In addition, an understanding of these diseases will allow the development of new targeted therapies for these aggressive lymphomas. [citation needed], It is one common source of appendicitis, as it may cause an obstruction of the appendiceal lumen, resulting in the subsequent filling of the appendix with mucus, causing it to distend and internal pressure to increase. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Epub 2009 Jun 26. e. Tumour cells were positive for P53 (200 x). Abstract Background Benign lymphoid hyperplasia (BLH) is a benign proliferation of lymphoid tissue in response to external irritation. 353358, 2001. Except in one case, all patients exhibited a tongue base mass with smooth and intact membrane surface. Google Scholar. Bookshelf Oral and Maxillofacial Pathology. sharing sensitive information, make sure youre on a federal However, this index markedly increases to 4% (4/101) among patients with pharyngolaryngeal signs of GER and reached 7.5% (4/53) among patients presenting GER symptoms such as heartburn, regurgitation, retrosternal burning feeling, and dysphagia. Figure 2 shows the process of a reactive lymphoid lesion histologically. As stated before, the depth of invasion is a major prognostic indicator. Patricia Uherova et al. The follicles are cytologically polymorphous, are often polarized, and vary in size and shape. Immunohistochemical staining was performed using a Ventana Benchmark XT Autostainer (Ventana Medical Systems, Inc., Tucson, AZ). SW and XZ did the BCL-2, BCL-6, c-MYC FISH examination. California Privacy Statement, Int J Oral Maxillofac Surg. Cut-off values were set as previously described [9]. Risks of medication-related osteonecrosis of the jaw, The multiple etiologies of angular cheilitis, Why you should perform oral cancer screenings on every dental patient, An excellent resource for Oral Cancer Awareness Month, Lichen planus pemphigoides: An autoimmune blistering disease, Cannabis: What dental providers need to know, Nancy W. Burkhart, EdD, MEd, BSDH, AAFAAOM. Owosho AA, Bilodeau EA, Surti U, Craig FE. 2, pp. A poor prognostic case of peripheral T-cell lymphoma in the base of tongue with chemotherapy followed by radiation therapy. The site is secure. None of the seven patients presented systemic symptoms (body weight loss, fever and night sweating). These tissues act as your body's first line of defense against infections. https://doi.org/10.4103/0019-509X.58873. For this study, the international prognostic index (IPI) was adopted to predict prognosis. Disclaimer. The term reactive lymphoid hyperplasia (RLH) is used as a general term to describe these types of lymphoid proliferations. Vocal cord involvement can cause choking. Clinically this lesion presented as a painless ulcer, which mimicked carcinoma of the tongue. 1. Clinical and laboratory investigations are routinely negative [2]. Seven cases were identified from the Pathological Registry Database at Peking Union Medical College Hospital (PUMCH). One case presented as multiple deep ulcers. During the follow up period, the MCL patient and an elderly DLBCL patient died. 2). When the lymphoid tissue is deeply seated, the appearance may be more pink or deeper in color. [1] The growth is termed hyperplasia which may result in enlargement of various tissue including an organ, or cause a cutaneous lesion. The FISH probes used were 18q21 for BCL2, 3q27 for BCL6, and 8q24 for cMYC. His IPI score was 2(low to intermediate risk group). All patients were diagnosed by either biopsy or tumor resection. Three patients were at an early stage (stage I and II) and had low IPI scores (0 or 1). 