包括一例已证实复发的犬皮肤内翻性乳头状瘤病例分析

王帆

A case series of canine cutaneous inverted papilloma with one case showing evidence of recurrence

包括一例已证实复发的犬皮肤内翻性乳头状瘤病例分析

作者：Teresa M.S.A. Boehm 等人

翻译：王濮嵩

Background-This article describes a case of multiple, recurrent, cutaneous inverted papillomas (CIPs) in a German shepherd dog, combined with a retrospective follow-up assessment of eight cases.

Methods-A 3-year-old, black, female German shepherd dog presented with four rapidly growing, alopecic, domed, hyperpigmented, shiny nodules, compatible with CIP. The dog was managed for pruritus, associated with atopic dermatitis, with long-term prednisolone therapy and this therapy was continued after the surgical excision. Twelve months after the initial presentation the dog was represented for two new CIP lesions, coinciding with an increased dosage of prednisolone during an allergic flare-up period.

Results-Histopathological evaluation was conducted on both the original and subsequent lesions from the case with recurrence. Eight cases of CIP, based on histopathological findings, were identified retrospectively from the authors’ diagnostic pathology service over the previous two years. All nine cases had lesions that exhibited varying degrees of inverted epithelial hyperplasia, multiple, endophytic, papillary epidermal projections, a cup-shaped base with central hyperkeratosis and active viral pathological findings (koilocytes). The submitting veterinarians were contacted and follow-up regarding recurrence and concurrent medications was obtained.

Conclusions and clinical importance-CIP is uncommonly reported, typically as a single lesion with no previous reports of recurrence, although one group of dogs with severe combined immunodeficiency developed invasive malignancies. In seven of eight retrospective cases no recurrence of CIP was recorded. The authors speculate that the recurrence in the German shepherd dog may have been associated with chronic (although lowdose) glucocorticoid administration.

背景-本文章描述了一例德国牧羊犬多灶的、复发性皮肤内翻乳头状瘤（CIPs），结合对8例病例的回顾性随访评估。

方法-一只3岁黑色雌性德国牧羊犬出现四处快速生长的、脱毛的、半球形的、色素沉着有光泽的结节，与CIP一致。该犬长期使用泼尼松龙治疗管理特应性皮炎的瘙痒，手术切除后继续治疗。首次就诊12个月后，该犬又出现了两个新CIP病变，与过敏发作期间泼尼松龙剂量增加同时发生。

结果-对复发的病例原发和现有病变进行组织病理学评估。8个CIP病例，基于组织病理学发现，从作者过去两年的诊断病理服务的回顾性鉴定。所有9个病例的病变都表现为不同程度的内翻性上皮增生、多发性内生性乳头状表皮凸起，伴随中央角化过度的杯状基底和活跃的病毒病理发现（挖空细胞）。联系了提交的兽医，后续关于复发和同时用药进行随访。

结论与临床意义-CIP是不常见的报道，典型的是单一病变以前没有复发的报道，虽然一组严重并发免疫缺陷的犬发展为扩散性恶性肿瘤。8例回顾性病例中的7例未记录复发性CIP。作者猜测在德国牧羊犬的复发可能与慢性（虽然低剂量）糖皮质激素使用有关。

Introduction

介绍

Canine papilloma virus (CPV) is an aetiological agent for a variety of skin lesions in dogs. Clinical presentations include pigmented viral plaques, oral papillomatosis (COPV), exophytic cutaneous papillomas, cutaneous inverted (endophytic) papillomas (CIPs), digital papillomatosis and genital papillomas.The common exophytic variants develop in young dogs on the face, ears and extremities; they typically resolve spontaneously over weeks to months.

犬乳头状瘤病毒（CPV）是犬多种皮肤病变的病原体。临床表现包括色素性病毒斑块、口腔乳头状瘤病（COPV）、外生性皮肤乳头状瘤、皮肤内翻性（内生性）乳头状瘤（CIPs）、趾部乳头状瘤病和生殖器乳头状瘤。常见的外生性出现在幼犬的面部、耳部和四肢；他们通常在几周至几个月自发性消退。

The CIP variant has been reported most commonly on the ventrum, digits and pawpads,and also on the ventral neck and concave pinna, or disseminated multifocally.The typical appearance is solitary grey to fleshcoloured, elevated, alopecic, dome-shaped masses of 1–2 cm in diameter containing a wide central pore. One boxer dog with distinctive histological features of CIP had multiple, black 2 mm papules. In a colony of laboratory beagle dogs with severe combined immunodeficiency (SCID), CIP lesions (mostly interdigitally and footpad located) were reported along with some exophytic papilloma lesions.

