One of the things that makes HPV-related problems readily manageable is that they grow VERY slowly and can be detected with periodic examinations.  I am not a head and neck specialist and  suspect that the doctor who told to get re-evaluated was following appropriate recommendations.

Most oral HPV infections leading to pre-cancerous growths are due to HPV 16, a virus which can also infect the genital tract.  Although it would be unusual to have serious infection at two different sites on your body, given your history, in addition to your periodic re-evaluations by the ENT, you should be sure to get regular PAP smears as well.

Your doctor will help to treat your infection, typically be removing infected tissue.  Your immune system will also help to control the infection.

I hope this perspective is helpful.  I suggest that you continue to work with the same ENT over time. there is a value to having the same doctor follow you over time.  EWH