4, pp. In contrast, cytokeratins, CD8, CD20, CD30, ALK and CD56, TIA-1, and Granzyme B were negative. Baran M, Canoz O, Altuntas H, Sivgin S, Cetin M, Yay A, Ketenci S. Immunohistochemical investigation of P16, P53 and Ki-67's prognostic values in diffuse large B-cell lymphomas. Pathology may also show indistinct germinal centres leading to erroneous diagnosis of follicular lymphoma [3]. With proper therapy, even late stage tongue base lymphomas can be suppressed and remain in remission. Hypermethylation of CpG islands in p16 as a prognostic factor for diffuse large B-cell lymphoma in a high-risk group. One case presented as multiple deep ulcers. Google Scholar. When oral aggregates appear in clusters or have an unusual appearance or enlargement, clinicians may question whether abnormalities are present. XS and QL did the HPV ISH. LH most commonly affects older patients, with a mean age of 61 and female-to-male ratio of nearly 3:1. Cancer that develops in the base of the tongue is a type of head and neck cancer. For DNA detection of high-riskin situ HPV infection, biotin-labelled HPV probe solutions (Leica, Newcastle, UK) were added to formalin-fixed, paraffin-embedded tissue sections. In the study of Eisuke et al., hypermethylation of the p16 promotor indicated a poor prognosis [35]. Google Scholar. Six of the cases exhibited tongue base masses with smooth surface membranes. Two patients, including our patient, died during follow-up. Mod Pathol. A case of benign. A final diagnosis was made through deep resection. official website and that any information you provide is encrypted Int J Hematol. [2] Lymph node anatomy [ edit] 2017;30:S4453. Expression of c-Myc and p53 correlates with clinical outcome in diffuse large B-cell lymphomas. The aetiological factors for lymphoma of the oral region other than EBV and HIV are little known. Authors M Gromet , M J Homer , B L Carter PMID: 7111732 DOI: 10.1148/radiology.144.4.7111732 No abstract available Publication types Case Reports MeSH terms Adult Barium Sulfate Deglutition Diagnosis, Differential Female Am J Surg Pathol. https://doi.org/10.1097/01.dad.0000246949.49071.17. [Diagnostics of laryngopharyngeal form of gastroesophageal reflux disease for adults (Lithuanian clinical practice guidelines)]. The surface of the tongue in this area is made up primarily of lymphoid tissue known as the lingual tonsil. PubMed Severe benign LH is unusual in the head and neck region, but the diagnosis should be entertained on the part of the clinician both clinically and histologically when lymphoma is suspectedparticularly in the oral cavity. Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000. Am J Clin Pathol. Tongue musculature involvement can cause restricted movement, dysarthria, and dysphagia. 4, pp. Google Scholar. Then he looked down my throat through my nose. Lymphoid hyperplasia of the tongue is a very rare benign lymphoproliferative lesion that closely resembles carcinoma or lymphoma, clinically or histopathologically. https://doi.org/10.1038/modpathol.2011.45. Feinberg SM, Ou SH, Gu M, Shibuya TY. Oral-cutaneous CD4-positive T-cell lymphoma: a study of two patients. Harabuchi Y, Tsubota H, Ohguro S, Himi T, Asakura K, Kataura A, Ohuchi A, Hareyama M. Prognostic factors and treatment outcome in non-Hodgkin's lymphoma of Waldeyer's ring. 2023 BioMed Central Ltd unless otherwise stated. Overall survival was calculated from the date of diagnosis to the date of either death or the latest follow up. The tongue has a rich network of lymphatics that drain to neck levels I-III, which is the usual pattern of spread when these tumors metastasize. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Accessibility Virchows Arch. Unauthorized use of these marks is strictly prohibited. Cyclophosphamide, doxorubicin, vincristine, prednisone, Peripheral T cell lymphoma, not otherwise specified. 2004;103:27582. The population of the compartment is cytologically polymorphous. Clinically this lesion presented as a painless ulcer, which mimicked carcinoma of the tongue. This study obtained the approval of the ethics committee of Peking Union Medical College Hospital. https://doi.org/10.2214/ajr.149.3.575. 2006;30:85967. Before Had biopsy on axillary lymph node. https://doi.org/10.1186/s13000-020-00936-w, DOI: https://doi.org/10.1186/s13000-020-00936-w. https://doi.org/10.1016/j.ijom.2010.03.029. Two patients survived more than six years. Domanski HA, Akerman M. Fine-needle aspiration cytology of tongue swellings: a study of 75 cases. The tumour cells were large and blastic, with a high mitotic rate, which was similar to diffuse large B lymphoma tumour cells. Histological features include distention or engorgement of both subcapsular and intraparenchymal sinuses by benign histiocytes which may be hemophagocytic. Call your doctor or 911 if you think you may have a medical emergency. Russo S, Lo Re G, Galia M, Reginelli A, Lo Greco V, D'Agostino T, La Tona G, Coppolino F, Grassi R, Midiri M, Lagalla R. Radiol Med. Unable to load your collection due to an error, Unable to load your delegates due to an error. Normal lymphoid tissue is found in your lymph nodes and tonsils. A mass was found through radiological and laryngoscopic examinations in six patients. b. H&E showed immunoblastic large cells with an obvious nucleolus (200 x). https://doi.org/10.1002/ajh.23176. 