多种CIP被报道最常出现在腹侧、趾部和爪垫，也出现在颈腹侧和耳廓凹面，或弥散性多病灶。经典的表现是单独的灰色至肉色、凸出的、脱毛、圆拱形肿物，直径1-2cm，包含一个宽的中央孔。一只拳师犬具有明确的CIP组织学特征，有多个黑色2mm丘疹。一群实验室患有严重并发免疫缺陷病（SCID）的比格犬中也报道了CIP病变（主要位于指间和爪垫）和一些外生性乳头状瘤病变。

To the best of the authors’ knowledge, there are 12 cases of CIPs reported in published studies and in all cases recurrence has not been reported.

据作者所知，已发表的研究中有12例CIPs被报道，所有病例没有复发报道。

Case history

病例病史

A female, intact, 2-year-old black German shepherd dog initially presented with four nonpruritic, indolent, smoothwalled, hyperpigmented, exophytic masses with a central, rough, indented crater, on the ventral abdomen. They ranged from 3 mm to 1 cm (Figure 1) and developed over a 12 day period. The dog had signs of atopic dermatitis (AD) from <12 months of age and an 18 month course of constant prednisolone administration at a dose of 0.19 mg/kg per os on alternating days, which the owner had elected to administer after informed veterinary advice. Historically, a 50% dose reduction led to marked pruritus within a week and disseminated pustules and erythema. Oclacitinib, antihistamines, essential fatty acids and shampoos had been administered for short periods many months previously and not helped the pruritus. The four lesions were excised and submitted for histological examination.

一只雌性未绝育的2岁黑色德国牧羊犬最初出现在腹部有四个非瘙痒性、无痛的、光滑的、色素沉着的中央粗糙的凹痕外生性肿块。范围从3mm至1cm（图1），发展超过12天。该犬在小于12月龄就出现了特应性皮炎（AD）症状，在18个月里，持续使用泼尼松龙治疗，在兽医指导下剂量为0.19mg/kg/os，隔日一次。之前，剂量减少50%就会一周内出现瘙痒和弥散性脓疱和红斑。曾经短期使用过数月奥拉替尼、抗组胺药、必需脂肪酸和香波，但是对瘙痒无效。切除四个病变进行组织学检查。

At the initial presentation, cytological evaluation of a nodule and surrounding skin revealed non-nucleated, pigmented keratinocytes. A complete blood count and biochemical profile were within normal ranges except for a slight monocytosis. Three days later the nodules were excised under general anaesthesia; no subsequent analgesia or antibiotic therapy was required. At suture removal the incisions had healed well. All four nodules were histologically confirmed as CIP, completely excised, with marked epithelial hyperplasia, multiple, endophytic, hyperpigmented, papillary epidermal projections extending into the dermis, forming a cup-shaped deep margin, with marked hyperkeratosis in the centre of the nodule (Figure 2 a, b). The stratum granulosum contained prominent koilocytes, cells with clear cytoplasm and with numerous giant keratohyalin granules (Figure 2c). Multiple basal layer mitoses were observed with a subepidermal fibroblastic stroma.

在最初的表现，细胞学检查小结节和周围皮肤显示无核、有色素的角质形成细胞。全血细胞计数和生化指标在正常范围内除了轻微单核细胞增多。三天后，在全身麻醉下切除结节，随后不需要止痛和抗生素治疗。在拆线时，切口愈合良好。4个结节的组织学确定是CIP，完全切除，明显的表皮增生、多发性、内生性、色素沉着，乳突状表皮突起延伸至真皮层，形成一个杯状的深边缘，结节中央伴有明显的角化过度（图2a,b）。颗粒层含有显著的挖空细胞，胞浆清晰的细胞和大量巨大的透明角质颗粒（图2c）。观察到多个基底层有丝分裂，伴随表皮下成纤维细胞基质。

One month later, the dog was enrolled in a clinical prospective atopy study, where the protocol required methylprednisolone (dosage 0.15 mg/kg twice weekly) and palmitoylethanolamide, 10 mg/kg p.o. every day (Redonyl 150 mg Ultra, Dechra GmbH; Aulendorf, Germany). As a result of a lack of clinical response, after a three week period the owner returned to prednisolone as sole therapy.