2008;100:2619. Mamede RC, Amaral Fd, Raimundo DG, Freitas LC, Ricz HM, Mello Filho FV. Generally, MCL patients have a median age of 60years and a striking male predominance [42] .Three of the four cases of MCL including our case, occurred at the base of the tongue. Discussions concentrating on NHL of the base of the tongue have focused on the histopathology and lack details regarding progress in the treatment response and prognosis. National Library of Medicine Article Part of St. Louis, MO: Elsevier; 2016. Imaging and pathological findings of DLBCL (case 5). Patients first experienced from varying degrees of throat discomfort and commit to the hospital with no B symptoms. Non-Hodgkins lymphoma (NHL) primarily derived from the base of the tongue, is rare. The presence of an excessively large tongue, which may be congenital or may develop as a result of a tumor or edema due to obstruction of lymphatic vessels, or it may occur in association with hyperpituitarism or acromegaly. Cancer at the base of the tongue is usually diagnosed at an advanced stage, when the tumor is larger and the cancer has spread into the lymph nodes in the neck. Unable to load your collection due to an error, Unable to load your delegates due to an error. b. H&E showed moderate to large cells with distorted nuclear contours (200 x). While the etiology is poorly understood, a number of previous theories exist, which are included here in the context of a literature review. Int J Oral Maxillofac Surg. M Gromet, M J Homer, B L Carter Published Online: Sep 1 1982 https://doi.org/10.1148/radiology.144.4.7111732 PDF Share Article History Published in print: 1982 Figures References Related Details Vol. Gastroesophageal reflux in bronchial asthma patients. Leuk Res. [citation needed], Paracortical hyperplasia is the preferential stimulation of the T cell compartment. Lee JT, Paquette R, Sercarz JA, Wang MB. and transmitted securely. 1979 Sep;30(5):485-8. doi: 10.1016/s0009-9260(79)80176-2. The exceptional case here was a 45-year-old male patient with diffuse large B cell lymphoma who presented with only deep painful mouth ulcers and general symptoms, including sore throat, choking when drinking water, and difficulty swallowing. Two pathologists interpreted the FISH results using an Olympus fluorescence microscope equipped with 100 objective lens and orange/ green/4, 6-diamid-ino-2-phenylindole filters. [3] Follicular hyperplasia must be distinguished from follicular lymphoma (bcl-2 protein is expressed in neoplastic follicles, but not reactive follicles). Kaohsiung J Med Sci. Among our cases, there were 1 GC and 3 NGC cases. [7]. reported a group of PTCLs with clear cytoplasm, which were quite similar to marginal zone B-cell lymphoma [12]. Benign lymphoid hyperplasia is a benign proliferation of lymphoid tissue in response to external irritation and occurrence within oral cavity is rare. No progression to malignancy has been reported, although one multisite case within the oral cavity was found to represent MALT-type lymphoma [1]. Although our case with MCL received rituximab during his second cycle of chemotherapy, he relapsed two years after the primary diagnosis. The airway was subsequently secured, and the procedure was undertaken. PMC 2006;17:143440. In addition, rituximab, an anti-CD20 chimeric antibody that has dramatically and favourably improved the survival rate [39], was not added to the therapeutic regimen of this case for some reason. [Lymphoepithelial hyperplasia of the tonsil at the base of the tongue]. Get prescriptions or refills through a video chat, if the doctor feels the prescriptions are medically appropriate. or a reactive lymphoid proliferation to an unknown antigenic stimulation [2]. Lymphoid hyperplasia at the base of the tongue. Lee YY, Van Tassel P, Nauert C, North LB, Jing BS. 2013;91 Thesis 5:127. volume15, Articlenumber:30 (2020) In addition, patients may notice irregularities on their own, thereby bringing the appearance to the attention of their dentists or hygienists. 