一个月后，该犬被纳入一项临床前瞻性特应性皮炎研究，治疗方案要求甲基泼尼松龙（剂量0.15mg/kg，每周两次）和棕榈酰乙醇酰胺，10mg/kg，每天口服。由于没有临床效果，在3周后，主人恢复泼尼松龙作为单独治疗方案。

Nine months after the initial excision the owner increased the dosage of oral glucocorticoids to 0.2 mg/kg prednisolone twice daily, as a consequence of multiple severe allergic flares. Within three months, two new nodules developed on the ventral abdomen, within centimetres of one of the previous nodules. These were excised and submitted for histological examination. The new nodules were elevated, shiny, hyperpigmented with a central crateriform indentation and ranged from 2 to 5 mm. One of the lesions was repeatedly self-traumatised (bitten down to the level of the skin) over a six week period yet regrew. The nodules were surgically excised and histologically confirmed as CIP.

在最初切除的9个月以后，主人增加了口服糖皮质激素的剂量至0.2mg/kg的泼尼松龙，一天两次，因为出现多次严重的过敏爆发。在三个月内，在腹侧出现了2个新的结节，距之前的结节1cm内。这些都被切除并递交组织学检查。新结节凸起有光泽、色素沉着伴随中央漏斗样凹陷，范围2-5mm。其中一个病变是重复的自损（咬至皮肤平面）超过6周的时间又重新生长。手术切除的结节，组织学证实CIP。

Immunohistochemical staining was performed with a commercial anti-bovine papilloma virus E2 antibody [5H4] (ab1072, Abcam; Cambridge, UK) and the keratinocyte nuclei stained positively for the E2 papillomavirus groupspecific antigen (see Figure 2d).

免疫组化染色使用商品化抗牛乳头状病毒病毒E2抗体[5H4]和角质形成细胞核E2乳头瘤病毒特异性抗抗原染色阳性（见图2d）

Further follow-up over two years reported no recurrence.

进一步随访2年没有复发报道。

Retrospective case analysis

回顾性病例分析

The authors reviewed the frequency of presentation for CIP using data from the authors’ Specialty Practice for Veterinary Pathology. During the whole of 2016 and 2017, 47,377 submissions of canine skin biopsies were examined; of these, there were 569 exophytic viral papillomas, eight of which were CIP. Primary veterinarians were contacted for follow-up; for seven of eight dogs there was no recurrence reported following surgical excision and the remaining eighth case was lost to follow-up (Table 1).

作者使用作者的兽医病理学专科临床数据回顾了CIP发病率。在2016至2017年期间，检查了47377份犬皮肤活检报告，其中569例外生性病毒性乳头状瘤，其中8例是CIP。联系首诊兽医随访，8只中的7只外科手术切除后没有复发，第8只失访（表1）

Discussion

讨论

In previous case reports common clinical features of CIPs have included occurrence at an age under three years, predisposed areas including inguinal and ventral abdomen, typical size <2 cm in diameter, firm consistency and raised dome-shape with a central indentation.Seven of nine of our cases were under three years of age. Nine cases had lesions located in typical areas reported previously. The case with recurrence had lesions most closely resembling Campbell’s type,located on the ventral abdomen. The exact clinical appearance of the lesions in the eight retrospective cases was not available.

在之前病例报道中，CIPs常见的临床特点包括年龄小于三岁，易感部位包括腹股沟和腹部腹侧，典型大小直径小于2cm，统一为坚实的、拱形凸起伴随中央凹陷。9例中的7例在3岁以下。9例病变位于在之前报道的典型区域。复发病例的病变最接近Campbell’s 型，位置在腹部腹侧。在8例回顾性病例中，无法得到病变的确切临床表现。

Given that CIPs have been reported only infrequently, eight cases being identified over a two year period was an unexpectedly high number, when compared with 569 exophytic papillomas (1.4%).