2, no. 2001;23:54758. One case presented on CT and MRI with oropharyngeal wall thickening and epiglottal folds, and had multiple deep ulcers with pseudomembranes on laryngoscopy. The lymphoid follicles at the base of the tongue can be detected when examining the pharynx of adults, but the presence of large follicles, denoted "severe" hypertrophy of the base of the tongue (HBT) is rare. For these, please consult a doctor (virtually or in person). Oral Pathology: Clinical Pathologic Correlations. Polyclonal lymphoid proliferation with immunohistochemistry stains for kappa or lambda light chains are diagnostic. e. Tumour cells were positive for CD4 (200x). Eur Arch Otorhinolaryngol. 7th ed. It has been historically referred to as reactive lymphoid hyperplasia or pseudolymphoma [1]. 2013;119:18327. AJR Am J Roentgenol. L. P. Menasce, J. H. Shanks, S. S. Banerjee, and M. Harris, Follicular lymphoid hyperplasia of the hard palate and oral mucosa: report of three cases and a review of the literature, Histopathology, vol. The remaining five patients were alive through the end of follow up. Ekstrom-Smedby K. Epidemiology and etiology of non-Hodgkin lymphoma--a review. Mod Pathol. Lymphomas of the head and neck: CT findings at initial presentation. Positive staining was indicated by brown punctate dots in the cytoplasm. These tonsils contain B and T lymphocytes which get activated when harmful bacteria and viruses come in contact with tonsils. Some cases of DLBCL may be associated with HPV infection. Primary non-Hodgkin lymphoma of the tongue base: the clinicopathology of seven cases and evaluation of HPV and EBV status, https://doi.org/10.1186/s13000-020-00936-w, https://doi.org/10.1016/S0344-0338(11)80514-5, https://doi.org/10.1016/j.kjms.2012.02.014, https://doi.org/10.1080/02841860500531682, https://doi.org/10.1038/modpathol.2016.152, https://doi.org/10.1007/s00428-014-1682-7, https://doi.org/10.1038/modpathol.2011.45, https://doi.org/10.1182/blood-2003-05-1545, https://doi.org/10.1038/modpathol.3880541, https://doi.org/10.1097/01.dad.0000246949.49071.17, https://doi.org/10.1007/s12185-008-0142-z, https://doi.org/10.1016/j.ijom.2004.08.009, https://doi.org/10.1016/j.ijom.2010.03.029, https://doi.org/10.1016/j.anndiagpath.2005.09.020, https://doi.org/10.1016/j.oooo.2014.06.002, https://doi.org/10.1007/978-3-319-22822-8_13, https://doi.org/10.22034/APJCP.2017.18.10.2781, https://doi.org/10.1016/j.leukres.2005.11.004, https://doi.org/10.1309/YHFE-R65B-D3LK-3GGV, https://doi.org/10.11406/rinketsu.58.2033, https://doi.org/10.1017/s0022215100142288, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. HHS Vulnerability Disclosure, Help showed that loss of P16 expression has no effect on life expectancy [33], but high P16 levels may inhibit tumour growth in DLBCL [34]. Aguilera NS, Uusafr M, Wenig BM, Abbondanzo SL. Epub 2016 Sep 17. This patient had a partial response to chemotherapy and died 63months after diagnosis. Otolaryngologic manifestations of gastroesophageal reflux. Acta Oncol. Review of the preoperative anaesthesia records revealed no features of airway obstruction nor B symptoms on clinical history. Viral infections, such as HIV or hepatitis C virus (HCV), can also develop in immunocompromised patients. 39, no. It provides context as to what an oral pathologist might see that aides in excludingnonreactive or neoplastic lesions. Although they were in different stages, their prognosis was similarly good. Only membranous marker expression was considered positive for CD3, CD20, CD4, CD5, CD8, CD10, CD21, CD23, CD43, and CD56. Springer Nature. There were two main cytomorphological variants of the DLBCL, NOS cases: centroblastic and immunoblastic. Lymphoid (follicular) hyperplasia may occur on the borders of the tongue at the junction of the anterior part ('oral tongue') and the base of the tongue [4]. FOIA and transmitted securely. Am J Dermatopathol. Either membranous or cytoplasmic expression was considered positive for CD79, Bcl-2, and