考虑到CIPs报道很少，在2年内确诊了8个病例，比预期数量高，与569例外生性乳头状瘤相比（1.4%）。

Our cases were selected based on compatible histopathological findings and eight of nine showed cytopathic viral changes. Histopathologically, CIPs appear as a partially endophytic lesion with a cup-shaped margin, with papillary epidermal projections extending centripetally into the centre of the nodule. The projections contain the cytopathic products of the papilloma virus infection, such as clumped, giant keratohyalin granules, prominent koilocytes and rare eosinophilic cytoplasmic or basophilic intranuclear inclusions.

本文病例选择基于组织病理学发现，9例中的8例显示细胞病毒变化。组织病理学，CIPs表现为部分内生病变，边缘成杯状，乳头状表皮延伸至结节中心。 这些凸出物包含乳头状病毒感染的细胞病变产物，例如成群的，大的透明角质颗粒，突出的挖空细胞和少量嗜酸性细胞质或嗜碱性细胞核包含物。

When rapid cell proliferation is induced by papillomavirus, a marked epithelial hyperplasia is typically visible clinically as a papule, plaque or nodule.3 Whether the epidermal hyperplasia produces an exophytic or endophytic folding of the epidermis is not apparently related to the virus because CIPs have been associated with multiple papillomavirus subtypes.3 Molecular analyses of four cases of CIP identified four different papilloma virus subtypes including canine papilloma virus 2 (CPV2) and two previously unknown papilloma viruses.4 In our case series we did not type the papilloma virus.

当乳头状瘤病毒诱导细胞快速增殖时，明显的表皮增生，临床代表如丘疹、斑块或结节。表皮增生是否产生表皮的外生性或内生性折叠与该病毒无关，因为CIPs与乳头状瘤病毒亚型有关。对4例CIP病例的分子分析，确定了4种不同的乳头状瘤病毒亚型，包括犬乳头状瘤病毒2（CPV2）和两种之前未知的乳头状瘤病毒。在本文病例中没有对乳头状瘤病毒分型。

Stress and immunosuppression may increase virus expression. In dogs various treatments for exophytic papillomas have been reported, although the interpretation of therapeutic success is complicated by the fact that exophytic papillomas typically resolve spontaneously. Topical therapy with imiquimod, autologous vaccines, surgical excision, cryotherapy or laser therapy have all been recommended; interferon-alpha was reported to be helpful in canine cutaneous and oral papillomas. Azithromycin was reportedly effective in the treatment of exophytic papillomas in one case series. Cimetidine is an effective treatment for papillomavirus warts in human medicine and has been used anecdotally in dogs. The only reported specific treatment for CIP has been surgical excision.

应激和免疫抑制可以增加病毒表达。已报道多种犬外生性乳头状瘤治疗方法，但事实上外生性乳头状瘤通常会自行消退，这使得治疗成功的解释变得复杂。外用咪喹莫特、自体疫苗、手术切除、冷冻疗法或激光疗法都被推荐；干扰素-α被报道对犬皮肤和口腔乳头状瘤有帮助。据报道，阿奇霉素在一个外生性乳头状瘤病例中有效。西咪替丁在人医中治疗乳头状病毒疣有效，也有犬用的传闻。唯一报道CIP特殊治疗是手术切除。

Because viral infections can be a consequence of immunosuppression in dogs, it is possible that in the case with recurrence the CIPs developed both initially and a year later as a result of ongoing prednisolone therapy. Most CIP lesions reported to date have been in dogs that were not considered to be immunocompromised.Three reports of CIP natural progression have been associated with a degree of immunosuppression, including the SCID beagle dogs which progressed to invasive squamous cell carcinoma,one bitch where the lesions developed postneutering and spontaneously resolved, and a boxer dog with multiple papules with iatrogenic Cushing’s disease in which all lesions resolved spontaneously upon withdrawal of prednisolone.Previous reports and textbooks commonly refer to 2 mg/kg once daily prednisolone as the immunosuppressive dose for dogs and <1 mg/kg as “anti-inflammatory”.However, the anti-inflammatory to immunosuppressive dosage of glucocorticoids in dogs may be individual and published studies indicating clear cut-off values are lacking.