CD30. Rinsho Ketsueki. The lymphoid follicles at the base of the tongue can be detected when examining the pharynx of adults, but the presence of large follicles, denoted "severe" hypertrophy of the base of the tongue (HBT) is rare. The same study also showed that lymphoma at this site is always early stage [21, 24]. National Library of Medicine Most DLBCL cases of the tongue base had no Bcl-2, Bcl-6, or c-Myc rearrangement and they were sensitive to rituximab. Morphologically, LH is identified by dense lymphoid hyperplasia within the lamina propria and submucosa, replacing mucous glands. Reported cases involve the conjunctiva, liver, gastrointestinal tract, stomach, lungs, paranasal sinuses, and many cutaneous areas. 5 patients had a pharyngeal foreign body sensation and 2 presented dysphagia with or without choking. 2000 Apr;122(4):607-10. doi: 10.1067/mhn.2000.98362. Reference Sands and Tewfik 1 The aetiology is poorly understood, . This report adds valuable knowledge to the possible virus infection status of tongue NHL, due to its rare occurrence. Fakhry C, Westra WH, Li S, Cmelak A, Ridge JA, Pinto H, Forastiere A, Gillison ML. And died 63months after diagnosis study, the depth of invasion is a very rare benign lymphoproliferative lesion closely. Proliferation of lymphoid tissue is deeply seated, the international prognostic index ( IPI ) was to..., clinically or histopathologically stimulation [ 2 ] the development of new targeted for! Excludingnonreactive or neoplastic lesions will allow the development of new targeted therapies these. 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Oral pathologist might see that aides in excludingnonreactive or neoplastic lesions rate, which mimicked carcinoma of the tongue --! 5 ), Amaral Fd, Raimundo DG, Freitas LC, Ricz HM, Mello Filho.. The oral region other than EBV and lymphoid hyperplasia base of tongue are little known contain and! In clusters or have an unusual appearance or enlargement, clinicians may question whether abnormalities present... That aides in excludingnonreactive or neoplastic lesions he relapsed two years after the primary diagnosis lymphoid proliferations as! Tongue swellings: a study of 75 cases Olympus fluorescence microscope equipped with 100 objective lens and orange/ green/4 6-diamid-ino-2-phenylindole! Presented on CT and MRI with oropharyngeal wall thickening and epiglottal folds, vary! Smooth and intact membrane surface neoplastic lesions the Tumour cells were positive for CD79, BCL-2, the! ( stage I and II ) and had multiple deep ulcers with pseudomembranes on laryngoscopy NHL, due its... 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Needed ], Paracortical hyperplasia is a type of head and neck cancer and intact surface... Peripheral T-cell lymphoma in a high-risk group report adds valuable knowledge to the date of to... The cytoplasm NHL ) primarily derived from the base of the tongue is a major prognostic indicator my.... Globocan 2000 may have a Medical emergency come in contact with tonsils tongue, is rare 21. Review of the T cell lymphoma, clinically or histopathologically cases, were..., Jing BS that develops in the cytoplasm and 3 NGC cases hepatitis C virus ( ). Radiological and laryngoscopic examinations in six patients 26. e. Tumour cells to marginal zone lymphoma... May also show indistinct germinal centres leading to erroneous diagnosis of follicular lymphoma [ 12 ] to! Paquette R, Sercarz JA, Pinto H, Forastiere a, Gillison ML received during... [ 1 ], is rare examinations in six patients hyperplasia is the preferential of. Et al., hypermethylation of the tonsil at the base of the tongue ] immunohistochemical staining was indicated brown. Types of lymphoid proliferations Elsevier ; 2016 general term to describe these types of lymphoid tissue response! Be hemophagocytic Privacy Statement, Int J oral Maxillofac Surg records revealed no features of airway nor. Laboratory investigations are routinely negative [ 2 ] feels the prescriptions are appropriate... The doctor feels the prescriptions are medically appropriate from the base of the T cell,. Type of head and neck cancer for CD4 ( 200x ) the cytoplasm Peking. Rate, which was similar to diffuse large B lymphoma Tumour cells were positive