由于病毒感染可能是犬免疫抑制的结果，复发的CIPs病例中，最初出现和一年后复发，可能是持续使用泼尼松龙治疗导致的。至今在犬上报道的大多数CIP病变，不认为是免疫缺陷病导致。三个自发性CIP的报道，与一定程度的免疫抑制相关，包括发展为侵袭性鳞状细胞癌的SCID比格，一只母犬的病变在绝育后自行消退，一只拳师犬患有医源性库兴伴有多发性丘疹，在停止泼尼松龙后，所有病变自行消退。以往的报道和教科书中一般将2mg/kg 每日一次泼尼松龙作为犬的免疫抑制剂量，小于1mg/kg 作为“抗炎”剂量。然而，糖皮质激素在犬的抗炎至免疫抑制剂量可能有个体差异，已发表的研究表明缺乏明确的界限值。

With respect to the case with recurrence; this was temporally associated with an atopy flare and associated increased dosage of prednisolone to 0.2 mg/kg prednisolone once or twice daily. The authors speculate that a plausible local immunomodulatory effect could have led to the development of the CIPs. In humans, proinflammatory cytokines are reported to upregulate glucocorticoid receptor gene expression, which leads to focal accumulation and increased glucocorticoid action in inflamed tissue. Such focal attenuation of a dosage otherwise regarded as “nonimmunosuppressive” in this dog, due to the inflammation associated with the AD flare, could have made the virus replication possible and triggered the formation of the CIP. Papilloma viruses are ubiquitous on canine skin,allowing opportunistic infection.

关于复发的病例，与特应性皮炎发作和泼尼松龙增加剂量0.2mg/kg每日1-2次有关。作者猜测可能是局部免疫调节作用导致了CIPs的发展。在人上，据报道，促炎细胞因子可上调糖皮质激素受体基因表达，导致在炎症组织中糖皮质激素局灶累积和作用增加。由于与AD发作有关的炎症，被认为本应是“非免疫抑制”剂量在犬的局灶性衰减剂量，可能是病毒复制成为可能，触发CIP形成。乳头状瘤病毒在犬皮肤普遍存在，允许条件性致病感染。

Figure 1. Canine cutaneous inverted papilloma; clinical findings at first presentation.

The ventral abdomen shows two crateriform nodules and two hyperpigmented papules.

图1. 犬皮肤内翻性乳头状瘤，首诊时临床检查。腹部腹侧出现2个漏斗状结节和2个色素沉着丘疹。

Figure 2. Canine cutaneous inverted papilloma in haired skin; histopathological and immunohistochemical findings

图2.犬有毛皮肤的皮肤内翻性乳头状瘤；组织病理学和免疫组化检查

(a) Papillomatous lesion with inverted endophytic growth. The multiple papillary epidermal projections open superficially into a central keratin core and extend downward to form the cup-shaped architecture. Haematoxylin & eosin, x40.

（a）内翻性生长的乳头状瘤病变。多个乳头状表皮突起的表面向中央角蛋白核心开放，向下延伸形成杯状结构。 HE染色, 40倍

(b) Close up of the epithelial papillary projections with keratinocyte hyperplasia and dysplasia; H&E, x200.

（b）表皮乳头状突起伴随角质形成细胞增生和发育异常H&E, 200倍

(c) Multiple keratinocytes in the stratum granulosum have basophilic cytoplasm that is compatible with viral cytopathic effect (black arrows); as well as an eosinophilic intranuclear inclusion body (white arrow head) and two apoptotic/necrotic cells (see black arrow heads). Other cells have clear cytoplasm and numerous enlarged keratohyalin granules (koilocytes), H&E, x400.

（c）多个角质形成细胞在颗粒层有嗜碱性细胞质，与病毒细胞病变相一致（黑色箭）；嗜酸性细胞核包涵体（白箭头）和两个凋亡/坏死细胞（见黑色箭头）。其他细胞有透明的细胞质和大量增大的透明角质颗粒（挖空细胞）H&E, 400倍.

(d) Immunohistochemical staining for papillomavirus (with a commercial anti-bovine papilloma virus E2 antibody (ab1072, Abcam; Cambridge, UK)) reveals positively staining nuclei in the stratum granulosum and upper stratum spinosum (see black arrow heads).

（d）乳头状瘤病毒免疫组化染色（使用商品化抗牛乳头状瘤病毒E2抗体(ab1072, Abcam; Cambridge, UK)）显示在颗粒层和棘层的阳性细胞核染色（见黑色箭头）。

南海

Vet武

红蓝紫

Ryohei

红蓝紫