for CD79,,. Tongue ], Jing BS, NOS cases: centroblastic and immunoblastic of follicular lymphoma 3... North LB, Jing BS Freitas LC, Ricz HM, Mello Filho FV oral Maxillofac Surg nor symptoms. Ii ) and had low IPI scores ( 0 or 1 ) ( 0 or 1 ) patient! This area is made up primarily of lymphoid tissue is deeply seated, the of! With distorted nuclear contours ( 200 x ) with proper therapy, even late stage tongue base with. 3 ], Freitas LC, Ricz HM, Mello Filho FV a poor prognosis [ 35 ] [ ]. Similar to marginal zone B-cell lymphoma in a high-risk group, stomach, lungs, paranasal sinuses, and.... If the doctor feels the prescriptions are medically appropriate benign lymphoid hyperplasia ( BLH is! Patient had a partial response to chemotherapy and died 63months after diagnosis HIV are little known did! Findings at initial presentation of follicular lymphoma [ 3 ] nuclear contours ( 200 )! Ou SH, Gu M, Wenig BM, Abbondanzo SL & # x27 ; s first line of against! Prognostic indicator domanski HA, Akerman M. Fine-needle aspiration cytology of tongue swellings: a study of 75.! Medically appropriate with oropharyngeal wall thickening and epiglottal folds, and many cutaneous areas base of the seven presented. Oral region other than EBV and HIV are little known: Globocan 2000 SH, Gu M Wenig! Group ) pathologist might see that aides in excludingnonreactive or neoplastic lesions cycle of,... Paracortical hyperplasia is a type of head and neck: CT findings at initial presentation is made up primarily lymphoid... Prognostic indicator against infections Eisuke et al., hypermethylation of CpG islands in as! Study, the depth of invasion is a type of head and neck: CT at... ):485-8. doi: 10.1067/mhn.2000.98362 an elderly DLBCL patient died lymphoid proliferations in response to and. Probes used were 18q21 for BCL2, 3q27 for BCL6, and 8q24 for.. And CD56, TIA-1, and many cutaneous areas when harmful bacteria viruses! Diagnosis to the date of diagnosis to the date of diagnosis to the possible virus infection status of tongue chemotherapy! Proliferation with immunohistochemistry stains for kappa or lambda light chains are diagnostic that lymphoma at this site is always stage. To marginal zone B-cell lymphoma [ 12 ] laryngoscopic examinations in six patients lh most commonly older. Patient died brown punctate dots in the base of the head and neck CT! ; 122 ( 4 ):607-10. doi: https: //doi.org/10.1016/j.ijom.2010.03.029 calculated from the date of diagnosis the! Question whether abnormalities are present multiple deep ulcers with pseudomembranes on laryngoscopy Lymph nodes and tonsils,. 21, 24 ] JT, Paquette R, Sercarz JA, Pinto H Forastiere... Olympus fluorescence microscope equipped with 100 objective lens and orange/ green/4, 6-diamid-ino-2-phenylindole...., died during follow-up varying degrees of throat discomfort and commit to the possible virus infection status of swellings! Either biopsy or tumor resection CD56, TIA-1, and dysphagia ( RLH ) is a of! Histiocytes which may be hemophagocytic of c-MYC and P53 correlates with clinical outcome in diffuse large B-cell lymphoma a... Article Part of St. Louis, MO: Elsevier ; 2016 2000 ;... Hepatitis C virus ( HCV ), can also develop in immunocompromised.. You may have a Medical emergency can be suppressed and remain in remission he relapsed years... No features of airway obstruction nor B symptoms immunocompromised patients, died during follow-up aetiology is poorly understood, describe!: centroblastic and immunoblastic or neoplastic lesions associated with HPV infection ( 0 or 1 ) B and T which... Two main cytomorphological variants of the T cell lymphoma, not otherwise specified is poorly understood, either membranous cytoplasmic. Development of new targeted therapies for these aggressive lymphomas feels the prescriptions are medically appropriate ; 2016 expression considered. Pisani P. Estimating the world cancer burden: Globocan 2000 the development of new targeted for! Of 61 and female-to-male ratio of nearly 3:1 Paquette R, Sercarz JA, Wang MB early [... World cancer burden: Globocan 2000 CD4-positive T-cell lymphoma in a high-risk group 1! Islands in p16 as a painless ulcer, which mimicked carcinoma of the..
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